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HomeMy WebLinkAbout0367 PLUM STREET - �s^x. T l S2" �.. 7y t e v i v i 1 a � y n.,e to NO o !a0DZI ~ t A r o 0 Town of Barnstable *Permit# -1 — 13 Expires 6 months from issue date Regulatory Services Fee �S Thomas F.Geiler,Director Building Division **4Pj Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us �o�vn' Office: 508-862-4038 'UoFax: 5e4QV-623 MI EXPRESS PERT APPLICATION - RESIDENTIAL ONL- Not Valid without Red X-Press Imprint ap/parcel Number /9(0 t�O operty Address RQ 1, 1, y ,u"/ /`9— Residential Value of Work) O OG f Minimum fee of$25.00 for work under $6000.00 wner's Name&Address �MIC elzc k-er 3497 Plum �$f�Q, ,6Ux S9) )ntractor's Name f% 1'15 �C�p kQt-W, 71 P/V I Lea- Y Telephone'Number 6 ome Improvement Contractor License#(if applicable) .)nsffactionftrivi'so-t's-'ilicenst-n-(ifappiieable-) �� .. . .... ]Workman's Compensation Insurance. Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (�b'ave Worker's Compensation Insurance surance Company Name S7141, 7 jJ4 C:::� orkman's Comp.Policy# `w C d / 02 l'/C spy of Insurance Compliance Certificate must be on file. xmit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Q Replacement Windows/doors/sliders. U-Value O. 2 (maximum.44) *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 Home Improvement Contractors License is required. iGNATURE: Forms:expmtrg .vise061306 I - The Commonwealth of Massachusetts ,.,-. Department of Industrial Accidents Office of Investigations a 600 Washington Street . Boston,MA 02111 3,•�,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print lLe 'bl Name(Business/Organization/Individual): . ,hi P m/v (, J V Address: (o O Q� � J A /t/7 0 y�� �' l'�h r �f o o/& J�I A,, City/State/Zip: w Lhly o o/. /-/ Jtj A, Phone:#:_ �S©6-- 36, l/ - 3/ 0 Are you an employer? Check the appropriate box: -Type of project(required):• . am a general con 1. I am a employer with � 4 ❑ I tractor and I g 6. El New constructi e on mployees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the-aitached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' co insurance.$ 9. ❑Building addition [No workers' comp,insurance comp. • required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their '3..❑ I am a homeowner doing all work 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.ROther L& /As 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 ornot those entities have employees: If the sub-contractors have employees,they must provide their workers'comp.policy number. lam 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.#: (f d 32 1/4r Expiration Date: �Y / p — lob Site Address:,3 & 7 /:�o M ,S � City/State/Zip:W /3/)d/L/9 1,4 .e 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ify under th pains andpenaIt' s ofper'ury that the information provided ab a is true and correct. 1 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#' 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 TeceiVer 01- [us_t3e-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 Kith 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-contractors)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 permittlicense 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 io 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 questionsplease do not hesitate to give us a call. The Department's address,telephone.and fax number: The Commonwealth of Massachusetts Departmont of Industrial Acci.&nts. Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-977 IMASSAFE Fax#617-727-7749 Revised 11-22.06 www.mass.gov/clia OpTHE� T'own of Barnstable. Regulatory Services BmINSUBLE, Kass. $ Thomas F.Geiler,Director s639• '�� . A,fo �A, Building Division Tom Perry, Building Commissioner 200 Main Street. Hyannis,-Na 02601 www-town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete .and Sign This Section If Using A Builder I, �� �� , as Owner of the subject property herebyauthorize G. to act on my behalf, in all matters relative to work authorized bythis building permit application for: . (Address of Job) Signature of Ovrner _ over o� i4fto�n�� Date Print Name Q:FORN S:O WNERPERMIS S ION To: Page 20 of 25 2016-05-19 14:58:01 (GMT) 18668561376 From: IncomingFAXES IncomingFAXES DATE(MMIODNYYY) A�?p� CERTIFICATE