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0027 SEAPUIT ROAD
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Y"1 ....e, _ !^`+.t _ ��t .�.•, � - o a ,-,.� G��, �' h�,� '� ,L �� . • TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION t Map Parcel Application # �7 — Health Division Date Issued ? 49g Conservation Division Application Fee Planning Dept. Permit Fee 5 Date Definitive Plan Approved by Planning Board Historic -OKH Preservation / Hyannis 'p Project Street Address Village Owner `"/ Address Telephone e Permit Request �i � !L �Cat/� �/OlT( � 'Minw. Square feet: 1 st floor: existing proposed 2nd floor: existing `proposed Total new IIIAM 15 Zoning District Flood Plain Groundwater Overlay T 2017 Project Valuation D Construction Type $ RAR/VS-rq QLE Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION — ' B7,,,c ER OR HOMEOWNER) Name de'/14i,70A v Telephone Number G ' Address License # Home Improvement Contractor# Email LejLya&4ao%"tiles! .C'o/�t Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE��m=ew = DATE �y1�7 FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ± FOUNDATION FRAME INSULATION _ tiF FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING th �Ko DATE CLOSED OUT ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations ' 4 600 Washington Street Y Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CAPE COD ALARM CO., INC. Address: 204 OLD TOWNHOUSE ROAD City/State/Zip:WEST YARMOUTH, MA 02673 phone#: (508) 398-6316 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓❑ I am a employer with 30 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I;am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8• ❑ Demolition working for mein any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3..❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof re airs insurance required.]t c. 152, §1(4),and we have no r employees. [No workers' /}3 Other ws l/!�C `• comp. insurance required.] 4 4k *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Associated Employers Ins., Co. Policy#or Self-ins.Lic. WCC-500-5006433-2016A Expiration Date: September 1, 2017 Job Site Address: - City/State/Zip SS .Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify 7unadr thepains andpenalties ofperjury that the information provided bove is true and correct. I Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City;or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: <v r:COMMONWEALTH,OF MS5ACHUSETTS:. " Commonwealth of Massachusetts Department of S m • • • • •: nt o a ....: fety ' License: SSCO-000248 EkiEFRfCIANS: Systems -S-License > Security y .� ,<:::> 3��" „<ISSUES THE FOLLOWING L_ i><':'' _ - " FCG(STiREb SYST.,EM:;CQNTRACTOR ' .< GENE cORMIER GN A CORMIER =j Employer CAPE COD.:ALARM'CO ING ;�:. CAPE COD ALARM In 204 OLd'C"fl t>HCSUSE Rp. ;. W WEST, .YARMOUTH,MA-:€U26 3-1531,; ; h nI Expiration: • 11�592� 'tU7'l31/2019, 123442 Commissioner 1 11071 2 018 <>��€~:COMMONWEALTH OF MISAUSE > ° }` I$$l1ES.�THE FOLLOWING Y`F EC E :ED SYS. V.:-:: CHNIC,I/?iN';s°h\ a Gee A CORMIER`' �g MARGAT>? r SOUTN b'4NiJ15,f111A 019.r 1507 Y _ CAPECOD-54 APELL CERTIFICATE OF LIABILITY INSURANCE DATE 9,/1/2 DIYYYY) 9/1/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES-NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 IAIC.No. AIc No): 877 816-2156 South Dennis,MA 02660 ADDRESS:mail@rogersgray.com INSURERS AFFORDING COVERAGE NAIC N INSURERA:Allied World Surplus Lines Insurance Company 24319 INSURED INSURERB:Arbella Indemnity Insurance Company,Inc. 10017 ` Cape Cod Alarm Co Inc. INSURER C:Associated Employers Insurance Company 11104 204 Old Townhouse Road INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDD MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ .1,000,000 CLAIMS-MADE X❑OCCUR 5200-1780-00 09/01/2016 09/01/2017 PREMISES Ea occurrence $ 100,000 X PROFESSIONAL LIAB MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 POLICY PRO- JECT F�LOC PRODUCTS-COMP/OPAGG $ 5,000,000 OTHER:when required by con . s AUTOMOBILE LIABILITY CO EO BINEDSINGLELIMIT $ 1,000,000 B ANY AUTO 1020005044 09/01/2016 09/01/2017 BODILY INJURY(Per person) $ ALL OW NED X AUTOS BODILY BODILYINJURY(Peraccident) $ . X �( NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ • S UMBRELLA LIAR [N OCCUR EACH OCCURRENCE $ 3,000,000 A X EXCESSLIAB CLAIMS-MADE 5201-0586-00 09/01/2016 09/01/2017 AGGREGATE $ 3,000,000 DIED I X I RETENTIONS 0 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X STATUTE I IER C ANY PROPRIETOR/PARTNER/EXECUTIVE CC-500-5006433-2016A 09/01/2016 09/01/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N❑ N/A (Mandatory In NH) - E.LDISEASE-EAEMPLOYE $ 1,000,000 If yes,describe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Certificate holder is provided additional insured status for ongoing and completed operations,primary/non-contributory including waiver of subrogation with respect to general liability when required in a written contract or agreement Certificate holder is provided additional insured status With respect to auto liability when required in a written contract or agreement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION' DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE 71el ©1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. I WCC-500-5006433-2016A PRIOR NO. WCC-500-5006433-2015A ITEM 1. . The Insured: Cape Cod Alarm Co Inc DBA: Mailing address: Attn:Gene Cormier FEIN:"-"'3528 204 Old Townhouse Road West Yarmouth, MA 02673-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 09/01/2016 to 09/01/201.7 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 11-000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTEA 184628 INTER SEE CLASS CODE SCHEDU E Minimum Premium ' Total Estimated Annual Premium GOV GOV Deposit Premium STATE CLASS MA 8901 State Assessments/Surcharges $27,277.00 x 5.6000% This policy, including all endorsements, is hereby countersigned by 07/07/2016 Authorized Signature Date Service Office: Rogers&Gray Insurance Agency Inc 54 Third Avenue 434 Route 134 Burlington MA 01803 South Dennis, MA 02660 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. � 1 Sunroom C ' Garage Bathroom Kitchen O O Master-Bedroom Master Bath Down N m � U Up 27 Seapuit Rd. Legend Osterville,NIA 02655 1 st Floor ®Smoke Detector ©CO Detector SMOKE DETEC RS REVIEWED O Heat Detector .S=r7 AT BARNSTABLE BUILDING DEPT. DATE FIRE DEPARTMENT BOTH SIGNAT(lRfSARE REQ(//RED FOR PERMIT/N& Bedroom Bathroom Bedroom CO CO O Down 27 Seapuit Rd. Legend Osterville, MA 02655 2nd Floor sO Smoke Detector CO CO Detector 0 o co Up I 27 Seapuit Rd. Legend Osterville, MA 02655 Basement sO Smoke Detector Co CO Detector TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 7 Y Map �,� Parcel �7� ©� ��� Application #A'-,// Health DivisionDate Issued Conservation Division �Py �� Application Fee Planning Dept. ONO �� Permit Fee 13� Date Definitive Plan Approved by Planning Board Historic - OKH —Preservation/ Hyannis Project Street Address St ft tAd V-0. Village 0S7Z9_W)1,, Owner f MT &Q.4P 'MACyN7J\at Address ):j iA;F'lTfh*� 471 W r_-,CT 039�Gtv(,� Telephone Permit Request 7 d � 1� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot'Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No . Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 3' 6 If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) -- - -- -. -� Name G19aMC • 6a fift AaA01M Ile, Telephone Number Address t b License# 0 W 14N S . r'n O Home Improvement Contractor# Q ar�9 Email Ala Worker's Compensation # V Q) 015U U 1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Du rnp 5W SIGNATURE At DATE yl l 7 FOR OFFICIAL USE ONLY 1 t r APPLICATION # DATE ISSUED MAP/ PARCEL NO. s x ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ,✓ ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUTI ASSOCIATION PLAN NO. Town of Barnstable Regulatory Services • f f MAS& ' • Richard V. Scali,Director 039.