Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0130 SEA VIEW AVENUE
P�el/nrT-� I�t/iA�utia ��-u6 �'` o �. 7 o ¢ ., o - � o � �. - - _ o o _ o o 6 o o � -� � o - o e o o _ _. - � o { � � .. _ a o o - a - a - a o o � � /� �_ - � � �.. � ,!! a - _ _ d Via. � � e � � _ - o a o - � - - ��, e e o � e � o .. o .. � C (' - .o � o _ o � o � - a — o o � � � � _ % - �a o o e 9 ` �� o o. n� o a e � a o i o o � � � .. � a o a ao° � � ° o o v _ o .v o �' _ n v o u- - � � o � 0 .. o o ° o .. � � o o u e a Q a' as o 0 o a a o.. � a � � o a a � b � 0 n a c -. c � � � = o o .. g �� a' '. o 3 a o .. o ,... ,. e '. � o o �y a .. a o .- { � .. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma I Parcel 0 A`?icatioon #"::�O' P P Health Division Date Issued ?J Conservation Division Application Fee La U Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board ,n1&- Historic - OKH Preservation / Hyannis V Project Street Address 130 S fl� Ui z il� 62A.� " Village a� L✓� `��. Owner t c7_ U)tG%+..ti+n.y Address Q 7 0 r-413 AV Telephone 15D 13- - We - Permit Request C2�. R d 0,J .5 Col, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay AY Project Valuation CDO Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) ' o Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's`iHighway: CYes ] No co Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)i Number of Baths: Full: existing new Half: existing ne�W, 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 (BUILDER OR HOMEOWNER) 1 Name d 4 5'� ���4 2 S Telephone Number "'(6 YX-316 S� Address License # (�ST�r(zyl LL Z, y%f 4- Home Improvement Contractor# Worker's Compensation # I C 356 ;4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY ) APPLICATION# « 2DATE ISSUED, AP/PARCEL NO c > K ADDRESS - _ - VILLAGE - -OWNER t . DATE OF INSPECTION: 7 « OU D T£N^f \ / . _ . . . . , ( FRAME / INS LATI } ..: . . - . . \ . w . . y . . { ' FIREPLACE iELECTRICAL: ROUGH .FINAL . . f . \ PLUMBING: ROUGH • FINAL - { 9fS s FNAL \ ' [ a INAL B DIN*` R�±o7 - •. � _ _ . . . . . . 7 3 .DATE'CL S.ED OUT., \ ASSOCIATION PLAN NO-- ƒ �' ` ^ . • . .. The Commomvealth ofMassachasetft ' Deparbne&ofIn&stnd Accidents t Office offavestigaiions `600 Washht6n Street Boston,MA 02111 www mass gov/dia ' Workers' Compensation Insurance Affidavit; Buriders/Contractors/FIectrieLIM/Plumbers Applicant Information Please Print Le ` Nmme(B ��8lion/Indiviclnal): � s� -dZ 5 • . •Adc#ress: /1/� t'Vl f]-,1�.� S) f�L�1 ,•-f- I� . . . . City/Sfnts/Zip:05j 1 t-4l L� c tit�'� Phone.# Are you an employer? Check the appropriate bow • Type of pi ojeat(require : I. am a employer with_� •4-. [] I mm a general contractor and I � • . employees(full and/or part-tone).*, have hired the snb=contractors 6. ❑New construction . 2.❑ I am a'sole proprietor or partner- listed on l e'attached sheet 7. ❑Remodeling Ship and have no employees These sub-contractors have g• Demohfion working for me is any capacity, employees-and have worlors' : [No workers' comp.insurance comp.insurance.$' 9. ❑Bmldmg addition I required.] 5. [] We are a corporation and its 10-❑Electrical repairs or additions '3.❑ I am a honneowner doing al-work officers have exercised their 1 L[I pug repairs or additions 1 myself [No wars'comp. right bf exemption per MGI, Roof insurance required.]t c. 152, §1(4), and we have no ❑ � employees. [Nb workers' 13.❑ Other POMP.insurance required.] *Any applicant ibat chroks boa#1 must also fill out the section below showing their worts,compensation policy information. Homeowners who submit this atndrdt indicating they are doing all work and then has outside conbmaetam;must submit a new aindavitindimfing such. tComhactnrs that check this boa Host attacbed an additicmal shcet showing the name of&e sub-contractors and state wbofl¢or not those entities have employes. If the sub-contmactm bave employees,they mmstprovide dieir workers' oli : camp.P cyaomber. I am an employer that is providing workers'compensation insurance for my employees. Below is th information. e policy and job site Insurance Company Name: �IJd1�1-I C��c�.� �.2�-f�G'�� /`�`� �tG�JC Policy#or Self-ins.Lic. lob Site Address:_ 13O z►4 V,' , /4vt 'Ity State/Zip: Attach a copy of the Workers' compensation policy declaraflon page'(shDyPing the policy number and expiration date). 036 57"f Faffim.to secure coverage as regaired under Section 25A ofMGL c. 152 can•leaa to the imposition of criminal penalties of a fine Tip-to$1,500.00 and/or one-year imprisomumn� as well as civf1 penalties m the form of a STOP WORK ORDER and a fine of up to$250.00 a day violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA far inerTrance coverage verification I iio hereby certify under e p d penalties of p 'wy that the information provided ab a is a and correct Sivnatr,rP �jj I vr� • Date: C' . Phone sag-yao 31 5 i Official use only. Do not write in this area,to be complefed by city or.town affici¢L City or Town: Permitucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.6. Other Plumbing Inspector Contract Person: Phone# I Client#:12032 2BISHOPRICST AMR& CERTIFICATE OF LIABILITY INSURANCE I DATE(MMI°°'YYYY' 02/29/2012 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 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). PRODUCER CONTACT Dowling&O'Neil PHONE o Et):508 775-1620 A/c No: 5087781218 Insurance Agency E-MAIL 973 lyannough Rd., PO Box 1990 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Hyannis, MA 02601 INSURER A:National-Grange Mutual Insuranc INSURED The House Carpenters,Inc. INSURERB: 1112 Main Street, Unit 18 INSURER C Osterville,MA 02655 INSURER D: 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 CONTRACTOR 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 ADDLSUB LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDY EFF MM/DDY YM EXP LIMITS A GENERAL LIABILITY MPJ3369M 3/09/2012 03/09/2013 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea onence $500 000 CLAIMS-MADE F x1 OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY j Ra LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMITEa accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS ON-OWNED PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ i DIED I I RETENTION$ $ A WORKERS COMPENSATION WCJ3369M 3/09/2012 03/09/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NIER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED9 N!A E.L.EACH ACCIDENT $500 OOO Mandatory In N(f yes,describe under E.L.DISEASE-EA EMPLOYEE $500 000 I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 9ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD IM,Additional Remarks Schedule,If more space Is required) Operations performed by the named insured subject to policy conditions and exclusions. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. i ,CORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S92900/M92899 LS1 j Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration. 