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HomeMy WebLinkAbout0010 BOXWOOD DRIVE foxU)Ooc fir, OxfordNO. 152 1/3 ORA ESSELT 10°io 1: •�i t ......�e.�n�..... - 'lw..•.eaw.._._,_..�i..e..w.r.,r.......�.a:.Jew....__....r..rn.ub�.vaYY11Y146s.';ar✓..e' ��tl'6� i:.was e.� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r 1 Map Parcel Ap, li at"i n #Health Division - Date Issued Conservation Division ; Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Projecttt��Strgpt Address I. r� if Villag 1 45 Owner --JPKK wrl Address Telephone 41 q1 IP Permit Request -K A® h .11jb ° ..Square feet:. 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay J Project Valuation Construction Type . ra'!�'"�� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sLFpp"orting do",dime ation. Dwelling Type: Single Family J21� Two Family ❑ Multi-Family (# units) CD Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's?Highway: &-Yes=, No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other = ' -.a Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new CD 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 U new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Aut horization ❑ Appeal # Recorded ❑ Commercial ❑Yes ®/No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Q Name �� Telephone Number , Address `��'(,G�U�a L� License#' too F Home Improvement Contractor# Email Worker's Compensation # W 4y�2S, ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL B TAK N TO Z�z IV SIGNATURE DATE 1 I FOR OFFICIAL USE ONLY ^APPLICAT,ION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ; 1. GAS: ROUGH FINAL = FINAL BUILDING DA X LOSED OUT' '` ASa0' ION PLAN NO. commonwealth,of Massachusetts Class A.Large Capacity License to Carry Firearms(M.G.L.c:140;§131) License Number. `Date of Issue pira6on Date" 12496974,A 01IA612014 �1(2U19 Issuing.pity/rown: `AARMOYTH t. - Restrictions:None , CASSIDY "ENRY 4 8 SHED W6W, WEST YARMOUTHA 02 3 t I � L w QiC•(l/C'Cr116 , c J Okt-Ice of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 l J'on-ie Improvement Contractor Registration Registration: -153567 Type: Private Corporation Expiration: 12/15/2`014 TO 233831 CAPE COD INSULATION, INC - HENRY CASSIDY 18 I;EARDON CIRCLE SO. YARMOUTH, MA 02564 __._.-..__..._..._......_.___-._.__.... .__ Update Address and return card. Marts reason for change. L� Address [-I Renewal Employment I Losl(:iu•d ��r �t`(", iir.iirnii flr'rrll� 'E I.' Oflirc„i Consumer Affairs Business Itebulurior, License or registration valid for iudividul use only - OMt IMPROVEMENT CONTRACTOR e expiration befure the date. If found return to: i� m e istration: Office of Consumer Affairs and Busincss lie gelation y ' 1.J3567 Type: 6 IU Park Plaza-Suite 5170 Expuaaon: 12/'15/2014 Private Corporatic•n Boston,NIA 02116 k.--Wl 'COI)IN;iULATION,.Il 18 RLARI:)ON CIR(:L.E .;,O YARiN101.)H'1, NIA 02664 —�� --——Ab ' - - •--- ----.__..-•-----_..__...-- _ Uudersecrerary witho t ual i'C The Commortwealth oft'klassuchuserts � Department of Industrial Accidents " — Office of Investigations 600 Washington Street �* Boston, MA 02111 www.rrlass.gov/dia Workers' (::ocupetisation fusurauce Affidavit: Builders/Coatratctorsf.Eliec tric:iaUsYP III III belry :aI,l11.ic:ti1rt '<nforliyatiou Ptetuse Pri.ut Legibly \,,li[c �1at�,inc��/Orbattirzttiot>/Lvdiridtutl): �r•/ �� C/ /. i its'?Jtatc/?:i� G% ==)r'!i/i�> >.