�A Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 I Office: 508-862-403 8 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR , owner of property located at P hereby certify that (Wki lca 6 7l : YU/kkk'k is no longer Construction Supervisor listed on the application for the project under construction as authorized by building permit# /bh— , issued on 2 201.9 . I understand that the project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building Division. P'kOPERTY OVNER DATE q/forms/newcontr reference R-5 780 CMR rev:07/18/16 ,- Massachusetts Department of Public Safety Board of Building Regulations and Standards E " 'License: CS-042246 Construction Supervisory. } GARY C GRAHAM ; Y:.46 GRANT WAY a .HYANNIS MA 02601 s a ` Expiration: 0312012018 Commissioner Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain t less than 35,000 cubic feet(991 cubic meters)of enclosed space. i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit, WWW.MASS.GOV/DPS I ovrvneanurealC�a��a�ac%rtae�. ;' Office of Consnroer AH'airs&Bnsiuess Regulation ME lMPRQVEAlIB Gply jj OR ` rsfratron ` 219 Type: G HAM;t LC. ! FRMS-;__—_�_;_; LL a S 4 GARY,GRgHgjN. 66 BRANT,WgY � Ei1/JWN(SMA02601 F�'is—•""�f �_. _ - Undersecntji4 :`t L'ieense or-reg�sh at�oa�valid for nidul.use only tiefore the ezp afion date: If fon_n`d r arn- o :._ r O`�ick of Consumgr AffanEs and B'usmes°s�Regulahon �.: ;.A lO=PsrkzPlaza Surte51'78' w Bgsbon;MA 6lA6 h of valid-wrthodtts�gnatq�e � I ' Town of Barnstable Regulatory Services s Richard V. Scali,Director. Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax. 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize C2, to act on my behalf in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature o Owned Signature of Applicant Print Name Print Nam Date QYORMS:OWNE RPERMISSIONPOOLS Town of Barnstable ' Regulatory Services dF Richard V.Scali,Director Building Division t MRNMABIAt Paul Roma,Building Commissioner MASS 1639. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone#. work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. - DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) s The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against-the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fomis\EXPRESS.doe 0620/16 27ze Commormeakh of Massachusetts Deparfiffent&f1rrdwftialAccide7ats O,Baca o, MV-Stigatiam IF 600 Washijigion Street Boston,AIA 02112 nim masagorldia Workers' CGmzpensafcan Insur2nce Affidavit:BuilderslCnntractiti-Electrician!Plumbers Applicant Infmmiafiaa. Please Print F�e�bly NaIIIB Address: �JQi1211i� Id1�� City/State! � A ri IJ I S . Phone a ` 77944 Are you an employer?Checkthe appropriate bon ' Type of project(required)-- I.21 1 ant a employes with 4. ❑I am a general contractor and I 6. ❑New constractim employees(fall andfor part hme).* leave hiredthe sub-contmctozs 2.❑ I am a sale proprietor ar partner- listed on the attached sheet.. �• o g ship and have no employees M=e mb-conlractum have 8_ ❑Demolition wod-ing forme in any capacity. employees and have wodwxs' 9. ❑Building addition LNo vvdmrs, camp.insurance Comp_irusurance-# 5. ❑ We are a cotporation and its 10❑Electrical repairs or additions 3_❑ required-]h] officers have exercised their 1 L Plumbic repairs or additions. I am a hotneovm�es tiaing a1>v�otit ❑ g . right of exemption per MGL �sdf�o workers'�p c.152, §I(4�and L..❑Roafrepaits . incrri=e required-]! 13_❑Other employees.[No workless' co=p_II1SQ[aIIce required-) 'Any appficaaLAstcteftboa;ntmd Rho M cut the swfianb9owsbaving their wale s'campeasat; vpoycyi=ffimM$6oa. t E ameownets wbo subamit rhds affidaeit inffic—c they axe damp sly want cad ibmhrim outsidE coutmctorsnmst mbmit anew affidselt iadicabao dfrTi rCanmutMffis2 durlrtlris b=must=ched as addi6-sl sheet shomingtbeaame of W sab-camdmctomsad stidewheflm or notfhase eaddeshwe employees.Ifthesub-cast esbave employees,thejr pnwi&dek worken'comp.policy aumbm I acre arc eerpfnytrr tlerrt isprouidirig ivvrkt'rs'eoarpensafiare inszerarrea for iris*cnrpToy�e¢s: $etory is fire policy erred job rite rnfol4rr(fdam Insumnce Company Nam: Ann)TI 16 C Q�Z - - Policy,4 or Self--im ISC.4: Fkpinifba Date: rob site Address: J 7 SEA P W T QD co/stateop.: (9ST-Ow 1 r t M.4.- Oa Attach a copy of the workers'compensationpolicy-deciaration page(showing the policy number and expiration date). Fadrsre to secure coverage as requiredunder Section 25A of MGL r- 15-7 can lead to the imposition of criminal penalties of a fine up to S15oa oa andfor onL--yearimpsison—a TA as w ll as civil penalties in the form of a STOP WORK ORDERand a fine of up to$254_00 a clay against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigatiam of the DIA for iris'MM n coverage mofmfi—an- 'T der hereby e�fy andd'er ttha pains andpsaaI es afffetgacty duct f ie irrfarma&n pti i&d a€m,0 is 6zre old carred Sizaature: Phone ik OJEchd use wd£y. Do not err ke far tfib Brea,ta be cmnpfete4 by cify or tort n njjrcinI My or Toww PerffitUcense;g Lssuing An9gority(cn ele one): L Board of I ealth I I3uTt}"mg Department 3.CitylTosrn Clerk 4 Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ormation an' d lastructions Massacd setts Ge�oaal Laws cbgA=M reganes all=igloyers to Provide wad'C0mpenS3ftDn for theii=PIo'YeeS- PMMzant'ta this ,an aTkyee is defined as.¢_.e7eaypms6min.flae service of aaotbea Tinder any contrast ofhire, mqx-tss or i mplimL oral or wziftum-" An ernToyer is defined as°`au iadiviffiA paainm b p,,assDciefi&A corPor�on or other legal emt�y,or any two or mote of the fioregoing fie•is a Joint e±mpoase,and inclndmg the legal rep==±9ives of a deceased mRployea,or Hue receiver or trustee of an indrvidnal,Puff=ship,association or ofher Iegal entity,emPloying employees. However the owner of a dweIIing house having not more than tI=.apmimenfs and who resides therein,ar the occupant of the - dwelling house of ano8=who employs pegsons tD do mamma,contraction or repair work on such dwelling house or on.the g ounds or bui7dmg appurtenaaafthereto shall notbecanse of such employment be deemed to be an employer." MOL rlaaPter 152,§25C(6)also states that¢every state or local licensing agency shall withhold ffie issuance or renewal of a license or permit to operate a business or toconstruct bufldhV is the commonwealth for any applic=twho has not produced acceptable evidence of cdmpIiamce with the fn mxanrz-coverage re- ed_ Ad Rangy,MOrL chapter 152,§25C(7)states'Neiffi=the conimanweahh nor my of its political subdivisions shall enter into any contract for the perPormanoe ofpublic work UOtiJ acceptable evidence of compliance with the msuance.• requiccuica s of this chapter have Been presented in the eomrarting.anthoiaty_" A ppIicaafs ' - Please fill o-at the vwkM'compmsat Dn.affidavit completely,by djecking tha boxes That apply to your sifnaiion and,if necessary,scupply sob-cont�s)naine(s), address(es)andghnnenxmmber(s)alongwiththeircet[Eicate(s)of iasarance. LimitedLiabiI4 Companies(LLC)or LmntEd.Liability-Padnersh ps;(LLP)withno =nPloymes other than the members or pant seas,are not requ>ired to cry workers'camp r satien insmmmce- If an LLC or LLP dDes have empIoyees, apolicy is regnued. Be advisedthatthis affidayitmaybe sabmitfed fn the Department of Industrial AccideEis for conformation of insmanoe coverage. Also be sure to sign and date the affidavit The affidavit should be-retained to ffie city or town that the application for the pemit or license is bung refine t. A not the D epartment of had st,iaI Acci =fc Tjouldyoubavo any gnesdons rega-ding fiie Iaw or ifyou are reqmred to obtain a workers' compensation poHcy,please call the:Deparfmem±at the n=ber Hsisd below: Self-mscrred companies should enter their self-ins-o¢`�ce lic®se rammber on the approF¢iate Ime. City or Town.Officials Pleas a be sine that the affidavit is complete and primed legibly. The:Department has provided a space of the bottmn of the affidavit for you to fill Out in the event the Office of Investigations has to comtact you regarding Hie applicant. Please be sure to ELI in the permit/Iicense nummber which will be used as a reference mmmber. In addition,an applicant fhat must sabmit mTIltiple pem/Iicense applications in any given yew,need only submit one affidavit indicating ctmrzt policy infornatioa(if necessa<y)and under°Tob She Ad&ess"the applicant should write"aR locations in (afy or town)-"A copy of the affidavit that has been officially stamped or mucked by the city or town may be provided to the aPPHcant as proof that a valid affidavit is on file for future permits or Hcenses. Anew affi mus davitt be fIled oirt each year.Where a home owner or citizen is obtaining a license or peianit not related business to any bu s or commercial ve=tLre m leaves etc.)said pmson is NOT wed to complete this affidavit (ie_ a dog license or permit to bu The Office of In -=would likc.to thmak you in advance for your cooperation and should you have any questions, please do not hesifalz to give us a calL The Depffi-Lmmf s address,inlephone and fax rammba- 113a ConmmaWedthE Of Departmmt C&IT;&Estdal Agents B MA Ei11F Tel.4 617-727-4900 eat 4€l6 or 1-977-MA.Sg� Fax #617 727 7M Revised4-24--07 wmnigavIdia- 1/19/2017 09:51 PST TO: 15087756688 FROM:6174886501 Page: 4 ACo CERTIFICATE OF LIABILITY INSURANCE �o n9/20,17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). Comp PRODUCER 00391 -001 ' i N/tMEE: Horgan Insurance Agency.Inc. CA/C:.No..49:._(508)775-5830...................................rarto,=.................................................. PO Box 250 : Hyannis,MA 02601 — ----..