6461 TYPe: 10 Park Plaza-Suite 5170 Expfra fiz=_g/ - 3' Supplement Card Boston,MA 02116 THE HOUSE CAR l!FFM- 319E _� f WILLIAM SCHM1171 ? 1112 MAIN ST UNA3;1$ OSTERVILLE,MA 025 -' Undersecretary Not valid-without signature ylassachusctts- Department of Puhlic Satet\ Board of Building Reutilations and Standards Construction Supervisor License License: ,CS 76571 WILLIAM L SCHMITZ 66 CARAVEL DR HATCHVILLES,' MA 02536 --o-i Expiration: 9/9/2013 ('ununi,viuncr Tr#: 3843 I Town of Rarnstable .i�.egu.lator� ��e,rvices TLuinag-1r.Geiter;Dfreetor Bading:piEvisdon TBoniifs o, ry;'CBO gU 11�I R��t�Q n'!n1FS$tdACY i200 Main Stteet Hyannis-MA 02601 y'�►�'ao�cn:bi�rntitahle.ma.us Office:_508-84�2-4038 Fxx: 508-790-62 U PrO.Pgjr� O rier.Must Connplete And Sign This Seetid' If Using A B, ulder. Peter C. Davies ,a.4.Owner iif rlic subjectpruiicTty hereby•autborme - I.►`L eon, �.` ,,;,. :s t�i act onriiv be ialf; in all tiial'ters rc lafi%to Rork authorized by' diiti l)uitif ng.petmit.application for (Addresg of Ji b) S aure of ri ate Peter C. Davies °Prin:r Tame: 'if Propeo .O*ner_is.appkw4ng for permit,please camfilete tha�lomeo�r'ners.License Excmptinrr fnrrn on the reverse ide. L'-�t��cra'dceoUik'rlphCstaiC.Dealt`di�muiftlEt`i�td:nssS.Tim�trtn lntcmct FilestCpntcrit.C?utlncik':i7EiVs7A;tiZtEXPKL'SS.Joc Avvised{}72.1 f0 i i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH Preservation/ Hyannis Project Street Address l S �/ / �w iJ --z VillageZ_V 1 1 L Owner l�'z�- Lt-)�eLvtv-Lc�, Address �7- , L52-4 V Telephone Permit Request ds C' 342 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) r o Age of Existing Structure Historic House: ❑Yes 'Cl No On Old Kings Highway Yes ❑ No Ln Basement Type: ❑ Full ❑ Crawl 0 Walkout '❑ Other -" o 80 Basement Finished Area(sq.ft.) Basement Unfinished Area (sq ft Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new w ,� 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 0 No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: 0 existing 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial 0 Yes 0 No If yes, site plan review # Current Use._ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name I OCkk5f CAS --.1 AsCk 5Telephone Number v "/ � Address License # -::� S�l Home Improvement Contractor# `(a (d( Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 2- �,S 4, . SIGNATURE �c� � DATE ;3 FOR OFFICIAL USE ONLY APPLICATION# ,DATE ISSUED MAP/PARCEL NO. y 5 s ADDRESS VILLAGE. OWNER y l _ _ DATE OF INSPECTION: ..FOUNDATION, � t FRAME } INSULATION_: r FIREPLACE r ELECTRICAL: ROUGH FINAL s. is PLUMBING: ROUGH FINAL GAS: ROUGH ;_, FINAL y: ,FINAL BUILDING `° ` ,s t DATE CLOSED OUT s ASSOCIATION PLAN NO. } . The Commonweal*ofMassachuselis _ Depofent oflnka&W Ai ddemEsv Office oflrtvesfigaM7= `600 Washington Street Boston,MA 02111 www mass govlifta ' Workers' Compensation InsIIr$n.ce Affidavit: BOders/Contractors/Mectricians/Pinmbers Aypficant Information Please Print Lem Name(Bnsmess/Or�n/Individnat): ems - Addmss: city/Stde74:_ ST (Z(//LL t g!� Phane.#_ 15�n S`_:4�— Are you an employer?Check the appropriate bay (required):.- ect a of ro }an a employer with 4• ❑ I am a general contrctor a and I project . • euoployees(irrIl and/or part-tnae). . have hired the sub-contractors 6. ❑New constnc{im . 2.❑ I an a'sole proprietor or partner- listed on the'atfached sheet 7. ❑Remodeling ship and have no employees These sub-coniractuors have 8. ❑Demolition working for me is any capacity. employees-and have worlars' [No workers' comp.insurance comp.mstnsnce.# 9: ❑ addifian 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.❑Phuribing repairs or additions Myself [No workers'camp. right of exemption per MCL insurance required.]t F. 152, §1(4), and we have no 12'❑RoofrepaiMi employees. [No workers' 13.❑ Other Camp.insurance reed,] «Any applicant fhat checks boa#1 most also fill oirt the section below showing their wmi=,compensation policy urination. t Hamenwn=who submit this affidavit indicating they am doing an work and thm him outside contractors must subaft a new afndavitmdicating such.rConttactars tbat cbeck this boa must attacbed sir addifiaaal sheet showing the name of the sub�ontractars and state whether arnot fbose entities have employe-s If fhe suh-contractma bave employees,they=rtprcvi&the r 'comp.poHcyaomber. I am an employer that is providing workers'compensation insurance for my employees. BeLow is information the policy and job site Insurance Company Name: L_( c S Policy#or Self ins.Lic. Expiration Date: 3 / l 3 - .rob site Address:_ /�C� S Z,�} (/I� AU �CP�� Istawzip: (� t r Z V i C L`L• t(i( 4fEach a copy of the workers' compensation policy declaraflon gage- (showing the policy number and eapirzaan date). DaR r� Farhne,to secure coverage as required under Section25A ofMGL c• 152 can lead tr$ie imposition of criminal penahim ofa fine bp-to $1,500.00 and/ one-year imprisonment, as well as'civil penalties m 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 imy be forwarded to the OfEce of Investigations of the DIA for insure coverage verification. I do hereby certify under the airs• d pen of p 'wy that the information provided abav,is tru and correct Si.gnatuae: Date: Phrme Official use only. Do not write in this area,to be completed by city or town affzci¢L City or Town: Per:mkUcense# 'Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plmmhing 6. Other Inspector Contact Person.: Phone# Client#:12032 2BISHOPRICST ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY) 02/29/2012 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 Dowling 8r O'Neil PHONE Insurance Agency kX AJANo Ext:508 775-1620 A/c No): 5087781218 IL 973 lyannough Rd., PO Box 1990 ADDRESS, INSURERS AFFORDING COVERAGE NAIC�F Hyannis, MA 02601 INSURER A:National Grange Mutual Insuranc ' INSURED INSURER B The House Carpenters,Inc. 1112 Main Street, Unit 18 INSURER C: Osterville, MA 02655 INSURER D: 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 CONTRACTOR 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MM/DD LIMITS A GENERAL LIABILITY MPJ3369M 3/09/2012 03109/2013 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY pqMAGE TO RENTED I POEM Eaoccurrence $500 000 CLAIMS-MADE 51OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY JE PR0. LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accdent ANY AUTO BODILY INJURY(Per person) $ ALL UTOOS OWNED AUTOS SULED BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WCJ3369M 03/09/2012 03/09/201 X WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? 51 N/A (Mandatory In If yes,describe under E.L.DISEASE-EA EMPLOYEE $500 OOO DESCRIPTION OF OPERATIONS below E.L.DISEASE-.POLICY LIMIT $500,000 ]ESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Operations performed by the named insured subject to policy conditions and exclusions. :ERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 ' AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. i ,CORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S92900/M92899 LS1 j fie•eam.