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HomeMy WebLinkAbout0023 WINTERGREEN CIRCLE �'� a ._ __" _ _._ -�..-.'. _ _..w_..._f"'S�3...�.,.�. r++�^�`.—.- ate_ ... .. - - — - � .wd..sc, -- Assessor's map and.lot number ......... ..... ... ......... I Sewage Permit number-,.; ,xi ..................... e SH � QQ Z 99T11DLE, i House number ...............:..........oC.3.. !..�?.................... . • - *°o rasa �F0 NPY'f►` TOWN OF BARNSTABLE BUILDING ANSPECTOR PC d F d ��' .. C� APPLICATION FOR PERMIT TO .... ........ .................... ...... .................................... F TYPE. OF CONSTRUCTION .............. .............J...� .�a.. !1.er:...........................`....................................... ..................... /3... 1 9&.4/ 7. ... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to_the following information: Location .....6....P)........................... ................................... ProposedUse .................................... . ................. : ............................................................................................................... Zoning District t .. .. ................ �........................��............Fire District ............................. .... ......................................... Name of Owner ....�/.�it!gt~.J. ........v..... .C........................Address ....�.�... ...............� ................................................ .... ... . }1 . d Name of Builder .........J.... .....�...............h..!.e........Address .....1�..� .7.......°.. a o �� Nameof Architect ...../..v°�l!.�........:.......................................Address ......................................:.................:........................... -Number of Rooms ...................................................................Foundation ............................................/O r � c a.'P'C.......... Exierior ..., ........Roofing ..'::....../T S ......................................................... ..... ............... ... .............!.........Floors 1P.. .. 1 ...........................�rPf2.pC rInterior �.........,........................................ Heating .......... 0�!/.. .................... `�. ..................Plumbing ...................................._ ............................................ 44 ,# Fireplace ..........®v.,0y..e........ .. ............... •.....................Approximate. Cost ..........�� .0�..(J............... .... ...... ..... ..... ll Definitive Plan Approved by Planning Board `` _______________:__________19_______. Area :./.. . �"!......... -76 Diagram of Lot and Building with Dimensions Fee /—f SUBJECT TO APPROVAL OF BOARD OF-HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS------.___. I hereby agree to. conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. n 4 Name ......�! -= Construction Supervisor's License. .................................... VENGRIS, JONAS A=119-63 No 2439..... Permit for .ADD GARA ........Single..Tamil y...Dwe 11irag....................... Location ...2,3.Wintargreen..0 rcle.............. .................. ........................................ Owner Ton,ass..Vengrj&................... Type of Construction game Plot ............................ Lot ................................ Permit Granted ....DW...15*.....................19 84 Date of Inspection ................................:...19 Date Completed IC ��m �J �v`I � Assessor's map and lot number ....... ....... "„7 : iNET INSTALLED IN CoA�� 1 v`51 °'`• Sewage Permit number/,1le r.•. . :................ N�1VI®�`'�'HEN T pTITLE 5 �� ,QQ ®VIROitl�U AL C i 33' _1sTa LE, House number ..........................a.z.... )..................... TOWN 9 ' 2639. 0 YPV f►. TOWN OF BARNSTABLE BUILDING INSPECTOR,. . APPLICATION FOR PERMIT TO ....... F. .�:r..... ............. ` .a ..`e'. .. ../ ....... ....................... TYPE OF CONSTRUCTION ........... J......... ..................................................................... .............. .Us!�Y....�.s. ..19&.. . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information'. Location �. ....... � ................................... .......................... ....... ............................................................................ Proposed Use ... I �1 ZoningDistrict ...................................... •—..�...........:.....................:.....Fire District .............................................. ................................� :. Name of Owner ..... N .S...................... ...... .......... Address, ...o ....�!�!..... .�.............................................. v. .. TTa z.... Name of Builder ........ ...ro�.ry..... .4.f ..l..Q.......Address ..... .7...�6.1.�1 0° ............. /.� . Nameof Architect ....X!R.:f................................................Address .................................................................................... C Number of Room'' Foundation /moo v�'e Exterior �l ..............................................Roofing .........../../....fo0�.,.... ./......................................... ..................................... ........................................ Floors f ........Interior P ezka......... ................. . Heating ......... f. ..a.N.. ......................................................Plumbing .. ....... . ................................................. Fireplace .........:d.... . . ..Z........................................................Approximate. Cost .......... ..�� ............................... .... ..... ..... Definitive Plan Approved by Planning Board -------------------_-----------19_______. Area ......r,��. .- '........'.... Diagram of Lot and Bui'I'ding with Dimensions .......Fee �! 176, _. ...................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ......v...... r..........:� ... ....... oar � s' y Construction Supervisor's License .................................... JONAS 26439 ADD GARAGE /PO11ZCH No ..,�............. Permit for .................................... ........................ Location ..23..Wiabergreen-circle................. Osterville ............ .................................................................. Owner '.Jonas Vengris ................................................................... Type of Construction ........Frame....................... .. ........ ................................................................................ Plot ............................ Lot ................................ Permit Granted ....... "aY..15. ................. 84 Date of Inspection .............1 9 Date Completed ........... -.,P..................19 f �dd qe VV a' f � A ® 8-6" a ci vx lot 16.S Ct Y JgxQ,Y- = 0K.e Sq.��� r ' I I ' . r 1 I t �r to 57 � � ,°°.S�era g Z a`J q ¢, ct y«f �p q e J ro O 702 O� • CJ P � �►I ,,fi�rr.. , • _, �. . r!Od ih enhGY4cs.. �oeYl . 1.. r. • r r t i TOWN OF BARNSTABLE Permit No. -------------------- 1 UUn.n Building Inspector y►' Cash - 0"& —-- �OA Ypa. _ [ OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to JOtlas Vei-1911 Address Aituier'st: is- Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ..................I..........................7 19......__ .................................................................. Building Inspector :lGhl UC GAG-'Et.�L.� vRt�i•1Z. /�51;� � \ USG•OUS` ���•�- tic) +� 3 L ;�G 6.P.L7. r l��•Gl tpp'/o TA,"k = U Ste- t ooc� d4,L- w� 41 �15POSA1. PtT - u`,E to Ulm,=c 3.SG� - 4 r-;T" r(QLVA�L AV-c--A. : t 3 Z S;z- pry r bar �32 sF 2.s : 33 d &-P-.L BVT TD,A C121:A 3 $F ti�►� � t .o = 1 13 'a.p.D. . . /ooa GAS �t 3� ..�'. ,� � SST,7►K•t Tt>To t_ !'7 �g,Q q� �� PMOCOL&TIO0 VATE : CIQ IMI u orz nk tr V CIF x 4L�ii rV b 1 L,do.o t�iii��. -• tuV Loi►M � F��o�.-- I oc�o � ',rs saes• .�c,< 4'PPEs Tom. � 1�v. �',.AL. 1 ,Gli3 ... • fox � q�.0 ScQnC �o' �; I wtru •� Wt"SNCD STO E_ 0. Sl 4 CEG'Tl�=!GL7 _PL.b-r �j #' r � p Qc>tC-��/I LLB� �h�• 14 � Tt-(!' 7 114C- �OUh�/�T10N 5l-to-.ut.) �?t_!�!J �Zi_i-�.'c►�TG� y CL"t�Ttl=mil - c VJ ITt-k Tl-li=: >I l7E L11_t� � awn ScTt�,ncK i'c4uc�C��-uTs o� Tµc:. - ovi Li` ot= Rv pti�1�5 C3 C�-Pro Z,-*< Z eo 11 to - tzac, e; r-,co i r1,4tt� 5u2v:=Yd� Tt-Ats IS "OT t'.0�c_t� v�•-t A�J �� IWSf Ctl.v�t-t.t; �,uc,�ir_�{ Tt1 c�FG% �< <,t•Ic,t�t� - A.PPt I -r .Sow .QLerc. gutt. �__ .l-'�Y' C',t� U•',Gt'� 1-�.► 17t�1'Ct�h{t:;l".y 1_O'T' LI.Ni�•>' - . -r IIet- r's map and lot 'number .... ...... PLO* TNE S6Woge Permit number.. .............................. 