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HomeMy WebLinkAbout0154 TOWER HILL ROAD K 1 �� t� i i :� April 101h 2019 In Accordance with 780 CMR Authorization to obtain a building permit for 154 Tower Hill Road,Osterville I authorize Michael Leblanc and Leblanc Builders to file for an obtain a building permit for our home located in Osterville MA for a new Velux Skylight replacement Owners Signature o Z p f,7 Town of Barnstable _ Building uwvsrws�, ; Post This Card So That it is Visible From the Street:Approved Plans Must be Retained on Job and this Card.Must be Kept M^M Posted.Until Final Inspection Has Been Made. Permit ib3o- ,� ' Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-19-1757 Applicant Name: Michael LeBlanc Approvals Date Issued: 05/31/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/30/2019 Foundation: Location: 154 TOWER HILL ROAD,OSTERVILLE Map/Lot: 142-018 _ Zoning District: RC Sheathing: Owner on Record: OBERG,ERIC&ELIZABETH L Contractor Name: MICHAEL L LEBLANC Framing: 1 Address: 10 RUE DE LA PEPINIERE Contractor License: CSFA-057337 2 FRANCE,. Est. Project Cost: $4,000.00 Chimney: Description: Replacement of bathroom skylight. Same size as existing.;Replace 4 Permit Fee: $35.00 with Velux M04 with step flashing. patch sheetrockI Insulation: and outside I Fee Paid:' $35.00 shingles around area. A ,! Final: Date: 5/31/2019 Project Review Req: Plumbing/Gas Rough Plumbing: "\,Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after`issuance. All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for.public inspection for the entire duration of the Final Gas: work until the completion of the same. - Y . Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this,,permit. Minimum of Five Call Inspections Required for All Construction Work: ,f Service: 1.Foundation or Footing 2.Sheathing Inspection T _ '- y_ .. Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: a�IMAE Town of Barnstable vernat " ' Regulatory Servic� 'F=6" �`�`� - o6fAffi� a _ � .� Ibchard�Scab,Interim IDireetor ���/ � L I MAIM B'Mftg nmstO 0//�V� T 1 ?016 Tom]Perry,CBO,Bmlding Conn$esiu eer, yip — 200 Main Street,Hyannis;MA 02601 WWWADWm.barnstable ma us `C Office: 508-862-4038 Fax:508-790-6230 �>�s�P T���LAMON 0 RESII)ENTIALe OILS' `� N°t Yalid x M0UtRedx-Press dmprint N�ap�parcel Number�7 Z ('/� / Property Address I'N Tr.✓ei l��!/ ( Ds-f e,r y i l I "'Rcsidcnlial Valne of walk S LZPAL2 Mmimum fee of$35.00 for work under 86000.00 Owner's Name&Address Zo k R X 41er ff f �S��r✓:IlP M,�1 O S�S� Contractor's Name AA TekphoneNumber ®�-7� �n.� ? Home Improvement Contractor Licemse#(if licable)1a(o �'f 3 Email Construction Supervisor's License#(if applicable)=�q?/d 2-1 ��WO*Mim's Compensation Insurance .Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have WorkeestCompensation htsm=, Insuzance CompanyName ® �{� SA�l l� . Co Workmam's comp.PoHr. , Y.G Copy of Insurance Compliance Certificate must accompany each p Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All constmction debris w01 be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Q,Ae-side .. 1 q Replacement Windows/dours/sliders,.0 Value - 30 (tuaximum 35)#of ' dows #of doors �Q Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. Separate Electrical&I3re permits required. °Whaeregmce� Issnanseaftlnspe�itdoesnbtexempicnmPewilhothertawn n;galetiiws.is .Consetvsfloq eon. "Note: Property er sign Property Owner Letter of Per missiorL A copy of H Improvement C(ntracorrs License&Construction Supervisors Iaoense is required. SIGNATURE: T:TXM D)Bulding Ch-ges\Exp REMdoc Revised 061313 , r t !1[)71i)t�t!'1[()�"C;(T1'tT t:tN7tit'f thrreA low so-twJOA Dalst lllab— 71g3*AWmw Set.kzw t Ctt. mrFL-Wm-:**,44somSe+vr�e am"A4ftby.if t=t*19=1tar;.0 tk/2'4"� Kl% Ted 1!WC7`tx-� 15-1 jet ZAP ; .iad.t�. ��.rat$, `s .l;"..,Q •ut2l�� _. � # .4�._.. 'ip ..p. 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'I fir 110\IF'UFPttT}t.\�t\ITit1tt71 U.\ttt)L�'1� litt>al IFS F'R REC tr-%'T 'OF"�rum T1., UAW. u'iTIKM'T afd r%tDat*drA M,��t•t'k t�Y rtft--=".5.1\"f 14 C"."' ; timing an.ea+tce,aa1+ti,-�c:.'ttcc it mw&4"'+a►mi x;w- Tbn Aprttum!a c..eaK tL'AWV--f tr: �Ibd cvMk►? •v.cx•S v ,ad seta+the Cmwfewt b_--.n zi.czSidawd3 ,SaFr.