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0968 OAK STREET (CENT./W.BARN)
B �f 1� 6i u ii u F If. 1 I. L. i, _ 1r 10% , .� +' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ' J Parcel 6 7 Permit# 1 kr�fi�5►�:BLE Health Division "Date Issued 1 3 AW l� Conservation Division /". J i �Z/O� ; ;'! 12 1. 1 : 20 Application Fee Tax Collector Permit Fee Treasurer- S1fT '.1 E.t;�Y Ca INSTALLED IN CCOMPLIA!" Planning Dept. VATH TITLE 5 Date Definitive Plan Approved by Plan ing Board ENVIRONMENTAL CODE AIL i1 i2� off_ T004 REGULA410n:S Historic-OKH 0� n Preservation/Hyannis Project Street Address Village ( 1) , 6 C2 s O Owner Address 56 r OGI S� Telephone �` ' 3 6 Permit Request (S , _CL �o� , X Square feet: 1st floor: existing ^ proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation dad Construction Type Lot Size ���, ��� Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 12t- Two Family ❑ Multi-Family(#units) Age of Existing Structure y r S Historic House: ❑Yes 9'No On Old King's Highway: aYes ❑No Basement Type: ZZ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing / new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing C., new First Floor Room Count Heat Type and Fuel: 36�Gas ❑Oil electric ❑Other Central Air: ❑Yes polo Fireplaces: Existing _� New Existing wood/coal stove: XYes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage: existing ❑new size Shed:❑existing Cl new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded Cl Commercial ❑Yes ❑No, If yes,site plan review# Current Use Proposed Use I I BUILDER INFORMATION Name Telephone Number �Lc.Z —2C is Address G aa IC License# a r N 5�b Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE s FOR OFFICIAL USE ONLY i '.l PERMIT NO. w - # DATE ISSUED ' MAP/PARCEL NO. ^• ADDRESS h VILLAGE OWNER if DATE OF INSPECTION: j FOUNDATION FRAME INSULATION — -- - —------__ - s FIREPLACE ` ELECTRICAL: ROUGH FINAL - j` PLUMBING: ROUGH FINAL r-a GAS: ROUGHS ; ; a ; ' FINAL FINAL BUILDING . � = rn r DATE CLOSED OUT '.ASSOCIATION PLAN NO. r 1 The Commonwealth of Massachusetts z - = Y Department of Industrial Accidents eflxce onflyestigaffoos 600 Washington Street Boston,Mass. 02111 wiiii IC�i����i�i ti0n Insurance %�%% name: Q , location _i phone t� r��� �` Teo-t0 Z✓ /�+`V�-- .z� c 2S a I am a homeowner performing all work myself. I am a sole r etor and have no one worlds in ca achy %%//%%%%%%%%%/%%%%//G/%%%%%%//// O%%%//m/%/%////�///!/%/////////O/%. am em 1 rovidin workers'compensation for my employees working on this job. }:•••,•: ?.:::::.: {:...... n :nam r.n.• ..................:.....:...........n...... ...:...... ;}: 't'�$t'B ::e>:; >?:t::i: ��ri3uian /// ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have workers' co ensation olices: llowin P :u th g ..mp.. coman ::nam :::.:..,.........:.. :................................. .... ..... .............r. :, ..... ...... ..i... .......n.......................•:v:::::::::::::::::.�::::.v:: ::::nvx::..••' t.. ?.vi: •......(..vi},v{::.vv::'�•::'v::;}i:•:ti}{::iiij::}:;vi:i};}}:3:{:ti{v:?j?i•}X:?':Ly::x::{{:.v:p:::::::::::::v..........•:....v...•w:..:........:....::v.....:wn. .�Q ... .... ..........:::::.:...........:':.v}::4:{???;•}:•;}:�}}}i:?;:};v:{.}:?{�}:-;:}};•;;i;L:{;{?{:??v:?f:{•i}:•}}}:4i;{:is?•};i•}::}}}}}}}}'f•}:':jG:4::4i;:?};:•}%:?•: ........................... ..:.�.....:.:.:.::::::.:::..:w:::::::::::•:::::v:w::n...................... .............:vv:•.v}:r:nw::::rvw:::::::r:.v:nv:•::::,v}:.}}:{^:•S.?^};i�vSW 1 ..JY:C{r;�.n;r. isfiTiiiTiji:i�iii:{:`iiii:vi};:+iiii'}:iiiS:�;;:�:::}}}};:•;i}'>:•.v}}}:::::�r- .... ..... .....:..............:::::w.••?•}}i;:v'�•i:{4:.;{.}}i}: .................. ............ .v:.v::.':v::::r::::::.,:w:r:r:::r,......v..v.....n........ :... :... ..... r.............. ........................:...::•::::::::::.....v....,..........................m::•.{?::::::::.:::v::::.:v::v:::::::::.v'-:r:v.::}:•i}:}:•;:•}}}i:•Y'}iv:•}'•}}:ii'�i?.•:i:• ...v.............................. ........:..x.................• .. .......r:::::::x........ .. .. ........ :.v.r....... .................... ...:.v:::::::::::::;.......' ............::::.v.:v::.:;.v::v::::::::;. .....................r:::.v::::n.v:.:..::. ...4aX.v};}..;..: .t..::::::::....:.....:.::.:�'::...........:............ :... ..............,.............. hone.# ...........::,.,:....,..:.:.....:,......................... :..::........................:v. . ..........:...:.......:.............:....:::::::i-:::::::::::::i:•.v}::i?•;}:i}:}i:iiii:•:}}:•};};:Jii:^J:{iiii:•i'Fi:{{}:?::i:rir:: .$....................::::::::::::::.vi.}i.+:•:v:::: ti;i:-:' ...:::::::::::::.�:::..:::.�:::.�:::::rv....:•.:v:::::::•:::::::::....v::::::::::::::::::..•;v::::.v:::::•:::::v:.::v:,v::::•........:::::xi}:^}}::}:j;::iiii:ii:+'!:iT:iiiii; .v.v,w v:rr.