---Ad o�./�aeaaelucaeCla Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:7xWA661 Type: 10 Park Plaza-Suite 5170 Expira13 Supplement Gard Boston,MA 02116 THE HOUSE'C�W� E'1 ' l.•. 1112 MAIN WILLIAM SCHMI`VrZ! P- ST UN�.1QVY= % OSTERVILLE,MA ON Undersecretary Not vali thout signature Massuchus'etts- Department of Public Satct\ AM Board of Buildin!� Rclgulutions and Standards Construction Supervisor License License:,,CS 76571 WILLIAM L SCHMITZ. 66 CARAVEL DR HATCHVILLES;MA 02536 Expiration: 9/9/2013 ('ununi�siuncr Tr#: 3843 I � HAR7v�PAm.� ► Town of Harnstabk .Regina ary $-ervices Thoutag- .Geiler;Director Ru"Oding.-Division Thiitjias Perry;'GBU iuild Rg.Comniissioner 20�Main Street; Hyagnis-N1A 02601 �'vi�t•.tovvn:bsrn.Kta 1►1e:ma.as Office:.-508-862-4038' Fax, 508=790-6230 I raP �er Owner-Must Complete grid Sigi<ii This Section. If Using A Builder Peter C. Davies - ,ar Owner_tifrhe stibjecTprcipert} hrrebV aurharize ` L tci act ori:niy belza' in'811 r ial tern- rriafiec.to cork auth6iue8 b_v Ais buitci n pe>znit.applieation for. ,(Address of Job) Signature.of QwriEf 15ate Peter C. Davies =Print Name: flfProp Oy-.nsi-ner_is-applyiaeforpermit,:plsus'cc�mpletetheHomeo�rnersL`ucnscExcmptiurr.Fnrm'onthe reverie sine: G:tU�cta'dccallik'r\pnL��rest.ocal.�dicrou,fti�l ir�ily.�slT��n�pr lntcmu FilcstCpntcn..f?uilncaFc'e7EiV t7rt;lZ:tEti!?KLSS:Jic 9ev i.-ec3..f}72.11'0 w TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map .(.v( Parcel y� 9 Application #C2101 l Health Division—. Date Issued Conservation Division Application Fee -<L <<oc) Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board (6� 3/)9/)Z-�& Historic - OKH Preservation/ Hyannis Project Street Address 130 514 Vi",a Xyl. Village 5TIAZV i LLB Owner Address f�� Sf�l Vr.u_l ' /4t/ Telephone SDC6- - ygA - 6 9 S-/ Permit Request >>�` 9-pa " J Square feet: 1 st floor: exi 'ng proposed 2nd floor: existing proposed Total new Y ZoningDistrict Flood Plain Groundwater Overlay � Y Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sqpporting do ume4tation. 0 Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) .Z Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings Highway: YeR ❑ No c n a Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq. cxr Number of Baths: Full: existing new Half: existing ne�r 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 (BUILDER OR HOMEOWNER) Name s�.�, � ��-(2.�4��o2-S Telephone Number Address LA,V\-k'+ License # 767 -3L/ Home Improvement Contractor# Worker's Compensation # 40C - 3 3 lo9 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ''DATE � 1 t <; FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED >t. MAP/PARCEL NO....-.-- ADDRESS VILLAGE OWNER ` r- DATE OF INSPECTION: n } FOUNDATION r; FRAME INSULATION >: , FIREPLACE 3 ELECTRICAL: ROUGH FINAL ' V PLUMBING: ROUGH FINAL :GAS: ROUGH: FINAL ;FINAL BUILDING - DATE CLOSED OUT ASSOCIATION PLAN NO. 4 _ v Tie Commonwealth of Massaclinsetts Department of Industrial Accidents Office of Investigations 600 Washington.street . Boston,M4 02111 ww"wnassgov/dicta Workers' Compensation Insurance Affidavit: Builders/CeimtractorsXlecta'ncianslPlumbers Applicant Information Please Print Legibly Name MumesslOrgan t=Madnadoal).- `TGb� Abu s^� ce .- f. -k Zs Address: I 1M,4'k 5f. I kK) i T 18 City/State/Zip: 6 sTrz ( a LO 3-5-Phone#: 0'6- -41X' Are you an employer?Check the appropriate boa: Type of project(required): 1X I am a employer with_1tZ 4. ❑ I am a general contractor and I 6. ❑Neu•oonstructiou employees(full and/or part-time)' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition c ci employees and have workers working for me in an y � tY- 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 doff g all work officers have exercised their I LEJ Plumbing repairs or additions myself.[No workers'comp- right of exemption per MGL 12>KRoofrepairs insurance d. c- 152, §1(4),and we have no l ` 13.❑Other employees.[No workers' comp.insurance requited_] 'Any applicam that checks box#1 amst also fill our the section below sbowiag their workers'compensatian policy information. :Homeowners who submit this af5dasdt in&catmg they are doing all wart and then Isere autAde contractors must submit a new affidavit indicating sadi. Contractors that check this box must attached an addilionai sheet showing the n=e of the sub-co=ctors and stare whether or not those entities have empkgees. If the sub-coutzactors have employees,they must provide their workers'comp.policy number. I am an employer that is proi4dirW workers'cougmisation insurance for rriy eni pIoygees. Below is Htepolicy and job site information. _ Insurance Company Name: J��i-T1OYl10-r �p2s}N��r ,l t51.A2AAJC-t Policy#cr Self-ins.Uc.4: (,J�,S �� 7 Expiration Date: f Job Site Address: c / s -11�1 ee- I City-�StStatozip: 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 ofcriminal penalties of a fine up to$1,500.00 and/or one-year imprisomnent,is 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)tereby certify under nthe pains andpenaltiss ofpedury that Hie igformafion prouided above is true and correct signature: 4J(�-�^^- Date: !2- -18 Phone# O chd use only: Doi not writr in fads area,to be completed btu city or town official. City or Town: PermitUcense# LBo:ar�d hority(c=i le one): Health 2.Building Department 3.C'ity/romu Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone M - - - - 6 I ✓fie -Pa�nma�uveal�o�.�acfivaet7a Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration 4*8461 Type: 10 Park Plaza-Suite 5170 Expiration ,./2',- 3 Supplement Card Boston,MA 02116 THE HOUSE'CARPE;NTERS Nt0 - ;�✓ . WILLIAM SCHMI,rZ 1112 MAIN ST UNI..... `��-- OSTERVILLE,MA 0 Undersecretary Not vali thout signature +� Massachusetts - Department of PUhlll' Safet7 AM Board of Building Regulations and Standards Construction Supervisor License License: .fS 76571 WILLIAM L SCHMITZ 66 CARAVEL DR HATCHVILLES;MA 02536 cam_ �i Expiration: 9/9/2013 Commissioner Tr#: 3843 L �1NE .,� Town of Barnstable Regulatory Services Thumas F.Geiler,Director Building Division T1, m ioas Perry,CBO Building Commissioner 200 Main Street, H}-annis,MA 02601 wvtw.towu.barnstahle.ma.ms Office: 508-862.4038 8x: 508-7W623 Property Owner Must Complete and Sign This- Section. If Using A Builder i Peter X C. Davies• ,m (.)wner of the aubjecrpro}x:rry he rehv authorize Z Lk, 4- to act on my behaft, in all Mal airs rc;latirt to work authatazed by this huilding peimir application for (Address of job) l � 4igna4ire;of Corner bate Peter C. Davies print`tame lfPropertv:Owner Kappkving for permit,please complete the Homeowners License Exemption Forrn on the reverse side. C`,tUscts'ctcccllil;rlppCsra�t.ozal'•�fiems.,tT'��1�i�Jt'.t'stTimpunin Into'mctFii'.~��G�ntcnt.f]aulrrc�F;f?F)V37��,17;tE.