OF LIABILITY INSURANCE4il9izol6 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 Matthew Sumares NAME, Cochrane S Porter Insurance Agency, Inc. PHONE FAX AIC. A/C No 981 Worcester Street ADDRESS:Matthew.Sumares@renaissanceins.com ADDRE INSURERS AFFORDING COVERAGE NAIC A Wellesley MA 02482 INSURER AWGM Insurance Company 14788 INSURED INSURERB:Stax Insurance CompanV 18023 Kenney Builders, Inc. INSURER C: 603 West Yarmouth Rd. INSURER O: INSURER E: West Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER:Master Cert. 16-17 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. POLICY EFF POUCY EXP 1 LTRR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A CLAIMS-MADE FO OCCUR DAMAGES( RENTED Eaoccurrence) S 50,000 PREA IS S' MPJ7842M 4/6/2016 4/6/2017 MED EXP(Any one person) S 10,000 PERSONAL BADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY❑JEa LOC PRODUCTS-COMPIOP AGO S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ' Ea aeeidentr ANY AUTO BODILY INJURY(Per person) S ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per auident) S NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS Perarridenn S UMBRELLA UAS OCCUR EACH OCCURRENCE S EXCESS UAB HCLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION PER OTF6 AND EMPLOYERS'LIABILITY y/N STATUTE I I ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICEPWEMBER EXCLUDED? NIA 100 000 B (Mandatory In NH) WC0849993 9/25/2015 9/2S/2016 E.L.DISEASE-EA EMPLOYEE S 100,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION (508)548-4290 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Falmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN attn: Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Falmouth, MA • ' AUTHORIZED REPRESENTATIVE H Sumaies/RENMS4 ©1988-2014ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 nnldnu Massachusetts Department of Public Safety ` Board of Building Regulations and Standards s License: CS-001895 Construction Supervisor , CHRISTOPHER T KENNEY 603 W YARMOUTH RD W YARMOUTH MA 02673 Expiration: Commissioner 01/13/2018 i I t0/����Y/,1JaCikG�t'iGG,l Office of Consumer Affairs and Business Regulation . 10 Park Plaza - Suite 5170 ' Boston, Massachusetts 02116 Home Improvement Contractor Registration ReGistration: 181256 Type: Corporation Expiration: 3/17/2017 Tr# 263713 KENNEY BUILDERS INC. ----- CHRISTOPHER KENNEY _— ---- --- --- 603 WEST YARMOUTH RD WEST YARMOUTH, MA 02673 Update Address and return card.Mark reason for change. Address r Renewal ❑ Employment Lost Card SCA 1 0 2OM-05/11 LOffice of Consumer Affairs&Busincss Regulation License or registration valid for individul use only _F. before the expiration date. If found return to: — etOME IMPROVEMENT CONTRACTOR Type office of Consumer Affairs and Business Regulation egistraUon 181256 10 park plaza-Suite 5170 p Boston,MA 02116 xpiratlon 3117/2017 Corporation KENNEY BUILDERS INC CHRISTOPHER KENNEY,';_:: :;` 603 WEST YARMOUTH:RD,; WEST YARMOUTH, MA 02673 Undersecretary No v lid without signature t � k.: DURABLE POWER OF ATTORNEY ; f, KNOW ALL MEN BY THESE PRESENTS, that I, CATHERINE D. CROCKER, of 2210 Main Street, West Barnstable, Massachusetts, 02668, have made, constituted and appointed and by these presents do make, constitute and appoint my daughter, JANE C. SWEENEY of 50 Sheep Meadow Road, West Barnstable, Massachusetts 02668, my daughter, KIMBERLY ROY, of 188 Carriage Lane,Barnstable,Massachusetts 02630, and my son, EARLE DIRKSON COFFMAN, of 5 Whitney Woods Way, Cohasset, Massachusetts 02025, all of them acting to- gether or any one of them acting alone, my true and lawful attorneys (hereinafter "my attorneys ' w' or attorney")with full power of substitution for me and in my name, place and stead: 1. COLLECTION. To demand, sue for, collect, receive and give discharges for any moneys, debts,rents, interest, dividends and other personal property at any time payable or ' i belonging to me. k . 2. LEGAL ACTIONS AND SETTLEMENTS. To commence,prosecute, discontinue, defend, and submit to judgment in any actions and other proceedings concerning me or my estate and to settle, compromise and submit to arbitration any matters concerning me or my estate as my attorneys or attorney may deem advisable. 