}•..:;i;; ...r:............. ................ ......::.�:::.::::.,...........:........ ...... ....... ........ .:...... .:..::.........:.:..:::::.::.................r..,. }..:. ....t..:�::.:..::::.::.................::. ::::,.:::::.::::.. ..............:.....::::.......... .... ::::...:.... ........................... .......:.v...............v:::..................:::.:..............:.:�:v.......................::::::::::v::::.wn, rr::v:.v:::.v:: ..::::. v.-�v:::•;... ....r.v:r:tiv:}::' Qll ......................:::.................•• ~: ..... ... ...... ....................... ..................... ...................m.v:::::v.:r;:v:::..w::is v:......:::.w:.v..:Y.:..'i%i�:!�-:v':iiii:i��i>iii:viiiii};;:;}?•:j is{•}:;•}:;?•:rf?•:::::::.::.::.�:.}:v;:.v..:v:{:::.!}'::$;?•;;}:{ti•;i:...;::?•:v:.: .-'/I:'::::::4i:•i}}}i::::?•i:.::.}w:?n:.:.v.:v?:e::.v:v:.:is':.::::::::::.�:::•:::.}:n:'i?}:C.;::..:,:.:: ii:<'C O.�}:?�ii::^:4}i}:•;.+::{J:;::�::^:^i:{i?b:;':ti4::v:;•;:!.}•}i:!.�:::}::{.;:{?:�:i}:.iii:}}::?Ch::•}}}::?�..;;i;•:i:;;.}}:?}:�?.::. :��Zunrsnce Fwh[re to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct Sigoat= I Date Priest name i L G c Phone#_4- oigdal use only do not write in this area to be completed by city or town o[ndal city or town: permit/llcense# ❑Building Department El Licensing Board ❑Selectmen's Office ❑check if immediate response is required ❑Health Department t contact person: phone#; -- ❑Other 0eviaed 9/95 PJf) f s 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 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 section 25 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,neitherthe 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 ;z supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may b e submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign an R 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`qaw"or if you 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 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 pemut/license number which will be used as a reference number. The affidavits may be retumed'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 Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents DInce of Invesugations 600.Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 r Town of Barnstable Regulatory Services ' BasxsT^BM ` Thomas F.Geiler,Director �QA 1YIAS3 039. `�� U�f .,a Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, 'improvement,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: r Estimated Cost Address of Work: - OVjc b CA Owner's Name: /9N17i4 R G-C1JJ1 qi Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 []Building not owner-occupied MP&er pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME 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 Contractor Name Registration No. R� Date Owner's Name I Q:forms:homeaffidav I Town of Barnstable pp SME T� . Regulatory Services Thomas F.Geller,Director f .�� Building Division QED ' Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Iffice: 508-8624038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:— JOB IACATI0N:. 7 number street p village n• ")iOMEOWNF.R": c ELLe D .2 ! X�( name home phone# work phone# CURRENT MAILING ADDRESS: /(p/o r (30 M city/town state -zip code The current exemption-for"homeowners"was extended to include owner-occupied dwellings of six units or less and. to allow homeowners to engage an individual for hire-who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns-aparcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one-or two-fancily dwelling,attached or detached structures accessory to such use and/or farm,structuie's: 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. -Theundersigned"homeowner"certifies that he/she understands.the Town.of Barnstable Building Department.., minim inspection procedures and requirements and that he/she will comply with said procedures and re ements. ^ Sipa6K oYllomeowner 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 states 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 of construction Supervisors);provided that if the bomeowner 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 of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed personas 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 fors currently used by several towns. You may care t amend and adopt such a fornileertifieation for use in your community. • Q S � (--� S � �'Q j cs - P ,4 cfA- } �oGrc�- 1 , I i Y f c.S t � p s t . i I • a I • J j S 1 i ! 