�Cf?KyS:Jc�4 f vvked P72:1 10 Client#:12032 2BISHOPRICST ACORD,. CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYM 02/29/2012 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: Dowling&O'Neil HON; Ext:508 775-1620 ac No: 5087781218 Insurance Agency E-MAIL 973 lyannough Rd., PO Box 1990 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis, MA 02601 INSURER A:National Grange Mutual Insuranc INSURED The House Carpenters,Inc. INSURER B: 1112 Main Street, Unit 18 INSURER C: Osterville, MA 02655 INSURER D: 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 ADDLSUB LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDY EFF MM/DDY EXP LIMITS A GENERAL LIABILITY MPJ3369M 3/09/2012 03/09/201 EACH OCCURRENCE $1 000 000 E X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500 000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- J CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ _ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ AWORKERS COMPENSATION AND EMPLOYERS'LIABILITY WCJ3369M 3/09/2012 03/09/201 WC STATU-X OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N ER OFFICER/MEMBER EXCLUDED? r NI N/A E.L.EACH ACCIDENT $500 000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-.POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,tf mote space Is required) Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 ' AUTHORIZED REPRESENTATIVES ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S92900/M92899 LS1 L TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Apph ion or, Date Issued Conservation Division ";Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis -77 Project Street Address �Pw `r� a2 ) Village �57_7�V I' L� Owner Address Telephone Permit Request 2 --$- C .1�s�-E� 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:_O Yes ❑ No Basement Type: ❑ Full ❑ Crawl \0 Walkout El Other ZE Basement Finished Area(sq.ft.) Basement Unfinished Area (sq�t� o 03 Number of Baths: Full: existing new _ Half: existing neP 5 Number of Bedrooms: existing _new -� o Total Room Count (not including baths): existing new First Floor Room Count w Heat Type and Fuel: 0 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 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization 0 Appeal # Recorded 0 Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Iyi 2 CIZ��-t-��Z 4� 5 Telephone Number Address License # Home Improvement Contractor# Worker's Compensation # oe-.S 3 3l0 7 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 33 T 5 V FOR OFFICIAL USE ONLY -.ar APPLICATION# DATE ISSUED j-t z MAF/PARCEL NO. L7 ADDRESS * VILLAGE r OWNER :S DATE OF INSPECTION: FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS:, ROUGH FINAL _. tF:INAL.BUILDING ;: r;•.. DATE CLOSED OUT. ASSOCIATION PLAN NO. i .. The Commonwealth ofMassachuseft _ Depar'bnent of jit&tsmd Ai ddm& Off we offnvestigatiow -600 Washington Street Boston,MA 02111 www.n=&gov1dia ' Workers' Compensation Insurance Affidavit; Builders/ContractorsiDectricians/Plumbers Aooficant Information . Please Print Le:sibly Name(Bnsmess/organ; onlladividual):` s ,� S Adc#ress: /// �rru S T City/St /Zip: S(`z I' , Phone.#��j R'. -4��'^ F,3. I n employer? Check the appropriate box: 'Type of project(required):. a employer with �' 4. ❑ I mm a general co�•actor�.d I6• New c®strnctien oyees(fan and/or parttime). have lied$�e sub�confmcixr ❑a•sole orpartner- listed on�e•artached sheet: 7. ❑Remodeling and have no employees These sub-cor±actors have 8. ❑Demolition ng far me is any capacity, employees and have warbmrs' 9:orkes' comp.insnancecomp.ims rmce.$ add�an red_] 5. ❑ We are a corporation and its 10.❑Electrical repass or additionsa homeowner doing in-work officers have exercised their11,❑p�mgrayons or additions lf [No workers'comp. r�rt of won per MCrL 12• RD& insurance required.]t C. 152, §1(4), and we have no ❑ repairs employees.[No workers' 13.❑ Other comp•inmramce regdired.] AIIy applicant ffiat checks bax#1 most also M Dort the section belaw showing ffieir workers'CDsr>peasatioa policy information Homeowners who submit this affidavit indicating fhcy an dDiRg all work and ffien hits outside contracta�must submit a tC new a�davitindicating such Dntraatrns ffiat Check this box mast attached additional sheet showing the name of ffit sub-contractors and state whether or not those entities have cmployees. If the sub-contnctom havo employees,iney mustprmidt ffieir wvrksrs'Comp.poIicynrmtber. I amo an employer that is providing workers'compinfensation insurance for my employees. Below is the policy and job site Insur-ance Company Name: �Jf A.C)a � 2 Policy#or Sett ins.uc.# &)L' ^ 33 Cf Expiration Date: 3'rJ Job Site Address: D _ S Vt•�cry/Slate/ 05 t zip (Ji Attach a copy of the workers' compensation policy declarafion gage(showing the policy nuumber and ezpirafian date). a S 5 Farhrm.to secure coverage as required under Section 25A ofMCrL c. 152 can lead to the imposition of gal pmmIti.es of'a fine Tip-to $1,500.00 and/or one-year imprisonent,m as well as'aryl penaltms m the form of a STOP V►TORg ORDER and a fine of up to$250.00 a day against 13te violator. Be advised that a copy of this stateme]it may be forwarded to the Office of Illvesdgadons of the DIA for insurance covera a verification. I do hereby certify un er tthe�' sand p •es o erjury that the information provided above ' true d correct Data: Phone Official use only. Do not write rn this area,to be completed by city or.town officiaL City or Town: PermitUcense# •Issning Authority(circle one): .1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. 6. Other Plumbing Inspector Coatact Person: Phone#: I T1. �om..�aa�rcueo o�✓�aooacluraet Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 19 Office of Consumer Affairs and Business Regulation Registration:-4-6g461 Type: 10 Park Plaza-Suite 5170 (� Expira� 13 Supplement Card Boston,MA 02116 -_: a��i THE HOUSE'CA`Rt`?'.��A i WILLIAM SCHMIiZ €_'/ J j 1112 MAIN ST UNIb�:J& / OSTERVILLE,MA Undersecretary Not vali thout signature lassachusctts - Dcpurtmcnt of Public Safct) Board of Building- Regulations an(1 Standards Construction Supervisor License License:.,CS 76571 WILLIAM L SCHMITZ 66 CARAVEL DR HATCHVILLES;MA 02536 Expiration: 9/9/2013 ('nnmisviuncr Tr#: 3843 Client#:12032 2BISHOPRICST ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DDfYYYY) 02/29/2012 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 CONTNAMEACT Dowling&O'Neil ac°No Ell:508 775-1620 Insurance Agency E-MAIL ac No: 5 087781218 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAICS INSURER A:National Grange Mutual Insuranc INSURED The House Carpenters,Inc. INSURER B: 1112 Main Street, Unit 18 INSURER C: Osterville, MA 02655 INSURER D: 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 CONTRACTOR 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 ADDL SUB LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF MMNDY EXP LIMITS A GENERAL LIABILITY MPJ3369M 3/09/2012 03109/201 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Esocarrence $500 OOO CLAIMS-MADE FY OCCUR MED EXP Any one person) $1 O 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY JERCOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acddent