3. INVESTMENT. To invest and reinvest my estate either in real estate or personal property, as my attorneys or attorney may deem advisable, including, without limitaton, bonds, debentures, shares of stock, shares of and interests in investment companies and trusts, common trust funds, and other securities and investments,whether or not lawful investments for trust funds; and to exercise rights to subscribe for warrants for the purchase of stocks, bonds or other securities or investments and rights of conversion or exchange appertaining to any securities at any time belonging to me. a 4. SALE, LEASE AND MANAGEMENT. To sell all or any portion of my estate, real or personal, at public or private sale, for cash or upon credit, together or in parcels; to lease F for any term; to give options to purchase or lease; to rescind or vary, on terms or gratuitously, any contract of sale or option; to contract for and make repairs, alterations, replacements and im- provements to-real estate; to employ real estate agents or managers, to take any action with E respect to tenants, including notice to quit and ejectment; to present for redemption or sale any bonds, debentures, shares of stock, rights of subscription, options, warrants or other securities or personal property belonging to me; all upon such terms and conditions as my attorneys or attorney may deem advisable. 5. VOTING STOCK. To vote stock owned by me, to appoint general or specific proxies, and to place such stock in voting trusts, upon such terms and conditions as my attorneys or attorney may deem advisable. 6. ADDITIONAL POWERS OVER STOCK. To participate in or disapprove an reorganization., recapitalization, consolidation,merger, or winding up of, or any action by, or he readjustment of the indebtedness of any corporations or companies in which I may at any time hold stock, shares or other securities; to deposit such stock with or give general or specific SYKES AND COLE proxies to any committees or depositaries in connection with any such reorganization, ATTORNEYS AT LAW 420 SOUTH STREET POST OFFICE BOX 1358 HYANNIS.MA 02601 TEL.(508)775-9147 I recapitalization, consolidation,merger or winding up, or readjustment of indebtedness, and to withdraw any such deposit; all upon such terms and conditions as my attorneys or attorney may deem advisable. 7. LIFE INSURANCE. To apply for,pay premiums on and maintain any policies of insurance on my life; to apply dividends on any such insurance to pay premiums thereon; to exercise all rights of ownership over any such insurance, including,without limitation,rights to assign,borrow upon,pledge or surrender such insurance,to change beneficiaries or to convert it into paid-up insurance. 8. OTHER INSURANCE. To apply for,pay premiums on, and maintain any policies of insurance which my attorneys or attorney may deem advisable, including, without limitation, accident,health,hospitalization and medical coverage, and insurance against loss of or damage to any property,real or personal, at any time belonging to me; in the event of any loss, damage or expense thus insured against,to apply for recovery or reimbursement under any such insurance policies and to agree to the determination of the amount of such loss, damage or expense as my attorneys or attorney may deem advisable. 9. HEALTH AND SOCIAL SECURITY BENEFITS. To execute and file, on my behalf, any applications,certificates or other instruments which may be required by law to obtain medical, hospitalization, convalescent or nursing care or any other benefits or public assistance provided by any governmental agency, including,without limitation, any benefits under the Federal Social Security program; and to execute and file in my behalf any applications, certificates or other instruments which may be necessary or appropriate to obtain my admission to any institutions,public or private, for medical treatment,hospitalization, and convalescent or nursing care or otherwise for my health and welfare. 10. MOTOR VEHICLES. To"regisfer any vehicles owned by me; and to apply for any license or permit of any type whatsoever as my attorneys or attorney may deem advisable. 