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Home My WebLink About0025 BURNING TREE LANE f I i j • I i • r I 0 UPC_12543 No,53LOR HASTINGS,MN _._,..�.,_,e,vu.�•.al --..�:. �..-Ite.'iSLGw.u3t�..�. - ��—.._.;,.. ..� .- -.. �-. .�A. "'ref-- =-i:ei.drtlf6' I TIE Town of Barnstable *Permit Regulatory Services pie 6 months from issue date PERMIT Richard V.Scali, Director 1631 tED MA't OCT _7 2014 Building Division Tom Perry,CBO,Building Commissioner TOWN OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number Not Valid without Red X-Press Imprint �`�j��j �� '`" Property Address 1J �J J` rN ` y-r,e— 4 Residential Value of Work$ S'O °' Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address be✓`fi O )tc r V✓'V\ 1 v� �V'c� � V1 Contractor's Name MO 1 lJ cis V1 Telephone Number Home Improvement Contractor License#(if applicable) l�J�� " l� Email: Construction Supervisor's License#(if applicable) Se��1(��h ��„ ❑Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name 1 Lr AV Workman's Comp.Policy# l7 l ,5 ibq J� 2 Copy of Insurance Compliance Certificate must accompany each permit. Permit equest(chec Re-roof urricane nailed) s tsi g old shingles All construction debris will be taken to \/` ❑Re-roof(hurricane nailed)(nmg 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 requ ed. SIGNATURE: QAWPFILESTORWbuilding permit forms\EXPRES .doc Revised 061313 JA Paul Gustafson Exterior Restoration Specialist 14 Jonathan Circle Plymouth, MA 02360 .Cell 508-269-1263 HIC License# 154549 CSSL# 105967 email at: gustafson.roofing@gmail.com July I; 2014 Attn: Mr and Mrs Bob and Shirley Stolte 25 Burning Tree Lane West Ba. stable, MA 02668 508-362-5206 rrstolte@aol.com Regarding : Reroof of all Cedar Sections. Properly protect home and grounds during construction.- Remove and properly dispose of existing cedar shingle roofing. . Inspect roof deck and cut back deck at ridge to accomodate new ridge vent. Renail as necessary. Adhere ice and water shield along eaves, walls and chimney. Apply 15# felt on remaining roof deck. Inspect and replace aluminium step flashing as necessary. Replace all soil pipe flanges. Reshingle with Certainteed Landmark Lifetime TL heavyweight shingles . fastened in a hurricane nail pattern. Install new coritinous ridge vent along all ridges. Rear addition only remove existing 3/4" roof pearlings.. Install new 3/4" CDX plywood over entire roof area fastened with 8 penny ring shank nails in accordance with new fastener regulations..;... Clean gutters and magnetic broom grounds upon completion: Main House Total: $5, 600.00 Rear addition Total: $4,480.00 Customer Signature: Authorized Signature: Page 1 s � I ' Nlas`sachusetts Department e Board of Bu+fiiing Regitlet+ons and 8tandares ` ' P �y.; ` r'Const, uc ro SuPen is or S c afiltN L . License: CSSL-1059617 _. f Is PAUL GUSTAFSON 14 JONATHAN.Cj'RCL S '� Plymouth 1VIA 02360 4_ ' y Cornrriissioner 11'12112016. ;a; I Office of Consumer Affairs & Business Regulation - Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation .` Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints I Registration # 154549 Home Improvement Contractor Registrant Registration Home Page Name PAUL GUSTAFSON Address 14 JONATHAN CIR City, State Zip PLYMOUTH, MA 02360 Expiration Date 03/19/2015 i I Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search http://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=5... 10/7/2014 Office of Consumer Affairs&Business Regulation- Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Home Improvement Contractor Registration Lookup F You can search filter the registration list by any of the criteria below. t.* Search by Registration Number Search Search by Registrant Name paul gustafson Search by City forestdale Zip Code 02644 Search Registrants Click on the registration number to view complaint history.You can also The list is current as of Thursday, May 16, 2013. Search Results REGISTRANT RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS NAME INDIVIDUAL NUMBER DATE. PAUL GUSTAFSON N/A 21 MERIDETH RD. 03119/2015 Current FORESTDALE, MA 026" ©2012 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. i i . http://services.oca.state.ma.us/hic/licenseelist aspx 5/17/2013 =� 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 ApOlicant Information Please Print Legibly Name(Business/Organization/Individual): (,l v C)P-c, Address: f u O Yl tkc City/State/Zip: 1 1M v l V1 Phone #: Are you an employer?dheck the appropriate boz: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor-and I- 6. employees(full and/or part-time).* have hired the sub-contractors 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 workingfor me in an capacity. employees and have workers' y P n'• t 9. ❑Building addition [No workers' comp.insurance comp.insurance. 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its P 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.❑6ther 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. t Insurance Company Name: 1, Policy#or Self-ins.Lic.#: Expiration Date::4. A Job Site Address: e-4b Rvi ^�V' Rb I e City/State/Zip: Attach a copy of the workers'compe sattion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as require 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 r insurance coverage verification.Investigations of the I do hereby ce f3'under pa' and pe es of perjury that the information providedZla ve is true and correct Signature: Date: �Z Phone#: J3 OPL Official use only. Do not write in this area,to be completed by city or town official 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.Other Contact Person: Phone M I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the . dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the 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(LLQ 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 i of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The.Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia of,NE r� Town of Barnstable *Permit# Expires 6 n:onlhs from Issue dote Regulatory Services Fee nnttxsTeate, = - MASS. ie' Thomas F.Geiler,Director �f0 MIA'I A Building Division Tom Perry,CBO, Building Commissioner le- 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Iced X-Press Imprint Map/parcel Number Property Address alVllV�o Residential Value of WJ_6__ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address_ 0Bgp_ TE )) -77 RMA) G Contractor's Name /IU /V-F—• (XU6 S�t� Telephone Number Home Improvement Contractor License#(if applicable) 7 3 Construction Supervisor's License#(if applicable) ` 5_70 / KWorkman's Compensation Insurance X®PRESS I • Check one: ❑ I am a sole proprietor JAN 2 3 2014 ❑ I am the Homeowner [_I have Worker's Co pennsattiion Insurance Insurance Company Name l �/yAteT l�s •� �� - 1TOWNO F BARN STABLE Workman's Comp.Policy#��a7 �l6 0 lJ��+.� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box). [f 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 #of doors -0 Replacement Windows/doors/sliders.U-Value 130 (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this pern-k 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 equired. SIGNATURE: C:\Users\decollik\AppData\Local\N4icrosoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 r 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 Avylicant Information Please Print LWblv Name(Business/Organization/Individual): Address: 2 41BI0,K) b City/State/Zip: ��uColNi Dl t�Phone#: A-101.2 0 Are u an employer?Check the appropria-bog: 4. I am a general contractor and I Type of project(required): 1. 1 am a employer with 2C� g 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' insurance. 9. ❑Building addition comp.[No workers'comp.insurance P• 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 1.[1 Plumbing repairs or additions myself.(No workers'comp. right of exemption per MGL 12.❑Roof airs insurance required.]t c. 152, §1(4),and we have no �adle_a Other D/ /� employees. [No workers' 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 is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: t1WXCf_ il Policy#or Self-ins.Lic.#:-4!A 0? el ��39 l Expiration Date: Job Site Address:a5 8 UC�/,(mot" l G/(,. City/State/Zip:,()• 6gff,1,j/�/P, !1 W 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 er the pains and penalties of pE:Jury that the Information provided above is 7, and correct. Si ature: Date: Z3 Phone#: g Official use only. Do not write in this area,to be completed by city or town offlciaL 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 Client#:30124 SOUTNEW ACORD,, CERTIFICATE OF LIABILITY INSURANCE s/o6 DATE(M12013 MIDDNM/DD/YYYI� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Anita Little Willis of New Jersey,Inc. PHONE g56 914-4660 F 856-914-1881 A/C No Ext: A/C Nc 1015 Briggs Road,PO Box 5005 ADDRESS: anita.little@willis.com PO Box 5005 INSURER(S)AFFORDING COVERAGE NAIC a Mount Laurel,NJ 08054 INSURER A:Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER c:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen INSURER D 26 Albion Road INSURER E: Lincoln,RI 02865 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY S202945900 8/10/2013 08/10/2014 EEAACMH�OECTCURRENCE $1 OOO OOO X COMMERCIAL GENERAL LIABILITY PREMISES EaE rrence $1 OO 000 CLAIMS-MADE FX_1 OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 POLICY jRa LOC $ MBINED A AUTOMOBILE LIABILITY S202945900 8/10/2013 08/10/201 Ea a.,.n,SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Peracddent A X UMBRELLA LIAB OCCUR S202945900 8/10/2013 08/1012014 EACH OCCURRENCE s5,000,000 EXCESS LIAB HCLAIMS-MADE AGGREGATE s5,000,000 DED I RETENTION$ $ C WORKERS COMPENSATION 0000068028-RI 8/21/2013 08/21/201 X wT.0 STATU- OTH- AND EMPLOYERS'LIABILITY YIN B ANY PROPRIETOR/PARTNER/EXECUTIVE AIC927818352394 8/21/2013 08/21/201 E.L.EACH ACCIDENT $1 OOOOOO OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE p • e ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088 AXL i t, Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supeni%or License: CS-095707 BRIAN D DENNISON 7 LAMBS POND EIRCL `; Chariton MA 01507 �,eG1�J " 1 Expiration Commissioner 09/08/2014 C��te 44c�po�rfvrre�a= a Office of Consumer A rs Business ego ation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 TTlse: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL FxpOaBon: 911912014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET.RI 02895 Update Address and return card.Mark reason for change , su r O saucsm ❑Address ❑Renewal ❑Employment 0 Last Card g...ri.,.w—w'/-�/..:a.r/..rri/.• ofCoaZ Aff' &Bashers Rrgatauoa License or registration valid for Individal use only IMPROVEMENT CONTRACTOR before the espintion date.If found return to: ofrwc or comumer Affairs and Business Regulation V.-E.X-Pffa9*M istration: 173245 TYPa: 10 Park Plan-suite 5170 9ft912o14 Supplement::ard Bostoo,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON DENNISON BRIAN 1137 PARK FAST DRIVE 7 WOONSOCKET.RI OMS a Undrrs<ercmry Not slid witbont signature r r • I Renewal mendersa RENEWAL BY ANDERSEN hU Li=w"17Li' Cr 1 26 Albion Road • Lincoln Ri 02865 ad r—0$237 . whhhoow ■[ruar[hhi ,eNnhrt..nC.mtun, , Phone 866.563.2235•Fax 401.633.6602 F,t,i Tax tit)a46-0513rh sa Southern New England Windows,LLC d/b/a Renewal by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyub)Name: '�6 p e Om offtm� Buyer(s)Sam AddmmCy Sumad Tip Code/PABmc EdtaitAddwc HomeTdepMnr Numbv: Wurklblephene Nwher. Buytrf,$)hereby jointly and sm-orally agrees to Purchase the products and/or services of Southern New England Wriclows,LLC d/b/a Renewal by Andersen of Southern lNew England("Contractor"),in accordance urith the terns and conditions described on the front and the roarrse of this agreement and on the attached specciiffiiccation sheet(s)(collectively;this`.Agreement"). O Historic ❑Condo ❑HOAT Tatal)obAmount�/` / Estimated Starting oats Method of Payment O Check D Cash 7 Financed ' ' ��Deposit Received(33�: / Credit Cards are accepted for deposit only-maximum 1f3 of the Balance at Sort of job(33%): � project cost Rkase see Credit Card Payment Famt)By signing this Euimated C"Jetbn DueAgeemertL you acknoviiledp that the Balance at Sun of Job and the Balance on Substantial /mil/� i _�6 rf& IC Balance on Substantial Completion of Job cannot be made by credit Completion of Job(331% / card and must be made by personal check bank check.or cash. Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing any of the terms of this Agreement.Buyer(s)acknowledges that Buyer(s) (1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and(2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only)Notice to Buyer.(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it.(3)You may at any time pay off the full unpaid balance due under this Agreement,and in so doing you may he entitled to receive a partial rebate of the finance and insurance charges.