3 I-// cl I 1 i I - i I � i I ! i _ i 1 _ ... Application to. 3a.egionai �Eqiotoric Miotrict Committee In the Town of Barnstable. CERTIFICATE OF APPROPRIATENESS ppliChapt r hereby made,with four°ofMassa hu Massachusetts, 1973, for proposed ete sets,-for the issuance of a Certifi work as dte of escribedtbelow and under on plans, of Chapter 470, Acts and Resolves rawings, or photographs accompanying this application for. :HECK CATEGORIES THAT APPLY: Exterior building construction: ❑ New ❑ Addition ❑ Alteration Indicate type of building: ❑ House ❑ Garage ❑ Commercial 9 Other S e ?. Exterior Painting: ❑ - o 3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign G� 1. Structure: ❑ Fence ❑ Wall ❑ Flagpole [I other TYPE OR PRINT LEGIBLY: DATEd ADDRESS OF PROPOSED WORK 9� Y 0C,L J-} `ASSESSOR'S MAP NO. OWNER v� e ASSESSOR'S LOT NO.— N HOME ADDRESS 0(2 - - FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across any public street or way. (Attach additional sheet if necessary.) efi 2 - r AGENT OR CONTRACTOR TELEPHONE NO. ADDRESS uJ• c f'� -, DESCRIPTION OF PROPOSED WORK: Give particulars of work to be done, including materials to be used. Please include locations of proposed signs. Signed Own e r-Contractor-Ag e n t For committee Use Only This Certificate is hereby Date /0 ZZ Approved enied Committee Members' Signatures: r Town of Barnstable Old King's Highway Historic District Committee r' SPEC SHEET FOUNDATION /J o-Ce e4,i d-s (� COLOR SIDING, TYPED C� ��Ar 1. CHIMNEY TYPE 0 VA_e COLOR ROOF MATERIAL COLOR Q PITCH WINDOWS � � COLOR SIZE TRIM COLOR . COLORS �r��i-� DOORS COLORS SHUTTERS �— GUTTERS COLORS DECKS MATERIALS GARAGE DOORS COLORS �— SIZE COLORS SKYLIGHTS COLORS SIGNS —� FENCE COLOR Fill out completely, including measurem o he used. Four copies of this ents and materials/colors t NOTES: with Four co ies of the plot plan, landscape form are required for submittal,of an.application, along P plan and elevation plans, when applicable. 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'•t�`�a�'' -�. �_�,(✓'�`� .`,.�.,.r, '� 's7 ".'t. >.. ..k�i*'r f.t.`:. }:`.:: y,T'; 3 ;k�..1 f' .r. 7 1.'.t:k. .J .•..�° -'t t.ricr: *•.,. ,.tr. �y�'.*,y ,;#2...•:..; .,;-,.'a 4ti- 1+>F YF,._�•4r'- i � :A ��.. _-�..��':4:-C,::��.-•. -r�� >� +t`�•. �ia��.�n«r i,:.y. °.F,13,'� } 'F` r - s,',K�t•_��yrc :,r n. i'�•Yam} .,�: ,Y. r _ } >i._; :w -.l� :l,rs7� `:�v=` fit.. .�.•f'Sa'- .l. w...��°'i ,��:}_ .tS.y t' .�.'!� :'_r,.L4...,ic��y n � t +h• •[ �tl�ram, Town of Barnstable *Permit# Expires 6 m nths from is�date Regulatory Services Fee inanSrAar.E, • d> v� Mass.1 63¢ ��' Thomas F. ler,Director 3 � Ge AEG N1A't A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 9 tP D,4 4 Sf✓e e-r [Residential Value of work .3/0o0 Minimum fee of$35.00 for work under$6000.00 � _ Owner's Name&Address N!•f .�.. ,�l C• ✓t • - -+ • _ -- Contractor's Name �/_ o Gj/i/ 'j. -ST 4AA r Telephone Number Home Improvement Contractor License#(if applicable) 1,007 V O i Construction Supervisor's License#(if applicable) C S '_ .�r:"� ►�rg► �,A� [ Workmau's Compensation Insurance Check one: MAY - 5 2014 ❑ I am a sole proprietor ❑ I am the Homeowner 1 have Worker's Compensation Insurance LNS vda �Co� �r TOWN ®E BARNSTABLE Insurance Company Name �S 5 o e,'A�P� P i Workman's Comp.Policy# ,ulL(, , o /07oixoii Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side /Q? /Q(e"/all ,f.4-We- 4J oZ/ #of doors VReplacement Windows/doors/sliders.U-Value . 3 D (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. I ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. F' SIGNATURE: C:\Users\decollik\AppD \Local\Microsoft\Windows\Temporarylnternet Files\Content.0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 'I - j Capizzi Home Improvement Inc. Page 7 of 7 Specifications and Estimates STATE OF MASSACHUSETTS - - T wVrrrrlFtu_"P,AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, � CLI`i, )WN THE PROPERTY LOCATED AT IN U ry s1�- / �e- ,MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE: _ SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: i RESPONSIBLE OFFICER TELEPHONE: . .. .. . IIGG ;fit rr x' �� �,•' a .' ' QQ AA © moo g,k ' CAPIHOM-01 APELL DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12127/2013 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 endorsemen s PRODUCER CONTANAME: Ann Pell Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/C No Ext: A/C No):(877)816-2156 AIL South Dennis,MA 02660 ADDRESS:apell@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIL S INSURER A:Main Street America Assurance Co. INSURED IN91RBt6:Associated Employers Insurance Co. Cap"lai Home Improvement,Inc. INSURER c: Capri Enterprises,Inc 1645 Newtown Road NORER D' Cotuit,MA 02635 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SU POLICY NUMBER POLICY EFF POUCY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY MP61075H 6/8/2013 6/8/2014 DAMAGE TO RENTED PREMISES a ocwrrence $ 500,00 CLAIMS-MADE Fx]OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE UNIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,0 POLICY X PRO-jECT X LOC $ AUTOMOBILE LIABILITY CO�aE�DdSINGLE UNIT_fFa $ SOO,OO A ANY AUTO M1 M28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS er acdd. X UMBRELLA UAB [I OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAB CLAIMS-MADE CUB1076H 6/8/2013 61=014 AGGREGATE $ DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION �( WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUnVE Y I N CC50050105472013A 12/25/2013 12/25/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? a N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS blow E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601-0000 AUTHORIZED REPRESHQTATIVE Goa ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Office oflnvestigations I Congress Street,Suite 100 — Boston,MA 02114--2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Organizafion/7ndividual):Capizzi Home Improvement Address:1645 Newtown Road City/State/Zip-Cotuit, MA-02648 Phone#:508-428-9518 . Are you an employer?Check the appropriate box: Tyke of project(required); 1.R✓ .I am a employer with 40+ 4. ❑ I am a general contractor and I [7- New construction employees(full and7orpirt-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or parhaer- listed on the attached sheet. Remodeling shipand have no employees These sub-contractors have � 8. ❑Demolition working for me in any capacity. employees and have workers' in�iran0e$ 9. 0 Building addition comp;[No workers' comp.insurance required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their J.❑ I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 1 4 and eve have no Roof r airs -12El ep- _ msuramce required.]t c. 152;-§..( ), - . `employees:[No workers' 13. ]Other WlV oW comp.insurance required.] *Any appIcant that cheak5 box#1 must also fill out the section,below shov&g their workers'compensation polii y informations" fi=Homeowners who submit this affidavit indicating they are(°%jug all work.atd then hire outside contractors must submit anew affidavit indicating such. #Contiagtors that check this box must attached an additionalSheet showinathe name of the sub-contraciors and,Mate whether or Dot those entities have e*loyc;es. If the sub-dontractors have employees,they must provide their workers'comp,policy mmiber: I:ain an employer that is providing workers'cortrpensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Associated Employers Insurance Company Policy.#or Self-ins.Lie.#WCC5010 547012011 Expiration Date: 12/25/201 Job Site Address: y ��� (1,4 City/State/Zip: 1,4&,4Q;rW1e Attach a copy of the workers' compensation policy declaration page(sho.wing the policy number and expiration date), Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up-to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above.is true and correct Signafore: - Date: B dal: Phone#: 5084.8-9518 Official use only. Do nofwrite in this area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority(circle one): Y:Board of Health 2.Building Department 3.City/Town Clerk 4.ElectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• s r. p 4 sr ij •. z.tee,� .� c s Y" s-- iAL r ry t - y s�. Town of Barnstable I �� Regulatory Services ate: r'o L� �3 d`TErOw Thomas 'F.Geiler,Director iT_ Building DiV3SiflHi Tom Perry, Building Commissioner 1631>. �m� 200 Main Street, Hyannis,MA 02601 ATEa '�a www.town.barnst2bte.ma.tis Oft-ice: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE FERMI' Owner:eta _eaa_-___ __ Phone: Install at: 9 Villa,.c,e: Map[Parcel: � �® � Date:_ _ Stove A. New Use B. Type: /Circulating C. Manufacturer: _ >7 . use—Lab. No. ? D. Model No.- Chimney A. New/ xistit f existing, please note date of last cleaning) G aK-13 13. Flue Size —�tS n '4a C. Are other appliances ttacheti to Flue? D. Pre-fa e and Man• facturer �P ason the md ine y "= C) Rea rth A t� D A. Materials: 1C B. .Sub Floor Construction: C04rlleI�e- w a Install*1.ermc2) M `CName: hAddress:Phone - t Location of Installation: _ I-I.I.0 Registration# Construction Supervisor OR check_Homeowner Installing,no l�cense required APPLICANTS SIGNATURE , APPROVED BY: Please make.checks payable to the Tots=n o Barnstable This constitutes an v{ficial stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 103107 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/individual): 01D 1P!nM 1 chnw 1 Address: 2,6 ki q1) City/State/Zip: M Phone#: _ Are Y9a an employer?Check the appropriate bog: Type of project(required): 1. I am a employer with 4 4. ❑ I am a general contractor and I employees(full and/or p -time). s 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' [No workers' comp.insurance comp.insurance.; 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL I2 ❑Pof 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. tContractors that check ibis 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: c � ��� Policy#or Self-ins.Lic.