11. PAYMENT OF OBLIGATIONS. To pay any obligations or liabilities incurred by me or incurred by my attorneys or attorney in the exercise of the powers conferred hereunder, including, without limitation, such expenses as to provide for my comfortable care, maintenance or support and any medical treatment,hospitalization, and convalescent or nursing care which I may require. 12. BORROWING. To borrow money from any lenders but without my attorneys' or attorney's individual liability therefor, and as security for such borrowing to mortgage or pledge all or any part of my estate,real or personal,upon such terms as my attorneys or attorney may deem advisable; and no lender shall be responsible for the application of the proceeds. 13. COLLATERAL. To take an action which m attorneys or attorney may deem Y Y Y Y Y advisable with respect to any loans for which property of mine may be held as collateral; to consent to the sale of all or any part of such collateral; and to make any other arrangements what- soever with respect thereto. 14. AGENTS. To deal with, direct and employ such legal counsel, investment counsel, agents and employees as my attorneys or attorney may deem advisable. 15. TAX RETURNS. To execute and file any tax returns, including, without limitation, any income tax or information return required by the laws of the United States or any State or the District of Columbia; to execute and file such protests, affidavits, claims for abatement, refund or credit,bonds,powers of attorney,petitions, appeals to the Director of S AND COLE Internal Revenue, to the United States Tax Court or otherwise, compromises and agreements, NEYS AT LAW )VTH STREET �! 'FICE BOX 1358 VIS.MA 02601 508)775-9147 2 �I t` I 11 �.,..� .. - T I 1 including closing agreements, as my attorneys or attorn_ ey may deem advisable; to execute and deliver receipts and discharges for any sums refunded and waivers and agreements extending the time within which any taxes maybe assessed against me,waiving any restriction, consenting to any taxes or any assessments or collections,or for any other purpose in my interests; to employ such legal counsel as my attorneys or attorney may deem advisable in connection with any matters or proceedings relating to any such taxes and to execute such powers of attorney to any such counsel as may be required. 16. BANKING. To deposit funds in,such banking institutions or bank accounts as my attorneys or attorney may deem advisable, including'any bank accounts in the joint names of myself and my attorneys or attorney or of myself and any other person or persons, and to endorse eheeks and 661e-f ifiStYMMIti payable t6 My brde'r for e8llection and depbslt; oii my behalf and for the purposes of exercising any of the powers'granted hereby,to draw checks on any bank accounts standing in my name or jointly as aforesaid, and to withdraw money from any savings accounts standing in my name or jointly as aforesaid(and to execute in my behalf any authorizatiohs,'certificates or other instruments required by any such banking institution in connection with the exercise of the aforesaid powers); and no banking institution or payee shall be responsible for the application of the proceeds of any check or withdrawal. 17. SAFE DEPOSIT BOXES.To have access to any safe deposit boxes, whether in my name alone or in my name jointly with any other person or persons, including my attorneys or attorney, at any bank or other place; to remove any securities or other property from any such box; and to execute in my behalf any authorizations, certificates or other instruments required by any banking institutions or other depositaries in connection with access to such safe deposit boxes as aforesaid. 18, INDIVIDUAL RETIREMENT ACCOUNTS. To make any and all decisions withriespecf' 0"ariy individual sRti ement:'Accn -(I ) stdin in my-name including, but not limited .to, directions for distributions from such IRA and directions for the purchase or sale of securities for such IRA. . 19. GENERAL POWERS. To do all other acts and enter into all transactions which my attorney shall deem necessary or proper for the protection of my estate and interests. 