LAUTOS O BODILY INJURY(Per person) $ ED SCHEDULED AUTOS BODILY INJURY(Per accident) $ TOS NON-0WNED PROPERTY DAMAGE AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ A WORKERS COMPENSATION WCJ3369M 03/09/2012 03/09/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITYIER �ICEWMEMBERPEXCCLUDEED ECUTIVEa N/A E.L.EACH ACCIDENT $SOO OOO Mandatory In(f yes,describe under E.L.DISEASE-EA EMPLOYEE $500 000 I DESCRIPTION OF OPERATIONS below E.L.DISEASE-.POLICY LIMIT $SOO,000 3ESCRIPTION OF OPERATIONS L/ OCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) I Dperations performed by the named insured subject to policy conditions and exclusions. :ERTIFICATE HOLDER CANCELLATION I Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ,CORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S92900/M92899 LS1 j � iiARJa9tAa� � `Town of:Ba -nstabk .Regulator . -erv�ces Thumax F.Ceiler;Director 1�>iIi�(htlg:DiYiS7011. T. I., mas PerryGBQ Buiid ng:t.9maiiscidner ;200 Main Street; Hyannis;MA 02601 K'�►�'aovvu:b�srn�tatile.ma:us Uff ce 508-862-4038 Fxx: 508-790=6230 Prop. � Qwtier must Complete And Si -Ti-jig Sect t n: If U-Sin'g A $uildef Peter C. Davies a-4 t.)tvnt tat d�c:st bjectp 6pc:rty hcrebv.nutholi.e - %AU. t� tti act on nays behalf; Diu all ibis building penniz app3iicatiou for. (Addreps of Job) l � :Sigila,nirc.of Owrky bate. Peter C. Davies Pni,:c �?ame: if Propertf:C3*ner_.is apphiae.for peritt�t,plc4sc'-camiilcte the HomemVners:License Exrinpti�n.Forrn 6n the rcvcrse side. - G:tUs�ia ticcclltE rlpnL'ata:i.cca�'.�dicmuft'i��iniltms%Tcrnpt.+rin'lntemet FilestCpnicn..(?utl�xik':hE)VR;ri tiZtE.�CPR 'SS_Ji+e 9 vi W:[}7�.11'0 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel COO V l Application # Health Division Date Issued Conservation Division Application Fee 0 a . Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board i f uho J� Historic - OKH Preservation / Hyannis Project Street Address 3� s�#v V Z., Village Owner ujkft1c) Cl_u_� Address &X ,�Iv Q Telephone t--L) Q�S Permit Request (n,,�j�' �dg`�- )n�Ji9��/ 1 L 3 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 5 00Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure lob Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other N O Basement Finished Area (sq.ft.) Basement Unfinished Area( .' ) Number of Baths: Full: existing new Half: existing Ep ne v Number of Bedrooms: existing _new a ,� Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other °° r Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stow! ❑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 Od Yes ❑ No If yes, site plan review# Current Use QAPI Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name mc, Telephone Number Job y2d 3 6g Address Wet-^0 SUITT License # 91�r 05aOlf/ Home Improvement Contractor# 16y r r6 Worker's Compensation # we �3 A ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �QOP)� SIGNATURE ,UG DATE la 201 0 ` - FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED r i MAP/PARCEL NO. ADDRESS VILLAGE OWNER • x DATE OF INSPECTION: ' - g FOUNDATION FRAME - INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO.f � i The Cotnntonivealtic oflTassachusetts Depai*Yntent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wivminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organiza.don/Individual): --,�kkc 1TyU5� �`�7J7tY7N — Address: M2 Alk) S7 • SU I 1 t )I?- G City/State/Zip: Phone.#: '31� Are you an employer? Check the appropriate bog: Type of project(required): 4. 1 am a general contractor and I 1.�I am a employer with � 6. ❑New construction employees (full and/or part-ti tn.e).* have lured the mib-contractors Listed on 2.El I am a sole proprietor or'partber-' the attacbed sheet T. 0 Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'.comp.-insurance comp. insrurance.x required.] 5. We are a corporation and its officers h exercised. 10.❑ Electrical repairs or additions ocers have er I I. Plumbing 3.❑ I am a homeowner doing all work their I �Plbig repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[�Roof repairs insluance required.] t c. 152, §1(4), and we have no • employees. [No workers' 13.❑ Other comp. insurance required.] `Any applicant.that cheeks 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. Cf the sub-contractors have employees,they must provide their workers'comp.policy number. f am an employer that is providing,workers'compensation insurance for my employees. Below is the policy and job site information. n 1 �+ )A Insurance Company Name: ` 10A)ff-L •6ft6-L AAI-TU rl, jJI,tS(>,QWF, Policy#or Self-ins. Lic. A Expiration Date: Job Site Address: I�O SU1EW�-U Fi City/State/Zip: UI��•U�' G'� 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 crimuigl penalties of a fine tip to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the forni of a STOP WORK ORDER and a fine. of up to 3250.00 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. f do hereby certify under the gins and penalties of perjury that the information provided above is true and correct A `v Si afore: • Date: _ Phone Official use only. Do not write in this area, to be completed by city or town offtciaL .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 r„ r>„,r r���� ,• Phone #: Client#: 12032 2BISHOPRICST ACOR®,.;�CERTIFICATE OF LIABILITY INSURANCE 0DATE 5/27/2009(MMIDDfYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling &O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR g y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Insuranc The House Carpenters, Inc. INSURER B: 1112 Main Street, Unit 18 INSURER C: Osterville, MA 02655 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER DDLPOLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM DD DATE(MMIDDfYYI LIMITS A GENERAL LIABILITY CPJ3369M 03/09/09 03/09/10 EACH OCCURRENCE $1 000 000 X f OMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED3 occurrence) $50 000 CLAIMS MADE a OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 .GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PE O--CT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ TH A WORKERS COMPENSATION AND WCJ3369M 03/09/09 03/09/10 X WC I IMIT FR EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Insurance coverage is limited to the terms,conditions, exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Nathaniel Ross DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL i_ DAYS WRITTEN P.O. BOX 97 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL West Falmouth, MA 02574 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZ�PRESE NTATIVE I~4. ACORD 25(2001/08)1 of 2 #S58090/M58089 LS1 © ACORD CORPORATION 1988 I ,� lie '(9oorvrieorrulna�l� o�✓G'C�,1JC��uJe�b License or registration valid for individul use only ru Office of Consumer Affairs&Business Regulationbefore the ex iration date. If found return to P . HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: , ,164776 10 Park Plaza-Suite 5170 -- _-�y P J Ex iration:• ,11/12/2011 Trlf 290521 Boston,MA 02116 Type: Private Corporation THE HOUSE CARPENTERS STEVEN BISHOPRIC`.