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HomeMy WebLinkAbout0249 SEAPUIT ROAD D ;.ems - s,rid - -- - .s:..,.mu;.., ,�_ ',-^ _ `l. • Town of BarnstA ble *Permit x lrxplmt ri areatht roarroar issuf dare )(®PRE5 : :Regulatory ServYces � �'e� Thomas F. Geller, Director (6 i I JAN Building Division �31 i Z Tom Perry,CDO, Building Commissioner !-OWN OF BARNSTABL.E . 200 Main Street,Hyannis, MA 02601 www.town.bamstable.ma.us Off0e: 308.8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTXAL ONLY Not Valid Wthout Red X-Press irripriat Map/parcel Number V I J Property Address - 4,� ,Z��//��� Rwidontial Value of Work - O/)lJ Minimum fee of 535,00,tor work under$6000.04 Owner's Name dt Address ST 1/1c�7�_ Contractor's Narne_� ,G' ��jL� _ Telephone Number Home Improvement Contractor License#(if applicable) , L14 - Construction Supervisor's License 1t(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeowner Qf1 have Worker's Compensation insurance Insurance Company Name _ zj2,V1��-l�L3S Workman's Comp. Policy.rJ Copy of Insurance Compliance Cart! cafe must Accompany each permit, Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to aie-roof(hurricane nailed) (not stripping. Going over L existing layers of rood ❑ oide (� Replucement Wind OW81doorslsliders, U-Value #ofd • (maximum.35)#of windows •Where requlred: beuance of this parmit does not exempt compliance wah other town department regulations,i.e. Historic,Conservation,etc. * •Nate: Property Owner must sign Property Owner Letter of Permission. A copy Of the Home Improvement Contractors License & Construction Supervisors License is ro ired, SIGNATURE: Q.IWPFILF2',FORMftW1dinypermit forinslEXPRSSS.doc o_..:. , •..� to -� Nlassachusetts- Department of Public Safeth Board of Buildin!- Relgulations and Standards ��►f Construction Supervisor License License: CS 63537 *•.^ DAVID R'COX PO BOX 401 S YARMOUTH, MA 02664 Expiration: 10/15/2013 ('unuuissii„�t,r Tr#: 4314 f��o ifairs License or registration valid for individul use only \` ~ OfficeFf C o mer itrsi ness egulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation //1 Registration:. 1.00497. Type: 10 Park Plaza-Suite 5170 Expiration: (.25t2012 Private Corporation Boston,MA 02116 D COX,INCJ-, _=! - =:•tea ?I= David Cox -19 LAVENDER LN Not valid without sign W.YARMOLITH,MA'02673€� :0`: Undersecretary . Y DAVID-2 OP 10:KG A�RL? CERTIFICATE OF LIABILITY INSURANCE Ef FIMMrDDIYYYYI 06129111 THIS CERTIFICATE 18 ISSUED AA A MATTER OIF 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 DOSS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the 48TMaate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject'to the terms and condltlons of the policy,prWn Policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In tleu of fuCh• Ora•m• s. PROOUGlR 508.7714632 Northwood Ins.AOenc ,Inc. 508-393•s955 �i __._ __._._.1wS..►isl—.__�__. ..._..... I40 Main Qtrset suite 9 Hyannis,MA OW01 e APPOItDINo coveRAms _�1._.,,NAIc• _ PI9U RA ITr'avelers Insurance Company NIUK0 .. Devid cox,IMC.1._..._r._ / UMM 9: __...._ _�.. ..... P.C,Box 401 INSUNRC: ....-•-- .S Yarmouth,MA 02664 INSURER D: .-_-_-- ---+-- -- I V CERTIFIC TB NUMBER' 1 REVISION NUMBER: THIS Ia TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AaOVE FOR THE POLICY PERIpO INDICATED. NOTIMTH8TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY RE ISSUEO OR MAY PERTAIN, THE INSURANCE AFPORDED 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. _ ._. __.... .._..... .............. _..—............... __� �• p P 1 TYP/W INaURANCE POLICY N ER LINTS e/N/RAL L�M4RY EACH OCCURRENCE S_—_ 1.000, A� E"MO1kEN'Ir6-`""'— A ^ COMM/RCUU OENBRAL LWILITV 1481M798 Q3114111 O'�14112 p 3_ _ 300,000 _1cLAws4tlLDe oocuR MEDEXP oneelR«__. �...._..__ sA0 X guainess Owners PERSONAL A AOV INAMY s. ..._ _ 1,0000,00 GENERAL AGGRHQATE_ 3 __ _2,�0�00 J PRODUCTS.COMPIOP AGG 3 2,000,000 09RI AQQREOATE LIMIT APPLI/e PER; POLICY F C I L LIM I BODILY INJURY(per person) 3.. ANYAVTO LAU so `OHTpED�UL$D e001LY INJURY{pOraegdenll AV e NON.OWN60 R HIRED AUTOS AUTO$ U�..,.__......_. _....... ... ..-.. f I ;.._ UMRRWAA LIAa ,OCCUR EACH OCCURRENCE "=aaU" CLAIM84 oe AGGREGATE �_._..._.