20. DOCUMENTS. To execute, acknowledge and deliver all endorsements, assignments, -bills`of'sale, transfers, deeds, instruments of lease, mortgages, pledges, notes, powers of attorney, proxies, certificates, applications, receipts, discharges and other instruments and to execute all other documents and do all other acts which may be necessary or proper in connection with the exercise of any of the foregoing powers and for carrying out any power incidental thereto. I give my attorney full power and authority to do every necessary or proper act which I might or could do if personally present, hereby,ratifying and confirming all that my attorney I shall lawfully do or cause to be done by virtue hereof. I further agree that all questions concerning the validity or interpretation of this Power of attorney shall be governed by the laws of the Commonwealth of Massachusetts. This power of attorney shall not be affected by my subsequent disability or incapacity sores AND co1.F except as provided by law. ATTORNEYS AT LAW 420 SOUTH STREET DST OFFICE BOX 13S8 HYANNIS.MA 02601 -- 3 TEL C508)775-9147- t T y I IN WIT ,NESS WHEREOF I have executed this document in multiple i counterparts hereof on this 18th day of October Two Thousand Four. Catherine D. Crocker Signed in the presence of. 'i is COMMONWEALTH OF MASSACHUSETTS Barnstable, ss On this 18th day of October 2004 before me personally appeared CATHERINE D. CROCKER to me known to be the person described in and who executed the foregoing instrument, and acknowledged the same as her free act and deed. David Vole Notary Public My commission expires March 22, 2007 5 AND COLE NEYS AT LAW IUTH STREET S FILE BOX 1358 [IS.MA 02601 08)77S-9147 4 Wrr.`A TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map— Parcel 5 Application# 0007. 717 1) Health Division Conservation Division Permit# Tax Collector Date Issued Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic- KH /0 0 Preservation/Hyannis Project Street Address 34 7 Mw 61*W Village U)&f lL�dl S�ZL��p Owner �&Ih I 'e `rXttr, Address L5& f�! /n tu. Telephone Ng) qq/' Lig qg EUuosG;to Request h b Y.Permit Re q 2P�uLK C �3 au $c'rivshl PotcSc AUD Dt-�;V_K i DOW 5 Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �',Z61 OW Construction Type UW D Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. NDwelling Type: Single Family .V Two Family ❑ Multi-Family(#units) pAge of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other N) Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new �! Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑newer size=.t t Attached garage:Cl existing ❑new size Shed:❑existing ❑new size Other: j Zoning Board of Appeals Authorization Cl Appeal# Recorded❑ - Commercial ❑Yes ❑No If yes, site plan review# Current Use emDaI niy, Proposed Use s►D l TyA'L � F2 BUILDER INFORMATION Name 6—S-AAMY1 92— VW"9f,I&C, Telephone Number 5�� ��$ • �f Q I Address L4 S KOSAri2.m tAAt6' License# Oo3a.5 q 9� W u�5 . RA, f��Q 1 Home Improvement Contractor# I 10&0 / Worker's Compensation# i5bllo o 0l 0100 ALL CONSTRUCTION DEB A RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1"l 14V.lIYVI ,S L 1'►ti - SIGNATURE DATE FOR OFFICIAL USE ONLY - 1 PERMIT NO. RAPE ISSUED - _MAP/PARCEL NO. ADDRESS' ' VILLAGE OWNER 5 ` DATE OF INSPECTION: t FOUNDATION :. f FRAME a+ - O 4, I INSULATION otnk FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT - ;. ASSOCIATION PLAN NO. , < < 1 rNr.o Barnstable Old Kings Highway Historic District Committee BA,,,,ST„BL ; 200 Main Street, Hyannis,MA 02601, TEL: 508-862-4787 Fax 508-862-4784 T MAS& O APPLICATION, CERTIFICATE OF APPROPRIATENESS Application is hereby made,with four(4)complete sets,for 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 all categories that apply, 1. Building construction: ❑ New 0 Addition ® Alteration 2. Type of Building: ® House ❑x Garage/barn ❑ Shed ❑ Commercial ❑ Other° -� 3. Exterior Painting,roof ❑ new roof ❑ color/material change, of trim, siding,window, door N ' s 4. Sign_: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 5. Structure: ❑ Fence ❑ Wall ❑ Flagpole x❑ Retaining wall ❑ tennis court ❑ Other 6. Pool ❑ swimming ❑ Other man-made pool Type or Print Legibly: Date: 10/4/0 7 Address of proposed work: House# 367 Street: Plum Street Village West Barns t a bA %ssors Map Lot# 196 Description of Proposed Work: Give particulars of work to be done: New breezeway connector, replace windows except large picture sash on breezeway side . new front step with 6" risers , 1 ' each side of door , regrading and new