• , 1018 RACE LANE /� MARSTONS MILLS, MA 02648 Undersecretary Not v li without ' nature g Massachusetts - Dcpartinent of Public Safety Board of Building Re-elation. and Sctn(I:irds Construction Supervisor License License: CS 47928 Restricted to: 00 i i STEVEN J BISHOPRIC C 1112 MAIN ST UNIT 18 d OSTERVILLE, MA 02655 I Expiration: 9/29/2011 ( nuui..i ncr Tr#: 4445 � r Town' of Barn-stable Regulatory Services . ="RNST"BL1% Thomas F. Geiler,Director a Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis, MA 02601 svww.town.b arnstab le.ma.us Office:-508-962-4038 Fax- 508-790-62 Property 0-v her Must Complete and Sign This Section. If Using A Builder as of the subject.property hereby authorize 54-�uEA to act on my behalf, m all matters relative to work authorized by this building pernut application for. 130 2 f (Address of job) o S ?�o Owner Date Print If Property Owner'is applying for permit please complete.the Homeovmers License Exemption Form on the reverse side. Town of Barnstable ��of Yt+e ram,o y � Regulatory Services F BA ��� Thomas F. Geiler,Director MAIM Building Division PrED 'y a Tom Perry, Building Commissioner 200 Mairi.Sfxt, .Hyannis, MA•02601 Rww.town.barnstable.ma.us Office: 509-962-4038 Fax: 508-790-6230 HOMMOWN7ER LICENSE EXEMPTTON Please Print DATE: 10B LOCATION: number street village "140MEO WNER": name home phone# work phone# CURRENT MAILING ADDRFSS: city/town state zip code The current exemption for"homeowners"was extended to include owocr-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 017 H0111E0'Gi XER 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 user and/or farm structures. A person who constructs more than one homy 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) Tl�c undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner".certifies that.helshe understands the Town of Barnstable Building Department min:num inspection procedures and requirements and that he/sbe will comply with said procedures and recj[.uxements, 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. a HOMEOWNER'S EXEMP170N .The Code states that: "Any bomeowner performing work for which a building perrrr t is required shall be exempt from the provisions of this section(Section ID9.),I -Licansing of construction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such wofk,that such Homeowner shall act as supervisor.,, Many homeowners who use this exemption are unaware that they arc assuming the responnbilitics 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 cnsufr that the homeowner is fully aware ofhisAcr responsibilitirs,many communities require,as part of the permit application,. that the homeowner certify that helshe understands the responnbilitics of a Supervisor. On the last page of this issue is a.form currently used by several towns. you may can t amend and adopt such a form/ccrtification for use in your community. Q:forms:homccxcmpt TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION Map Parcel Application Health=Division Ze o G - 40/ ' Date Issued v d ��/`' Conservation Division � Application Fee Planning Dept. Permit Fee '3� ' Date Definitive Plan Approved by Planning Board cog) ff' Historic - OKH Preservation/Hyannis �'V Project Street Address SfA,0 v 2%-J Village O SteeU �l e., Yh f? Owner w t Amara cAup, Address [ so set.ok-ew Atx _ Telephone 1 I Permit Request ?,ePa-rz. DecL -�-r-reo S- XZ0c-r'xQ L YYlex1L6 Z R�Q ��iuJq I O Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5,oaa-oa 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 -3Z) 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 L4 new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: i XU. t - �j N ; Zoning Board of Appeals Authorization ❑ Appeal # Recorded Ell "'' Z Commercial ❑Yes ❑ No If yes, site plan review# s Current Use Proposed Use w r n, APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Z10-QI5t3 -�Y - t 1S6P0c Telephone Number Address I l l L CnaVQ 572J,-C O i ftt,AR License C�db55 Home Improvement Contractor# 10 6 k i Worker's Compensation # Wce- 500,31 y 50 ba00"7 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE A01 DATE ZttLa� �J 4 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED, , I k MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH " - FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL r '-FINAL BUILDING x DATE CLOSED OUT ASSOCIATION PLAN NO. i ' The Commonwealth of Massachusetts : Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation rnsn.rance Affidavit: Builders/Coutractors(EIectricians/Plumbers - A licant Information Please Print Legibly Name (Business/Organizahon/lndividual): ���iJGN �. �iS oPR�C, ui3OE"fZS Address: 111'a Mt1 O Si left City/Statf-tz- : ©SieZQ 112., .1t 1� �o� Phone.#: 50B' 4aO - 3165 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with _ 4. ❑ I am a general contractor and I 6. ❑New constnxtion employees(full and/or part.timc).* have hired the s'tib-contractors 2❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have g, ❑Demolition employees and bave worker' working for me in any capacity. 9. �]Building addition • . [N[No workers' eo�.-insnanCe ��.insurance.t o'Wei] 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 repairs incnranco required_]t c. 152, §1(4), and we hart no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that chicks box#1 mutt also fM out the section below showing their workaa'cor pmsaAm policy infra mtion. t Homcowncn who submit this athda,,it indicating they art doing all work and than hire outside contractors must submit-new affidavit indicating such. TContractots that cb=kthis box miust atiacbcd on additional cbect abowing the name of the sub-contratlrna and stale wbcther ornot those entities have caployccs. If the sub-contractors have crrploycu,they must provid6 their workers'comp.policy number. I am an employer that is providing workers' compensation insurance for my empLoyees. Belaw is the policy and jab site information. . o` lanwacc Company Name: ne.,J1%P3G- i n Policy#or Sclf-ins. Lic. #: UJ C.C.5 00 3 I 1 So (9,00-1 Expiration Date: k a1A wa Job Site Address: l30 S8a,1-,9_ .) A4e- City/State/Zip: oSTeQ00te , (na Oo`Z(05:5.. 