(4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(5)You may cancel this Agreement if it has not been signed at the main office or a branch office of the seller,provided you notify the seller at his or her main office or branch office shown in the Agreement by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the brayer signs the Agreement,excluding Sunday and any holiday on which regular mail deliveries are not made.See the accompanying notice of cancellation form for an explanation of buyer's rights. Iluyer(s)received the consumer education materials provided by the Rhode Island Contractors Registration Board. (Ihgrr's lrtitials) Renewal by Ajkdersen of Southern New England I, uyer(s) By: _ Si`nat of Product A•lanager Sign:uure Signature I hm Caz�W_ 6 t R. SToGCQ. Print Name of Pmduct Manager Prini Namr. Print Namr YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. x- - - - - - - - - - - - - - -X• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - N L X NOTICE OF CANCELLATION Date of Transaction 1.You may cancel Date of Transaction .You may cancel this transaction,without any penalty or obligation,within 1 this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any I three business days from the above date.If you cancel,any property traded in,any payments made by you under the 1 property traded in,any payments made by you under the Contract or Sale,and any negotiable instrument executed I Contract or Sale,and any negotiable instrument executed by you will be returned within test business days following I by you will be returned within ten business days following receipt by the Seller of your cancellation notice,and any 1 receipt by the Seller of your cancellation notice,and any security Interest arising out of the transaction will be security interest arising out of the transaction will be canceled-If you cancel,you must make available to the Seller I canceled.lf you cancel,you must make available to the Seller at your residence,in substantially as good condition as when I at your residence.in substantially as good condition as when received,any goods delivered to you under this Contract or I received.any goods delivered to you under this Contract or Sale;or you may,if you wish,comply with the instructions of I Sale;or you may,if you wish,comply with the instructions of the Seller regarding the return shipment of the goods at the the Seller regarding the return shipment of the goods at the Seller's expense and risk.If you do make the goods available Seller's expense and risk.If you do make the goods available to the Seller and the Seller does not pick•them up within to the Seller and the Seller does not pick them up within twenty days of the date of cancellation,you may retain or I twenty days of the date of cancellation,you may retain or dispose of the goods without any further obligation.If you I dispose of the goods without any further obligation.If you fail to make the goods available to the Seller,or if you agree I fail to make the goods available to the Seller,or if you agree to return the goods to the Seller and fall to do so,then you I to return the goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the remain liable for performance of all obligations under the Contract.To cancel this transaction,mail or deliver a signed I Contract.To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice or any other 1 and dated copy of this cancellation notice or any other written notice,or send a telegram to Renewal byMdersen of 1 written notice,or send a telegram to Renewal byAndersen of Southern New England at 26 Albion Road, in hyR�� 65, 1 Southern New England at 26 Albion Road,Lincoln,RI 02865, NOT LATER THAN MIDNIGHT OF I NOT LATER THAN MIDNIGHT OF I HERDateEBY CANCELTHISTRANSACTION. 1 I HE Date) CANCELTHISTRANSACTION. I K Buyer's slptatu a Print Name Date Buyees signature Print Name Date RhA ir—w Whit. Rrnor Cnnr Ypllnw P—or C.nnv.Pink �- Town of Barnstable *Permit# ti o Regulatory ServicesFees6nrorlflrsfronrissrre[)!n 1aAItV57AHLE, * 5�• tT y yftSS. 1619- Thomas F. Geiler, Director r �� Ca lk - lace Building Division �e�tx�d Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 Office: 508-862-403 8 www.town.barnstab le.ma.us EXPRESS PERMIT APPLICATION - R.ESIDENTIAL .ONLY ax: 508-790-6230 Not Valid without Red X-Press Imprint Map/p c .1 Nurnber� , ? Prop rty Address � e vr/yin 0 p ce 1121 sari Residential Value of Work (, Minimum fee of$35.00 for work under$6000.00 Owner's Name & Address ,6 4- C S 41n Contractor's Name &.)&In _� Telephone Number Home Improvement Contractor License#(if applicable) Con uction Supervisor's License#(if applicable) 99� T_G Workman's Compensation Insurance � q`L Check one � : P l?ess ❑ I a a sole proprietor ❑ I m the Homeowner OCT have Worker's Compensation Insurance j'�w 7rl(j Insurance Company Name 136,1 co/v. �V'144 Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit.. Permit Request (check box) i ❑ 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) ❑ R side #of doors Replacement Windows/doors/sliders. U-Value ©; .5 (maximum .35)#of windows L ltkE )t *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: j QAWPFILES\FORMS\building permit forms\EX PRESS.doc Revised 072110 f i The Carnrrrorriveal'th oflVirssachusetts fZ Deparfinent oflrzriustrial Accidents Dice of Investigations 660 Washington Street al Boston, AL4 02-711 nlivf}.rnass govldia "Workers' Compensation Insurance Affidavit: Builders/+Con:to-actors/Elech icians/Plumbers Apphcant Information Please Punt Legibly Name, (Btisiness/Orgmtizatio vt real) 5jo(�' INC- Address: Address: !/ �� 110k I City/S ni te/zlp: W t7 7� Phone#: 7y 7) are u an employer?-Ch. the appropriate box.: Type ofproject(requiiv d): 1- I am a employer with . ❑ I am a general contractor and I etx3ployees(ft�.11 and/or part-time).* have hired.the sub-contractors 6. ❑KNcon-struction 2.❑ I.am a sole proprietor orpartxter- listed on the attached sheet. T deling slap and have no l gees These sub-contractors have p �of $_ [].Demolition ivor)Ling for in any capacity- employees and have wwkers' [No workers' comp.insurance camp-insurance.. 7 9. .Building addition �. We are.a corporation. .and its 10.❑Electrical repairs or additions regtr.ireci:) ❑ 3.❑ I.a=a homeoumer doing.all work af5cers have exercised their 1 L Plumbing repairs or additions tuysel€ [No workers'comp. right of exemption per 1MG1, 12.❑Roof repairs insurance:required.]1 c. 152, §1(4)„and.we have no employees. [No woTi-ens' 11❑Other comp,inmranc:e reggired.] 'Amy applicant ths.t check box C.nmst also 5ll out the section below showing.their workers'compensafiom policy inforunartiao- Y Homeowners who submit this afhdzvit in&cating:they are doing all wmt and then hire outside coat mctnrs mast submit a new.eiiidas it indicating such. lCostraciam that cbeck this box must arttached an sdditioast sheet showing the name of the sub-courtractors snd state whether or not those entities have employees. Ifthe sub-contmdors:hsve employees,.they.must provide their workers'comp.policy number. Innt a>1 ernp.Zoyer fltrrf is prottidirtg nrorlrers'c�nrpeats n 2rt sa rrrr�ce for rrty'e��rplay�eas Be,'lonl is tiie polic)-rrrt:rd jo.b sitex0 - ft,�or>urrt,tiQxt. Insurance Company.Name: C U'/ / co . Policy#or Self-ins-U.C.#: 8 C Expiration Date: /0 —/ /a Job Site Addre_-m 1 UM/y ��° LV City/Statelzip:w Attach a copy of the workers'compeni tion policy titci.aratio.n page(showing the policy aumber and expiration date). Failure to secure coverage as required under Section 2.5A 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 rival penalties in the form of a STOP WORK°ORDER and a fine of up to$250.D0 a day against the violator. Be advised that a copy of this statement may be,forwarded to the Office of Investigations of the D.IA for insurance coveralge verification. I do It. by ciertlfy rtrtdor tltepairts anrd pen.abigs nfper,jury fltat tit--it forrrrRfion prm,ide.d.a.baiv is ue and correct. _ Si hre: lam-�99—� /� Date: X o Phone#: �� 6// b �0 Fr�ss.ningAuthoiity �cial.use vnly. Do not.write in fibs arm. ,fo be cosipleted by rift or town o cinl ty or To-"m: Permit/License (rir-cle one): 1.Board of Health 2.Building Department 3. City/Town Cltrk 4,Electrical Inspector S.Plumbing.Inspector 6. Other Contact Person: Phone#: 6 •'� 1 . Y <l fit_ ,''�.