entry step to breezeway. .:.On new breeze- way, center front door with new 9-lite door with one double-hung , each side; new 6 ' slider on rear. Agenbox EIotox(print): N o r t h s i d e Design Assoc. Telephone#: 5 0 8—3 6 2—2 210 Address: 141 Main Street , CmDukhporl , MA 02675 Cart'xotor/Agent' signature: NOTE All applications must be signed by the current owner Owner(print): Catherine D. Crocker Telephone#: 508-776-9099 Owners mailing address: _. P O B 5910 W. Barnstable, M A 02668 . Owner's signature: �'"i f,i���� • b ,C For committee use only. This Certificate is her APPROVED/DENIED Date y Members sign a L DECEHE OCT 0 4 2007 Any c di ' o ppr val: TOWN OF BARNSTABLE ' 0 jam` 1 Q:I GMD-Groups101d Kings HighwaylOKH New App IOKH Cert Appropriateness 07.doc r Town of Barnstable Old King's Highway Regional Historic District Committee CERTIFICATE OF APPROPRIATENESS SPEC SHEET Please submit 4 Copies Foundation Type: (Max. 18"exposed)(material-brick/cement, other) concrete block Siding Type material: white cedar shingles Color: match existing Chimney Material: n/a Color: Roof Material: (make&style) match existing Color: match existing Trim material match existing Color: match existing Roof Pitch: (7/12 minimum) see plans Window: (make/model) Andersen material. vinyl color white Size(s): Varies, see plan Door style and make: 9—lite material fiberglass Color: match existing Garage Door, Style n/a Size Material Color Shutter Type/Material: vinyl Color: match existing Gutter Type/Material: aluminum Color: white Decks: material PTW w/5/4x5 Size 1Ox12 Color: redwood WeatherBest or equal Skylight, type/make/model/: n/a material Color: Size: Sign size: n/a Type/Materials: Color: Fence Type(max 6' ) Style n/a material: Color: Retaining wall: Material: fi Ye l d stone Lighting, freestanding n/a on building illuminating sign Please provide samples of paint colors and manufacturers brochure of style of windows, doors,garage do'kru fences,lamp posts etc ADDITIONAL INFORMATION: Short stonp, retaining walls and brick walkwa Signed: (plan preparer) t name Gordon Clark III 4tel.no. 50 8—3 6 2— 0 Location of application: treet no. 367 Street Plum Street Village West Barnstable 2 QAGMD-Groups101d Kings HighwaylOKH New AppIOKHCert Appropriateness 07.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + a 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Naive(Business/Organization/Individual): 6 J J"777 nvttE�Z 2 it/ A e Address: 9 ROS4714/ ,LAA( I City/State/Zip: ? / lUl�� � O21�0 Phone (�5D8 �Q. 'Alg I I AWu an employer?Check the appropriate box: Type of project(required):. 1. am a employer with 4• ❑ I am a general contractor and I 6 ❑New construction . -time).* have hired the sub-contractors employees(full and/or part 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ( modeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition comp.insurance.$ [No workers' comp.insurance 10.❑ Electrical repairs or additions required.]qu 5. ❑ We are a corporation and its . 3.❑ r a homeowner doing all work officers have exercised their 11.0 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 13.❑ Other 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 Frame: Policy#or Self-ins.Lic.M 6-D 0 0 6 7 cR l 2 DU Expiration Date: U i Lo 8 [� Job Site Address: Yi 1' ��•� J �� 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi er the pains 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#: i Client#:2093 2JAXTIMEREJ A.CORD- CERTIFICATE OF LIABILITY INSURANCE 0117107°` '"' :--:ODUCER THIS.CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO.RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 West Main St.PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A Acadia Insurance E.J.Jaxtimer Builder, Inc. INSURER B: Ernest J.