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 rri_m?tial 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 advisod that a copy-of this statcmcrit may be forwarded to the Office of lnvesti tions of the MA for Insurance coverage verification. I do hereby certify unde chap S-and penaWas of perjury that the information provided above is true and correct Si afore: c Data: $ ; 1 0 Phone# S0ir 4a0 _31 b5 Official use only. Do not write in this area, to be completed by city or town offu:iaL 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#: 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 hue, y 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 engages]in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee ofanindividual,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 an 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 Iocal licensing agency shall withhold the issuance or renewal of a1cense 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 commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until acceptable evidence of compliznce with the in-sura.nce rcquircmcnts 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, i.f necessary,supply svb-eontractor�s)name(s), address(es) and phone numbers) along with their certificate(s)of hn rance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no-employees other than the nembers or partners, arc not required to carry workers' compensation insurance. If an LLC or LL.P does have :mployecs, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial ALceidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should >e returned to the city or town that the application for the pest or license is bring requested, not the Department of ndustrial Accidents. Should you have any questions regarding the law or if you arc required to obtain a workers' :omipcnsation policy,please call the Department at the nurpber listed.below. Self-insured companies should enter their ;clf-insuranco license number on the appropriate line. :ity or Tower Officials 11rase be sure that the affidavit is complete and printed legibly. The D cpartmcut has provided a space at the bottom ,f the affidavit for you to fill out in the event the Office of Investigations has to contactyou regarding the applicant -leasc be surc_to fill in the permit(liccnsc number which will be used as a reference number. In addition, an applicant hat must submit multiple,permiyacense applications in any given year, need only submit onr,affidavit indicating current •olicy information(if necessary) and under"Job Site Address" the applicarit should write"all locations in (city or )wn)."A copy of the affidavit that leas been officially stamped or marked by the city or town may be provided to the pplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be 5llcd out each ear.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture _e. a dog license or permit to brim leaves etc.) said person is NOT required to complete this affidavit he Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, (case do not hesitate to give us a call. to Department's address, telephone-and fax number. The Commonwealth of Massachusetts Dg3artmmt of Industrial Accidents Off"im of Investigations 600 Washingtan Street Boston, MA 02111 TeI. # 617-727-490.0 cxt 4.06 ar 1-M-iviASSAFB :d 11-22-06 Fax# 617-727-7749 www.mass.gov/dia I 8/21/2008 Time: 10:35 AM TO: @ 9,15087906230 Page: 001 Client#: 12032 2BISHOPRICST ' ACORD. CERTIFICATE OF LIABILITY INSURANCE 08/21108D/rvrr) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling 8:O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance Steven J. Bishopric,Inc.A/O Chestnut INSURER B: 1112 Main Street,Unit 18 INSURER C: Osterville, MA 02655 INSURER U. INSURER E: COVERAGES 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 SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ; IN SRADD' POLICY EFFECTIVE POLICY EXPIRATION LTR INSRN TYPE OF INSURANCE POLICY NUMBER LIMITS A GENERAL LIABILITY CPA004717019 12/08/07 12/08/08 EACH OCCURRENCE $1 OQO 0O0 X COMMERCIAL GENERAL LIABILITY _ DAMAGE S O REoNTED $250 OOO PRECLAIMS MADE 5-1 OCCUR MED EXP(Any one person) $5 000 X Bl/PD Ded:250 PERSONAL 8 ADV INJURY $1 00O O00 GENERAL AGGREGATE s2,000,000 GEN'LAGG RELATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY JE T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS . BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS . BODILY INJURY $ - NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WCA025879011 07/19/08 07/19/09 X WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500 OOO If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500 000 OTHER I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - i C� Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE C NCELLED 5`EF,0RE T F�CPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR O MAIL DAY WRITTEN 200 Main Street - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE L ,BUT FAIWE TO O SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UP O THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R PRESENTATN,E�+� ACORD 25(2001/08) 1 of 2 953186 MAK 0 ACORD CORPORATION 1988 �oFTMEr TOWn of Barnstable Regulatory Services Mi sa $ Thomas F. Geiler,Director. lEohwta Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable-ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder Z/hi % as Owner of the subject property hereby authorize_ l��i tar/G A, to act on my behalf, in all matters relative to work authorized by this building permit application for: :_1 n 5 can Vic A VC/ (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable OF T HE r Regulatory Services • Thomas F. Geiler,Director : BARNgrwat.>;. MASS, ,�� Building Division PTfD µAte Tom Perry,Building Commissioner . 200 Main Street; Hyannis, MA 02601 vrww.town.b ai-nsta bl e.ma.us face: 508-862-4038 Fax: 508-790-6230 H0h1EOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: village number Street "HOMEOWNER": work phone# name home phone# ,. CURRENT MAILING ADDRESS: city/town state rip 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. bEFINITION OF HOMEONrJNER 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 itivo-year period shall not be considered a bomeowner, 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) 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 be/she will comply With'sait3 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 >tate 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 .f this section(Section Io9.1.,1 -umnsing of construction Supervisors);provided that if the homeowner engages a pc sons)for hire to do such cork,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. _u)cs&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness oflcn results in serious problenss,particularly 'hcn the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would With a licensed upervisor. 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, at the homeowner ecrtify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by venal towns. You may care t amend and adopt such a fom✓ccrtification for use in your community. I Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registratiori: 106141 / Board of Building Regulations and Standards Expiration: 7/22/2010 V Tr# 270447 One Ashburton Place Rm 1301 Type:- Private Corporation Boston,Ma.02108 w STEVEN J. BISHOPRIC INC. Steven Bishopric''' 1112 MAIN ST UNIT 18 OSTERVILLE, MA 02655- Administrator Not valid without ignature Board of Building Reeulatfoi{a a� Construction SupeM License: CS kense Birthdate: 9/2947,8 /tg48 Expiration: 9/29/2009 Tr/ 5111 Restdctlon: O0 STEVEN J BISHOPRIC PO BOX 656 MARSTONS MILLS, MA 02648 Comm-fiWow Board of Buildi Re I HOME IMP Bulatfons and Standards y VEMEN CONTR.46 J. p, on: 06141.