__..-- ---..__.—_.......... _—Ri�LIREFt(�7.9FfQADltitz __...._................................................................................................................................................IN$URERA.:...Atlantic Charter Insurance Company.......VDAC 44326 .. INSURED —MSURER B — --.--_------- Graham,LLC — QiSURI R C:-----------... ---------------.__._..__. 66 Brant Way .INS.URER.D.:..................................... .................. . .... Hyannis,MA 02601 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ................................................................................................................................ ...................................... LTR:.......__._.___...._.._TVPEOFQISURANCE-- -- POLICYNUMBER FITS ..............c __c °hSS� ....__. _ ........._..._..._..._._.__....__......_,..._.__._...__._.................................... GENERAL LIABILITY 'EACH OCCURRENCE is DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY — .P.REMJSES.(Faotxurrence)......s ..... .. CLAIMS-MADE OCCUR ' MED EXP(Any one person) i PERSONAL&ADV INJURY J S �..._...v.._...._..... —-----------------------...-- €GENERAL AGGREGATE S ................. ....................................... _ € € ...........................__................ ,........................................ GEML AGGREGATE LIMIT APPLIES PER: ' 1 PRODUCTS-COMPIOP AGG :S i ! i OC PRO- ..._.:...._ UCV_..------- 1 T_...... -L AUTOMOBILE UABLLlTY € € '(Ea ............................_..... MBINED SINGLE�l.OuilT ��$ ....... ehxideltU..................... .. .. ANY AUTO 'BODILY INJURY(Per person) `8 ALLY i AUTOS ED BODILY INJURY(Per acddem) S -ti _...OPE......_.. - HIRED AUTOS €NON-OWNED € AMAGE -€ ;....... AUTOS ...Mer.accioent)..........................$..... UMBRELLA LIAR OCCUR € T _..EACH OCCURRENCE S _- ._._...... —_..__._...._.._.._._.._.... EXCESS LIAB ! CLAIMS MADE AGGREGATE $ ....... .................. ..... .......................... : DED RETENTION S ----- y=--- ---------- YIN•: ppNNyypgp����r p/� EcuraE- WCV01059004 1/29/2017 1/29/2018 E.L.EACH ACCIDENT An obis 500,000.00 /fj OFFICEWMERIB�ED Y i i N/A .......................................... .................................... (Mandatory In NH) --': € 00,000.00 Policy Coverage State:MA _.__._..- ----.........._.._--- --..__..._._._..........500,00000 E.L.E DISEASE-EA EMPLOYEE S p ���,dar D :RIFTION OF OPERAMNS Debw —— — _— i EL DISEASE POLICY LIMIT €S --- Gary C Graham is covered by the workers compensation policy AND Laura A Graham Is notcovered by the workers compensation policy. ............................. ........................................... ......€..............._..__............................._............................:._.......................:.........................:_.................._.......................:- ...._...................._..... DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101.Additional Remarks Schedule,it more space m required) CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 Main Street BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY Hyarmis,MA 02501 WILL ENDEAVOR TO MAIL NOTICE i&l. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE p 1988-2014 ACORD CORPORATION.All rights reserved. .ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY i Town of Barnstable Regulatory Services M Richard V.Scali, Director �'�EDMECIp,� Building Division Paul Roma,Building Commissioner 200 Main Street,.Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY I, C>�12y C�6zA - , Construction Supervisor License # o q,)L,)4 hereby certify that I have assumed responsibility for the project under construction, as authorized by building permit# (� 3�/�5, issued to (property address) kJ P U,I T" 9 0, 0 57'EQ V► )1y, on spa , 201_7. The following documents are attached: copy of my Massachusetts State Construction Supervisor's license or Homeowner's License Exemption form (if applicable) copy of my Home Improvement Contractor registration (if applicable) Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit. Road Bond (if applicable) C 4a�,1 LICENSE HOLDER DATE gftrms/newcontrb rev:07/18/16 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION M . r � 27 ap Parcel Application # Health Division Date Issued z3 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 0- Oil Village �s1 P� �Ile- � OwnerTo6J uk-J hla Address LAB u g4 Telephone ��� 01f L Permit Request -T.I d l b1_6 4, I h ► T r Ccl� b �cM��e Woo �,�,�. �� �►tom Square feet: 1 st floor: existing_"d ed 2nd floor: existing :proposed Total new Zoning District Flood .Plain Groundwater Overlay Project Valuation Construction Type t�0 Lot Size `�.5 &C 1P.r5 'Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: dull ❑ Crawl 0 Walkout ❑ Other Basement Finished Area (sq.ft.) -�" Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: .5 existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ll�Gas ❑ Oil ❑ Electric ❑ Other Central Air: ®Yes ❑ No Fireplaces: Existing New Existing wood/o`d�yt�� ❑Yes ❑ No � Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ exi _ting ❑G n RvPPiEe_ Attached garage: 2(existing ❑ new size _Shed: ❑ existing ❑ new size _ OtherN ®V 21 Z . -� oW 0"eARNST Zoning Board of Appeals Authorization ❑. Appeal # Recorded 0 ABLF Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) �< aC db Name �P Telephone Number � d Address 1 .�� License # F. Home Improvement Contractor# .Y f 6 Email 6- L+/Ce-102 O czk Worker's Compensation # JO WC 6"7 5 FW ALL CONSTRUCTION DEBRIS RES LTING FROM THIS PROJECT WILL BE TAKEN TO V SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/.PARCEL NO. f ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION 3 0 - FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT t ASSOCIATION PLAN NO. ' I oF� • swxivsrna�. , MAM .059 Town of Barnstable s639 �� p�A Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, bber �� �� , as Owner of the subject property hereby authorize h L14 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) I 1 la /t Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Oudook\2PIOIDHR\EXPRESS.doc Revised 040215 T fie Commonwealth of Massachusetts Department of Industrial Accidenis Q,()'rce of Investigations 6#0 Washaigton Street Boston,MA 02111 wmv mass.gov/dia Workers' Compensation Insurance Affidavit: Baders/Contractors/EEIectricianslPlumbers Applicant Information Please Print 1*6bly Name(Budnew/Osgamumfian&dividnal): Address: 0, Rod 3o City/state/Zip: ie /C4 Pk !Dt'K Phone 47 Are ou an employer?Check the appropriate box: Type of project(required)_ 1.EI am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-lime)* have hired the sub-cantractors 2.❑ I am a sole proprietor or partner- listed on.the attached sheet 7. ❑Remodeling ship and have no employees These sob-contractors have g_ ❑Demolition working for me in any capacity. employees and have woreers' 9- ❑Building addition [No workers' comp.insurance camp-insuranoe—I required-] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12-❑Roof repairs insurance required-]i c.152, §1(4),and we have no employees-[No wards' 13.