( �� ' R S+ktC.aa•t I.�.ea•e U5: q ed% 40axv&mnner , 03/24/2016 10:29 5083783176 EDSON INSURANCE AGEN PAGE 01/02 i I t , mmaehusetts-Oepa,bi nt of Public Safety Board of'Building Regulations and Standards • >rnnstrUtt1A11$open•ianr SpCC1Hi._ License:CSSL-0l 62 Y 44 CMCLR X1»�tMrt �s Watdaa:MA mn T � � ,,1,5. 1c1a�a �` F�rpiratfon �.LcommIssione oe+avZct7 Cnmmlssione► --�---• d7��o�,.�uer�,/!�r�A�aeerrr�i.rx4/A. OlTice of CooaRnler AlFiire&lrutrae�t Regollrtron OME IMPROVEMENT CONTRACTOR egiEtraUon: A49128 Typer ! 'ration:._:.1'11��2017 IndWduel i 11MOnW HANSCOM TIMOTHY HAN$CO4. *CIRCLE OR WAREHAM,MA OWI Uudtreteneairy ! 1 � I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 .www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aonlicant Information Please Print Legibly Name us o(B mess/or an�on/Individual)-_ 1 1/►�b`t �t�l � �-/ ns c o n� Address: C 1 ricJe, 6 r l Ue— ~ City/State%Zi : �'2b � Dau`_7/ Phone#: Are you an employer?Check the appropriate box: l.❑ I am a employer with 4. C] I am a general contractor and I Type of project(required): ,..�(employees(full and/or part-time).* have hired the sub-contractors . 6• ❑New construction 2.1�1J I am a sole proprietor or partner- listed on the attached sheet 7. []Remodeling slip and have no employees These sub-contractors have 8. [l Demolition working for me in any capacity. employees and have workers' [No workers'comp,insurance comp,insurance) 9. ❑Building addition required:] 5. (] We are a corporation and its I0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their . t I.(]Plumbing repairs or additions myself. (No workers' comp. right of exemption per MGL insurance required,]t c. 152, §1(4),and we have no 12.0 Roof repairs 3a.❑ I am a homeowner acting as a employees.[No workers' I3.❑Other general contractor(refer to#4) Comp.insuranCe 1eq111ed1. Any appliarat that checks boa irl must also fill out the section below showing their wad=&compensatio4olicy infotmajion.t Homeowners who submit this affidavit indicating they are doing all wort;and then hire outside contractors must submit a new affidavit indicating such_ fCoutractam that check this boa must attached an additional sheet showing the name of the sub-coubwtom and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'co oli n�ber.camp.P cy I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information: Insurance Company Name: Cbm Mt-f Policy#or Self-ins.Lic.M Expiration Date: _ Job Site Address: 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 imprison rent;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 certi under th pains and enalties of perjury that the information provided above is true and correct Si a Date: Phone#: O,(j`rcial use only. Do not write-in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.CitylTown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• Phone#: office of Consumer Affairs and Business Regulation ffi 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Nome Improvement Contractor Registration F3ep istratio n: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC. ANDREW SWEET _ 2455 PACES FERRY ROAD, HSC C-1 i ATLANTA, GA30339 __ ..__..._..... .._.._.._....._......_..... Update Address and return card.Mark reason for change. Address "-j Renewal !j Employment i i Lost Card office of Consumer Arfairs&Business Regulation License or registration valid for iadividtLal use only before the expiration date. if found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plaza-Suite 5170 Expiration: 8/3/2018 Supplement Card Boston,NLA 02116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME_SERVICES ANDREW SWEET 2455 PACES FERRY ROAD,HSC ATIANTA,GA 30339 Undersecretary Not v with ut signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, NIA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lmibly Name (Business/Organization/individual). The Home Depot At-Home Services Address: 908 Boston Tpk City/State/Zip:Shrewsbury,MA 01545 Phone#: 508-962-6942 Are you an employer? Check the appropriate bog: Type of project(required). . a general contractor and I 1.