'SEPTIC SYSTEM MUST It 33AR33TA.BLE. House numb& .............. A.:�...................................... ' NAGEL • 'INSTALLED IN coMPLIANd 1639- 0 TOWN OF BARN' T AND REGULATION S BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... cue, . ..........................i�f.................................................... TYPE OF CONSTRUCTION ............ ................................................................... .................. TO THE INSPECTOR OF BUILDINGS: -4, The undersigned hereby applies for a permit according to the following information: ,-0, -Location ........ e ev C..u..0.../t................... .5.....0. .......................... Proposed Use ..........P.. Zoning District ...... RC..........................A..........................Fire District ...... A16US Name of Owner NT,e�.Q.(5....110 41 OA-/5 4�w e- A............... ......................Address i?..74 .......................... Name of Builder ... ...... .... . .....................Address Name of Architect A,1�0?j..... ...............Address 02.59-1 Number of Rooms .......... ...................................................Foundation .... �4 ............................. . Exterior ........T-.xa......................;..................................Roofing ........1114" ................................................ 0 Floors ...........nd-k....................... If- / ......... ......................................Interior ......... .........0—............0............ Heating ....... ........................Plumbing ...................0....................... Fireplace ..........awe. .. ........................................................Approximate Cost ....... ....................... Definitive Plan Approved by Planning Board ----------------------------- Area lit.........lq .o 66 Diagram of Lot and Building with Dimensions Fee ................................ 7' 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. Name 61 VENGLIS, JONAS r- ' � �2699 No ................. Permit for .QAQ..1/2...S.tD. .v. > ....... ..ingle„Fami.],Y..A �1 .�x1g. ............ ' � � r Location _Lot `2,-23 T+Intergre� •••Gircle Q � . Osterville r Jonas Ven lisp• Owner ..........................g...................................... r Type 'of Construction Frain i Plot ............................ Lot ................................ 1 As November l 2 5 ' 8 0 ` .r Permit Granted .............. 1�1�/..�;....!.�19 Date of Inspection .../. .......................19 -� Date Completed .. 19 fit, r i Y1i PERMIT REFUSED 1 . ............ ..a — .:. .................... ....•! 119 1 J ,,4' r �r /� , ' , J1 • ���I ............. � i ,�� , � J• Approved .:.............................................. 1,9,•� # �f' t .. ......................................................................... .................... ................................................... j. Assessor's m'p and lot number .....�� ..... J �*THE, WA t0� Sewage Permit number ' ..' . ......................:.....: l EADTADLE. % i House number ..........:............... h.;.:3 BS ............`...................:.....:' 90 rasa O i639• \0� r' �o MA-1 a• TOWN OF BARNSTABLE BUILDING , INSPECTOR' ,..,.. .C r CJ Gv //l eU J APPLICATION, FOR PERMIT TO ..................� .....f��'�..............................�1..................................................... TYPE OF CONSTRUCTION ........... .. 4...9...............!........�................................................................................ .................. �.�!'..! TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: cZ R/ /( / Location ..�'d.............. / �eFC�.a ��' P�/ 1. 1 i- 5......P...................�, S , C' (! r.?: F....................... .... .. ......... we Proposed Use ............................,................................................................................................................................................ n l Fire District �.,.�'?{! �t v/�� Zoning District ...... ................�............V.............. / Nameof Owner ........�....../...?...........................�.........................Address .............�....<... � f Name of Builder ... ✓.!� ?. .... u !1...?