❑Other comp-insurance require&] *Any apph=that checks box#1 cost also fal out ibe section below showing then woakera'compensation policy informatitm. I Homeowners who smbmit this affidsma indicating they are doing all waft and then hire outside contractors cost submit a new affidavit indicamg such lContractors that check this boot must attached an additional sheet showing the mane of the sib-couw Lois sad state whether cur not those entities have employees- If the sabtooYt aors hwe employees,they must provide their workers'comp.policy number - lam an employer that ispmvidWg workers'couWansation inairance for cry eegplvjrees. Below is the policy and job site information. ], Insurance Company Name: Ar(,4;,C l/n jf�7Q P�ocYSS �y, va1l i' Policy#or Self-ins.I.ic.#: Fatpiration Date: 6 �� Job Site Address: S�vL City/State/Zip:(-,**VA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 andlor one-year imprisonment,as well as civil penalties in the frnm of a STOP WORK ORDER and a fine of up to MOM a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Inveshga- f the DIA for insurance c verage verification- I do hereby y lit er th an allies ofgediuy that the information provided above is inw and e°orrec S' Date: ! /b Phone#: �)i `' ,v- Orcial etse only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 9 Issuing Authority (circle one):- �y� C:\ e � elliklApp�ata�AcalUv7i�oso t m wsmporary'�n�efai�es��onetern QiidoEogM e1��S5doPlumbi�ng Inspector Res I87f$ Contact Person: Phone 9: i ,,Y k + t A p —� -- � ik4tJq JIR IA S1 P� p 1 RESIDENCE MODIFICATIONS MICHELE CUDILO, P.E. Consulting Structural En ineer Centerville. Momchusetts 02632-1979 508 771-7601 7 SEAPUIT RD. Drawn By: Mc Date: 10/24/16 Drawing OSTERVILLE, MA scale: As NOTED Rev. 0 jo S K—' 2 MIA nme BUTLER Project No.2016-275 _ ._ s - - . �-. --� _._' '�- 3• -d,•A"' s w,Ct",.1'16: nr � t �'" 07 C, } _ TIC S I :,w.___ - *b6 `.r:>` { , 'D" _C - •- - _; .x .rye`-y-�2� p �,t, ©Iz- 4 3 'I X�j'� S TL, 's y�At.rl..ri �' s-------- AMC D �, ,,, E •" t _ r h 20 r 's RESIDENCE MODIFICATIONS MICHELE CUDILO, P.E. Consulting Structural En! *Weer Centerville, Massachusetts 02632-1979 508 771-7601 7 SEAPUIT RD. Drawn By: MC Date: 10/24/16 Drawing OSTERVIUE, MA Scale: AS NOTED Rev. 0 j0 TT cL _._BUTLER Project No.2016-275 n TS —� W G�ugETj b N + + Z0 `rO�i9 a Jl7 pLD P4 J U�Z �dh 3 + o 'Q } o ?�yO�Woo P��y ❑oWZa1 d 1-Li 0►-�li v U 02 W J' } Li Z(y i QW e a Ll;5 Lj WqWix } {i W Q• a.,►� ►~-�Q� jW V4 �J t i z _ z _j W c4 Qo .. I c m J M I V) a Y Z ❑63 II IW F- Q cu y3 ww f U i � J O > Z J - QHF-= Z � W OAUJ I I V Q Ua`�=J y � WaaZZ i_ + tW.�I=-d� v _a .-� N Cv)O J Z �' J f W LL. J # 3 eb- 0N . ¢U O "' J QO cu J + --� UX J D N A H LLJ N\O %• Q �Cai0G W W N+ -J C3F-U) LJiFJ ��� W �` L+J LY J Q 1 < ` �'• W J t Nil a t 1 A k • z �. W F- i + + LD r-1 PROJECT: MICHELE CUDILO, P.E. lTc_-1t—_4 Consulting. Structural Engineer s Centerville. MMsachusetts 02632-1979 FOR•• Z? FOIT' 9-3P, Drawn By: MC Dcte:, Figure 1 Checked By: Scale- l% � Pro ect No.: S K- W r G�vSESTS b s + + ---- - z yam° a o 3lzg $ 0 w9C-S)� JMD LO 0LO I ! p}q , j �U�o c> u�11 <Z �Z t ZQ��yy ?� + 3 0 "W o a y°wwoo QP� F- } J W + Z JOE Lj3 v .-4w p. 0- Ld.p W, + w¢ I F- LLJ f pq. .0 + z�� I LJ cc4 ~a 0 0 M . Jw i Z ~ �= zZ E Q � N t%3 WLL) 1 0 > � JWl/10Z J Q1-F-=D W J Xao Ela� U Q. V d Pq=-1 I \ Ce zz p (L V1.W F-Q. t X: —I \arK W�- (p� + Cu J --� � lJ X J N,CuLLJ 0 J LLL. + � � \ p t J N@Jw Iw- .-+ 3 W L7 W ter ¢. W U. H. aHl7 W ! p + ��J . pro LL: fJ �� W ". �W tY .J Q 0H . I. it + 1 Z O W _ � H .� W J 2• N PROJECT: fib► at�D� irc�,�s MICHELE CUDIL4, P.E. 1`-r"c ►.c Consult'i'ng Structural Engineer .Centerville,, MAssachusetts 02632-1979 Z7 V(7 Drawn By: MC Date:. Flgure FOR: t�..:b , z 1 tf l Uj7 Checked By: Scale: SK— Pro'ect No.: CERTORCA` E OF LIABOLOTY ONSUMNnpCE [-70AE(MWDDNYYY) MATTER OF INFORMATION ONLY uV THIS CERTIFICATE 1S ISSUED AS A AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 10/31/2016 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTA"M OR PRODUCER,AND THE CERTIFICATE HOLDER. MPORTAN T:If cerM"rratiB holder is an ADDI t TIONAL INSURED,the pOUCy(les)must be endorsed.If SUB ROGA 1ION IS WAIVED,subject to the tonne and olicy.Certain policies may require an endorsement A statement on this certificate does not confer rights to the cer6frca0e holdeonditions Of the per ur Cceu o --i endorsement(s). PRODUCER co Ac NARSE: Automatic Data Processing Insurance Agency,II PHONE F x 1 Adp Boulevard NO E'd ruc.No): Roseland,NJ 07068 -ADDRESS: �: INSURERS)AFFORDING COVERAGE NAIC- INSUREO INSURERa: NOrGUARD insurance Company 31470 dOSEPH BUTT-ER (NsuR�Rs- DBA:NOalh Bay INS URERC: MA INSURERD: INSURER E- COVERAGES INSURER F- THIS[S TO CERTIFY THATTHE PO CIES CERTIFICATE ICNSURAN E LISTED BELOW HAVE BEEN[SSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INREVISION NUMBER:- DICATED_NO�►1THSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE BAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IXCW51ONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IL7R rYPEOFINSURANCE INSO wVD POL[CYNUMBER PO nYEEr PO�CYEXP LIP9TfS �MMERCIAL GENERAL LIABILITY EACHOCCURRENCE S CLALI7%MDE OCCUR PREMISES aeaolence S MED EXP(Any one person) S PERSONAL&ADVINJURY S GlU1 AGGREGATE LIMfTAPPLJES PER: _ POLICY❑JRCoT f—IU LOC GENERAL AGGREGATE $ OTHER- PRODUCTS-COMP/OPAGG I5 AUTOMOBILELDIBILlTY I s COMBBIIN®ISINGLE MIT S ANY AUTO ALLOWNEO SCHEDULED BODILY INJURY(Perpemn) S AUTOS ALnOS NO"VVNM BODILY INJURY(Peraaaderd) S HIRED AUTOS AUTOS PROPERTY DAMAGE (Per2cddentl S UMBRELLALIAS OCCUR S EXCESS UAB EACH OCCURRENCE S CLAIMS-0tIADE AGGREGATE S DED RETENnONSI MUM $ AANNPD EMPLOYERS L1ABiiy njLO YIN STATUTE I V I A OFfrCER/I,IQdMREXCWD �Y NIA N JOWC675823 10/28/2016 10/28/2017 E•L EACH ACCIDENT y 100,000 (I8a+r0aGery in NH) yyeess EL DISEASE-EA EMPLOY S 100,000 inESCRIPrl NO OFO ER---NSbelmv 500,000 EL DISEASE-POLICY LIMIT S tor.AddiUonalRemarksStkeMWrayDeaWdledIfmorespaceLsrequInd) DESCRO'rrONOFOPERAT[O6&ILOCA7[ONSIt/EHlCLt (ACORD CERT(FICATE HOLDER CANCELLATION SHOULD ANY OF THEABOUE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Chafham ACCORDANCE wffm THE POLICY PRowslONS. 2G9 George Ryder Rd Chatham.MA 02633 AUTH]ORREDMPRESENTA7IUE LACORD 25(2D9 m) A©1988-2014 ACORD CORPORATION_AU rights reserved The AGORD name and togo are regtstered marks of ACORD A66Z0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `� 1 10/31/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:CONTACT Customer Service Department Gaslamp Insurance Services PHCC. N u (800)920-4125 F No:(800)920-4107 ADDRESS:Certificates@premieragencyservices.com 3234 Grey Hawk Ct. INSURER AFFORDING COVERAGE NAICs Carlsbad CA 92010 INSURERA:Preferred Contractors Ins Co. 12497 INSURED INSURER B Joseph Butler, DBA: Northbay INSURERC: 8 Fourth St INSURER D: INSURER E: Harwich MA 02645 INSURERF: COVERAGES CERTIFICATE NUMBER:a MAster 16-17 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSUBM �TR TYPE OF INSURANCE D POLICY NUMBER MOLICY EFF MOOLICY YYP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS MADE X OCCUR PREMISES Ea occurrence) $ 50,000 PCA502S—PC207021 10/28/2016 10/28/2017 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POUCY PRO- JECT El LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N/A EL EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE ,$ II es.