�TIG /Ji y, ` PYlone#: L 71-7 J 2 Z/' .[c you 412 ett►pluyt ir? Check the appropriate box: Type of project (rccluiretl): f .� au , ctiipluycr witlh._ ,? 1. ❑ I am a Seucral contractor and 1 ern Flu ccs hill ttncl;tor xr t-time have hired the sub-eonir ctors 6. ❑ New construction l Y ( o p' ). listed on the attached sheet. 7. ❑ Remodeling L� ! :utt u sole proprietor or partner- .ihtp flit/ huvc no C11lployCC9 These sub-contractors have 8. ❑ Demolition wurkutg for me Lin,any capaciry. employees nd have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.[ 5. We are a corporation and its l0.❑ Electrical repairs or adchtiuus n;yttirt d:J � , 0 I am a horneownnr doing ell/ work officers have exercised their J.1.❑ Plumbing repairs or additions 3. 1nysclf. [No workers' comp. right of exemption per N1Gi. 12 ❑ Roof repairs I isurA.ncc rcqulrcd.] t c. 152, §1(4), and we have no t.�J I ata a hoatcowncr acting as a employees. [No workers' 13. Otheru �encmt contractor(refer to #mot) comp. insurance required-] 'Ally JI)JAIt::wt dint Checks box tPl must also till out the sccnoo below showing theirworkcn'compcnsudO jwlicy infomwdon. Flunivwucts who subri: t this affidavit iuWcating they arc doing all work and thcn hire outside contractors must submit a new atlitLt tit wdit:ating ouch. i uuu�:wra that L:hcu:k this box trust arwched an additional sheet showing the oama of the sub-coutrnt:wtA and 3Luw whether or not[host eulinca have .:mployccx. If We rub-contractors huve crnployees, they must provide their wurkct-3'comp.policy uumbcr. ! urtr w cayloyer that is pro viding workers' compensation insurance for my employees. 11'elow is the policy and job site nfurarulrurt. IOSUL t.ILC l:uutptuly NW11C: Policy if or Sclf-iris. Lic. #: I'L �l]4, L @5 ExpirationG>�ty ii City/StateJZip: - ZUh '' .vn.cu x.cupy of the wurkers' cotnpeasation policy declaratiun page(showing the policy atAmber and expiration t1; c). 1:.ultac to ,ccurc,coverage as required under Section 25A of IvIGL c. 152 can lead to the imposition of cruninal pellahics of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine 01 up to S250.00 a day against the violator. Bc advised that a copy of this statement tray be forwarded to the Off of 1-nvcsnS4Eiot1x of the DIA for ul t.trancn coverage verification. 1 du hereby certify; muter the oir gnat penalties of perjury that the information provided above is trite nut correct. y � � Qdlciul ate only. Do not write in this area, to be completed by city or town official i t,'ity or 1'uwu[: Permit/License# — — l'i[ttng authority (circle oat): I. /lour[/of Health 2, Building Department I'City/Y'own Clerk '4.Electrical Iuspector 5. Plumbing Cnspector 6.Other l'untuct fenoa. Phone #; CAPF-COD-27 MYOUNG CERTIFICATE OF LIABILITY INSURANCEvvvvl HACA'l I-: IS I L)SSUE AS A NIATTE 'R OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 1-FIE CERTIFICATE 1:10LDER.THIS DOES No -i" AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVI:;RAGtz- AFFORDED BYTHHOUCIES utl.uV'1 IRIS CERTIFICATE- 01: INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TI-I-E ISSUING INSURER(S),AUTtIORIZED 11'I-PUi:.SLN'IATIVE ORFIRODUCER, ANDTFIE CERTIFICATE HOLDER. JticSUBROGATION ------- It Ulu cuti -1.k7t lic)ldur i.