�.... DID IvtG TATU• O H. wonKan coMrlINSATION X LIEAI7S..._.. .E9...._.._._ I AND SMPLOY/Ra'LIA/H.rTY VIM KU891OX742211 07I151i1 07/11112 E.L.EACH ACCIDENT % 100100 ! A ANY PR"NIETORIPARTNeK+e 06MVE r:'1 NIA __.. __.. /Y/qR 904LU0/D9 i T 1 E�.l.DISEASE-Fro EnnpLOYE i n M�MMrorMpRATIONf Wow I E.L.DISEASE•ooucr LIMIT 9 ,0� OESORiPTrON 01 OPMr4N3 I LOCATIONS I VaHIM (Aftd+ACORD tOt,AddMonel Remarks Schedule,B mero epee•la ro41drod) / C RTIF TE HOLDER CA LLATI TOWNBAR SHOULD ANY of THE ABOVE oes03:6BED poLlclr?s BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WrLL BE DELIVERED IN Town of Barnstable ACCORDANCE INrrH THE POLICY PROVISIONS. 230 Main Street Hyannis, MA 02601 AUTNORUD RI£PRI[SUTATLVE �r�CZt�<t��• 010 9-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010108) The ACORD name and logo are registered marks of ACORD Tire: Cavnntoms-ealth ofA-fassachtrse/ts DeparfinenI of ridustrial.4ccieleytts Office gflnvestiggayiorrs 600 Wash-inglou Street Bosfon, M4 02111 Ipit*,P.rrrrras.gow'dia Workers' Compensation Insurance Affida-vit: Builders/Contractors/E 1�an�t umbers e � t Infna' !tare _ bly Name(19uusiiaet�Oraa�atim/leseliviawl): ��l ��,�.,f��P� Ci /$tate/Z O Phone* �- Are Tm as employer?Ciswk dis spgropriato bm Type of project(required).- L Q 1 am a employer with 3- 4. ❑ I am a geotmsl cantrector and I 6. ❑.New constnxtion amployem(f aU and/or pul4isue}" have hired the sub-contractors listed an the eun6ed sheet. 7. Q Remodeling �,❑ I,am a axle prop:ieeor otrptttttoet- hese ash-contractors have ship aatd hwe no empiaywo T 8. ❑Detuolitiou wonting br tine fa any espscity. etployees and havx wodcerc' 9. ❑Building addition assurance cdtnp.wsuranoe.t o tvoxloets 5. ❑ We art a cosporatioa and its 10.❑Electacal repairs or additions Muked') orfBom have exes'cised tlmir 11.0P1u nbi s airs or additions 3.Q 7 am a homeowner doing all word '� eayselt[No workem'coup• right ,11( ),and Per lv s 12�Roofrepairs i:airtssaoe srquited.I t G 152,�1(4),sad.we!race ao employees.(No woegem 13.0 Other camp.inwraws required.j 'Any W&M tasttlsetra'b"AN attta alto Sllottte+e sscrioo beleer r tttairr+aa]las'mmpensstiaa polio leto+mstiaa 1)bmaaw"x whD sabtatt wj atddsvr lNiert!!e I lacy the•dolma rt[weat teed d=kbv act"camuaetoa aatest after a w,aMdsrtdt ln&estkra rock tCooasctars fret astir tblt boot aawt amdaa•sddlriotut abut thtmhts the•natas or thn swb.cmmvcwn and sue whether or not those entities have UV ysss. W*o ntbrtontoetoa:rm wt mans,ttseyarust provide their wor>ca2v coup.Pahey--hu. I trot art otvSploya Bien is pronPd�'htg tt�ar'kers'co+�rpiusxeYon ixsu++rntex ter ray t+mplo}'s+ar. Ba+i!orr v Rt*policy ctt�f,�ob state t't�oraat>rtlora _ IMINInce COngpaoy Nam: Policy#or Seluaa.uc.a6t l/ �� ,� �'� Expiration Dare: ' lob Site Addrva; Z,"—/9 ,:�,2 I'1J777 city/SlawZip: As #wA a copy of th*worksa's'sompatretiospoliry dedarationpags(showing the paHcy tsmmber end=piratdon dete). pWbm to seam eoverags as mquired undw Seet+ou 25A of MOL a I52 can lead to the imposition of criminal peca ies of a fine up to$1,500.00 and/or one-year imjnisoomen.t,as we11 as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day againd the vioUtor. Be advised"to copy of this 614temeut may be&rwarded to the Office of Iavte dptic=of the AAA fan iztat>zaace coverage veriScallon. Iota trtmrby arrr�,y it rhapr+dna m o .1�rry Mat the iriorararicn prorKdid a_ c,•,is G►w and ccrrert: phone —c3 QQselol two only: Do not ier'i'l+In IN#area,Io be eoMpleed by city or rotva ereial City or Toam: Perrait/License# Laain j Authotity(circle one): 1.Boad o(Realth 2.Sunda!;Department 3.CLty/rorvn Clerk 4.Electricnl hupertvr S.Phtmbbig Invector 6.Other r r' i6.7�,• Town of Barnstable Regulatory Services Thomas F. Geller, Director Building Division Thomas Perry, CBo Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.bit rnsta ble,ma.us Office: 508-862-4038 Fax: 508-790.6230 Property Owner Must Complete and Sign This Section If Using A Builder Owner of the subject property hereby authorize� �I>l,D� ��� to act on my behalf, , in aU,matters relative to work authorized by this building permit application for: (Address of Job) ignature of Owner Da tler Print Name Ir Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. f �OF THE TO�'I, Town of Barnstable 4e6rn(u_tV(35 e O Expires 6 nronthsjronj issue date Regulatory Services Fee • saartsrnsLE, 9� 1639.MASS. Thomas F. Geiler,Director / q aIEpMA�A � I l Building.Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Q� l Not Valid.without Red X-Press Imprint Map/parcel Number V GI s W OOPro erh'Address Add Jl � P �l PResidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name l//C� �i�5 Telephone Number Home Improvement Contractor License#(if applicable) /0�G�9� Construction Supervisor's License#.(if applicable) c� �` ❑Workman's Compensation Insurance Check one: X-PRESS 9—ERMIT ❑ I am a sole proprietor — ❑ I am the Homeowner I have Worker's Compensation Insurance NOV 3 ® 2009 i Insurance Company Name % Jt�j)rrG1£ �� TOWN OF BARN STABLE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side . #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is uired. SIGNATURE: .Are w QAWPFILESTORMSUilding permit forms\EXPRESS.doc Revised 090809 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I' 600 Washington Street Boston, MA 02111 wwm mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �/� //�� �i11-' 2,yej Address: City/State/Zip: Phone #: — A�ree,yyou an employer? Check the appropriate box: Type of project(required): LAL- 1 am a employer with _ 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ZAemodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers'comp. ❑ Building addition [No workers' comp. insurance comp. insurance.i 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] 3.❑ I required.] 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.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.Insurance required.] Any applicant that checks box#I 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. tContradtors 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: / ;?xwmly,�,— — Policy#or Self-ins.Lie.#: /O4 G Expiration Date: 7 I ZV Job Site Address: 2�V�Y39', z AfJ City/State/Zip 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. I do hereby certify is der the pains and penalties of perjury that the information provided above is trice and correct. Si ature: Dat Phone#: L Official use only. Do not write in this area, to be completed by city or town officiaL I 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 M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing 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 dwelling 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 house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)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,MGL chapter 152, §25C(7)states"Neither the conunonwealth 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 have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. Please be sure to fill in the permit/license number which will be used as a.reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the.applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, 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 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia r �rHE T Town of Barnstable Regulatory Services 9s^xr'e as.B�'� Thomas F. Geiler,Director I Building Division I Tom Perry,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, Adj,"Z)OZ! S:2 / 'S , as Owner of the subject property hereby authorize • A /�9 to act on my behalf, in all matters relative to work authorized by this building permit application for. P�JT (Address of Job) Signature of Owner ate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O W N ERP E RM IS S I ON Town of Barnstable OF THE)per o Regulatory Services anarvsrnBLe Thomas F.Geiler,Director utass. t639. ��� Building Division lED MA{A Tom Perry,Building Commissioner 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 t6 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) 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 of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempLDOC r Frcn.:Kathy Gedd,s FaAD Northwood Insurance Pagc 2 of 2 Date:?!/120009 09'59 AR9 Page.2: CERTIFICATE OF L1ABILITY. INSURANCEOP ID KG DATE(MM/COIYYYY) PROD DAVID-2 11/12/Q9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NorthWood Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 540 Main street, Suite 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA-02601 Phone: 508-771-1632 Fax:508-393-2955 INSURERS AFFORDING COVERAGE NA1C# INSURED I INSURER A. Travelers Insurance Co, ( INSURER 9: Travalars Insucance company David Cox, Inc. INSURER C' P. 0. BOX 401 S Yarmouth MA 02664 INSURER Cl: _ INSURER E: COVERAGES -THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED P!4W.EO ABOVE FOR THE POLICY FERIOD INDICATED.w-lwI HSTANOING ANY REOUIREMENT,TERM OR CONDITION OF AIvY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PF..RTAIN,THE.INSURANCE AFFORDED BY THa POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY WVE SEEN REDUCED by PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDr YYY) DATE(MM/DDA-M) LIMBS GENERAL LIABILITY EACH OCCURRENCE '$ 10 0 0 0 0 0 .