•.,Qli, '•<Y:J:S.c.`: ' ,,•7.J r.i.a r. •3s:M'd`�Nt!c S•. .•(Ql Cpo � � N� ' '� ..�¢]?"fix 1E..,.•'4�i- 4&0 •� � _ �Yd41 , �I i •� LIAMIL.I I T IIVZlJKAINKOC OP ID av MOONA-1 05/07/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RT 02838-0001 Phone: 401-769-9500 Eax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC9 INSURED M00n Associates Inc. INSURERA Hational Orange insurance co 14788 BBA Gutter Helmet A$ k Renewal by Andersen of RI INSURERB: Seacon Mitual Insurance Co. AE.11A Gutter Helmet Roofing D8A Moon Works INSURER C' 1137 Park East Drive INSSURERD: , Woonsocket RT 02895 INSURER E: COVERAGES THE POLICIES OF INS P.*ICE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MPAIDDIYYYY) DATE Q11WDDAYN) LIMITS GENERAL LIABILITY EACH OCCURRENCE $10 0 0 0 0 0 A X COHMERCIAL GENERAL LIABIUTY MPS26619 09/16/09 09/16J10 PREMISES(Eaoccurenoe $500000 CLAIMS MADE ®OCCUR MED EXP(Any one Person) $ 10000 PERSONAL 6 ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $2000000 MGENGENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 0 0 0 0 0 0 POLICY PRO ,IECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A X ANY AUTO BIS26619 09/16/09 09./16/10 (Eeaccident) ALL OWNED AUTOS BODILY INJURY $ SCHEDLLED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NO"WNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $1000000 A X OCCUR D CLAIMSMADE CUS26619 09/16/09 09/16/10 AGGREGATE $ $ DEDUCTIBLE $ X RETENTION $10 0 0 0 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER B ANY PROPRIETOPJPARTNERJEXECUTIVE El 10/01/09 16/01/10 E.L.EACH ACCIDENT' $500000 OFFICERIMEMBER EXCLUDED? I Eyes, tory In be un E.L.DISEASE-EA EMPLOYEE $50 0 0 0 0 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION RENEWAL DATE THEREOF,THE ISSUING INSURER VOLL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Renewal, By Anderson 1137 Park East Drive R(=PRESENTATIVE$. Woonsocket R1 02895 AUTHORIZED REPRESENTATIVE ACORD 25(2009/01) O 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1137 Park East Drive Woonsocket.Rhode h4nd 02E95 R.L Re&a;tt239/30839(Moon Assoc.ates tml (8OD)97b=6666 OYa' Conn.W.O W1125 tMeeo Assotates lm.j D l-� 4x,.Me1195351e.den Assetistes a+c., Purchaser(s)Name Gf IttstaBatimAddress: UetM i v%(> R-tI✓ A S $ ce Mailing Address: SrAme Hothte Phat►a�4-3♦9.-�9�0 6 Ceti Phone:77 Y 44 y Y3'� E-mail: Year Home Built: Customerinitiatts.-Y Taxes Paid In Town tit N p 7?1d C 1/We,the above purchaser(s)("Purchaser(s)-)and t ner(s)of the property located at the above installation address,hereby jointly and severally agree to contract with Moon Associates,Inc.("Moonworks")to furnish,deliver,and install of an materials as described in this agrcement("Agreement`),the attached Spec Sheet(s)and diagram(s)which are incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all jobs at the end of the installation. Order Number: Order Number. Order dumber: Project Type: �P—N Project Type: Project Type: Agreement Amount $�$ 0 Agreement Amount $ Agreement Amount S Less Depositt $ 01D Less Deposit, $ Less Deposits $ Balance Due On Completion $ Balance Due On Completion $ Balance Due On Completion $ 1 tMmimum 33%of Agreement Amount due upon crecution. smintmum 33%of Agreement Amount due upon execution. tMhdtmvo 33%en AgretmemA"ro t&m upm ewcWx rl Indicate Payment Method For Balance Indicate Payment Method For aahnes btditate Poll bent MMlmd For aafande / /77 Due at Thee of installation: Due at Time of InsWIation: Due at Time of installation: /(� l j Est.Stop Dat Est.Co pleb Date: Est.Stalt Date:' E�Completion Date: Est.Start Date: Est.Completion Date: P DE SIT/PAYMONTOPt10N�{Strbjefs tofurdvvffl on and/orcrelatapproval) ej�i3piyble hleesCheck or Money Order Ck a< 3.Finaneft to Moonworks) Acct# Approval Code 2.Credit Card'(circle) Visa MasterCard Discover Actt a Approval Code Aect N Ex Date Security Code Uwe agree to allow Moonrorts to charge the referenced credit cord for the deposit amount P tY heated sapnu to be charged to credit card upon canPlahon of:ah9ation a noted above. R k agreed by and between the parties that this Agreement constitutes the entire uutderstatwfitog between the parties,and there are no verbal understandings changing or modifying any of the terms of Mis Agreement.Purchaser(s)hereby acknowledges that Purdiaser(s)1)has read the front and reverse of this Agreement and has received a completed,signed,and dated ropy of this Agreement,including the two accompanying Notice of Cancellation forms,on the date first written above and 2)was orally Informed of hls/hu right to cancel this transaction DO NOT Si %THIS CONTRACT iF THERE ARE B K SP S. Pu se Purchaser Moomvorks Si nature Signature Signature osefvr S 8 Print Name Print Name Print Name r YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TAME PRIOR TO MIDNIGHT OF THE THIRD BLISINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELOW FOR AN EXPLANATION OF THIS RIGHT. _I_... !---I !—I 1OF CANCELLATION Date of Transaction M--/15/ZA Date of Transaction You may cancel this transaction,without any penalty or obligation, You may cancel this transaction, without any penalty or obligation, within three business days from the above date.If you cancel,airy within three business days from the above daft ff you cancel. airy property traded in,any payments made by you under the Contract or property traded in,awry payments made by you under the Contract or Safe,and any negotiable instrument executed by you will be returned Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt by the Seller of your cancellation within 20 days fallowing receipt by the Seller of your cancellation notice,and any security interest adsing out of the transaction will be notice,and any securty interest arising out of the transaction will be canceled.if you cancel,you must make available to the Seller at your canceled 0 you cancel,you must make available to the Seller at your residence,In substantlaRy as good condition as when received,any residence, in substaifift it as good condition as when received, any goods delivered to you under this Contract at Sate;or you may,If you goods delivered to you under this Contred or Sale;or you may,ii you wish,comply with the instructions of the Seller regarding the return wish,comply with the Instructions of the Sella regarding the return shipment of the goods at the Sellers expense and risk.if you do make shipment of the goods at the Sellers expense and risk.If you do make the goods available to