-3 On ADDITIONAL INSURED,ilia policy[ieti)IlItIst bc,011001'SUCL It SUB ROGATIO NIS VVAIVI�D.5iibltict tu OIL (Vill't, Jns Ulu Policy, certain policies may I-equiru an onclorstinient. A statement all t1jiti cul-tificite I.1cles licit cuntvl I'll 1115 tullio •"'rlll"ttu IIIJILIVI lit HULL CAI fall ClOrSe 111 eilt Lit ulrlu It I:,C--Sl4Q62 CONTACT NANiE, �atalet ot1c___ ..­.__._ .­­ A( um:y, 111c. PuONR FAx 1 Kw I.i.i JA611—C. 0 E� PiUk 02660 E'NIAIL ADDRESS,111YOU11C] rogertigraV. .com INSURERS AFF ROINGCOVERAGL-: NAIC 4 INSURER A:PEERLESS INSURANCE COMPANY MSURER 0:COMMERCE INSURANCE COMPANY k­II1V k,;kAl lWWRCR C:Eva nstaii II"ISLII'ZtI1Ce C01111PA11v Hf Ro'll"doll cilvl� INSWERD:ATLANTIC CFIARTEI� INSUI:ZANCE G ROUFI suuUl Yzilf"101.4 U IVIA 0266.1 CERTIFICATE NUMBER: W_�VIS(01\1 NUMBER: TIIAI' I'[IE POLICILS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED-1-0 THE INSURED NAME H'0 ABOVE 1`01-1 TFIE PLA.IC.Y l L.IIIU0 cl "J(!, 1,10 I*VVITFISTANIDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITFI I-`<L,'jIJCCI'10 WHICHINIS 11,11-Al L NIAV 13L' ISiPED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS'SUB.JECT TO AIJ,11-IL TERMS. 0:41 IN'.,ANO CONC)I'l)ONS, OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 900C SOOR INWEK ILWao 1-11411 S AuIiLl Mil FOUCY NU -1-yru jhItAmillyyyyj EACH Q(CUI?RL:NCC A UI::.NERAl_LIAUILI I'Y CBP6263063 41112013 4 Pl 4 Y, MHO FXP(Alw bio AIM',MALk.. I-ERSONAL ZI,XIV INJUIRY I, 'I ODU,UU GENCRAL AGGREGATE Ii ............. M k-�klL:I(MII'API"L.IL'S F`Lti 2,000,00 000 rut Ik'I 1 1.121:1CCIL I-L-1-LOC 551_A'G CE-C.I M I T ea nca lulu_..._...._.................... 13NINIBCKvmK 41112013 41112014 BC)DiLYINJLII',Y(I'di'poitia(l) 1i x SCHUL)ULED 1100ILNINAIRY(P-A ucCJdQIIk) _A`C3 x NONADVVNIZ0 A ALITOS FCA M_....... ........... I A I JZACII OCCURRIENCL XON,1453512 '11.1120,13 mIll/2014 AGQR LGAT 15 CLAIM.-NIADC. '10 000 W­ 0. L fkafl+ Y I N WCA00525904 6130120-13 6130P20U F.L.e,,\CFjACCioF-NT $ N/A E.L.DISEASL-12A I;MPLOYI' $ it,NH) ---------- I."' 'EASE.'-POLICY LIMIT .1,000.0m i­-01`i�,IIA I(UN6 .......... Comj­it�.jtimi inciticlot; Officurs or Proprietors. 4LUI.Lls it. I.1I'0VidU(I LIIILIUr the'General Lldbility when fe(ILlited by wrilLeticuatract or agreement with the Cel'lifiezAto I-1011.101. Xrd 11 It:A I t: I-IULDl:::R CANCELLATION ................ SHOULD ANY OF 1'HE AROVIR DESCRI0L-0 POLICIES OF CANCIzLI_LDUEr0IIE THE EXPIRATION DATE; THERQ01', 1\10'1'lCj� WILLDELIVERED IN i�alj,; Cod lllt:ikll�Ltiull, I(IC ACCORDANCE WITH THE POLICY PROOSIONS, AUTHORIZED RPNICSPNTATlyl! ............ (5-N88-2010 ACORD CORPORATION. All rights 1,11501`11011. ("o 1 u/u5) The ACORD'name and logo are registered marlis of ACORD Ci Housing kill Assistance Corporation Cape Cod HOME OWNER WEATHERIZATION WORK PERMIT & FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM 1F YOU ARE THE APPLICANT HOME OWNER. of "L°j� I r i hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation (herein after referred as "Agency') on the property located at: Z> -) The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping &caulking of windows and doors, insulation of attics, sidewalk& basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home I agree to the following: i 1. I give permission to the"Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. Home Owner. (Signature) �... Date: e 4 11AV)Agent. (signature) Date: 3— HAC approved Weatherization Company : (-gc �✓t ��o - All Cape En y Cape Cod Insulation pe Save Efficient Buildings,LLC .Frontier Energy.Sol.utions. Lohr.