#: ExpirationDate:� Job Site Address: 9U2 C& City/State/Zip:1h Bawl VNIN MIN 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce u d ains and penalties of perjury that the information provided above is true and correct. Si ature: ' Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ��► Town of Barnstable Regulatory Services a XAS& Thomas F.Geiler,Director �E 639-a Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 wir w_own.barnstable.ma.us Office: 508-862-4038 fax: 508-790-6230 Property C�vner Must Complete and Sign T Ws Section If Using A Builder as Owner of the subject property hereby authorize" to act on my behalf, in all matters relative to work authorized by this building permit application for. �-4 SLa �]Q- (Addms� of job) Si re of er 'Date Pnnt Name If Propedy der is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWh ERPEXA!SS1UT' r - JUN, 13. 2013 12: 52PM HART INSURANCE NO. 407 P. 1 AC RO Q� CERTIFICATE OF LIABILITY INSURANCE oATE 06111312013n THIS CERTIFICATE I$ ISSUED A$A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMAT'IYELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ins)must he endorsed. If SUBROGATION IS WAIVED,$object to the terms and conditions of the policy,certain policies may inquire an endorsement. A statamont on this carHHcato does not confer rights to the cer0ficate holder in lieu of such endorsament(s). PRODUCER HART INSURANCE AGENCY,INC. r N a Laura J Murphy PHONE (508)759-7325 Ne (508)759-7366 243 MAIN STREET PO BOX 700 lmurphy@hartinsuranceagency.cwm BUZZARDS BAY.MA 025320700 INSUR AFFORDING COVERAM NA►C» INSUROtA: MAX SPECIALTY INSURANCE 20079 UISUMD Sandwich Chimney Sweep INSURIM e- ATLANTIC CHARTER INSURANCE COMPANY 44326 PO Box 90 Sandwich,MA 02563 INSURERC; INSURER D INSURER E e INSURER F '.OVERAGES CERTIFICATE NUMBER. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1SR ADDL SUER POLICY NUMBER MMAN W IS Mmof E LMITS IS T1fF+EOF{NSURANCE A GENERAL uA6RRY MAX013100005253 10/09/2012 1010912013 EACH OCCURRENCE s 1,000.000 COMMERCIAL GENERALL1ABIIJTY IUKIMEW $ 100,000 CLAIMS-MADE OCCUR MED EXP(Affy one persaN S 51000 PERSONAL&ADV INJURY S 1,00D.000 GENERAL AGGREGATE S 2,000,000 GENLAGGREGATEUMrr APPLIES PER' PRODUCTS-COMPIOPAGG S 1,000,000 POLICY PRO. LOC S AUTOMOBILE LMMUTY M INEO PULE LIMIT ANY AUTO BODILY INJURY(Per peram) S ALL OWNED AUTOS �08�O BODILY INJURY(Per eaiaarq S MIREOAUTOS AVIO ON-OWNED P.,wddde DAMAGE S S UMBRELLJI LIAB OCCUR EACH OCCURRENCE S CLAIMS-MADE AGGREGATE 5 DM RETENTION S $ 3 WORKERSCOMPENSAnON WCV01032WO 082=012 08/28/2013 wCSTATLL OTt•I. AND EMPLOYERS'LIAORM Y I N ANY OFFICEMEMBOPRIETOPM FR E. LLUOE07 ECUTNE � NIA E.L.EACHACCfDEMf E 500.000 (Mandatary in NN) E.L.DISWE•EA EMPLOYEE S 500,000 Ir yeas deseibe vdv DESCRIPTION OF OPERATION hdow EL.D{3EASE-POLICY LIMIT $ 500,000 ESCRIPIION OF OPERATIONS I LOCATIONS I VE►flCLES Much ACORD'D',AddMnai Rematke Sdmdul■,U mom space Is requked) aerations as performed by Terms&Conditions in the policy. ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Bamstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,Ma.02601 AurNOR¢ED REPREstarAznrE 01 NO.2010 ACORD CORPORATION. All rights reserved. CORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD -/,w 6�6 " Massachusetts - Department Of Public Safety Office of Consumer Airs 117sine Affairs& ss Regulation HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards ards Registration: -,:.-A20859 Type: Construction Supervisor I & 2 Family Expiration: 3/.12/2014 Private Corporatior License: CSFA-058557 SA WICH CHIMNEY.-SWEEP-ING KEITH A CLIFF PO BOX 90 KEITH CLIFF SANDWICH 28 EMERALD WAY','1.;:...."z-.!c-_.- FORESTDALE,MA 0264A.", Undersecretary ;J 1% Expiration C,fn u ,inner 0212712015 `:COMMONWEALTH OF MASSACHUSETTS- IN Nam SHEET METAL WORKERS AS A MASTER-UNRESTRICTED T-. ISSUES THEABOVE LICENSE TO < Z" > cmKEITH'-`..A.-.;C L I F F_: o -0 "?--EMERALD WAY 1Z CUM 0 R-E�S T-D A L E `MA .02644 U) 1.1-088 02/28/15 --.-.;3 30 0-94, `LIcE*N'SE NO.- EXPIRATION DATE"" . SERIAL NO..7! License or registration valid for individu I use only Restricted-One-and two-family dwellings or any before the expiration date. If found return to: accessory building thereto, irrespective of size. Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Not 4vali thout signature For DPS Licensing information visit: vvwvv.Mass.Gov/DPS CONTFICIL# H-575047 IMPORTANT g M, .1 g 5 a t 0 If this license is lost or destroyed, notify your Board at the: -=" a�- yER�.,a Division of Professional Licensure, 1000 Washington St., Suite 710,Boston,MA 02118-6100. 