� I am a employer with 200+ 4 � Im a 6. New construction 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 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions re q ] 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 insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[ Other comp. insurance required.] re �rc&-w e.J e *Any applicant that checks box 41 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: New Hampshire Insurance Company Policy#or Self-ins. Lic. #:WC 015519215 n Expiration Date:311r2017 Job Site Address: 1'� y o i ( d• City/State/Zip: 01,j of y l 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 f r nsurance coverage verification. I do hereby certify u er pains and penalties of perjury that the information provided above is true and correct Si mature: Date: Phone#: 401-714-6 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: '/• ' ♦ ® DATE(MM/DD/YYYY) AC"R o CERTIFICATE OF LIABILITY INSURANCE 02/1812016 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). CONTACT PRODUCER NAME: MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER A/C No Ext: A/C No): 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC# 100492-HomeD•GAW'-16-17 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Co 16535 THD AT-HOME SERVICES,INC. 23841 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 REVISION NUMBER:8 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 ADDLTYPE OF INSURANCE INSD INVD UBR POLICY NUMBER MWDDY EFF MMIDDY EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY GLO4887714-06 03101/2016 03/01/2017 EACH OCCURRENCE s 9,000,000 DAMAGE TO RENTED CLAIMS-MADE a OCCUR PREMISES Ea occcurrence $ 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 9,000,000 POLICY El PRO ❑ LOC PRODUCTS-COMPfOP AGG $ 9,000,000 JECT rl OTHER: $ B AUTOMOBILE LIABILITY BAP 2938863-13 03/0112016 03/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS H $ AUTOS Per accident UMBRELLA LIAR I OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE s DIED I I RETENTION$ $ C WORKERS COMPENSATION WC015519215(ADS) 03101/2016 03/0112017 X BrATUTE ERH AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE YN" N/A WC015519217(AK,KY,NH,NJ,Vl) 03/0112016 0310112017 E.L.EACH ACCIDENT $ 1,000,000 D (Mandatory in N )EXCLUDED? ❑ WC015519216 FL 03/01/2016 03/01/2017 1,000,000 (Mandatory in NH) ( ) E.L.DISEASE-EA EMPLOYE $ If yes,describe under Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATIANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjeeav�ao� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD c CAPE COD INSULATION IIYdA YIAI StAtll[sf SipAT IGAM u 7 uuiQILINm uurtsss wsusanoN nGs 1-800-696.-6611 I / T C : "T'own of Barnstable VA�L� Regulatory Services 7—f L Building Division 200 Main St Hyannis, MA 02601 Dale: Dear Building Inspector l Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building PerformaneRristitute ' (BPI) inspector. All work preformed meets or exceeds Federal & State Requ.elnents. m Property Owner Property Address Village �w r- M 05Aw, Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted rn Ceilings Slopes ( ) ( ) ( ) ( ) ( ) Floors Walls ( ) (X) ( 13 ) Sincerely He ry E Cas y Jr, President C, e Cod I - ulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma L' Parcel `� Application t P Health Division Date Issued Conservation Division Application Fee _ U Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board P Historic - OKH _ Preservation / Hyannis Project Street Address Z ;,- tzid AA ,,Znj Village Owner -611 aad 4Z& 4 14s2 q Address y�.� � < 11 .= Telephone O'71: Permit Request 141, S`J �� Aa��-:- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 4 7od, 6 o 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 )4 No On Old King's Highway:' ❑Yes J,No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: 0 Gas ❑ Oil ❑ Electric ❑ Other Central Air: 0 Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: 0 Yes 0 No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing 0 new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing 0 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 �� � ���/ ,��.