& Sons ..Resolution Energy Shed 0 TOWN OF BARNSTABLE Permit } BARNSTABLE, 9 MASS. 1639. 1 3�pie Pern:it Number: Application Ref: 200701921 20070734 Issue Date: 04/10/07 Applicant: WHYTE, MARGARET A Proposed Use: SINGLE FAMILY HOME Permit Type: SHEDS 120 SQ FT & UNDER Permit Fee $ 25.00 Location 10 BOXWOOD DRIVE Map Parcel 216063 Town WEST BARNSTABLE Zoning District RF Contractor PROPERTY OWNER Remarks INSTALL AN 8'X10' SHED Owner: WHYTE, MARGARET A Address: 10 BOXWOOD DR W BARNSTABLE, MA 02668 Issued By: )L t W.S. T E.:FR. .... . . .. ...T T..Y 4 ...... R ...............................................:.:.:<.;:.;:..:.;:.; ............. ... .. . C ..... .....SO... .CIA..... .5...........5....... ......... ... ............................................................................................... ..:............... ............... �'.O S.. ...'>c. S.... . ........................................................................................................:................................................................................................. .. .. .............. Town of Barnstable " CF fNE Tp� �P� tio Regulatory Services • Thomas F. Geiler,Director MMSfABLE, 9� MAS& �0� Building Division 39. ° Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www,town.barnstable.m a.us Office: 508-862-4038 Fax: 508-790-623( I _ PERMIT# �� !�� FEE: $ SHED REGISTRATION 120 square feet or less D i>A s+ -e ��}- Location of shed(address) Village Property owner's name Telephone number Size of Shed Map/Parcel# . 0- Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) t Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. c THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042506 RPPU4c ion to, ` Old Kiii s Highway.RegionalRis ric District Committee in the Town of Barnstable for a CERTIFICATION.OF EXEMPTION Application is hereby made, in triplicate,for the issuance of a certificate of exemption .under Section 6 and 7 of Chapter 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans, drawings,or photo- graphs accompanying this application. . TYPE OR PRINT LEGIBLY DATE —©7 'POOL, ,1 13ooK IS � ADDRESS OF PROPOSED WORK Y x 10 l OO L Td er ASSESSORS MAP NO. P6 I13.3 OWNER A R-6 A 3Q 4' T 19 U1) t4 X T—f-^ ASSESSORS LOT NO, / HOME ADDRESS �n:CW� d D � �.�lIP� TEL. NO.`L° 6-a -L/ AG ENT ORCONTRACTOR I'dA:1 5 5 del"'rL*`� ADDRESS �S.)D I�cLI IMn�7%H 17'2 TEL. NO. S This application is for exemption of proposed exterior construction on the ground that: ❑ (1) It will not be visible from any way or public place. ❑ (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission. (Check applicable box) PROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot,and, if an addition is involved,show ing location of existing building. Q y� v /` 0 T-e)o� ,� � lL �Ft-60(R -"4 �.V?£R to 0— �s, FI. C_0Wc-AE 1"r, 13AILK -5 eV,-A,tJ/ I PV-14- 4 )t t/ kPssv-3q £ rip-c1a'mI' 1;( 'Q%3.tutAA`Roiv 1i3eQw15 / R6oh Q 1YC "7'iRVSyeS 14" CA-1 LeA1T e� Se l . Jeq Ii�q Jig pLltc�(4 S'L�I1N,�t&S -- rZq Y w(itl$ VA -yC,oOe) 0 W i'TE->y . v,w y _ C/Qoo rlr� S lb,NS Yv►a Te_fP caLorq 6^fT SIGNED Space below line for Committee use. . 