0 CL If your name or address shown is changed, notify your board of correct name or address to insure proper mailing of next 0 Renewal Application. Always refer to your license number. R�1.ff- Rgga� L 2 M This license is subject to the provisions of the General Laws g as amended. It is a personal privilege,and must not be loaned y other person. Keep this license on your P w or assigned to any = . E person or posted as required by law, �t T Town of Barnstable *Permit- �6 Expires 6 monAu from issue date �T Regulatory Services Fee ' PERMIT .. Thomas F.Geiler,Director ED MAt AUG 2 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 �--�� W� OF BARNS-TABLE www.town.bamstable.ma.us 0ffi'ceO: -$08-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number-2 0 Property Address A(: 5-t V Residential Value of Work C1.1Z. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name J oSQp� Telephone Number 5rQ 43a 241-Q, Home Improvement Contractor License#(if applicable) C 3g 5 3q Construction Supervisor's License#(if applicable) i Ic3 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑'I am the Homeowner E2-1 have Worker's Compensation Insurance Insurance Company Name L [�2�-t�,l o-4 u A 1, Workman's Comp.Policy#l( '� '� l S'�aCj,7 a Q�,l _412-G[/3 Copy of Insurance Compliance Certificate must accomp na y each permit. Permit Request(check box) 2 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to�rrF�f tti� ��Niy� q ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requi SIGNATURE: C:\Users\decollik\AppDat cal\Ivlicrosoft\Wmdows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 Massachusetts.-Dep;u=hnent fit, Puhlic SaP't• p Board of Buil(linh.'Re!-,uisttif)ns aiul Stand:i (t' -a Construction Supervisor Specialty License.. .I License.' CS SL 99163 Restricied.to RF,WS,. ` JOSEPH JACINTO 3 LAKEWOOD:DRIVE ~HARWICH, MA 02645 �✓--G-.!yam ;Expiration: 10/7/2013 y � • � ty.�y. ('ununisvunmr TM 4431 5,1 , c -.s.._ •.'-tt ,�`�..�-,�» S+r' '.. 1. .�f � ! 'Fa.b (� eDj� r.Ny � >¢ • -' �7/',�.Q - ,r. r �$Zi'� i ra:' �'y�f p7;'ure Y, t..fix i,-��kNI C �. � h7 i j� ✓/LC TDCY772 i i 1�J'�.iUG(tC�LIIL ai�� L a''r C e At V�i 2 Office of Consumer Affairs&B mess Regulation?; t � t' HOME•1MPROVEMENTC_ ONTRACTOR = Registration 4,38539 Expiration. 421s1%2013 f SE IDE ROOFINGDII 5. JOSF,PH JACINTt - 3 LAKEWOOD dR \c\ •� �`'r �~' •�� / .. '� :HARWICH,MA02645`' Undersecretary gprygh� r f tF , ,y ot:e t ,� ti• r , _ C 1 O t 4ta o- .,T .... SF x.°"T"J. 'L.` "T v z i.+, a.:,. ,:,,-,.,,>�y >• ..:= i f C . ' .i ��L.+-... .. :T',.`1..}.3 ..,. .�..1_...;1 b:4.ti1t,.!-.' ♦•�"k i.. -.:..•n�K�;k..l,„F. {� i. 1 'IAA . : >�'�!•.�itr t ti�oi.,'ihRcet�:�`�'�� ::ar�i 4 f e ti The Commonwealth of Massachusetts Department of IndustrialAccideuts Office of Investigations 1-0 600 Washington Street Boston,MA 02111 wnnv..mass gov/dia Workers' Compensation Insurance Affidavit: Baders/Contr2ctnis/Electricians/Ptumbers Applicant Information Please Print 1&zibly Name(Business/Orgmiim ion/Individual):3 i;SP�1Q_�1 Address.--�) CitylStatelZi tcA CtUQqS Phone# g'a- Are you an employer?Check the appropriate box: Type of project(required): 1.2I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time)- s have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached street 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity employees and have wour=s' 9. ❑Building addition (No worims'comp.insurance comp-insurance-1 required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.ff Hof repairs insurance Vie_]x c. 152,§l(4),and we have no employees.[No workers' 13.0 Other comp.insurance requied.] *Amy applicant fat checks bow#1 mad also Ell ant the section belm showing their waters'compensation policy infnrmaean. i Homeawnets who submit this&M&vu indicating they are doing all wa t and then hue outside coetracroas most submit a new aSdawit indicating such. ZCautmctars that check this boat must attached an additional sbeet showing the name of the sab-ca rs and state whethu or not those endtes have employees. If the sub-contractors have employees,they nsust provide their werken'comp..policy number_ I om art employer that is providing workers'congwnsation i►surance for my enggWoas. Below is the policy and job site information. Insurance Company Name: f�-/Lao AH ,a 1,4,,t�— Policy#or Self=ins.Lie.9: �o �1, r� Expiration Date: Job Site Address:2-6 E 12A S7 City/State/Zip: k-4v 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 imprisonmezr,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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here ;fy under t ' s and penalties ofpeduty�that the informationprovided above is bue and correct S' lure: Date: Phone#: Official use only. Do not write in this area,to be camptetod by city or town afficirat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 oFn+e rqf, • BAMSrABLE, "�: ,0� Town of Barnstable '0�eo nna� 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: 508-862-4038 Fax: 508-790-6230 ]Property.Owner Must Complete and Sign This Section If Using A Builder I, 'AN 'I A JA4j ,�14 ro l.