�'...................Address / '0••C;d '!d'.. /. !J�/ .............................. . O/,U,.. !... �'fc/ $ i �a s �,�a ..... . `^ v �n1 n> .a �� h..& S i' ' �f Name of Architect ...............! ......... ............... Address c1..�.. �..... ................................ �/. �.. /dim. Number of Rooms ........J� /V— .........................................................Foundation .... .................... .....!`'....;...............�............. Exierior ....... ... .! . ..........................................................Roofing ..........�:SSA//cY.; ........................................... Floors ........... .............................................................Interior ......... Heating ....... ........................Plumbing .... ....................................... Fireplace ..:.......f r!! .�...........................................................Approximate Cost .......`�`.U....... ,,��......... c Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area �s.✓............/...6..6.............. 61 Diagram of Lot. and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH Tv� 1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. .... �..... ..i ;.......�.. .. ....�....:„.. .-..c.r ..1-_ ...,:.J.. _...:.1�, ...:......:.... ..-__...:....;-...-.�......... .� ...- .._'A..._. .,., r ..._.�. .. ..... a ...3i.-..e..I�..,.. j'��' 4� ...�g'./�. - . p ... .. * / \/ENGI,IS, JONAS 119-63 �369� One 1/3 Story . . . ' prn � for ----..`----`- . ' ` .............. ' | _ _ g.4; ��� ...Cirole ` ` {}oterniA- le ' --------------------------. / � Jonas �e I�s Owner -------..���-::�--------- ` Typo of Construction ' ^ ` Plot ^ ' � 0 ' ,arm/, Granted . � , . . ' � Date Completed ^ ` . , . ' � ' ' � ( � . � � �E/MIT RE USED ` � .............................. ........ � ` ......................... ................ . . - -~.---. � ' ____,.. ----. ` ' ' ' ` Approved -----' --------- lQ � ' J � ^ ^ ` ----------------...--------. � ^ ' ` -------------------...---~- ' ' | TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION IIrr /�\\ Map �4 Parcel r)r�3 Application # 6 '1 U 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 Z.3 ..� • ,.>Z�Z�� .� L' .�Z Village r�:c--a . ... f Owner Address ',�I o \.S\3 Telephone zdz - -z-.\.o - Oky%-\ v . .��, vr� Permit Request \ l=6.,Vs �O b�C E.v P�'��'♦ C, , Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District 4 Flood Plain Groundwater Overlay Op v ` Project Valuation Ioe>. 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 t��t Historic House: 0 Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other a o 0 Basement Finished Area (sq.ft.) Basement Unfinished Area (sq) �-. e z Number of Baths: Full: existing Z new Half: existing new o Number of Bedrooms: 3 existing _new Total Room Count (not including baths): existing (o new First Floor Room Count j Ln Ln ;o 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 ❑ i Commercial ❑Yes ❑ No If yes, site plan review# 6,4urrent Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number soB- Address 3it- License # Home Improvement Contractor# \.Z Z S Email Worker's Compensation # t_o �L N ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE A i FOR OFFICIAL USE ONLY g'APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE ` OWNER. DATE OF INSPECTION: FOUNDATION. FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING S DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(-Business/Organization,-individual): 0onserVislon Energy Address: 376 Route 130 Suite C City/State/Zip; Sandwich, MA 02563 phone#: 508-833-8384 Are you an employer?Check the appropriate box: Type of project(required): 1.E## I am a employer with 8 4. ❑ 1 am a general contractor and 1. 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers' comp, insurance, 9. ©Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L0 Plumbing repairs or additions myseif..[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required,] "Any WeStll2ri�tiOn •Any applicant that checks box#{1 must also fill out the section glow 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 lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I aria as employer that as providing workers'compensation insurance far my employees Below is the policy and job site information. Insurance Company Name: CS&S/WORKCOMPONE Policy#or Self-ins, Lic.