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Verification of Coverage *Subject to all policy terms, exclusions and conditions* CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Verification of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Justin Duenas/TIANA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) "��c orrr�uuirruen�/�o��Jl�a�;rrc�n�e(/s Massachusetts Department of Public Safety Office orConsomerAftirs&Business Regulation Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR License: CS-079488 Rsgistrafion:' 184119 Type: � . c- Construetion Supervisor ^ a Expiration: DBA NORTHBAY JOSEPH A BUTLER 8 FOURTH ST EHARMCHMA 02645 JOSEPH BUTLER 8 FOURTH ST j HARWICH.MA 02645 Undersecretary xpirabon: commissioner 05)W2017 a Construction Supervisor License or registration valid for individul use only Restricted to: before the expiration date. If found return to: Unrestricted-Buildings of any use group which contain Office of Consumer Affairs and Business Regulation tation less than 35,000 cubic feet 091 cubic meters)of 10 Park Plan-Suite 5170 enclosed space. za Boston,KA 02116 P L 1%t valid without signature Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:VAM.MASS.GOVIDPS TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL--ID lib. 124 GEOBASE ID 6095 ADDRESS : 27 SEAPUIT ROAD PHONE' (508)428-7554 jOsterville ZIP - LOT BLOCK LOT SIZE DBA oh DEVELOPMENT DISTRICT CO PERMIT 16919 DESCRIPTION SINGLE FAMILY DWELLING (PMT.#14316) LPERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY 1 CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services ( TOTAL FEES: THE BOND $.00 Ox CONSTRUCTION COSTS $..00 756 CERTIFICATE OF. 00CUPANCY * SARNSPABLE, • MASS. OWNER CAPELAND REALTY TRUST, 039• ADDRESS P.0.BOX 192 FD M1� OSTERVILLE, MA BUIL N D BY DATE ISSUED 07/31/1996 EXPIRATION DATE ;.L' ..... .._... .n , :J-,.. _. .i..,.._.....'y ...J....f.I ...-<..�-._..+.1.9..L;•. ..I: u'-a...-Y...:..__�4i1�,!�\•..:.;.:'.�1'.�.L:.:a,3.:.::�1.'._.Cb.:..:� "i'1L ;:,.:j,:.: .. .� I TOWN OF BARNSTABLE ' - ' BUILDING PERMIT PARCEL ID 118 124 GEOBASE ID `6095 ADDRESS 27 SEAPUIT ROAD PHONE (508)428"=7 Osterville ZIP - LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CO PERMIT 14316 DESCRIPTION SINGLE FAMILY DWELLING (SEW-PMT-#96-98) PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT CONTRACTORS: PHILBROOK, T.VARNUM Department of Health, Safei ARCHITECTS: and Environmental Service TOTAL FEES: $430.00 Oki BOND $.00 . CONSTRUCTION COSTS $130,000.00 101 SINGLE FAM HOME DETACHED 1 PRIVATE P ' 163�. OWNER CAPELAND REALTY TRUST, ADDRESS P-0-BOX 192 BUII,Ij' IO OSTERVILLE, MA BY DATE ISSUED 04/05/1996 EXPIRATION DATE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET.ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY•THE.JURISDICTION.STREET OF ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROMTHE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OFTHIE PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE.SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED - FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND E WHERE APPLICABLE, SEPARATE THIS CARD KEPT POSTED UNTIL FINAL INSPECTION 1.FOUNDATIONS FOOTINGS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERER ING STRUCTURAL MEMBERS(READY TO LATH). - ' • �. � PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH- ANICAL INSTALLATIONS. i 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION Ar. ROVALS ELECTRICAL INSPECTION APPROVALS v6 0K �� -7- - 2 1 ,tav 7- 50 7 3 1 EATING INSPECTION O,ppROVALS ENGINEERING DEPARTMENT 2 BOARD F HEALTH OTHER: SITE PLAN 16ZW APPROVAL t.-IV6-if-,W__\- 71jj 3( WORK SHALL NOT PROCEED LJNTIL PERMIT WI IL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTIC 'WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS )F DATE THE PERMIT IS ISSUED AS TELEPHONE OR WIIITTEN NOTIFICA- TION. NOTED Af .OVE. TION. II 1�6 3 . L� Y y � ,SEAPUIT ROAD N6724 09'W g 120.46'- _ 100.39' 17.27' 9 i %ad) liml LOT 73.0' F0UNDA TtoN �ITiD�1S 7 � LOT 8 u 59.21 69.08 - Sy2 y ati LOT R = 50.00' o o N 6 e L = 23.47' 0 1�7-k7 wN i A` \ o LOT AL ` a /w SBT4745 E 144.46" \ I 24 0' o 0 0 - cr 4.0' s.°QN 14.0 6 o.UNDATION mac„ !, - 12•° 0 28•° DETAIL 8 5 10.° 7 m cr 4,2 NOT TO SCALE 4.3' 5 0' �. FLOOD ZONE "c"_ FO UNDA TION CERTIFICA TION RES ZONE: "RF--1" TO AN.•OSTERVILLE SCALE:1"=80 A REF.-15055H ELEV N/A I :CERTIFY THAT THE ABOVE YANKEE SURVEY CONSULTANTS FOUNDATION IS LOCATED ON Uf P. O. BOX 265 THE GROUND AS SHOWN, AND �' IT'S POSITION_� F,� OS' ----- �o PAUI y� UNIT 5, 40B INDUSTRY ROAD CONFORM TO THE ZONING LAW MARSTONS MILLS, MASS. 02648 MERrrHBV SETBACK REQUIREMENTS OF �o� TEL: 428—0055 o FAX 420-5553 BA N_S_TA_B_L_E �s EcIST Qa --- I LAKO SJ JOB PAUL A. MERITHEW DATE. 1_9zl96 NuAfBER50904FND r' a,.s.aow�so =El I .eom..a r�a"•'t Cl I .•.o.rtD `DdeR 6leti•.+Y lEK '4P.KtaeN .—...—. _... —_..--�2 'KO1T1_�. SW Q,.x>h , PHILBROOKtE�lahv ENGINEERING& I R` I mD.aoc CONSTRUCTION t�•s•` "��" »'^•`I I Y °t""^R35 fill r_�.,a. i.a,.a•,tia i _ tvf®u, oRr i 0~ _ I ¢•..•..ti _ I�Y�M��!NM T p'1/ - � •5 • >. . e..0��:,'...:"tee:.�'�"::�:i:'� I - 1�.a a•Y... aD .t f,5 " - :. ....._.,..._.._a.�.�=ate:.:_�... . . •�„_��-.1 •�;,..w � E i+� MW� L�— .y...w 4 _ o.r•�.��_D•w If► b S �R• __ Pwa aW./1Y o•.._�.Q.a 1c.s Fe...o.t � >; C j° T pi..T 41 _ 1 Q,cKc eys,ws.�.. - C9 ' a.�•P•+«m eov.. P'R�+U.16 PK I � I y.,�r.• 3o - /D/ok 13�� �niTioNs t; r�� � Nei F 4 - 1-�j s�„y E r :x '..,-Yr ,£^' �•Q� - S.�f. .. .�e ZJa��v»zovzureal� a�x,�aad�uveClsF �. _ - Restricted To: 00 3 6 9 4 0 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 00 - None Number: E a Birthdate: lA - Masonry only CS 006083 1/14/1998 01/14/1951 A - 1 E 2 Family Holes ' w 0",-Restricted To: 00 Failure to possess a current edition of the ri> Massachusetts State Buiildiny Code THOMAS V PHILBROOK is cause for revocation of this license. 107 BEACH ST s DENNIS, MA 02638 COMMONWEALTH OF MASSACHUSETTS DIVISION OF ' IN E N G I'N E-E R I N G ` .TIOME IMPROVEMENT CONTRACTOR REG/PROF ME:CHAN+ICA,L ENGINEER " =. ,Registration 101422 ISSUES'THIS LIGEN$E TO T e DBA rl�^ �`n` a4 E piratlon 06/25/96 - T VARNUM:RM LByROOK 10 7 BEACH S T R E E T� ,` f - �r Phi lbrook Engr.. 6 Constructl ' T V. Philbrook DENNIS M 2 6 3 8—18 2 6 Q .�"G� 44YBeach Street : ADMINISTRATOR �l. r-. \ Dennis MA 02638 ` 30690 06/30/96 685410 EXPIRATION DATE ,�. sj- t U ,y r 'f y. t'F ,. .. c`31 1ti sCv•!.�>q;a! F} r. 'rS� -y i y`'��+� ,2`•�Y'" - t A .. t '+>fi *t13..r � + t y �}''-J.•tc,Y-+a��� �W M�,9 Yj!r�i`�.'F�?(��""�tr��ul�'C3�+ �f .' � + a„ SL rT�.�'S,rJ"•.uL�v" {+�r.c a ( '.u.' 't'� _ 3�^,�'.�w �a C irt.,a`4,.[�11. �h � -N. •f•4} 'S> 7 �..e �7l ly}'x'�Y'T 6 4 r.j r �'�^y� � �_` � .'S -, ,�_. < ri �a�f'';r���+.`��a'Y�-s '� •���,-. r 3 s , Jr `�.s � r,., <� r -�t: i �r r'` `;,. o''�-art ��" 1� :� a h�.4 kE./Le7'Jt�.`ti f.,f•v`tnx uY�� ;'t �. t:� .�a2 til < -�x"ZI " ,ytw 4T�` ' '`YrR 1.a r rt >• '*his 4 '`M t-'�J xro -,r3 '�t�nyl'� ,? '�s ? s s •z` �z Y+'ti.1 �r ;K ^i.� r'tF ¢ ?}L ��- < � �'..`..�{`L v a 'r¢: '7" ^! "ll�. L .; 'F' '> yi ta�-f J' f `. �r x yx �.. +: ..• �, i,n�, -+j .'-'eify,' r +'��- •- a y, L,vyJ r F �4 y+: - �ir. V<i y�y�y� �'+ ��` 'w 4 ! ' r s i s! ...r'p v:. Vrei ° ♦r '" r�`}ec'"7 v 3 x g�x"'` .•, 3 fal4* x 2t-:r�.3cra`L X1}I• tys`�L '� F �2'l�. .G'G vyelJ l�. t 1 J i { 4 �eh'�.t .. tY c S i -r Zv -. "�^' ''' i M.rl + -!! t. '•� 3 r t i y � ,.� i"�y...+,.� �" F ,, Sh�i� � ar)ccy,-.w 1 •xK-.c z.,A� `� < ; .',sJ.,. -fFYy.• 3r 2 .T .� ..t� d _+.]':'S -} + �tFy�t 1 F . • `"�' The ConnnuJnN'calt/n f fAtassach ett-w Department of Industrial Accidents 0/llceofIRY9 WISMW 61111 f1 zsGingwn Street i=•� +--� ". Boston.Muss. 02111 �•' Workers' Compensation Insurance-Affidavit _ �ARnliennt ntorma anss- name `�i iC.�t/L✓J�� c��41f,� YL3i'l DIS��CZ� l�''`t-� D�sJ6►"t � �'u1L�.7i�ts �C• locationCin , nhonr o ❑ 1 am a homeowner performing all work:myself. ❑ 1 am a sole proprietor and have no one working in any capacity i~=�ii►1r •r�r � '4l ❑ 1 com not nnme 0 �jJr�cih•• bTzr+N<s �p2�. ` - da6�j% nhnne#s incur•tneeco, /('S Nv &'7 '-rS? AA am a sole proprietor general contra clog or homeowner(circle one)and have hired the contractors listed below who hai dhe foDlouing workers' co po ices: cvmn•tm n�mc � G'J'ui/�Ef ' J►� �%C�-- !/��•' phone Ih �g��f•�7 4j. nnee Co. CbMVIAV�; seller# l^+�1'�;.- .«----::-• --..-..sn•a�o;..•.asw�r?�'r+..�•:TRe;«s^Af'� -J'--�,---- �°ts4`7�_ r•�t•_—'__�-_'_,�_—:�••_���.__:-- ctimnan♦ name ���� '•'`�������G` "��� r c�6 f izz-Ci C L � c. -7 5 J it�rit� ���2�''./��9G� �'¢• phone� / �C ��/l 6J?1�c� '73EFt��9� 39S insurtnee co c��� !''f'� "Offev o Atiach additioiisl'sheit if access_^• z --'�.wa r..r• .