&Marie T.Jaxtimer INSURER C: 48 Rosary Lane INSURER D: Hyannis,MA 02601 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING IANY 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.AGGREGATE L!MITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY D(PIRATION LIMITS LTR NSR DATE MM/DD DATE M N A �GENERALLIABIUTY CPA010264813 01/01/07 01/01/08 EACH.00CURRENCE $1 000 000 rGENI'L MERCIAL GENERAL LIABILITY PA MISE SD aED s250 000 CLAIMS MADE a'OCCUR MED EXP(Any one person) s5 OOO PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE $2 O0O OOO GREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2 OOO 000 ICY jECOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALLOWNED AUTOS BODILY INJURY {Per person)- $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY- $ 'NON-OWNED AUTOS (Per.accident) PROPERTY DAMAGE $ (Per accident), GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S • AUTO ONLY: AGG $ A EXCESSIUMBRELLA U.ABILITY CUA010264913 01/01/07 01/01/08 EACH OCCURRENCE s2,000,000 X• OCCUR CLAIMS MADE AGGREGATE s2 000,000 RDEDUCTIBLE S X RETENTION $0 $ A WORKERS COMPENSATION AND WCA020455010 01/01/07 01/01/08 WC STATU OTH- EMPLOYERS'UABICITY ex,.EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA FaAPLOYEE $SOO,000 If yes,describe under ' E.L.DISEASE-POLICY LIMIT :s500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Job: Bussmann Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIC Town Of Barnstable DATE THEREOF,THE.ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORt2ED REPRESENTATIVE - '�,✓/a..� `7 p ACORD 25(2001/08)1 of 2 #46052, LS7 A CORPORATION ti CCORD 1 311te -16�wtm Board of Building Regula ons and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Improvement�Coiltractor Registration Reqistration: 110609 Type: Private Corporation Expiration: 11/3/2008 Tr# 124739 E J JAXTIMER, Bl11LDER, INC. ERNEST JAXTIMER �= ` 48'RQSARY L N HYANNIS, MA 02601 Update Address and return card. IVlarlc reason for change. � Address Renewal Employment Lost Car( 'I a'S 5 -Os/08-PC8490 — i` I I jr• Nf��r '` , J?' ` ,.r i j c.� a>>t, u 1 yy .+ �,�.ti'43+f,i� y'� ��Y,�- . f l R ��:'�e �Aoa�vJ�ttSbzweal " , I'I � 'tB4 �RQif, I�1DlraGi I +,�legne' OiS�RUC�TO�1 SU2SIIS0 Ml 06 251,. i 4 1,956 TV y i. �� pl► t�4 8 Te. no; 12839 H' - `, e CRf ES, J 48 fj� ARY LAN ! wYANN1S; MA 02601 ��= C .• ,• . vI l �.'.YT6=�M•��C���II,r1�'OC��•5c,,t"• �"7'•T"Tj •w�ic�,r—� '^�'�'p.1 9^u�•�� aa�r S� .,3 i ' r •1v1Tia v1 J.saiuoL-C4MAV 5 �� Regulatory Services L Thomas F."ex,Director . siarsru� d's ,,•� Btu'lding]Division Tom.Perry,Building Commissioner .200 Main Street, Hyaamis,MA 02601 www.towA barnstable.ma.us Fax: 508-790-6230 Ftce: 508-862-403 8 permit no. Date AFFMAYIT HOME BVIPROYEMENT CONTRACTOR LAW -SUPPLEMENT TO PERMIT APPLICATION MGL c. 142Arequires that the"reconstruction,alterations,renovation,repair,modemizatioq conversion, �¢prov ement,removal,demolition,or construction of an addition to any pre-existing owner-occupied kaprov at leas containing t one but not more than four dwelling limits.or to structures wb3ah'are adjacent to be done by registered contractors,with certain excerptions,along wig other such residence or building requirements- 0,00 Type, of Work: DEatunated Coat Address of Work:i Owner's Name. f • Date of Application I hereby certify that: Registratign is not required for.the following reason(s): Work excluded by law [37ob Under$1,000 [3Bu>7ding not owner-occupied []Owner pulling own permit Notice is bereby given that: 0,�pMJ.MG MIR OWN PERMIT 0RDEALING WITHUNREGISTERED FOR APPLICABLE HOME WROVE WENT WORK DO NOT HAVE' CONTRACTORS ACCESS TO THE ARBTTRATIONPROGRAM OR GUARANTYFUND UNDERMGL c.142A. SIGNED UNDERPENALTITS OFPBRMY I hereby apply fora permit as the gent fe owner: �� JJ �x ntiErL- I oc,oq Contractor Signature. Registrat<onNo. Date OR Date Owner's Signature Q:wpfa,imms:h=gfndav Rev 060606 ` ofS .t � Town'of Barnstable Regulatory Services 9T' $ Thomas F:Geiler,Director SrABIA 16.39. c►;� Building Division -Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 ffice:. 508=862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder , as Owner of the subject property . hereby authori Jze J �)(-` 7144L:Y?— &! l l-DL l aUCto act on my behalf, in all matters relative to work authorized by this building permit application for: LE (Address of job) Signature of Owner Date Print Name Q:F0RMS:0V NERPERMISSION l� 07 o REINSTALL CUPOLA ASPHALT ROO SHINGLES TO MATCH EXI T I RAKE TRIM AND SOFFIT T 28 2 IRA gA T 2 9 28 T Z q NEW I I WFLR .C. FE]r — ING — —.—.._.—.—.—.—.—.—.—.—.—.—.BOXES MATCH ' — —.—.—.—._..—.