9�4ner•Gontract r-Agent Received b(y�.H.D.C. _fig j� The Certificate is hereby D E E 0 W E p r`1 T B T Date '4_9 A HISTORIC_ PRESERVATION Approve d ❑ The categories of work entitled to exemption are listed on Disapproved ❑ I the back of this form. F?J Engineering Dept. (3rd floor) Map v2 Parcel 3 Permit# 303�3 House# �� ��J Date Issued 'a2�—��' Board of Health'(3rd floor)(8:15 -9:30/1:00-4:30) `-77_7 7 /- Fee Conservation Office (4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) � 'O'q• Definitive Plan A d by Planning Board 19 BARNSTABLE. N O RNSTABE Building Permit Appli tion Project Street Address Village ct Owner �oF}N �1 tN is K� Address /U t3ox4Vo�t7. �, P_1VP Telephone Ce - g nn - � Permit Request c� '�Y til� / env► 1 [ �' w� %'-,1� -Tab�L i oo N2, �x t 0 0:1 , ►vrC First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ e3 "-Z) Zoning District �� Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name 44 yyL-�- ,i2,- Telephone Number J� cr._ Z ` ,Y Address 1��4, 3oy &s 1P License# (f S 0695_0.S 5- ✓ iou7�-� Home Improvement Contractor# %/ (v 4/ Worker's Compensation# Ul(f. 6 3 ILLS NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO i i SIGNATURE DATE C�/ G Q BUILDING PERMIT DENIE FO THE FOL WING REASON(S) 1 , ``. &r �► FOR OFFICIAL USE ONLY PERMIT NO. _ DATE ISSUED • `"' MAP/PARCEL NO. ADDRESS VILLAGE ♦ram OWNER f - DATE OE.INSPECTION: r _ FOUNDATION FRAME w ,, INSULATION `� { FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL - FINAL BUILDING `�✓ 6 DATE CLOSED OUT ASSOCIATION PLAN NO. The Town of Barnstable Department of Health Safety and Environmental Services rEo ► Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissione For office use only Permit no. I Date ' AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion,rimprovement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work• iec � Est. Cost �Address ofWork: /O %�c�y GU/so Owner's Name �o ' Date of Permit Application: 7'�3�< O I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HONE IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contr ctor Name Registration No. OR Date Owner-s Name f - i The Commonwealth of Massachusetts .--:�_, Department of Industrial Accidents ONice of/nsestigaGons " 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name: location: city phone# ❑ I am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity /am an employer providing workers' compensation for my employees working on this job. �compnnv name: lvox2 C -,- addressr��13 b y �ttv Jr (��®��OG ` � phone# ����7Z 7 7 insurance co. h�' 10/1/ Zy56f !1/Ct� �/ olicv# Cl I am a sole propn or, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: ... city _phone#: olkv# iiisurnnce co. cam any name: - address: phone#. citV. insurance co.. / j / /. ..//// / /% Failure to secure.coverage a+required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the OfIIce of Investigations of the DIA for coverage verification. 1 do hereby certify tat the pains and enalties of perjury that the information provided above is ttru/o and correct Sipature �" —0 Date / / _ Priat name Phone# Ec.ntact ly do not write in this area to be completed by city or town olIIcial peemit/license it ❑Building Department ❑Licensing Board mediate response is required ❑Selectmen's OPdce ❑health Department n: phone#; ❑Other 11 (re%um 9/95 P1A) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contrac 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 