� COWE14CIALGE.VERA.LIABILIIY I-680-1481M796—COF 0903/14/09 03/14/10 PRE MISE6 Eaccrurenco) 5 300000 CLAIMS MADE FX]OCCUR MED EXP(Any c.�.a person) ;5 0 0 0 X Business Owners I PERSONAL aADV•INJURY $ 1000000 GENCRALACOREGATE I12000000 GENL AGGREGATE LIMIT APPLIES PER: i I PRODUCTS-COMP/OP AGO 12000000 Poucr Jecr Loc CSL 2000000 AUTOMOBILE LIABILITY I I ANY AUTO COMBINEO SINGLE LIMIT (Ea accruellU £ ALL OWNED AUTOS SCHEDULED AUTOS (Par BODILY INJURY I (Per p,^sor?) HIRED AUTOS � NON-GWNED AUTOS BODILY INJURY $ (Por accident) PROPERTY DAMAGE $ I (Per accident) i GARAGE LIABILITY ku'ro ONLY-EA ACCIDENT y ANY AUTO OTHER AUTOTHAN EA ACC AUTO 5 ONLY. AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE ; OCCUR u CLAIMS MADE I AGGREGATE s $ OEDUCTIBLE ' S RETENTION $ O C c 8 S AND EMPLOYER B'LABILITY 1,I N iTORY UNITS B ANY 0 FICERIMEMBEREXCLUDED? C rIVE ❑ 6KU8910X742209 07/15/09 ) 07/15/10 E.L.EACFIACCIDENT S 100.000 gas, tory In NH) I E.L DISEASE-EA EMPLOYEE I S 10 0 0 0 0 gas,dascrlbevndor SPECIAL PROVISIONS below E L.DISFA.SF-POI ICY t(MIT I S 5 10006 OTHER --r--- DESCRIPTION OF OPERATIONS I LOCATIONS/V H LGS I EXCLUSIONS ADDED B'f ENDORSEMENT I SPECIAL PROVISIONS f - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWNBAR DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL TOWN OF BARNSTABLE BUILDING DEFT IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 367 MAIN STREET REPRESENTAn%-.S. HYANNIS MA 02601 AUTHOR REPRESS AMVE //7. ACORD 25(2009/01) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD f Massachusetts- Department of Public Safety j Board of Building Regulations and Standards Construction.Supervisor License j License: CS 63537 Restricted„to 00- DAVID R COX PO BOX 401 A' S YARMOUTH, MA 02664 Expiration:'10/15/2011 Commissioner' Tr#: 5822 •, ✓1te L/O7ILI)ZO?tCIfCCLLUZ O�✓/�LC7.00[tCf P, i` .__.�—._. _. ._ _ Board of Building Regulations and Standards HOME IMPROVEMENT: License or registration valid for individul use only ' CONTRACTOR before the expiration date. If found return to: i Registcatio`_n: .\I 100497 Board of Building Regulations and Standards Expiration One Ashburton Place Rm 1301 —6718/2010 Tr# 268012 Typee_P_rivate Corporation Boston,Ma,62108 1 _ V DAVID COX, INCH i David Cox - 119 LAVENDER LN' "aye W.YARMOUTH,MA 02673>� _• t. Administrator Not valid without s' nature "^ ' F trrate erttr of 11 Re.515tance %STE,4 REGISTERED ISSUED BY : et C FABRIC F Date ee p •: NUMBER TOPTEC, INC. manufactured �. 1905 N.E. MAIN ST. SIMPSONVILLE, S.C. 29681 • 2 84?E1 140 . 01 1 4 12 95 This is to certify that the materials described on the obverse side hereof have been flame-retardant treated (or are inherently nonflammable). FOR CAPE COD TENT RENTAL ADDRESS P 0 BOX 263 24 PLANT RD UNIT 3 CITY HYANNIS STATE MA 02601 Certification is hereby made that: (Check "a" or "b") a (a) The articles described on the obverse side of this Certificate have been treated with a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Nameof chemical used............................••....................................Chem. Reg. No............................. Methodof application.......................................................................................................................... ® (b) The articles described on the obverse side hereof are made froin a flame-resistant fabric or material registered and approved by the State Fire Marshal for such use. The Flame Retardant Process Used WILL NOT Be' Removed By Washing TOPTEC, INC. -- MODEL TX202000E Name of Production Superintendent SERIAL# 951184E ;WY2d l� Certt"ft"rate of SlRr,5t',5tanrr ♦STE,Q REGISTERED ISSUED BY �v .• C E` FABRIC Dote .; NUMBER TOPTEC, INC. manufactured �• �+ A ; 1905 N.E. MAIN ST. �,,y�,,�• ,,.•'�� SIMPSONVILLE, S.C. 29681 F ReT�,a 140 . 