\ OR Expi ,. ,. 2/2008 TYPe: STEVEN J e Corporation BISHOP IC INC. Steven Bishopric 1112 MAIN ST U T OSTERVIL 18 LE, M I 02655 DeputY Administrator pe I I ICI � i I I i I I ( pew 0.emsl -�O�T I II a ?os'ce'o So►�A cy v o is c il . 0 t c" l Jok T � I I I vl°,d�i CST e --� , - , . �1 f� '1 r• = '. •� . '1� � t � t. - � T _. �s 1a ' � �`>. �` � � ' . _ t r` .: � � _ :. . :,. . � , __ � j 1. \, � � � 1 ., �t t, f �,� -� - 1 r r. ...: .- � 'z t � ..� ` .�F y � � - -- - - - - -- .. r i i ` __ 1 ` L + � } {/ . r rj i ' n C fIW � � i - �_ ra b' .a"�""" .. ..w Mw► ���.� � �r� #'! �� f ,�� #1 ' ,.� '�* ; __ .,, r� I' T, 5 � _ k IN i� 9 40 lMimi 1 • ' I 1 9 y Ut 4ca.. p, I +4� i 4 i w_ t Y ... M Nu110V� NUI1flV� NOIJI F d .r r T r ir.�<-..ems► -�s�>R---'-.-,. �. - -_.. � r Y 1 � v _3 3AV2, .. 6 1 _ W S 13 8 2008 Assess"W's map and lot number AcAl... ...g4P Sewage Permit number .......................................................... FTNEt��`ow TOWN N OF BARNSTABLE i - a� • i BARISTADL i NAM ,,• BUILDING INSPECTOR APPLICATION FOR PERMIT TO ... .............................................................................. TYPEOF CONSTRUCTION ..................................................................................................................................... .�'..1....� ................19.L4. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: , Location ....` ...K.R4�k ...1 ...... ..... ..... ....�. ... .� ►i,.Ti .ti.�lllrL+ ProposedUse ............................................................................................................................................................................... Zoning District ........................................................................Fire District .... Name of Owner ..... . . ...................Address .t... VjA. Nameof Builder .. .................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ....................................................................................Roofing .................................................................................... Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board ---------------_---------------19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. + � .. .... �.Q ..'. ......... Wianno Club • No ...18884... Permit for ,,, demolish barber iA shop ............................................................................... Location 130 Sea View Avm,ue ............................................... ................ Osterville .................................................. Owner a Club ..................Wi.........nno....................................... Type of Construction frame . .......................................... ................................................................................ Plot ............................ Lot ................................ Permit Granted ,,, December 20 76 .......................19 Date of Inspection ............... :...................19 / Date Completed ......�. ..............lj(p PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... r'Ass6s - is ,map and lot number .kr�.'.....I. L r c � . SewagePermit number .......................................................... THET,�`o� TOWN OF BARNSTABLE i 9AS39TODLE, %• 9 "b q o y �e� BUILDING • INSPECTOR _ aY a• _ APPLICATION FOR PERMIT TO .................... TYPEOF CONSTRUCTION ..................................................................................................................................... n� W ................................C ^ . ...............19......... TO r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: c Location ...!:;..!:...#........'...........':...... ..!..... .......... ...........`. .........................`.........!+1:; .. . !. .....`.............. t. ......r� ProposedUse .........................................................................:.....................,............................................................................. ZoningDistrict Fire District ... •. +� n 1R; Name of Owner .......l..........• .............Address ' ....asu.. - ! IZr �: ................................. r Nameof Builder ............•.. .... ` .................................Address .................................................................................... Nameof Architect ..................................................................Address ..................................................................................... Numberof Rooms ......................:...........................................Foundation .............................................................................. Exterior ....................................................................................Roofing .................................................................................... Floors ........................... ..........................................................Interior .................................................................................... Heating ...........Plumbing .........:. ....................................................................... ....................................................................... Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board -----------_------_-----------19________ . Area .......................................... Diagram of Lot arid Building with Dimensions . Fee ............................................. SUBJECT TO .APPROVAL OF BOARD OF HEALTH i I hereby agree to conform to,all the Rules and Regulations of the Town of Barnstable regarding the above construction. 1 Wianno Club A=1,6T-19 18884 demolish barber NNo •................. Permit for shop rear 130 'Sea View Avenue Location' - Osterville ...:........................................................................... Wianno Club Owner ................................................................... ' Type of Construction frame YP .......................................... ............................................................................ _ Plot ............................ Lot .................................. December 20 76 Permit Granted ........................................19 s Date of Inspection ....................................19 Date Completed ..........................:...........19 PERMIT REFUSED :.............................. �....... 19 - ...:...... ... . ................................. ..... ............. . .. ....-. ............ ................... } ..... ............. .. . .......................... ........................... . . ............................................ i jApproved ............................................... 19 ............................................................................... s ........................................................