� , as Owner of the subject property hereby authorize 3-�Cr=#Dk�I B-►�tI-A=6 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signa e of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 NOTICE NOT TO ICE a � Y a w . EMPLOYE � TO ES v E K MPLOYEES The : Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL 1 Congress Street, Suite 100 AI' ACCIDENTS 617-727=4900 - htt :�� Boston, MA 02114-2017 As required by Massachusetts General Law, Chapter 152,Sections 21 , 22that I (we)uir have provided for payment t VVV1�W mass OV/dla Y o our injured employees under the above-menti 30, this will oned ive cha notice insuring with: p by LIBERTY MUTUAL FIRI.; INSURANCE COMPANY NAME--------------------------- OF INSURANCE COMPANY PO Box, 9102 Weston, MA 02493-9102 ADDRESS OF INSURANCE COMPANY WC2-31S-342974-032 POLICY NUMBER 04-26-2012 04-26-201 MARK T VOKEY INSURANCE AGENCY EFFECTIVE DATES 3 NAME OF INSURANCE AGENT (508) 945-3535 PO BOX 1247 PHONE # ADDRESS OF INSURANCE AGENT CHATHAM MA JOSEPB JACINT0 EMPLOYER 3 LAKEWOOD DRIVE ADDRESS EMPLOYER'S WORKERS'COMPENSATION OFFICER IFA ( NY) MEDICAL T DATE The above named insurer is required � RE`�TMENT 9 in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services the provisions of the Workers'Compensation Act. A co to the injured employee. The employee may select h' tin accordance with the services provided ee the treating copy of the First Report of Injury is or her own physician. The reasonable bost, of given necessary and reason ably.connected to the workewilllated be in u y the insurer, if the treatment is employees are hereby notified that the insurer has arranged for such attention J ry.In cases requiring hospital attention, at the NAME OF HOSPITAr. i TOWN•OF BARNSTABLB,: Permit,No. t} •�"aaa»resc r. Y/gRuil Ins Sectordsng s. Gash — — "+eYa+d OCCUPANCY PERMIT Bond "No building nor structure shall be erected,'and no land, building or structure shall be used forma. new, different,'.changed, or enlarged `use without a Building Perinit- therefor Ps first having .been:obtained'from the Building Inspector. No building shall be occupied until a r certificate of,occupancy;has' been`issued by jhe 'Building;Inspector." -Issued to! Robert Pi6kering Address °' liarrlstab e 1y 1bt: 6 _.t 968° oak Street, West Barnstable Wiring Inspector f Inspection date Plumb ingispfectoi Inspection date f` Gas-Inspector .+t* Inspection date V Engineering Department �f ,_, 7 �v ,, : Inspection date - L THIS PERMIT WILL. NOT BE VAI,Ibi AND'THE BUILDING SHALL'N®T..EE OCCUPIED• UNTIL. SIGNED Jr'BY THE, BUILDING INSPECTOR UPO 'SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. _ p 19 . _ ........ _. _.. . f� p Building Inspector w ` y LOT 1 N f l� EXISTING WELL O p ; �4 36 _ A - a3D.o ' C)A K .T .EEC. . . ' � ''• � � Sim_ .1_r ✓ ------- `-`. �7c�^vF .�.',�,J� r PL'0. 7. PL.A /V,- � 0C,4 ;^i. �,:, =Li/aR1V5-TA13LE�1�IEST�MA.` / - i ---A n1 r 6 n1: 1 4r aE•IN& LOT b A5 51-10401l p�. GEr+RGE I N PLAN BOOK ii4 6 oAGE 69 JR. `3 L-'T1IcY Tiov.��;.�����'E�. , } A:; ;H�,V•v' qn �_17DES_ COn.F�e�i t/i;=r' 47 As'Ihsor's`map and lot number ���'...'....... .. d/�= !�- .. � ... � Q CFTHE TO Sewage Permit number .. '/...... ................................ SEPTIC $YST House number ...... 9 RP �' INSTALLED IN L , . .......... ................................................. . w,E7 n yAY a� EN tRLOMEWAL AN®TOWN OF BARN�STABN REGULATIONS BUILDING INSPECTO APPLICATION FOR PERMIT TO ...1 :: ? ........ ........... . .. .L .................................................. TYPE OF CONSTRUCTION .......� . CYl1 ��. ..:..................................................................... ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..,1o./lo.....--...........C>.04......... -+��•. �T.. .....W�—.. /......... 1 ��/ ��:l.l.:✓... ........................ __ Proposed Use . . .IL).iQ7..................................... ZoningDistrict ........................................................................Fire District ..wFr . ........ ................. Name of Owner ? Y........ t .P—.1.W.1........Address Tf..Q,....ilpx.......1:�.a.z...........//.1.�ll�d(�� .. Name of Builder .............0G.S e"Q.C..P ,..............................Address ���1.� .Pq ...... . Name of Architect .. �'�d' s.......... �'s+? .�- ...............Address ....... �.. ?`........... ......................... �r c . Number of Rooms ...............5 ..iU .:.[ .............................Foundation ......t1 .!"a.(LA-�,.��.......... t�.1.02?'. Exterior ... J .� �............54 b. ..............................Roofing ......../9�.