the Seller and the Seller does not pick them up the goods available to the Seller and the Seller does not pick them up within 20 days of the date of your Notice of Cancellation,you may within 20 days of the date of your Notice of Cancellation,you may, retain or dispose of the goods without any further obligation.if you retain or dispose of the goods without any further obtlgation.tf you fall to make the goods available to the Seller,or it you agree to return fall to nuke the Bonds available to the Seller,or N you agree to return the goads to the Seller and fail to do so,then you remain liable for the goods to the Seller and fall to do so,then you remain liable for performance of all obligations under the Contract. To cancel this performance of all obligations under the Contract. To canal this transaction, mail or deliver a signed and dated copy, of this transaction, map or delver a signed and dated copy of this cancellation notice or any other written notice,or sep=nd to cancellation notice or any other written notice,or send a telegram to MOONWORKS, 1137 Park East Drive, W Moomtorla, 1137 Path East Wive, Woonsocket, Rhode Island 02995,NOT LATER THAN MIDNIGHT OF (Dante). 02695,NOT LATER THAN MIDNIGHT OF (Date). I HEREBY CANCEL THIS TRANSACTION. 1 HEREBY CANCEL THIS TRANSALTMN. Consumers Signature Date Consumers Signature Date R = r� R E w e It R M Nor e 121 Yellow Copi.,* Cuslunty oFI►E Town of Barnstable *Permit# \ pExpires 6 mop s from issue date r Regulatory Services Fee } ♦ r + BARN3TABi.E,MAW + 9c� , Thomas F. Geiler,Director AlFp�.tA Building Division Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 13�—Q?• I� Property Address_ �_ e(Ati)ty T'ey-2 Ow.e. , I�.esTQAa�s o�. 0266�'laid Residential Value of Work 7j sZ�p Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 9(JA?Ai R,"/—S l&�1/G, �Q S , s7p LT•Z, 19(-Api�'t/ r'�-Q, �/7_9146 2� 8tArv)%r. T'/t�eP ( -e� , V4s7T9mrs-�m , A - o-,2- 68—/oIU Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance « ' �9� PERMIT one: !A-I" ❑ I am a sole proprietor OCT 2010 13 I am the Homeowner a I have Worker's Compensation Insurance `?"nWN OF BARNSTASLE 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 L(P.-1TQX "TIZ" s'l�pwi c, ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Im rovement Contractors License & Construction Supervisors License is req SIGNATURE:. QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 , t The Commonwealth of Massachitsetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 w4 •�•`y" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i Applicant Information Please Print Le ibl Name(Business/Organization/Individual): v O Crie Address: P to r--,) TO 1 /ae2 VP"� City/State/Zip: wxs t9M ok,67M(t, Phone.#: _S—bR —X,2_—sue 0 6 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with . 4.'�Rf 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 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.] *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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 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 c un r erjury that the information provided above is true and correct. Si afore: Date: d 2 .l o _ Phone#: -SO 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#: Information and=Instructio-ns---=- -- - 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, i 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 representativei of a�deceased employei;'oi `— receiver or trustee of an individual,partnership,association or other legal entity,employing employees.'However the owner of a dwelling house having not more than three apartments and who resides,therein,or the occupant of the dwelling house.of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §.25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the 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-con6actor(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 roof that a.valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each p year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person,is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777749 Revised 11-22-06 www.mass.gov/dia + r J P`0I► rti Town of Barnstable Regulatory Services gq (ASS. Thomas F. Geiler, Director $A .639. p ub la,�,At Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnsta b le.ma.us Office: 518-862-403 8 Fax: 508-790-623 0 -------------------- HOMEOWNER LICENSE EXEMPTION Please►'riot DATE:� 11-2- 110 _ 10B LOCATION: ImQ INI T^jee Gty,� tA/ew number street village "FIOMEOWNER" R �y SID u-p_ ,B►R��rr %& Qe40y7-9U.57- home phone k work phone# CURRENT MAILNG ADDRESS: a_q, l7 Wl N/& z A (/r/✓�� wtsr&a owl9dle0 m6- DJ.66S-1 o/D city/town state zip code The current exemption for"homeowners" was extended to include owner-occupied dwellings ofsix units or less and to allow homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more.than.one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit.to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,. bylaws, rules and regulations. The undersigned" that he/she understands the Town of Barnstable Building Department minimum inspection pr s d e r nd tha e/she comply with said procedures and requirements: gnature of ome n.er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section.127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code stales that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing ofconstruction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack ofawareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor..The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/cerlitica(ion for use in your community. Q:\WPFILCS\FORMS\building permit fors\EXPRESS.doc Revised 072110 of 1"E T� + HARNSI'ABLE, Town of Barnstable i639--g9. �0 �lFp MA't A , Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 50 862-4,038 Fax: 508-790 6230 Property Owner Mu t Complete and Sign Th.i Section If Using A Bui er l .. d �► as wrier of the subject property hereby authorize J/}rHQ /v1 G to act on my behalf, in all matters relative to work authorized by this b ding per application for: (Addre s of yob) Signature of Owner Date 'r Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. QAWPFILESIFORMSIbuilding permit formsTXPRESS.doc Revised 072110 10/5/2010 1 : 53 : 45 PM 8868 ® 02/02 710/05/2010 (MM/DD/YYY) .. CERTIFICATE OF LIABILITY INSURANCE •ia THIS CERTIFICATE IS ISSUED AS A HATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TBIS CERTIFICATE DOES ROT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES HOT CONSTITUTE A CONTRACT BETW=N 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 endorsament. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT William Palumbo Insurance PHONE TAY Agency Inc - Bryden Ins Agcy (A/C. No. ENt): (A/C. No): E-MAIL 125 State Road, Route 6A j ADDRESS: PRODUCER Sandwich, MA 02563 CUSTOMER IDR. 331SURED(S) AFFORDING COVERAGE HAIC e .S. INSURER A: A.I.M. Mutual Insurance Co James McNally INSVRHA B: 56 Highfield Drive INSURER Sandwich, MA 02563 INSURER P: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAVOM ABOVE FOR THE POLICY PERIOD INDICATED. "WITHSTANDING ANY REQUIRFffiT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESBECT 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. ZOet POLICY NUMBER POLICY EFF POLICY EXP LIMITS Ltr TYPE OF INSURANCE 1A01/OD/'RTTA IW/tD/RTT> GENERAL LIABILITY Each OCCURASCE 6 ❑CCMMERCIAL GENERAL LIABILITY DREMIse SitE ate.1TED enve) 6 E]EICLAIMS HARE OCCUR t® EXP (Any one pezeonl 6 PERSONAL 6 ROG INJURY 6 ❑ GENERAL AGGREGATE 6 GEN'L AGGREGATE LIMIT APPLIES ER: POLICY DPROJECT ❑LOC PRODUCTS— COUP/OP AGG 6 6 AUTOMOBILE LIABILITY CmmxNED SINGLE LIMIT (ea accident) 6 ANY AOTO BODILY INJURY (Per P—M) B ❑ALL OWNED AOT03 ❑9CNEDVLED AUTOS BODILY INJVAY(ser accident) 6 PROPERTY DAMAGE AIRED AUTOS (Per accident) 6 e 6 ❑DA4..A LIAB O OCCUR EACH OCCURRENCE 6 EXCESS LIAR El CLAIMS MADE AGGREGATE 6 ❑DEDUCTIBLE 8 �REIR NTIOR 5 6 WORMERS COMPENSATIONDTx- AHD EMPLOYEES LIABILITY TDQ LDOTs en THE PROPRIETOR/PARTNERS/ EXECUTIVE OFFICERS ARE E.L. EACH AccxaeNr 6 100,000 A ` ❑ incl '®' excT l6013296012009r� -_� E.L. DISEASE'-EA EMPLOYEE -6 `- -500,000 ' 12/31/2009 12/31/2010 E.L. DISEASE -EA EMPLOYEE 6 100,000 COMMENTS DESCRIPTION OF OPERATIONS OR LOCATIONS: ., JAMES MCNALLY IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEL17ERM IN ACCORDANCE WITH THE ROBERT STOLTE POLICY PROVISIONS. 25 BURNING TREE LANE WEST BARNSTABLE, MA 02668 AUTHORIZED REPRESENTATIVE Received Time Oct. 5. 2010 1 : 50PM No. 1526 1629 Assessor's map and lot number .......................................... SEPTIC SYS1"�M M L, Y INSTALLED WsT-+ 7' 71'� ALLEp IN C E Sew,gge-{Permit number ...........................r.............................. WITH A,4TI OMPN_IANCE SANITARY CAE II STATE 7NEj� TOWN OF BARNbo-V tED T�w� i DA*TAtLSi i oINjYa:�� O BUILDING INSPECTOR .,y 1/f .art- �.t r7•. <.`. l Z. APPLICATION .FOR.'PERMIT.TO ........ - l...i ...................... .............. �?? ....... .......:. TYPE OF CONSTRUCTION ................. A4GC .. �fi�!f! ..... ......................................................... .......E�.........��................19.t77 TO.THE INSPECTOR'OF.BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........ -� ...�, ... 9.. F� i��itt/.( . .�� lY�� ......!!P �.! �A�lt/5Ti� ................. ProposedUse ..... ® ................................................................................................................................................... Zoning District .............. ....... r............................................Fire District ..4�. �T'a/o��/ T� � C ................. ................. �................. Name of Owner ... �! ... ° ! .......................Address ....4 ". P40.�.m.14...................................... Name of Builder �! ✓' . �h.1 �..........Address ........................................... Nameof Architect ...................................................................Address .................................................................................... Number of Rooms ......... ...................Foundation Zo'v C Exierior ...... ...........................Roofing ......!'t�.�d .."'�� !��"�/A/ .L ............................. /.�. ��e'!V ....................................Interior ............................................................... Floors ..................... Heating � �tl,d6.... Plumbing {......................................... ...,.......... ..................... .................................................................................. ,Y.�S S-d 60. Fireplace ......... ...........................................................Approximate Cost ...............�................................................... Definitive Plan Approved by Planning Board -----------_------_-----------19________. Area � ... . Diagram of Lot and Building with Dimensions Fee �J.' S SUBJECT TO APPROVAL 'OF BOARD OF HEALTH 'fy. 3 0 �bS' j2 VZ� Uy W: lo I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Al .......................... V «t* / Bates, JwXma � � � ' . � � .......... \ ................... --'��.. .��.]��---- -. ---`—_. ...................... ....................... ' . . + ' , C}wmov ---..^�Q)M..B��AW----------.. . ` Type of Construction ----.�f�mm��-----. � _._..:__,____________________. i . ' . ' #13 p�� ---------. �� ----------.. , , Y ' ? , ' 78 ' -Permite-PermitGranted --. y 25 ---]g k. Dote of | ... Co mpleted omo��e6 —�� l� �� . �e~''�----''—xPd�' ^�— � PERMIT REFUSED -----_—..—.—..—.------- lg ' ` , ...-------------~--..—.------ ' .---........`...—.--.--.---.------.. `.^...—.....----~.--..---.-----., , --^~^^--','—'`—^^^^'^^^^~^`7'^----^'' ' � . - ' Approved -----------../�-�.—.. lR . ' -------------.—.--...--~.----. - _ ' . / / -------`-----'--'--'-7^--^^^'— ' — | w 71 a: ^ � ..� �� a •'_��7T1l�s�'�. "d.&..4 ��"�' i a:. �}�l s fc q� '^+r^� �' 14, TI � P ef• r 5 A 4 "d �r <!i►.'a+ wTtwi6"t'£ �. . > 'iJ��,�i J1,,f,J�r��,lj�/� ,�j ref x� {!jam_ �.L:�. �. ^+.4�n tr P i '� '�fM1 j3 •� � - �" :.-14 'iK '�", �4.e, 6.I{r".tp P'j"' vow -f— f .q Ps.M{+CIf .jt,-. }.i >+ws�N. ', If ...,'+ Y' g 4 >�` k'+ � • ..�aP °R'�..IK ! OF ¢ i GY: 1. is 5►+taP�C t r � � �.ec-f✓I: ` r.+ �,'� � ,.,µ, ma { �',�f'�*' � W �' ! S "' � ��•N ��L{n'k r F n_. h`^� tl�+�' ` iy TIT z r kT�' i� 6.4 a s1 AYX �i� Ig-.r, iV✓ ,4� Y'"R. - s *` } f ) a �40 "S^� .4 r ht ''Q°u'•�<5.. � '-. ''� W �.: �� 41.r � 9 _ � M 011, 04 �� , "' I�� ,a� i `t '�.y r�r'� � �° � �� *ate s k«• � s '3 �t .. ... •� i 4" 4' �p.� 1 v��'��jd 2 t p K R ".*�- .� 1 .•4�.. � 1 i .{r'fy_ e rt;{+• J *i i i � 1 1` r t f i �„�-:..4--�••�'`+r-•'P�-,'.`,�-"1ri`7�+i+--+.�•-.-.�•..�Mi.-1.F`..»+[�.v.•�v. ww..•-r�tt�+....F�w.i��Ya-^-Nr.I+�"�+� , 1wr TOWN OF BARNSTABLE Permit No. .....19911 BUILDING DEPARTMENT Cash TOWN OFFICE BUILDING I 7 .Ml ► HYANNIS,MASS.02601 Bond f .. rr CERTIFICATE OF USE AND OCCUPANCY Issued to JOHN BATES Addr8s 25 Burning Tree Lane, 'West Barnstable r USE GROUP FIRE GRADING OCCUPANCY LOAD 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. January 14 19...94.......... / R .......Jf �............... Bu'ing Inspector P e Assessor's office(1st Floor): r T " ,.Assessor's map and lot number `.Map 136; Lot 28 `Y� i'i!Ib SYSTEM�!{lU ®��Cai��TNt>O Conservation N/A y/ Q ,3 INVALLED IN COMPLI � �e Board of Health(3rd floor), WITH TITLE 5 � Sewage Permit number �<' • �!/e � � • j �,AIO ��':: ��ip ( OD ,to �sai ruct rua Engineering Department(3rd floor): *`" ma 's oo oe39. House,number. 25 Burning Tree .Lane �0ar� Definitive Plan Approved by Planning Board t9 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Add to deck area and add 20 x 20 room to existing dwelling TYPE OF CONSTRUCTION Wood frame 3/31 1g 93 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 25 Burning Tree Lane - Point Hill, W. Barnstable Proposed Use one-family residence a�a .v,-,��.