01 4 21 95 This is to certify that the materials described on the obverse side hereof have been flame-retardant treated (or are inherently nonflammable). FOR CAPE COD TENT RENTAL ADDRESS P 0 BOX 263 24 PLANT RD UNIT 3 CITY HYANNIS STATE MA 02601 Certification is hereby made that: (Check "a" or "b") a (a) The articles described on the obverse side of this Certificate have been treated with a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Name of chemical used..................................................................Chem. Reg. No.---....---------............ Methodof application.......................................................................................................................... ® (b) The articles described on the obverse side hereof are made froin a flame-resistant fabric or material registered and approved by the State Fire Marshal for such use. The Flame Retardant Process Used WILL NOT Be Removed By Washing � 1 TOPTEC, INC. ._ MODEL TX201000C SERIAL# 951289 Name of Production Superintendent zU' to ' wrtJ • .1k:r The Contttntnivealth of!Massachusetts ;r,l ' ' �_ 1•_.� Departnre-ttt'.of hidustrial Accidents _ - Office ofluyesMatloas ,\ .i% _�' 600 Washington Strcel • '.;;� Buston.;Aia�s 02111 ` Workers'•Compcnsation InsuranccAffidavit --- -- Please PRINTie��,y• �„� �r A fit iE nformalion - James E. Moriart 24 Plant Rd . #3 clt� Hyannis MA 02601 nhone 508-77.1-1017 I am a homeowner performing all work myself., , ® I am a sole proprietor and have no one working in any capacity I am an emplover providing workers' compensation for my employees working on this job. • 3 nm Itlr i nhone ff: nolie incurzince co ----*- [) I am a sole,proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who h: the following workers' compensation polices: m my nirn addrris7 , nhone N! i n%u r n a c e c o �..T --,,..,,��,..- r q,,r• s-•r v�3c �.�-�-+�- — nm an%• na e- r cir� nhone tt• • aQlicti•�!. • 5ur•rnc rn _ �ttu_h additional sheet if titccsa �= V"R"�'� `•� ��T� ::: `�t�•+ r �IFI ��•wz .:� Fuilure to secure coycrzgc as required under Section ZSA of INGL ls2 can lead to the imposition of criminal penaltin of a fine up to S1SOO U0 aod/c unc ,•can• imprisonment Ar „'ell as civil penalties in the form of a STOP NVORK ORDER and a fine of SI00.00 a day against me. I understand that cops of this statement may be forwarded to the Office of Investigations of the DIA for et»-mge verification. l do hereb.t•cc ifj• nder the pal. utallies of perjurr that the information pn nided above is true and correct Sicnaturc Date Print nam J Phone# 508-771-6768 omcial use only do not Nyritc in this area to be completed by city or town oftleial ciry or town: permit/Ilcense tl rlBuilding Department t �uccasiar Buard t check if immediate respunse is required 0Seiectmen's Office r 011c2lib Department t. pbone 0: —Oihcr contact penon: �. b Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for th emplm-ees. As quoted from the "law-, an enrpli{ree is defined as every person in the service ofanothet under ally contract of hire: express or implied. oral or written. n emplurcr is defined as an individual. partnership, association. corporation or other. legal entity, or any two or mo lie fore;_oin�_ enLnued in a joint enterprise, and including the legal representatives of a deceased employer, or the ccei►•er or tntstee of an individual , partnership, association or other legal entity, employing employees. However tl ►viler of a dweilinc house having not more than three apartments and who resides therein, or the occupant of the ►vel I ink_ house of another who employs persons to do maintenance , construction or repair work on such dwelling he r on the _rounds or building appurtenant thereto shall not because of such employment be-deemed to be an,employc GL chapter I52 section 25 also states that every state or local licensing agency sltall withhuld the issuance or enewal of a license or permit to operate a business or to construct buildings in the commoni%-calth for�,any applicant ► •Ito ltns not produced acceptable evidence of compliance with the insurance coverage required. dditionall►•. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the erformance of public work until acceptable evidence of compliance with the insurance requirements of this chapte- een presented to the contracting authority. .._....