#: 6011316349 Expiration Date: 03/11/2015 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 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 hereb fy der th ns nd penalties of perjury that the information provided above is true and correct. Signature: Date: — `g Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector 6.Other Contact Person: Phone M r.� CERTIFICATE OF LIABILITY INSURANCE OAT 0311712014 319 1171 7120 9 14 4 THIS CERTIFICATE IS ISSUED AS A(MATTER OF INFORMATION ONLY ARID 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: H the certificate holder Is an ADDITIONAL INSURED,the policy(ies)roust be endorsed. N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certaln policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder in lieu of such endorsement(s). PFUMCER - - - - CONTACT CS&SNYORKCOMPONE NAM` ROM PO BOX 9465M uU .Ex* to no): MAiTILANfl,FL 3ZM4580 Ems__.. Phone-877-724-2669 ADDRESS: Fax-877-763-5122 (NSURER(s)AFFORDMG COVERAGE NAM g INSURER A:Continental Casualty Company 20*13 INSUR20 INSURER B: CONSERVISION ENERGY 376 ROUTE 130 INSUREP SUITE C msuafR a:CorU�Casualty Company g6643 SANDWICH,MA 02563 INW RERE.Continental Casualty Company 20A43 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS iS TO Cva"'Tii Y THAT THE POLICIES Of MSURM4CE LISTED BELOW HA'VT BEEN ISSIUM TO THE INVvREO t4Ai EO ABOV'E FOR TN ?OLJCY; Fr=1NMICAT I),N0�.9THSTANDi.G 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 POLITIES DESCRIBED HEREIN 1S£i;B+ECT TO ALL THE TERMS,EX.0 ISIOMS AND CONDITIONS OF SUCH POLICIES.LIMITS Sl OVM MAY HAVE aM REDUCED BY PAID CLAIMS. ADOL VIBR LTR TYPE OF INSURANCE INSR W VD PaUcY t umal:R M61/CD LII,UT£ GENERALL►ASIUTY EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED � CLAIMSA4ADE ®OCCUR PREMISES(Ea occun 300,00 enca) 300 000 A Y N 6011316335 03/11/2014 03/11/2015 MED EXP(Any one , PERSONAL A ADV INJURY $1,000,000 GENERAL AGGM1REiaATS $2xQ GEN'L AGGREGATE LIMIT APPLIES PER: ------ —--- POLICY -- PRODUCTS-COMPWA13B $2,000,000 JE¢ rul LOC A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $1,000,000 (la ecd0em ANY AUTO L'4DIL'Y 1N fURY(Per L`o*=•: A OWNED AUTOS N N O 1316335 03111/2014 0311112�015 rsDi3ur INJURY(rcrar�asmj ")RED A'STQ5 ALIT D PR',DA�RTYGA„;A�. (Per aocww) UNBRELLA I'AB OCCUR EACH OCCURRENCE 1,000,OlIO D MMESS UAB HCLAIMS-MISDE N N 60`11316352 03111120% 03/1112015 AGGREGATE IDEDIXRETENTIONS 10,000 WORKEmScO FENSATtON Y:CSTAT.I- OTH- ANDEMPLOYMMUAB/UTY Tf�YP iI6,r TS I ER ANY PROPMETORIPARTNE VEXECUTtVE YIN E L EACH ACCIDENT $100,000 E OFFICERIMEMBER EXCLUDED? N N 6011316349 03111120/4 03/1112015 (wmwory in NM) E.L.DISEASE-EA EMPLOYEEIf yes.descAbe urmkw $100,000 DESCRIPTION OF OPERATIONS belovr $500,000 £.L.DISEASE-POLICY LIMIT OESCRiPTK)N O`OKRATIONS l LrJ-AT S I V£."JCS$4A."m c t ADD 101.Add' !R-a*s$4 a i IAe,iir.v--e spam i5 d) Certificate Holder Is added as an additional insured as provided in the blanket additional insured endorsement. CERTIFICATE HOLDER CANCELLATION .Rise Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1341 Elmwood Ave THE EXPIRATION DATE THEREOF;NOTICE WILL BE DELIVERED IN Cranston,RI 02910 ACCORDANCE WITH THE POLICY PROVISIONS. ALITIO tZEDt?E?PESENTATPE ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 t20101Q5) The ACORD name and logo are registered marks of ACORD CaoMScs r .. i + ' `IiB l,^Gt%riftl�iNnZJ!�r�r(�-f�st+ttttatiel{„ --^---. ` Osiier u€C�asutnee�Tt�trs&.Rnstaess Re atstiae Licinse or registration valid for individuf use only - ME fMPROVEMENT CONTRACTOR before the expiration date If found return to: lstmtlon: 171251 Type: Office of Consumer Affairs and Business Regulation expiration: 311/2016 Partnership 10 Park Ptaza-Suite 5170 Bosion,M4 02116 CON- Cr:1fc ENERGY COMOR MCINERNEY 3 376 ROUTE 130 SUITE C SANDWICH,MA 02563 t;adtrseeretury Not valid without signature Boat'I its B ieicwng P=egutatianis_ -Trd Startdaf*a COxOR m MCA"MY. 39 SIASCONSET.MM SAGAMOR€BEACH NIA 02%2 MIA% fAPARVWS6 mass sale -�- PERMIT AUTHORIZATION FORM 1, yXI' 4-0 �,�5 ,��. i/ L G , owner of the property located at- (Owners Name, printed) (Property Street Address) (Cityfrown) �,� �'g_ ♦,�'6 g ` hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and.obtain a building permit to perform insulation and/or weatherization work on my property. O ner's Signature Maw FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Dome Energy Services Participating Contractor to the above referenced project: C-C►r;5.t-c'LV, �J (-- — nn Participating Contractor Date Rev.12132011 , Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee , Q anxxsrnsi s ��. 