-` '` ""''"' 'ul''� '—'- ' Failure to secure coverage as required under Section 3A of 111GL 152 can fend to the impostuon of erimtnal penalties of a fine op to 51.500.00 and/or une •ears'imprisonment as well as civil penalties in the form of a STOP NvORK ORDER and aline ofS100.00 a day against me. f understand that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herebr cenify under the pains and penalties of pe jurr that the infornmtion ptntzded above is true`and cornet Signature �Z, ate Print name _Phone# oificiaf use only do not write in this area to be eompieted by city or town official permitfil ense# r•iBuilding Department cfh or town• �1.1censing Board O check if Immediate response is required CSeltxtmea's Olrce C31leafth Department contaet person: phone fh r�Other__- 'information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to pmvide workers' compensation for thci: employees.- As quoted from the "law", an empinree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An enrplityer is defined as an individual, partnership,association. corporation or other ;4gal entity, or any two or more the fore�_oing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwellings house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling lion or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer MGL chapter 1.52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ll: been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completeiy, by checking the box that appli:;s to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tlie affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. • ... _ ..... •• .. •�. _ "' `y;., '.,1�w.l.:.'� :f:=��S•,6.^.^ .'AG'i',71�.,f..j�����•: '1osY•:r:{a ,+••777 City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plea be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any question please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents _ Office of investigations 600 Washington Street — Boston,Ma. 02111 fax#: (617) 727-7749 -. phone #: (617) 7274900 ext. 406, 409 or 375 o cn ICE VALLEY ROAD m K 9, D. �m �y 724b9""0 SEA P UIT ROAD �y 'E yob f,P��o• sa -+ 120.46' eace a of• 4 ca a T 100: —.e7p� -.1"veue°N80'09"Jr-q-W 205 B5'' \ 0'r2�EEC . —108 arm. 6t-J0z19 • ,�� / 1 O TA6 SOLT _ '� (ASSUAfED so•suIi7AW 5Ep es € ,`_ ` �,,, ;.s LOCUS MAP RESTP.ICT/ON!!.4'E (M BE WM) LOT 7 J02 ✓✓✓ Pat? { •. \ . / 69.1" 26' J+or�s 2a' �a0 08 95 io -�� 94 \aka e�8B9 08 �_ 59.21 - —�`�90— s\ Jv .-1 / / LOT ,552 6p. R = 50.00 "s o � 9 ' B 'L = 23.47" �0 121 �( 1•� I i n� I �� -,. N5 PROJECT L OCA 51ON ��. �tN LOT 7-27 SE_APUIT ROAD ! A. OSTER VILLE, JfA. S87 47 45'E 144.48' ' I ! / I bCa APPLICANT.- DISTINCTIVE HOMES j P. O. BOA' 192 ! OSTERVILLE, 'ILIA. -02655 : ! YANKEE SURVEY CONSUL TANTS P.O. BOX 265 ASSESSORS MAP 118 GRAPHIC SCALE UNIT 1, 40B INDUSTRY ROAD PLAN REF. 50 25 50 t 0 200 MARSTONS MILLS, MA. 02648 15055 H PH.(508)428-0055 - FAX(508)420-5553 RES. ZONE.- 'RF--I" SCALE. 1 =50 DA TE. 3�15�96 FLOOD ZONE. "'C', ( IN FEET ) 1 inch ' = 50 ft. REV RE-V.- JOB NO. 50904 SHEET OF 6 .Ti engc�- �+tYi?�411 � s . '¢w-1� 'kl d. ✓�+ rt as :'.'�`r+.�.t W •�!�. �. •� 1n r¢t�!-y -c 1 �r 4. -h l�..:U t . � 4 cs• _—___ _- _ � : gip :. ; • . _ _ o , o _ � ® t till •� Pr ,- 7 flll�l • - - �:_ � III�I I 6n 5. - ! � Ili• ;i Cc — � •I I� II ,!ill III Dlstlncdve Homes wealmosruNwiwox �...e.......�.a.,.. t IA a C ' - I I 1 _T >ti.o..... slat �•��' ' I1111 II I II I I I I ICl— •w.....w., S[CIlO1V DBrAIta . LEFT ELEVATION MUDILAUNDRY AREA, .. Zm f � T' am e•.nwm -:.�.. ..�: -' '-- a � l *SECTION DRiAR<' . RII'QI^DWINGROOK BEDROOM S FOR] F9fll - _ IIII III .I II - 0 8 I � REAR ELEVATION • o °� i i • ae +.d 7•r a il' I �.i ' u e: 4 D v nV - 71 71 eye II = M f1 II ♦ - 1 - ff.. � H i�t •- - 7i y S _ y 9 + I C Y O O / / I� I �� - ___ Y f<<�•� 1 Itl jl I I\� % � �' llosn 1 : - Ply pil kP III' $I � 9 •Iq Ilsi . I I •� i - y ..� a•v •rw• as * �-b y7�II �ti�• IH'c. .. -,-�I ,j.. • � I YYf a� I a �I �.., cl �.•. . I 1 b - ° OO a 1 P I'. Distinctive Homes Mvrr••r/rwhr+r�nw M �/rwr wrp.rw 4.MAa P.7 . i 1 1 .. i If. I.'.I. ,or ti• p•4G�F 77- b• ,t7 F II ►p —71 1 " _ I dil ♦ L � IwI i l.•w I - a 3 I a R Zvi t Distinctive Homes nrsr�leuu+cnssoavrs � G 9 a �". -• - roemmosre�uew�oass e•�..,..Nowe.wa.t... " V T , Via- . .Memorandum From: Dowling&O'Neil • Insurance Agency,Inc. a 222 West Main Street P.O.Box 1990 Robert G Dowling III Hyannis,Massachusetts 02601 g 508-775-1620 Fax:778-1218 3 - � -� � A. , PA G `bP�) -�h i S. Cl.� Cs u3N ;5.6--w laff r MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL APPLICATION FOR WORKERS' COMPENSATION INSURANCE MAIL TO: The Workers'Compensation Rating&Inspection Bureau of Massachusetts P.O.Box 9006 Boston, MA 02205 (617) 439-9030 IMPORTANT This application must be typed or printed and filed in duplicate with the Bureau. An original bl-fold form must be used. A separate application must be filed for each legal entity. Enclose check made payable to: The Massachusetts Workers'Compensation Assigned Risk Pool (MWCARP). Coverage will be tentatively bound provided that,upon review,Bureau Staff finds that the application was satisfactorily completed. The earliest date coverage can be bound is at 12:01 A.M.the day after the application and deposit premium are received in the once of the Bureau. Under no circumstance will coverage be bound if:payment or deposit premium does not accompany the application;the declination requirements are not met;there is a record of coverage in force for the entity making application;or,the applicant is in default of premium for prior workers'compensation coverage. The undersigned employer is unable to purchase workers'compensation and employers'liability Insurance in the voluntary market and hereby applies for such insurance in the Massachusetts Assigned Risk Pool and expressly represents that such insurance is sought in good faith. Requested 1. GENERAL INFORMATION Effective Date: 1. Curs ��► s}�c �/e�o s�Q.SI n a $uA �1.4 A5S ock NAME OF EMPLOYER (Name of sole proprietor,general partner(s)or trustee(s)m be iv with the tra ame of the business.) MIAs t40 E49Lay6ES 1 .e 4 nv OLD 1 Nis SMiCAA Se-curt !1V is 011� )�l�a— El PENDING 2. FEDERAL EMPLOYERS IDENTIIFFICATION NUMBER (If pending,attach haatcopy of the IRS application.) // 3. ��� , Z>y- 19 d �S CxVi `\e ) '- l�. oa (0 55 \So5�y,�a^- �755r MAILING ADDRESS Number Street City State Zip Phone a. :cA cal �c� �S�exYt��� 1�11�_ 0a1o55 CS."�.lya ' MASSACHUSETTS LOCATION Number Street City State Zip J Phone r 5. _ �n tLQ_ OTHER MASS.LOCATIONS Number Street City State Zip Phone (Attach seepCparate sheet if necessary.) 6. •V LOCATION OF RECORDS Number Street City State Zip Phone 7. LEGAL STATUS `Sole Proprietor ❑ Partnership ❑ Trust ❑ Limited Partnership j❑"Corporation ❑ Other(explain) II. CORPORATE INFORMATION List the Name,Duties,Percentage of Ownership and Annual Salary of each officer listed in the Corporate Articles of Organization. NAME DUTIES %OWNERSHIP SALARY President Treasurer Clerk NOTE: Corporate officers cannot elect to be excluded from coverage in Massachusetts. See the Massachusetts Rate Pages for corporate officer maximum/ minimum payroll limitations. Sole proprietors and partners cannot elect to be covered in Massachusetts. III. INSURANCE COMPANIES WHO REFUSED TO WRITE VOLUNTARY COVERAGE According to Massachusetts General Law,Chapter 152,Section 65A,an employer may obtain workers'compensation coverage through the Massachusetts Workers'Compensation Assigned Risk Pool if they have been rejected by two companies licensed to write workers' compensation insurance in the Commonwealth of Massachusetts. 1. Attach two letters of declination from Insurance companies who have declined to write voluntary coverage. The letters must be submitted on original letterhead; they must not be dated more than sixty(60)days prior to submission; they must have original signatures; and,they must be signed by carrier personnel authorized to bind coverage. NOTE: If you are currently insured in the voluntary market,one of the declinations must be from your present carrier. A copy of the cancellation or nonrenewal must be attached to the application. 