✓5��� isirJ Telephone Number Address / 12ell/li nl 4z G'/ License # Home Improvement Contractor# Worker's Compensation #J,2 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE Z124DATE "Zo��,�if r Ir • FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED � MAPS/PARCEL NO. ' ADDRESS - VILLAGE t OWNER ' DATE OF INSPECTION: utfO.UNDATIQN�»•+�-s,r:.r�L••r��::�*��r�.-��u: - FRAME : INSULATION:. f FIREPLACE ELECTRICAL:. -ROUGH FINAL { PLUMBING: ROUGH FINAL €' GAS: ROUGH FINAL \LI 'FINAL BUILDING'. • .. f t DATE CLOSED OUT_ `T r ASSOCIATION PLAN NO. ' OWNER AUTHORIZATION FORM I, u!!�" (Owner's Name) owner of the property located at ZZ (Property Address) I&—2 a In 4 j (Property ddress) hereby authorize C �1 J p S (oj (Subcontract ) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Si lure 3 Data The Uommonwealth of Massachusetts 9 Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 'www,mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianOlumbers Applicant Information Please Print Legibly Name (Business/Organizadon/Individual); �•� �'G, ��. Address; City/State/Zip: /� f� o phone #: ��- Are you an employer? Check the appropriate box: 1.E� I am a employer with ~_ 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors , 6• ❑New construction 2.❑ I am a sole prbprietor or partner- listed on the attached sheet, 7. ❑ Remodeling ship and have no employees These sub-contractors have working for me in any capacity, employees and have workers' g' Demolition [No workers' comp, insurance comp, insurance•, 9. ❑ Building addition 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 . l I•❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per'MGL insurance required,] t c. 152, §1(4), and we have no 12•❑ Roof repairs 3a.❑ I am a homeowner acting as a employees. [No workers' 13.R Other .. /���,o general contractor(refer to #4) comp,insurance required]. •Any applicant that checks box#1 must also fill out the section below showing their workers'compnsatiodl =Policymformadon. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mus ubmit a new affidavit indicating such, tContmctors that check this box must attached an additional sheet showing the name of the sub-contrscton and state whether or not those entities have employees• If the sub-contractors have employees,they must provide their workers comp.policy olic number, 1 am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: Policy#or Self-ins. Lic, #; ' / f Expiration Date: Job Site Address:_^ ,,�` City/State/Zip: jAttach a copy of the workers' compensation policy declaration page(showing the policy n mberndexpiration 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 certtfy un the p� and penalties of perjury that the Information provided above is true and correct r Signature: Date: /� u Phon Official use only. Do not write In this area, to be completed by city or town official i City or Town: PermitlLicense# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector•5. Plumbing Inspector 6, 0ther Contact Person: Phone#: J V CAPECOD-27 KLIGETT ��-- CERTIFICATE OF LIABILITY INSURANCE DA. '1,2'DO/YYYY) 014 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(les)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 Ileu of such endorsement(s). PRODUCER CONTACT Rogers&Gray Insurance Agency, Inc. NAME: Barbara DeLawrence 434 Rte 134 PHONE --- (A/C,No.Exl�_ 877)816-2156 South Dennis,MA 02660 EMAIL — ADDRESS•bdelawrence ro ers ra .corm INSURER(§1 AFFORDING COVERAGE _ NAIC N "— --- — -- INSURER A:Peerless Insurance Company INS REp _ j INSURER B:COMMERCE INSURANCE COMPANY__ Cape Cod Insulation Inc INSURERC:Evansto iInsurance Company 18 Reardon Circle South Yarmouth, MA 02664 INSURERo:ATLANTIC CHARTER INSURANCE GROUP- - INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: T IS 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, E(C).USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CLAIMS. RSR ....�-'--...