1 ,��' Richard V.Scali, Director QED MA'I p Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAHT APPLICATION - RESIDENTIAL ONLY t Map/parcel Number oc (�Not Valid without Red X-Press Imprint -1 I Property Address 3 A,.i W)�e� W C . 2U1 , 0 S k c� 0&Residential. Value of Work$ I S6, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address u QW q vt,�%S Contractor's Name.. 1�n�r�,r - i' Telephone Number Home Improvement Contractor License#(if applicable) L- I. , Email: Construction Supervisor's License#(if applicable) L5—L 7-3 ❑Workman's Compensation Insurance Check one: OCT 29 2014 I am a sole proprietor � I am the Homeowner TOWN OF BARNSTABLE ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate,must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is - required. SIGNATURE: 4�v� Q:\WPFILEST0RMS\bui ding permit forms\EXPRESS.doc Revised 061313 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ ,S Address: City/State/Zip: sPhone Nab Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑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 3.❑ 1 am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp:insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: c�d� tV i w 6•1-{a hiLPy✓ City/State/Zip: 10 S5f r.il;I Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. - I do hereby certify unAer the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: P / Phone#: — Official use only. Do not write in this area,to be'completed by city or town official City or Town., .' Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department J City/Town Clerk 4 Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• P Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more;than three apartments.and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state onlocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the . applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. . The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www-mass.gov/clia i Y �L tHE T i • BARN6TABLE, • 6_19. Town of Barnstable T�' �• Regulatory Services Richard Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,"MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder r d �ol(S Ve V- 1 4 /S as Owner of the subject property hereby authorize �8�� w S "\ to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job). Signature of Owner Date Ve 1�A-Zc'S Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:IWPFILESTORMS\building permit formAsmokecarbondetectors.doc Revised 050412 i e o � 9 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Cnnstrurtion Supervisor I & Family ,N ` License: CSFA-057394 i ROBERT G WAL5-H' VcN-' ' 1111, 160 HIGHLAND AVE; r Cotuit MA 02635� t Expiration Commissioner 06/02/2015 Office of Consumer Affairs&Business Regulation I License or registration valid for individul use only s— @OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 141991 Type: Office of Consumer Affairs and Business Regulation y7Expiration:...3/3/2016 DBA 10 Park Plaza-Suite 5170 _ Boston,MA 02116 HARBORSIDE REMODELING: ROBERT WALSH 250 CAPTAIN CROSBY.ROAb" CENTERVILLE,MA 02632 Undersecretary . Not valid without signature i i I 4 ConzarWdon 05 ............ h J.r• ............................ 11/14/14 Thomas Perry, CBO Town of Barnstable Building Division 200 Main St Hyannis, MA 02601 RE: Insulation Permits Dear Mr.Ferry, This affidavit is to certify that all work completed for insulation work at 23 Wintergreen Circle (application#201404434) has been inspected by a certified Building Performance InstituteABPI8 © Inspector. .,�, zE t toy': All work performed meets or exceeds Federal and State requirements. co 'X- Sincerely, _. .. Donor McInerney ConserVision Energy 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVTODAY.COM