2. Have you received any offers of voluntary coverage? (Include multi-line or retrospective rating terms.) ❑ YES KNO i IV. TINSURANCE RECORD YES NO 1. Has the applicant previously had Massachusetts workers'compensation Insurance 7 2. If YES,complete the following for the most recent three years: INSURANCE COMPANY POLICY NUMBER POLICY PERIOD PREMIUM 3. If NO,complete: XNew Business ❑Self Insured ❑Other(explain): 4, Former Self Insurers are subject to the Premium Determination Endorsement-Former Self Insurers-1.An audit must be completed before coverage can be bound. Refer to the Procedures Manual for details. If self Insured within the last twelve months,provide the termination dale: 5. Is there any unpaid workers'compensation premium due from you or any other commonly owned or managed enterprise? If YES,provide the entity name,balance and policy number(s)below. If the premium is being disputed,attach an explanation for Bureau consideration. x If an arrangement for payment has been made,attach a copy of the*signed agreement. 6. Is the employer In bankruptcy? If YES,attach a copy of the approved bankruptcy filing. 7. Does this entity or any commonly managed or owned entity have operations in stales other than Mass.? If YES,attach a list of employer names,slates,carriers and interstate or Intrastate ID numbers. 8. Has there been a name change within the last five years? 9. Has there been a merger or consolidation within the last five years? 10. Has there been a sale,transfer or conveyance of ownership interest within the last five years? 11. Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last rive years? 12. Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? COMPLETE AN ERM FORM AND ATTACH TO THIS APPLICATION IF THE ANSWER TO 7,8,9, 10, 11 OR 12 IS YES. V. BUSINESS OF EMPLOYER YES NO 1. Does the applicant supply employees to other businesses? If YES,complete and attach the supplemental application,Side A,and refer to the Procedures Manual for instructions. X 2. Does the applicant regularly have employees supplied to them from other businesses? If YES,complete and attach the supplemental application,Side B, and refer to the Procedures Manual for instructions. 3. Mass.law provides that you,the employer,are liable for injury of employees of uninsured subcontractors. Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated that subcontract labor will be utilized during the policy term? If YES,estimate payrolls made to subcontractors without certificates of insurance. $ Transfer this amount to Section A and Identify by classification of work performed. 4. Do you use independent contractors? If YES,you must maintain documentation which supports that they are,In fact,independent contractors. If such documentation is not available,or if the designated carrier finds evidence of.an employment relationship, then premium may be charged as if the individuals were employees. V. '°BUSINESS OF EMPLOYER (continued) 5. Completely describe all operations of the employer by location. Also,completely describe any changes that have taken place concerning the business of the employer or the nature of the operation. Attach a separate sheet if necessary. VI. MASSACHUSETTS CLASSIFICATIONS,PAYROLLS; AND PREMIUM CALCULATIONS Payrolls of corporate officers must be Included. Attach the four most recently filed Form 941's or DET Form Vs. Payrolls and classifications on the application will be compared to prior audits and payroll records submitted. Describe the Duties of the Employees by Location Class Number of Total Rate Premium Code Employees Remuneration Clerical NOC 8810 44y 43?OCO A 3 U Outside Sales 8742 �1 Drivers,NOC 7380 i Employers'Liability / I TOTAL PREMIUM 1.7 Z c>r� " Experience Rating( )or Merit Rating( ) ------- Massachusetts Construction Credit( ) " Loss Constant l V V o STANDARD PREMIUM of /3 /. v0 Deductible Credit( ) VII. DEPOSIT REQUIRED : " ARAP 1. Installment Options """ Insurance Charge( 10% ) Estimated Installment Minimum Additional Expense Constant ,C) 0 C) Premium Basis Deposit Payments U Under Annually 100% none TOTAL ESTIMATED ANNUAL PREMIUM $5,000 At least Semi- 75% one DIA Assessment( �. %)of Standard Premium U U $5,000 Annually y . At least Quarterly 50% three TOTAL EST.ANNUAL PREMIUM AND DIA ASSESSMENT $10,000 At least Monthly 25% nine DEPOSIT PREMIUM $25,000 0� / 5 C l 2. Enclosed is check number ��OS in the amount of$ a/�' U U made payable to the Massachusetts Workers'Compensation Assigned Risk Pool(MWCARP). A single check must be submitted. Any binding of coverage is based on the assumption that the check is negotiable. If the check is non-negotiable,the assignment will be rescinded. 3. Is the premium being financed? ❑ YES IRJ�NO If YES,then 100%of the Total Estimated Annual Premium and Massachusetts DIA Assessment must be sent with the application along with a signed copy of the finance agreement. " If applicable. Refer to the Mass.pages of the Basic Manual for Workers'Compensation and Employers'Liability Insurance for details. """ Applies only to Former Self Insurers. Refer to the Procedures Manual for details. i Vill. APPLICANT'S STATEMENT �+ 'The undersigned hereby certifies that he/she has read and understands the statement in this application. Furthermore,in consideration of the issuance of the policy of insurance,he/she also certifies that the statements made in this application are true and agrees: 1. To maintain a complete record of all policy transactions in such form as the insurance company may reasonably require and that all such records will be available to the company at the designated address. 2. To comply substantially with all laws,orders,rules and regulations in force and effect made by the public authorities relating to the welfare,health and safety of employees. 3. To comply with all reasonable recommendations made by the insurance company relating to the welfare, health and safety of employees. This insurance is being provided through the MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL,and not through the voluntary market. NOTICE: MASSACHUSETTS GENERAL LAW,CHAPTER 152,SECTION 14(3)PROVIDES: "Notwithstanding any provision of section one hundred and eleven.A of chapter two hundred and sixty-six to the contrary,any person who knowingly makes any false or misleading statement, representation or submission or knowingly assists, abets, solicits or conspires in the making of any false or misleading statement,representation or submission,or knowingly conceals or fails to disclose knowledge of the occurrence of any event affecting the payment,coverage or other benefit for the purpose of obtaining or denying any payment, coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...shall be punished by Imprisonment in the state prison for not more than five years or by Imprisonment in jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars, or by both such fine and imprisonment." Q�A r cu Af�a SCAN ��B14, (Business Name of Em yer) D&W 6ignature and Title(ale prietor,General P rtner,Corporate Officer or Trustee) IX. AGENCY INFORMATION AND PRODUCER STATEMENT The producer hereby certifies that the information provided,including premium information,is true to the best of his/her knowledge and belief. ) AGENCY POW/,ncl C711d 0 ����/ 5: ,'7cicy ��c C��� -��.SY/`/��� Name(Pnpleb') /yr `✓ Agency Federal Identification Number ADDRESS �tq a Ctle.S'f/&;,1 7�s �yI O;�E,U S�� 7-5 Street/ City State Zip ude- Telephone PRODUCER i10 b2I'�- �j ��'��'^ �. `1�7� �=�3�/l9� � �'/3G Name(Printed) ignatute ff'A'?), 111SI6r°aRce A Ir:pate Agency License Number MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL RULES AND PROCEDURES PLEASE READ CAREFULLY 1. Applications will not be accepted by FAX machine. 2. An additional or replacement entity cannot be endorsed onto an existing assigned risk policy as a named insured unless an application and check are submitted and coverage is assigned by the Bureau. Refer to the Procedures Manual for instructions. 3. The Pool is able to provide coverage only for Massachusetts employees. If an employer has operations in any state other than Massachusetts,or commences operations in such state after policy inception,application for coverage for those operations must be made to the appropriate Bureau or other agency administering the Residual Market In that state,if voluntary coverage is not available. 