�-_�..�--._ .. � .�:.. 'i. .. 'a�t;�!T.�►'--L. •-,•. .i►ft.::r�'::.w.:n�'..�:i.•l.�:a::.= .ru,:r,:� .r-;(,��7y' ::'"• .-^••-�+�•— pplicants I ease ;I I in the workers' compensation affidavit completer-, by checking the box that applies to your situation and uppivin` company names. address and phone numbers as all affidavits may be submitted to the Department of dustrial Accidents for confirmation of insurance coverage. Also be sure to sibn and date the affidavit.' The ffidovit should be returned to the city or town that the application for the permit or license is being requested. of the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are require obtain a workers' compensation policy, please call the Department at the number listed below. �._ .. ..•- - ._ ..'--�....-. - �y�.; ..,...:.. _ �,..,. .:^-.c,-•' 'yam,. .• -- it`- or Towns lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c e affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. PIC sure to fill in the permit/license number which will be used as a reference number. The affidavits maybe returned e Department by mail or FAX unless other arrangements have been made. le Office of Investigations would like to thank you in advance for you cooperation and should you have any questio ease do not hesitate to giye us a call. le Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents y• Office of Investigations 600 N-'ashington Street Boston, Ma. 02111 - fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 Engineering Dept. (3rd floor) Map C/( Parcel Permit# House# Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee "?sr 01 w Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) I Planning Dept. (1st floor/SchoolAdmin. Bldg.) fTHETp;_� Definitive ,-Plan Approved by Planning Board 19 BARNSTABLE. W TOWN OF BARNSTABLE I Building Permit Application Project Street Addres ,y 1 / l Village r�r1-20u& Owner �/�6� `� �� �j-�2j/f Address oJ10'0SMQ 2&161 0! Telephone 6'0V') Permit Request} First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 No.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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Ant orization ❑ Appeal# Recorded❑ Commercial ❑Yes to If yes, site plan review# Current Use Proposed Use Builder Information -_/ Name /�A, •Ca/ L /�/TC'__2 / Telephone Number 6'0 P' 77! —6 769 Address 0-?Q 4 236 ;Fe..3 License# -9A1 PXX V/ ,�,i 3 Home Improvement Contractor# U�fT/i111 W� 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 BE TAKEN TO SIGNATURE DATE h BUILDING PE IT DENIED FOR THE FOLL ING REASON(S) s �c1*- _ 7- 79 ,..Assessors map'and lot number .. ..................................... "' CF THE TO Sewage Permit number �.. ...�f� .. Y,�j SEPTIC SYSTEM MU q INSTALLED IN COM TAXIS, i House number °:::......... ..rr�% /••................................... WITH TITLE 5 ' rnea 0-17/>9 Op f639 b `d lwlr Ta�j TOWN OF BARNSTADLEMU�ToNS Ya. BUILDING INSPECT011'40 "d oUddd 'L .�3 ,0 uJl cYY�J APPLICATION FOR PERMIT TO ... 4. :� �?��. �.� ! ' .46.. ... ... ...... ................. ........... ...:................................................. TYPEOF CONSTRUCTION ........................................................................................:............................................ r- ............�..7..........................19.�Y TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .................... ......f1..J.:..................oz—_J I.................................................................... .. Proposed.Use ............100.I3.1............................................................................................................................I......................... (� 1 ' ZoningDistrict ....9....�...�.................................................Fire District .........�..........................................................:.. Nameof Owner . ..61..6.d:w.�... ....................Address .................................................................................... Name of Builder II�O t-.w..,.. .....:.vv.Z........Address .1, .....�� .......okf�"a4.1. 5'........................... Nameof Architect ..................................................................Address ...........�........................................................................ Number of Rooms 0.... ...................Foundation ...`6..f.!�—......................... .... ................................... .................................... Exterior ...........................................................Roofing .................................................................................... Floors ...03.Y1..Z....................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace .........�.u. .........................Approximate Cost 1 l.�r..�!.,......... Definitive Plan Approved by Planning Board -----------_______-----------19 . Area x.................. ....................... Diagram of Lot and Building with Dimensions Fee ........... ..................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name , .................... � vv � Davis, Holbrook 21271 swimming pool � --------.---.--------.-----.. , 2/�� I���d ' Location -------�������---------' DatervilTe .-------.------------------ Holbrook Davis ' - - Ovvner --.-------------------. ` . ^ ' Typo of Construction .......................................... . � -------^--'----------------' ' Plot �� ................................. ---------� � ' ~ 7 . _ lg7g � J��xw 496'tmonspect'jon- Date Completed .................. - J ' PERMIT REFUSE0 lA --. � . . ' --'' ' ......lT' -------'--------' ' � �� �� . ---- . ------. ' --- m�'��' ----- ' ' ' rn ' . ............................................... � .. � wp ' ---.- ' . mw ' '� M� 00 ' . mw � / _ ------------.. lV nn ~"_/ � � �M C3 ` --------------..-------.---.. . . -------'-----------~-'--~^^^'' .. �P 9P v i r`, 112 C. Cerl; P8 SS h f'/ate J5723 ._ v 1��•{ ��,. - e. _-• �r7.�g �� �• fl �!'�J !•.r ��7n� ' r ;�f � 0 v � •o � o r cD fir; ZIP fA Ar _ ,39-;..6;n' �~ Ce rf' Inc p�if • • . u: ON 10l_f1d_s�"d'dS"#rc?OO1IF/fl' OV piAAt ,572K �' l terrify 1*8f`Il"is plan eves' . j c L JV-61*1 74 4(-1 '. made %n accordance rrJ!/i' Land • , � � � Cow t in�lruc:ans of I9So. SL"a e �� d@l��'r17 inch. r t a0r � /�' /9.5'6• 7."E Sle9rrtstt'n, �rri/Fii ,new; J w• 7 C' rdd/�borv. ,,.y.�-.}1n�e .tt acE._ -+.�'- '• n• _..•...�Y • +eS��i� .v�.. $'c.'°!nZs Z. Assessor's map and lot number ....: , �.. ................... / . .. Sewage Permit number ..:.................'¢' . `T"ET°��o� TOWN . OF BARNSTABLE B98B9TOBLE. :� O 30. BUILDING INSPECTOR APPLICATION FOR PERMIT TO. .............Tool shed � x�'6 .............................. ............. TYPE OF CONSTRUCTION ............. 1 =„k wood ........... ...................... .. ................................. .............................. r .........May..:1.........................19.75.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Sea-puit Road, Osterville, Mass, ..... ProposedUse ............................................................................................................................................................................. ZoningDistrict �i, n..........................................Fire District .. Centerville-Osterville ........................................................... Name of Owner ....Holbrook Davis.............................Address ....Sea.pult..RO? .,...Q.SteXY.].UC................ Name of Builder .Rogers„& 1�pI mlpy'—!T q.............Address0sterville ............................. Nameof Architect ..................................................................Address ..................................................................................... Number of Rooms ................Orie...........................................Foundation .................Block............................................................. Exterior ..........WOOd................................................................Roofing ............WOOd............................................................. wood None Floors .........................................................Interior .................................................................................... None None Heating ..................................................................................Plumbing .................................................................................. None $3, 000 Fireplace .......... .....................................................................Approximate Cost ..................................................n.............. i Definitive Plan Approved by Planning Board -----------____---------------19________ . Area l.