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 c building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h,- not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 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 yoi are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of th 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. The affidavits may be reed io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.. please do not hesitate to give us a call. The Departzneat's address,telephone and fax number:The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imlestl0atlons - 600 Washington Street Boston' Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 r • 1 • RECOMMI�NDE"D MAXIMUM SPANS FOR FLOOR JOISTS 60 TS11 LIVE LOAD PLUS 1:U PSF DEAD LOAD Normal Wad Duration I 1000 Iasi L = 1.,300,000 psi T3'l)iC,'-d Wllues rear SOLI 111L1'il-Yellow fine #2 (I'ressul-C TI'LatCd) Exterior use (e.g. dec:ks.) ,Dist Size - Sl.�aci��� i 2x6 F. W 2x I U 2xJ2 1 211 8-6 11 -7 14-3 17-4 1611 7-4 I U-U - •12-4 1.5-0 2011 6-7 5-1.1 . 11-0 13-5 2411 - G-U 8-2 10-1. 12-3 Design Cri(cria: Strength: - Livc load of 60 hsr I)Ius Dcacl load cal' aU I)sl' I)roduccs hC'ndi119 stress or 1.000 I)si at spans shown. r Nctc: Dcsibii values 'IdjustCd [or normal (iurCitlUll loading. s PLOT PLAN FOR LOT N Indicate location of garage or accessory building Additions with dashed lines --------------- Sewerage disposal (cesspool) Well I (Lot....................ft. rear) — — — — Abuttor's .buttor's I Name lame I Lot N of A Rear Yard �00 � ........... ft. AM If this is a f this is a u 1 corner lot, '�n� write in n-ite in w Lame of Ia2nG Of other street. Sideyard )then street. HOUSE Sideyard _ ft. ft. Set Back .................ft. (Lot....................ft. frontage) \\ // -------------------------(Name—of meet)~ --_---------------- __. 41 / \ Information Supplied by / Mark North Point 1" N 0 0 � • s` � ,,� ��•. ® � 1 ems. ♦ � ° ! � A v � ems`„ �.� �s ► A !4 " Wed Jan 07 13 : 19 :31 1998 page 2 T >: . DA eIAAM! DMfI ?: ACDIED : RT'[ :::I l T 1 ti ' :: ' : `: : .. :oss :::f D PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Drake, Swan & Crocker HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Let's Hollow Rd.,90 Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans KA 02633-0429 COMPANIES AFFORDING COVERAGE saM A Nmeon COMPANY PhamNe, 308-233-3212 FeiNe. A American States Insurance Co. INSURED COMPANY a Legion insurance Company COMPANY Mayne Densmore C P 0 Box 639 COMPANY S. Yarmouth NA 02664 p -0. R v . ���:?>:? : :',•' ? : : >: :: :;;:;:;;:;: i s is :::::::>.:: ::::::::>:•' :i>:>: : ::;:;: >:;i i.`•: 5:>: >: :: ::THIS IB TO CERTIFY THAT THE P POLICES OF INSURANCE LISTED BELOW FIAVE 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 WMICM THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPGOFDLSURANCi POUCYNUMW7t P P DAn(MM/DO1YY) DAT9(M"D/YY) UMRS OiNiRAL UAORITY GENERAL AGOREOATE 1600000 A 11 COMM[RCIAL GENERAL LIAEe ITY CICD467 697 50 07/07/97 07/07/98 PRODUCTS•COMP/OP AGO 1600000 CLAIMS MADE[I OCCUR PERSONAL 4 ADv INJURY 1300000 OWNER'S 0 CONTRACTOR'O PROT EACH OCCURRENCE 00005 PSIS DAMAGE CAM oro flM 150000 MrD w Uu,Y ero venom 13000 AUTOMOWLL UAWLTTY ANY AUTO COMBINED SINGLE LIMIT ALL DWNED AUTOS SODaY wJURr 1 SCNEDULEb AUTOS IPer PenoN MIRED AUTOS BODILY pp��JURY NON•OWN W AUTOS (Pet a yW21Wu PROPERTY DAMAGE I 20AOi UABWTI' AUTO ONLY•EA ACCIDENT 1 ANY AUTO OTHER THAN AUTO ONLY: ............. 