4. If voluntary coverage has been cancelled or nonrenewed at the Insured's request,the insured Is not eligible for assigned risk coverage. The insured-or their agent must replace coverage in the voluntary market. 5. When a Pool policy has been cancelled twice for non-payment of premium or at the request of the finance company,the employer must reapply to the Pool for subsequent coverage after all outstanding balances have been paid. 6. Applications for joint ventures must include a copy of the joint venture agreement. 7. Payrolls and classifications are subject to review by Bureau Staff and may be changed. 8. The Waiver of Our Rights to Recover from Others Endorsement,WC000313,Is available to employers who require the endorsement by contract. Refer to the Procedures Manual for details. 9. Agents are not agents of the Mass.Workers'Compensation Assigned Risk Pool and cannot Issue Certificates of Insurance. 10. If you have any questions about the rules governing the Massachusetts Workers'Compensation Assigned Risk Pool,refer to the Procedures Manual. If additional information is required,contact the Workers'Compensation Rating&Inspection Bureau of Mass. at(617)439-9030 or write to either P.O.Box 9005,Boston,MA 02205 or 101 Arch Street,Boston,MA 02110. EDMON 11-95 �t Dowling & O'Neil Insurance Agency, Inc. 222 West Main Street P.O.Box 1990 Hyannis. 7 -Massachusetts 02601 775-1620-7751178 March 20, 1996 The Workers ' Compensation Rating & Inspection Bureau of Massachusetts P.O.. Box 9005 Boston, MA 02205 RE: Richard Jean D/B/A Distinctive Homes Design & Building Associates Dear Gentlemen: Attached you will find a new workers compensation application, two declination letters, and payment in full for the above insured. Please assign to a carrier. This should be a minimum premium Clerical policy. Insured has no employees, therefore he has no Federal Tax ID number. Sincerely, Kelly C. Bolton, AU, CIC, LIA Commercial Marketing Representative KCB/250487 �• i 1 .t� I ce st Parcel t# Conse ation Office(4th floor)(8:30- 9:30/ 1:00-2:00) W6 , AkMaA% Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) fee U =- Engineering Dept. (3rd floor) House# PTiC S BE Planning Dept. (1st floor/School Admin. Bldg.) INSTABLE . IANCE Definiti Plan App v d PI nning Board P, 19 . QNME DE AND OWN OF BARNSTABLE TOWN REGULATI®iS a � Buildin Permit A plicat' n {, TO* etAdgress� o� Village j/ Owner Gdtza( octiJ:o 0-OALI-e a S-t" Address p0 1Q� aTi:�Jtit,�. c� c�a6s` Telephone �-b" "/55+ Permit Request First Floor square feet Second Floor square feet Estimated Project Cost $ l ®i©eo Zoning District Flood Plain Ho Water Protection ;V0 Lot Size Grandfathered ? -Zoning Board of Appeals Authorization Recorded Current Use r�n�tzi -�• Proposed Use EZ5^16- g J{"11_y Construction Type Gcy9®-,- F ' OE_ Commercial Residential L/ Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure %asi�t T p�Finished Historic House Unfinished c/ Old King''ss/Highway �J Number 'of Ba htO4"e v2 No. of Bedrooms 3 Total Room Count(not including baths) First Floor 6 Heat Type and Fuel v7 � Central Air �0 Fireplaces v2 Garage: Detached Other Detached Structures: Pool lY� Attached �/` Barn Mo None Sheds HO Other Nd if (� Builder Information Name Telephone Number es- 6 9-7- Address I U License#�QQ 60 ti3 Home Improvement Contractor# o I Li ZZ Worker's Compensation NEW.CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO� SZie� SIGNATURE/Gf DATE ����CtJ BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) Olt ' . FOR OFFICIAL USE ONLY f �' ERMIT NO. TE ISSUED P/PARCEL NO. IRESS VILLAGE OWNER DATE OF INSPECTION: . FOUNDATION FRAME' INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: W-UGH-? . FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ��� Map Parcel �a Permit# Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) /I �t/� s��Date Iss Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) �— Fee oil Engineering Dept. (3rd floor) House# IKE Planning Dept.(1st floor/School Admin. Bldg.) [Tt*Street n Approved by Planning Board yzt�: 19 TOWN OF BARNSTABLE Building Permit Application Address aZ� QUf 7- Village .Owner Address , 'y ��p I 1�2 Telephone !Y:2°� .:-Permit Request �,F�e&le,,;+ eX. First Floor square feet Second Floor square feet Estimated Project Cost $ 6,'y6V40 Zoning District 4 ( Flood Plain 1_/0 Water Protection Lot Size 0& 4094—'S Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House 14/0 Unfinished Old King's Highway kD Number of Baths l No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name ephone Numbers 9' Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) a FOR OFFICIAL USE ONLY f P MIT NO. - D ISSUED P/PARCEL NO. ADDRESS VILLAGE , OWNER DATE OF INSPECTION: FOUNDATION • FRAME , INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED OUT ASSOCIATION PLAN NO. The Cotitnion►t'ealth of Massachusetts Department of Industrial Accidents OMCO011,,019SUya11ONS 600 Washington Street Boston.Mass. (12111 Workers' Compensation Insurance AMdavit name; KC -t�. c3t,a-*-f ,fl6t4 P,s`ZMCtcUc` �foRste�ct �uu,.ot•�e. sC loca ion: eb Ob7L l`l� Cv_rir,•tJ1UAa, IMA_• &2G�s city O5�'.fLc/i�c @ Phone# �g 7SSy- 0 1 am a homeowner performing all work myself. ri I am a sole proprietor and have no one working in any capacity _ •- .. ;_ Fi I am an emplover,�providing workers' compensation for my employees working on this job. comannl•name: address: MI.: phone#• insurance co. policy# ( am a sole proprietor, eneral contractor or homeowner(circle one)and have hired the contractors listed below who have the following workers' comp ion polices: om an •na Nc2Z*ted 4uL"Cr CJ C)t�© fL address: city: Q��.ttS(1�`�fZ�� W v phone#• 390 qq-7+ insurance ce. f SON I �4, i PA C.. policy# 6,14 J G -S.9 7 06 JS i..:M.s :..:_.� - - = rcnr7.-• •:7�•i„-�-r, .�.is p.�^'fr..'y'�;'r�"• .'�[7VF+3'JrS�•aoj'r�iC7l�r•s�f°S�1�c�y+v^�sy.®g:,=^Rx�••�^-^3r c(impany name: address: cih•' phone#• insurance co. Rolicy# .Insurance if neeessa '"'W - > r;P `a+ R+►G^� ^� •� "�"�^" +'�'"� �'L'.:...�• .; ::: -.,... �'' ,ass dim. Failure to secure coverage as required under Section 25A of 1%IGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Omce of Investigations of the DIA for coverage verification. !do hereby certif}•ssnder the pains and p sa/lies of perjurq-that the information provided above is true and correct. Signature Date j,26�� Print name KI Ck"V2,0 Phone# r ..radr •� ofroicial use only do not write in this area to be completed by city or town omcial city or town: permit/license# r'iBuilding Department OLicensing Board O check if immediate response is required OSelectmen's Omce Health Department ' contact person: phone N; nOther [revised 3l95 P1A) Centerville-Osterville-Marstons Mills Water Department P.O. BOX 369 - 1138 MAIN STREET OSTERVILLE, MASSACHUSETTS 02655 OS 2 � � OFFICE OF u WATER i BOARD OF WATER COMMISSIONERS 3► DEPT. WATER SUPERINTENDENT 9q TEL.No. 508-428-6691 STONS FAX No. 508-428-3508 March 29, 1996 Town of Barnstable Building Inspector 367 Main Street Hyannis, MA 02601 RE: Lot #7 - 27 Seapuit Road, Osterville To whom it may concern: This is to verify the disconnection of water service from the water main and water meter from the above mentioned property. There is no water available to this property as of March 29, 1996. If you have any further questions please do not hesitate to call our office. Very truly you , 67, l''l�U t Donald F. Rugg Superintendent sj n J Commonwealth Electric Company 2421 Cranberry Highway ■ Wareham, Massachusetts 02571 CONflectric Telephone (508) 291-0950 484 Willow Street Hyannis, Ma 02601 March 27, 1996 Town of Barnstable Building Inspector 367 Main Street Hyannis, Ma 02601 To whom it may concern: This letter is to inform you that the electric service and meter have been removed from the property at 27 Seapuit Road in Osterville. This was completed on March 27, 1996 at the request of Richard Jean of Distinctive Homes. Should you have any further questions you can reach me at 508-790-1721 EXT: 5781. Very truly yours, Judith A. Webb, Customer Service Rep Hyannis District Office