� Zoning District Residential Fire District West Barnstable Name of Owner John and Anne Bates Address 25 Burning Tree Ln, W. Barnstable, MA Name of Builder Jeffrey W. ,Harris Address Box 296, 8 Kettle Pond Way, So. Orleans, MA Phone: 255-5703 Name of Architect Timberpeg, Inc. Address Box 1500, Claremont, NH Number of Rooms 1 new 20 x 20 bedroom Foundation poured concrete L Exterior white cedar shingles Roofing red cedar Floors wide pine In dry wall Heating electric Plumbing remodel existing bath and add shower Fireplace N/A Approximate Cost $60,000. Area 400 sq. ft. - new room �j128 sq. ft. - new deck Diagram of Lot and Building with Dimensions FeelJ� 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 Construction Supervisor's License BATES, JOHN & ANNE No 35773 permit For . BUILD ADDITION Single Family Dwelling Location 25 Burning Tree Lane West Barnstable Owner John & Anne Bates `-' Type of Construction Frame t r LS Plot` Lot Permit Granted April 141 19 93 Da o�n 19 f � • i a T' Date Completed 19 j 1 f i Assessor's map and lot number 31 ' " p • 1 �' l/�' �� ' � - 7 7 ...................... .................. l L Sewage Permit number ....:..................................................... FTNET TOWN OF BARNSTABLE BABB9TADLE, i 039.�,.. OY DUILDING INSPECTOR • I' �' PYa' vJ�j .�✓v?! �"..�/t/LIJ� / APPLICATION FOR PERMIT TO ..........�,�................................................................................................................ TYPEOF CONSTRUCTION .............................................................:....................................................................... .......... ......!n ............ 19.? TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........�0?........ 't / i.r71//�� p`' '/'/.. ..:: ............/.... ............................. .. ............................................................................... Proposed Use .: �ry....... ........................................... ZoningDistrict ...................... ...........................................Fire District .. f:.: .......... ..... .. ............ ..::................. r Name of Owner /��:a.r"1 /�i/ `sq'. ........................Address /C' c„ti�1+1� /�et'0V .................................. ....:............r............... .................. ......... Name of Builder .... '�:" 'J='T!' " f i,`....f•17t ...�'�..........Address .. ,.Pd�/ 4�. /0+. ............................................. ........... ....... ............... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .........5..................................................Foundation .�Cv.% � C �.4/(' ........................:................................. Exierior ke �i � /!! ..�-............................Roofing ...... J©n/7 ^.�-.'' ............................. ........................................... „�?r.�/ram / ....................................Interior .............. Floors .......�................ ...................................................................... Heating ......: .........t:'........ .i-�..'!�........_....: ............Plumbing .................................................................................. Fireplace r .S"49� p /! '.;............................................................Approximate Cost ................. .................................................. Definitive Plan Approved by Planning Board -----------_______-----------19________. Area :� �.q`#{................ Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH ZyYc 3Z 0 76?' ti le �! s )NK,' y ` ,r �f I hereby agree to conform to all the Rules and Regulations of the Town•of Barnstable regarding the above construction. ,r Name ...ie1%i�.f''•./r-}.`.:x:../..-~......................... Bates, John 2-9 West Barnstable Owner ..........Jmh ---n ....——es.---------.—' frame Type ofConstruction .......................................... � � � . #13 ' . ' rw/ ,o/ �z` ~ Permit^ Granted 19 � ~... of Inspection. . . - 19 uu/e Completed ` � ^ � '--'-' --- SE/ . 19 . � .. .// .� -- -"�— '' �— ]r--___.. ............................... ...................................... ......�' � ^^'—'----'--^`—^'—^^^'^^~^--^----- � � , Approved ................................................ 19 � ' . ---------------.......—...----.. ' � ...............— ............................................................ ' Lo i 9 &IRA111V 7;k;'GF 44 NE r. 7- 1 -y IV -417 ,gyp' J8 �o t i // PL,.Aj6J Lo-r 13 IA/fr-teG- LAME El'AmmoN -t ALTEP-4 rI oN 5 6G°/6 02 "v ; . I 160. 00 - 3 • goo I Memo-if-ari slum TO: Building Commissioner SUBJ: Modification to Prior Approved Plan FROM: Sally`Sylvia''_ ' 3 Secretary to the OKH Committee DATE: 3/15/93 A minor modification has been approved by the OKH Committee to a prior approved plan for the applicant(s) named below. The modification is briefly summarized and I have attached backup material for your records. Applicant(s) I Ann,- H Rat,-c� Address of Proposed Work 25 Burning Tree Lane-Point Hill West Barnstable, MA. 02668 Meeting Date Approved by OKH 3/10/93 Minor Modification Replace larger single skylight with 2 smaller skylights I 4. ° Application to 93 J oaa 1,yPppG O,E JtiP �'lNO 1P Np _ y.PNS,PP NHS P Gp Old Kos Highway Regional Historic District Committee in the Town of Barnstable for a CERTI FICATE OF APPROPRIATENESS Application is hereby made, i<Eiplicate or the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building Q Addition [v3' Alteration Indicate type of building: 2'House ❑ Garage ❑ Commercial ❑ Other 2. Exterior Painting: ❑ 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign. 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY ADDRESS OF PROPOSED WORK 77-re Xa��e ASSESSORS MAP NO. LliCST �4tb/f,.�1i4 �zG6 S OWNER ,�hne_ f325 ASSESSORS LOT NO. a8 HOME ADDRESS -96 �ale /,-)7' TEL. N0. 02- FULL NAMES AND ADDRESSES O``F,ABUTTING dWNERS. Include name of adjacent property owners across any public street or way. (Attach additional she�i.if,necessarry). �=E �77-4 CEO F0Z ,9ODi�'/a.�.9G L /1 l 6,7.&IR r�r 11 AGENT OR CONTRACTOR 1 1442611 IV /fQ,'ri.S TEL. NO. ADDRESS DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No. 8,other side), including materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). S;�ec° ® Q lh\-J \ \� ` �V� Signed Owner-Contra for-Agent Space below line for Committee use. ReceivedH.D.C. d �� - 1 DThe Certificate is hereby ��Viol e 0 Approved92 - IMPORTANT: If Certificate is apprQyed, approval is subject to the 10 day appeal period provided in the Act.�',�c�'1'Cls-Q, `Oxw ��,�� Disapproved ❑ oC i ADDITIONAL INFORMATION FOR MAKING AND FILING AN APPLICATION FOR A CERTIFICATE OF APPROPRIATENESS The four categories for which a Certificate of Appropriateness is required are: (application for demolition or removal is a separate form). 