94M ACCIDENT 1 AGGREGATE I EACH OCCURRENCE UMPS"FORM AGGREGATE I OTHER THAN UMBRMLA FORM / rLm; RIMU COMPENSATION AND T may"LIAWUTYEL EACM ACCIDENTIi00000 SPROPP&TOR/ INCL NC30116345 09/11/97 09/11/98 ELDLSEASE•POUCYLtdR •300000 PARTNB+BIFXECL1TrJE EL DISEASE•EA EMPLOYEE / OFF�EFO ARE: EXCL 100000 DTMiR Ca ro MOM 011 MN - - - ^--- — CTI i3 I , fts�.•fin,,✓�.':.a.:,,�D�c�.�taaoa�tueQ1 OEPART�N�ENT OF PUBLIC SAFETY LI `� OME.IMPROVEMENT CONTRACTOR CONSTROITIa-,SUPERVISOR LICENSE ;,y,,. R.@9istretion ,416191 r TYpeINOIVIDUAI` -° °r WN-1 Expires: }, �Resdio ee f s �' � DENSMORE.REMOLDING . `Q ;-_ '`:r w 'TAAYNE`R':�DENSMORE NgYN€.,ROE9ISMORE 611ACKBON:RD/PL0. BOX 1313 PO BOX 659' f` ADI �pwoR- MASHPEE^MA 02649 S.YARNOUTH, NA 02664 >"_�`'^. s=,-•. f, 16 ' 14' DOUBLE 2X10 P.T. OUTSIDE BOX 2X10 P.T. JOIST 16"O.C. HANGERS BOTH ENDS FLOOR FRAME DMUORE MWDMMG John & Peggy Whyte scale NONE DENSMORE So South 10 Boxwood Drive date REMODELING o'�4h�et� Hyannis Ma, 4 21 s8 508.-994-7249 362-4897 lab number Why362 i r 14' 2X6 P.T. CAP 36" FROM DECK 2X2 P.T. RAIL 4" SPACE APPROX. 3/4" AIR SPACE 5/4 X 6" P.T. DECKING DBL. BOX SINGLE JOIST 16"O.C. 0 2X10 P.T. FRAME 1/2" X 6" LAG BOLT 4X6 P.T. POST 1/2" X 9" CARRIAGE BOLT GRADE TO TOP OF DECK 16" SIMPSON POST ANCHOR 48• . 10, SIDE VIEW DUSMORE REMODELMG John & Peggy Whyte scale NONE P.O. Box 869 DENSMORE south Yarmouth 10 Boxwood Drive dote REMODELING m02"W84 husette Hyannis M a, 4 21 98 508.-394-7249 362-4897 job number Why362 1 � 16 ' 14' (I IF� 5 11 1 11 , DOUBLE 2X10 P.T. OUTSIDE BOX 2X10 P.T. JOIST 16"O.C. HANGERS BOTH ENDS FLOOR FRAME DENSMORE REMODEIMG John & Peggy Whyte scale NONE DENSMORE P.O. hYarmSouth 10 Boxwood Drive dote REMODELING 0M2a.m.4chuse"'s Hyannis Ma, 4 21 s8 508.-994-7249 362-4897 job number Why362 is 14' 2X6 P.T. CAP 36" FROM DECK EM - - - 2X2 P.T. RAIL 4" SPACE APPROX. 3/4" AIR SPACE 5/4 X 6" P.T. DECKING DBL. BOX SINGLE JOIST 16"O.C. a 2X10 P.T. FRAME 1/2" X 6" LAG BOLT 4X6 P.T. POST 1/2" X 9" CARRIAGE BOLT GRADE TO TOP OF DECK 16" SIMPSON POST ANCHOR .;i 48' 10' SIDE VIEW DUSMORE REMODELING John & Peggy Whyte scale NONE P.O. DENSMORE Suth Yaremouth 10 Boxwood Drive date REMODELING 02a6a84chuaette Hyannis Ma, 4 21 ss BOB.-994-7249 362-4897 job number Why362 BENCH MARK--N.W. CORNER OF I 92.6 I 4, STOOP = 93.29 TOWN GIS± STK set I r LOT 4 " ss44, ti .N .A,) 93.9 ® , z u 15, 500± S. F. 94 93.8 N /F 0 92.9 TR 0 E ��. 92.4 / ♦ 94,0 .0 92.5 93.7 i 9 NC �O ✓ 3.2 i X i E'er 93 ,s b yo 91A3 CTLON SCHEDULE s �' INSPE TO Qse�e �`SF :.� 92.7 9 4 '� A L R.J. CADILLAC C L FILL.9 • O )s*T 2.9 ' ; TO BACK FILL.ra 2.9 TH 10 INSPECT PRIOR WELL 92, ■ 2.0 5 �$ 0 92.8 s/ob Cth 3,1 92.4 ��/ 9 p.,q.3.64 93.0 AV 91•5 760, 9 _•04 i S�y`sSO� � 91,54 � ,�.. •} '' 1,7 � <v �,' i IN 90.89 92.7 \\ 90• a 90.9990.8 �90.55 \ �' �' !/ : Bath Den \ \� �91,08 , N / Bedroom \ \ ? set \ 7.+ ::"::: :•;;;::' 5 ' i ALLEN Kitchen Garage 7 \ 91.4 / i i 2 \ a Bedroom Living Room eth \\ � 92.09 i 2,8 BENCH MARK--TOP PK NAIL IN �\ \\ FIRST FLOOR 1 PAVEMENT= 9 .20 GISt \ \ dc, �92.7 - NOT TO SCALE \ \ \ \ 4tj \t 92.7 N \ 8�' \� \h� \ 93,t,- OW,EN S \ 93.2 �2,98 .0 w THIS PLAN IS A VALID COPY ONLY I .1001//^\J AN ORIGINAL RED STAMP AND SIGNi 0FS5'e- i �Too 6 R MP 3P4N CIApg� • ApNl��