----------•— LTR TYPE OF INSURANCE POLICY NUMBER MMIDDY EYF MMI DIYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ l CLAIMS-MADE L X� OCCUR CBP8263063 04/01/2014 04/01/2015 TC�ENTE6--- $ —• 1,000,000 - PREMISES(Ea occurrence) 100,000 -- MED EXP(Any one person) $ 61000 PERSONAL&ADV INJURY $ 11000,000 G. N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 - - POLICY l—..I JECOT LOC — - PRODUCTS-COMP/OP AGG $ 2,000,000 � OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 3 1 ANY AUTO Ea accident $ 11000,000 14MMBCKVMK 04/01/2014 04/01/2015 BODILY INJURY(Per person) $ALL OWNED _x SCHEDULED _ _ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS X AUTOS NON-OWNED. AUTOS PROPERTY DAMAGE $ Per accident �( UMBRELLA LIAR X OCCUR EXCESS LIAR EACH OCCURRENCE $ 1,0001000 _ _ CLAIMS-MADE XONJ453514 04/01/2014 04I01/2015 AGGREGATE $ DE X RETENTION 10,000 Aggregate $ 11000,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY PER TE ER 4NY PROPRIETOR/PARTNER/EXECUTIVE YIN WCA00525904 06/30/2014 06/30/2015 OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) _-- II Yes,describe under E.L.DISEASE.EA EMPLOYEE $ 11000,00 DESCRIPTION OF OPERATIONS below i I E.L.DISEASE-POLICY LIMIT $ 1,000,000 i I 1t I ES9RIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) orker4 Compensation Includes Officers or Proprietors. idi to at Insured status Is provided under the General.Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. l ERTIFICATE HOLDER r'AkI/^CI I r Massachusetts -Departn4nt of Public Safety �3b�rd of Building Regula;ions p•nd Standards Consmictiou Supct-visor •� f ;, License; CS-100988 1-1E.NRY.E CASSI])'( 8 SHED.ROW r WEST YA1.tMOlP111 ; ✓..�,.T ,Ci, -� 'I1"' Expiration Commissioner 11/1112015 ' r t: sr ; Office of Consumer Affairs and Business Regulation = 10 Park Plaza - Suite 5170 Boston, Massachl.}setts 02116 Flo.rne Improvement CQ.;a ra:gtor Registration - .' . `i Registration; 153567 Type; Private Corporation r;.•r•t_•: : .. :;: . : :: Expiration: '12/15/2014 Ti-ff 233831 CAPE COD INSULATION, INC l HENRYCAS S , _....---.._._...................... ...........-.. 18 REARDON CIRCLE 80. YARMOUTH, MA 02664 ;.1,..• "; ,�'.'1lpdnto Addrt s nad return enrol. Mark rensun For chnugc. "! .•�`'" wal C7Employment J Lost Cord.Reau : '��,3`�(4�r+t•r�tu�atuera.11� c`�C?/�t!rtddct<:�ttJ(e(13 0II1t•e of Coil N-11 III 1a•AtTI111-$& Busi11ess 11CguIntiU11 License or registration Mid for indivitf ll Use only OME IMPROVEMENT CONTRACTOR beforo fho expirotlon date. It'round return to: egistration: 1'53�67 Type; office of Consumer Affnirs nud Business Robulntion xpiratlon: 121TK01 A Private Corporallon 10 Park Plaza-Suite 5170 Boston,KA 02116 (00 INSULA-1•1-ON Y CASSIDY 4 WON CIRCLE A MC1U11-1,MA 02664 flurlerseeretnrY ...^—AV of VAV twitho f ' notZ I I f Town of Barnstable Regulatory Services ?homes F.Geller,Director KAM � Building Division �o Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PEI7MIT#6 F 5 -4 FEE: $ DD SHED REGISTRATION 120 square feet or less IS4 TOWED H+iLL 9D. , 05TI-7-QV I LL E Location of shed(address) Village. WILLIOrM 4E2P s C"01-)(N PLOWADE 78-1 - 862 - `I791 Property owner's name Telephone number S x ( Z = 9( si 4. I Y a O IS Size of Shed Map/Parcel# 9 3- signature Date 0 Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? N 0 Conservation Commission(signature required) PLEASE NOTE: IF YOU ARE WITH3N THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:121901 Z0 39Vd OEZ906L805Z6 6Z:00 E00Z/LZ/50 E N/F JOHN B. LEBEL Bx 12 Shell 110.90 +10► 4ow% $ide Ic (iNe . a + 30' w Q Year 14 We N _1 ~ _J 13.0 Q 3 tt7 O O cV e: f 0.3 l(i 0 } 23.3 r- N0. 542 •! Q Z L 1 1/2 STY. N r i 32.4 c !!Q Z 3.00 99.00 Z TOWER HILL RD . MORTGAGE LOAN INSPECTION MU542 SAGAMORE SURVEY ASSOCIATES SCALE: 1 IN.= 40 FT. SHOFV, P.O. BOX 28 DATE: AUGUST 10, 1994 Ea` SAGAMORE BEACH, MA. 02562 +� THOMAS [12 08) 888 8667 ,� C.CERTIFY TO oPONTORIANpHAT THE LOCATION OF THE BUILDING SHOWN HEREON CONFORMS o No.34314O THE ZONING OF THE TOWN OF OSTERVILLE CERTIFY THAT LOCUS DOES NOT LIE WITHIN THE FLOOD HAZARDONE AS DELINIATED ON MAP 0016C COMMUNITY NO. 250001 LAN REFERENCE: BARNSTABLE REGISTRY OF DEEDS REGISTRY OWNER: OOK/PAGE: BOOK 6330, PAGE 209 LOT NO.: LAND PLAN BY: DEED BUYER: DATED: JUNE 27, 1988 THIS INSPECTION NOT MADE FROM AN INSTRUMENT SURVEY AND IS NOT TO BE USED FOR FENCES, HEDGES OR TO ESTABLISH LOT LINES. FOR USE OF BANK ONLY.