1. EXTERIOR BUILDING CONSTRUCTION (new or existing buildings): An application is required for any exterior of a building to be erected or altered including windows, doors, siding, roof, light etc., that will be visible from any public street, way or public place. The following scale drawings are required in duplicate with application: plot plan (if addition — show existing buildings in outline), floor plan and elevations. Also required are snap shots of existing buildings, where additions or alterations are to be made. No plot plan is required for addition or alteration which does not touch the ground. 2..EXTERIOR PAINTING: An application is required for any portion .of a building, structure or sign to be painted that is visible from a public street, way or public place. Color samples must be attached to these applications: An application is not required when repainting existing colors, changing to white, or using colors approved by the Town Historic District Committee. 3. SIGNS OR BILLBOARDS: An application is required for any sign or billboard to be erected within the District, with the following exceptions: a. Existing signs or billboards on November 27, 1974 shall have until November 27, 1977 to secure an.approved Certificate of Appropriateness. b. Temporary signs for use in connection with any official celebration or parade or any charitable drive as long as they are removed within three days of the event. Certain other temporary signs that the Committee feels does not detract from the Act may be allowed with the prior permission of the Committee. c. Real Estate signs of not more than 3 square feet in area advertising the sale or rental of the premises on which they are erected or displayed. d. A single sign of not more than 1 square foot in area showing the name, occupation or address of the occupant of the premises on which they are erected or displayed in a residential zone. 4. STRUCTURE: An application is required to build or alter any structure within the District which is defined by the Act as a combination of materials other than a building, sign or billboard, but including stone walls, flagpoles, hedges, gates, fences, etc. GENERAL REQUIREMENTS 5. Work on projects requiring approval shall not be started until the Certificate of Appropriateness has been filed with the Town Clerk by the Committee. Approval is subject to the 10 day appeal period provided in the Act. 6. No changes shall be made from the original approved specifications without advance approval of the Commission on an amended application filed with the Committee. 7. A separate application must be filed with each project requiring a Certificate of Appropriateness. 8. Under heading of "Detailed Description of Proposed Work" give detailed data on such architectural features as: foundation, chimney, siding, roofing, roof pitch, sash and doors, window and door frames, trim, gutters —leaders, roofing and paint color. 9. Unless application is complete and legible and all material required is supplied, application will not be accepted or acted upon. Copies of the Act establishing the Regional Historic District may be obtained at the Town Hall. r� t . ,s 6 rgrol 3 ,... -iv.{ x: OLD K I NG'S HIGHWAY HISTORIC DISTRICT FOUNDATION lured Gv��f� aO "xaO Y:. '} i�C n es COLOR SIDING TYPE_ �� 2d�r s� 9 COLOR . rt CHIMNEY TYPE ROOF MATER 1 AL `ed GPr S�iin9� COLOR PITCH /vmo�.� ��z Ally z �s J ,q,GoE.eSo�/ .7;eIR4 E (x/id MeM. SIZE WINDOW : TR I-M OLOR C�6a7- ��i� �� — 1�,2/F7WDo1� G•2�'Y �',- . C 3,x s ' 6 COLOR hsr<�� DOORSi°S 771m Co%r C C SHUTTERS Yl� h GUTTERS DECK �irrm Co% COLOR GARAGE DOORS . Q Q including measurements and Notes : Fill out completely, . materials/colors to be used. or m Three copies of this form are required fes each of an application, along with three cop the Plot plan, landscape plan and elevation plans .-, when applicable. *Plot plan need not be "Certified" should show all structures on the lot to sca ' �. '��1� �ti - `�•;�;is :-:- :, � ��i III; . �.:: � � �� - •.r u�•�i-:fir.;. i„��.� .,. +1 :: � �r �J AY :�1 F� � . . y� �f tS� iI i��,'''i. ' y,f __ F `*, �'II I I� 16 � , �:� �, � �`<�: . . .. , . . ;�, - •; ,;��,�: � ,'j � ur'�> i� r � �� ..�..� _ "� � � � �� y_ +- i' . _.,; -,:.�J � � �� . i. _ ..ti.►.... ;,. r ,�. �. �..-. - • ' "'" A , i cam+ � � �� ► 7 A r la k7",\ S� ► . 1• � A.R. � ►►+�"-�,. ;�" - - �.� i -- :�,, - � � -� ..i .,�T - • }.� x �`� ', t. `,} � .. �- -�, - -,�. ... .�� ,� ,. �/.I[.; may,�.,__ __ _ - �2:. w _ �. - y � .fi aw / a� / a� z z N HN OT Z",SW 06 � r d' A P,f � A � o q1,f c�a A \ � �JO •. M � 1 fr F y � f\ �~ ef' fi s +- mow► _ ��-. it , c . Dt e .• t ' I j;y ' f � •s. .,. � 1�• Prix � � i it •11• r. :�� _ _ r ?;� na•` • Fr n7 ;r. Zr i c: RE: Addition and alteration to the home of John and Anne Bates 25 Burning Tree Dane West Barnstable , MA 02668 We, the undersigned appointed agents for the Point Hill Realty Trust, approve the plans submitted by Anne and ` John Bates for an addition and alteration to their home at 25 Burning Tree Lane, Point Hill, West Barnstable , MA. Date : ,;2 -5 Milton Larson Gera S ree D Donald Tyni � � D COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF' 1010 COMMONWEALTH AVE. V MASSACHUSETTS BOSTON,MASS.02215 /� •ENCLOSE CHECK OR MONEY OF LICENSE ' FOR REQUIRED FEE, EXPIRATION,DATE 1 1y.A CONSTR. SUPERVISOR : r •06/30/1993 7 G MADE PAYABLE TO 5 EFFECTIVE DATE LIC NO. G. "COMMISSIONER OF PUBLIC SAF RESTRICTIONS NONE' O6/30/1991 '. 005888 . . 1 JEFFREY W HARRIS 5 n(DO 7N %,SEN�CASV).-, . DALEY WAY. L�l--" PA;"' PHOTO(BLASTING OPR ONLY) FEE: 100.00 E FECTIVE FES. -1lf 1989 HEIGHT: STAMPED VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY STAMPED-OR-SIGNATURE OF THE COMMISSIONER D NOT DETACH` LlCt""E THIS DOCUMENT MUST BE SIGN NAME IN FULL-ABOVE SIGNATURE 1 CARRIED ON THE PERSON OF SIGNATURE Of LICENSEE THE HOLDER WHEN END COMMISSIONER OTHERS-RIGHT THUMB PRINT ED IN THIS OCCUPATION. , ,r i, i 20OM-2-87.81429 eommowalea&A ol,4&Madwe6ea t! HOME IMPROVEMENT CONTRACTORS REGISTRATION. ; '1 Board of Building Regulations and Standards, 1 One Ashburton Place - Room 1301 i Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR - ; � Registration 104021 Expiration 07/13/94 Type - INDIVIDUAL HOME IMPROVEMENT CONTRF Registration 104021 - 1 Type - INDIVIDUAL Jeffrey W . Harris Expiration 01/13/94 ,. 8 "Kettle Pond Way , Box 296 Jeffrey W. Harris S . Orleans MA 02662 8 Kettle Pond Way, Box jj d S. Orleans*MA 02662 ADMINISTRATOR i 1 � ,- Z✓8�- 8X j LU t Vi Vi Ni 36 .00 Qb 1 _ R -!Z Ulf -Z`8 8r� J$ 8X� 7 - _ I .I " ' ' - , , _ I , 11 . 1. .... I I I-- . _: i�' , I I _ . I .1 � I � .'I , . - �21 , , I ,I, �I . . � -I I I'. ; .. . I I � ; 4- "_. I.. ". . . � � I . I : � . I . 1.; I .� . ,: ,�I . ** ' � �.-r7'W--X'm": 11--m-i-,M_�_ , � � � � 1:,,,*": . . _ , ; I , , .I .- I . . I I �l , 'I-.- - ' - ' ' " I � . I . . I . o ' I � - - :� . �_'�. ' 7 _"T�'V-7i'-Ir,lq�- ., , . 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