� ...S Diagram of Lot and Building with Dimensions Fee 5o SUBJECT TO APPROVAL OF BOARD OF HEALTH P/6 j P _ f + �O I hereby agree to conform to all the Rules and Regulations of the Town of Bar stable regarding the above construction. Name .&.�.).... .............................. Davis, Holbrook ^ . ` � 17667 tool shed No ................. Permit for ------------ ' .......................... -----------. ! ' Seapuit Road ' ; ----._. --.---..�..----~--.------ .. ^ oatervllla � ----.---------------------.. , . ' / OwnerHolbrook Davis | -----.----------..�-----. ' � ' fra�a � Type of Construction -------.------.. � ` ` -----.—'—~---------'-------. ^ . \ ' \ ( p6t _��--_—__� �t —.---------' � ! ' May 2 75 ' . Fei6rih`Grmnle6 ........................................ � Date of-Inspection ' ............ ........lg ' ` . - - - ' - ` Dote 1� �d� l� � �~ ^p��" — — ' '-- ----' .. ' ' ���88�-������0 . ............................................. 19 � ^ . �} .. /----------'-- —'-----------''�' � ^ �..��---~—.�—..--.----------.--. � ~ ^ ` .—.------^---..—.,,'..------.--- . . - . .---------.----------.—.—.~.— ^ , -.,Approved _--------------. lV _ f ` ' ' . ----------------------~---. ' . '. . -------`----------------..— -' ^ 4�� ~�� Assessor's offioe Ost floor): Assessor's map and lot number 915- 5 ��— '` ofTHE>o ..:; Board of Health (3rd floor): )lot I��2 �®� Le, . Sewage Permit number .............................�1/.ot .......... , Engineering Department (3rd floor): House number ............................ APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00•2:00 P.M. only'. CO u .•,'r ".db �� � ®E TOWN OF BARNSTABLE r ; BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO ......................... .�s .................................................... TYPE OF CONSTRUCTION � S>,. ..-...©.... v----........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........�% Q........ U. .... ! ....... ........................................ Proposed Use .....4, !V1�.... � C.`..... ... y..l?.?45.... a ....................................... Zoning District ..........P-F..'....I...........................................Fire District ........ ...fir......................... 77 Name of Owner . ... � ....... v�.4�..........Address ......24 ....�5J. ... /A^I�?...... Name of Builder .!!.IVjk)(. Address ... Nameof Architect .........' ................................................Address .......... ..................................................................... QC- Number of Rooms ... ...)...0 7 Foundation Exterior ...... ..... ..���............................................................Roofing .....�i�� � I(LAi�G1,.. ............... ...... .................................................. Floors .... ..Interior ........ Heating 6-�`C! �...... .....................................Plumbing ...........N �� ............................................................... Fireplace .... .1..... I........... .... L..v�G...............Approximate Cost ................................................��................... Definitive Plan Approved by Planning Board --------------------------------19-------- - Area ........`J ...:�.............. Diagram of Lot and Building .with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 4. i 011 I OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam .. Construction Supervisor's License .026.f��.............. DAVIS , HOIUBROOK No .................31333 Permit for Addition .................................. i Rg;L,�...T�--jMilv Dwelling...... ......... ... ............................ Location ... S.qAPAI.it...Ro.ad.................... Osterville ............................................................................... Owner ....Holbrook...Davis ......................... .... .. .... .. .... ..... .. . .. Type of Construction ..................Frame......................... ............................................................................... Plot ............................ Lot ................................. Oc-C-ober 22, 87 Permit Granted ..................................... 19 Date'64 Inspection ......................19 Date COmpIE4ed ......... ................19 -0 "9