�C ............................................... Floors .......61A9 .P47..........................................................Interior .............. ........................I................ ............ Heating ........ ���.�................................................Plumbing ..... ....... Fireplace c...........................................................Approximate Cost �0 ......... ...... ..... .�............................... .. .. .. C. �Q �.Definitive Plan Approved by Planning Board _ _ 19 _( . Area ......�...... .......... Diagram of Lot and Building with Dimensions Fee .......... ................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH &a AW . r � { IVA_G 1 a0 1 � 10 1 - �` l o0 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name1)� .. .-. .... . ... Pickering, Robert s '4lo 21.528....... Permit for ....2,..stCry-'d IIn raeY g• ` ............................................................................... Location ..............1Qt--#&-.968••Oak--' t............. .............................W..-Banri,%table..................... r Owner Babtert.P.' Typ of Construction ............. ramp................ _ P ............................................................................... Plot ............................ Lot ................................ Permit Granted .................. ugust..�.....1979 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ......................................................... . 19 ............................................................................... N ....... a. ............................................ g .,z . . �,. ........................................... APPed rov - :. ............................. 19 ; ............0.�. ... ............................................ »" VD .......... . .................. ............................................... a< �y 40 .. Assessors map and lot, number ���....... _v� �/'J� /'E� � THE T ( V � Sewage Permit number r .` ... :.<..... ..................................... s /Ply h Z 'EAEBSTADLE. i - House number ...... .......i................................i........`......., vpo NA 0� �9 'F�YpY Ar. 639. TOWN -°OF BARNSTABLE BUILDING } INSPECTOR , "4 APPLICATION FOR PERMIT TO ................................ .............. TYPE OF CONSTRUCTION ..... ,i1/�J .......................................................................... .. .. v ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location s ....--........... ;f'.......... ?? c" :7 ....��..5.,2...... . 19/ / J� C ................... s Proposed Use ' .... W S7" RNSi�4 Zoning District ........................................................................Fire District ......... ................_..f�.......... ` t`s• Name of Owner . , ...... ��.�,;�� . ,.I. 1 ra .......Address �l t..©......� C3�C........%.�.a�.y...........� f1!Jt// . i, 1 �_ �4S r•�cv N �' ........ k' Name of Builder f'�1.�,/.�,,f...,��..,.................................Address .....................................................:...................... ,..................... v Name of Architect .��eF?29gf................... ..9... Address e�-s I O � /�lf4r�<• Number of Rooms � .11.s..:.!!..!.............................Foundation C. �..R `1` ........... a:�. _ .. Exterior ............�5 �9.�. Roofin �d° A!/ ... A....... ..................... g ,......�... ®�T Interior .............. � Gc�/�� C. Floors .............. ........................................... J% ................................. Heating- •� �`1' FC f f.::. -.::: - ........;—Plumbing 4:.......................... Fireplace Ys S Approximate Cost *—� �o r;•, < Definitive Plan Approved by Planning Board ______________ _�_ _____19 _ . Area //0 ..................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH �.� I OD 71 i B� 4' i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .......... ............ Pickering, Robert A=216-67 No ....2.15.2a.. F for ..2—skary••dwel-ling Location ............. .....................W.,...Barnstab-1s............................. Owner ......Robes:t..Picker•i-ng......................... Type of Construction .........f ....................... .............................................. ....................... Plot ............................•. ............ ................. r,t August 1 79 Permit Granted ............................1.'........19 Date of Inspection ....................... ..........19 Date Completed .................I ............19 PERMIT REFUSED .. >D.. . . .. � 19 ..... ... .................................................. .............. . .......... ..... ........................ di Approved ................................................. 19 ..................................................................