—. — — EXIST 00I�I� TW2892 LASHING AGAINST BUILDING '--------------- NEW RETAIN SIG WALLS-CONTI AND WALKWAYS O FINAL E AND o DETERMINE Q Q PER SITESZ CONDITIONS i `I -pw wt c I-AWN l� ® REINSTALL CUPOLA I f, NEW ROOF AND SHINGLES TO MATCH EXSIT ROOF PITCH TO MATCH EXIST RAKE TRIM TO - - - MATCH EXSIT ---------------------------- 7 j 3 28 8 F GG 6 TW2032-2 FAC. MULL TW283G W-C! SHINGLES TO MATCH EXIST GRADE FIELNON D LOCATED BEAR ELEVATION VEW WINDOWS TO BE INDOWS REMOVERUEA NLESS'RWISE SPECIFIED C4, `.O/'K I TW2842 JI ' NEW DECK //\ NEW BLKHD - - AND RET WALL i LEFT ELEVATION claGKb� �n PLUM sr w "ww,S"�t&L6 / ® REINSTALL CUPOLA TW2842 ROOF PITCH TO / MATCH EXSIT jSHINGLES TO HATCH EXIST i - - ►.6H E � { W �V OW O R—AI WINDOWS TO REMAIN r^� /1�10� Y• liar" l'� I IV I I , I m A 1 A ; m ; r r OO = - - mmm T A E 70 D 7c0 Q Z OO .� A Omm O j 2-um 3 N a O== c Iz m m O F y �A o I 10 U O "' `� WALL DOOR AND — - -------i m WINDOW.TO ' Ni _-_BE REMOVED_____. I I iD J� NEW LV A-T- E= En Ibl Z WINDOW TO C,0 MAIN E I ( z A-2E i I r -Z' 3-0•r I 1 A zNm z i o =E i cEj I N m-1 A m I E Z Q O n N I ! D DE . -D '� n I 70 n ^ m I i m '. n u I , D n j• N VAULT I VAULU z O T N r ' � \ m AE OCP I y m-1 in -�- m0 I rn E-4 rn I m 71) . I D I I D I I m 1 I E ------------� J E N T _ U f � C(�OCrG�. '�--- FIELD LOCATED 10' SONOTUBE W/ TREATED BAND 24' FOOTING NEW DECK FRAME _IO a ' O O CUT NEW GARAGE PEOPLE DOOR IN EXSIT GARAGE FND N 0 NEW CMU BLOC K - ______,.WA -F D_________________: L-L- E LL r• EXSIT ACCESS LL Q QQ NEW HDR FOR EXISTING JOIST HGRS ; 'LL GARGE OLL,V � r W I NNE � Z11 OC NEW CMU BLO •K INFILL OPN L__ __ ---- ------------1 WHERE REQ. (SITE DETERMINE) - ------ ____ i TOO I SL i SLAB FOOTING i C) Q % FIELD LOCATE , � / //WALL FOOTING RIDGE VENT RIDGE BEAM NEW ASPHALT SHINGLE -� ROOF PITCH TO MATCH TO MATCH EXIST EXIST NEW 2XIOaIL" O.C. ~ R-SO INSUL 1 X ! W (MATCH EXIST) w U SIDING (SEE ELEVS.) I- H TYVEK HOUSEWRAP � < _ -�_� VAPOR BARRIER (L .\ 1/2" GWB A.O 1/2" COX. SHEATHING 2X4a16" O.C. R-13.FBGLS. INSUL 3/4" TtG PLYWOOD SUB FLOOR a GLUDED AND NAILED .�®FIRST FLOOR FLUSH W/ EXIST— _ — (TYP) CMU BLOCK WALL R-19 INSUL CRAWL SPACE DUST CAP 2" DUST CAP 0 COMPACTED FILL I i BLAB -SLAB OII FOOTING - �i� I RIDGE VENT ROLL VENT RIDGE BOARD MAYfSTR OVARY) SIZES LMATCH ISEE ELVS.1 - IS-PELT PAPER / HOUSEWRAP 6/S'COX PLYWOOD RAFTER VENT X PLYWOODWIDTH TO ESIDENCEINSULOLY VAPOR BARRIER IHII—BLTT B. 21dO RAFTERS—�► I OTYPICAL STUD WALL O RIDGE VENT DETAIL ec•Le Ian•-r-o• 2 etas lyrr-r-a w. S .z m E ul r TW2842 TW2842 7C r E0—4 oyZ.m mm ODE c E NZZ ANC m my < -4 N m m mAp u 03 MCIzDm m /� E n � O P 70 O m P A O 3 O 3 E U 1.I \ m ul D E u / = w =R,-4 A u � E O n m m m 0" Om T m u -4 W I a-o• m A i E m r � < O0 = 7o p 00 E O O „ A u = C E r m m O I!'-O• u FEIII f 1 W. M u5 ----------------- EX! - AG iI 1 T � I n , NEW , JOI: i J ! / EXSITING FOUNDATION BULKHEAD 1 �' FND I I S P L Z \ SLAB Q FOOTI G ROOF PITCH TO MATCH EXIST i i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION . t Map Application Parcel a A lication# Health Division Date Issued Conservation Division Application Fee , Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKHretten/Hian Project Street Address cJ cFP Village Owner r Address dlC Telephone Permit Request p yO�r/ O A_el CIA- Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay v Project Valuation �/(l Ovv Construction Type [%1�-eC C 01 c, Lot Size Grandfathered: es ❑No If yes, attach supporting o`cumenta�on. izs Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) fvz 'Age of Existing Structure Historic House: ❑Yes ❑No 70nOld King's Hig way: ❑Yes ccQ No m Basement Type: ❑ Full ❑Crawl ❑Wa ut ❑Other Basement Finished Area(sq.ft.) Bas ent Unfinished Area(sq.ft) i, Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑El ric ❑Other Central Air: ❑Yes ❑No Fireplac : Existing New Exi ' g wood/coal stove: ❑Yes ❑ No Detached garage:0 existing ❑new size Pool:❑existing ❑new size Barn. existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Auth ' ation ❑ Appeal# Recorded❑ Commercial ❑Yes No If es, site pla review# Current Use2 Proposed Use ,494 _ems BUILDER INFORMATION Name r ? iv Telephone Number�1 2� 1`� "C�r�C� Address License# JJ Home Improvement Contractor# &6 `d O 7 Worker's Compensation#�a D� 177 ALL CONSTRUCTION DEBRIS ESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE OO FOR OFFICIAL USE ONLY. APPLICATION# DA-t ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER e � o DATE OF INSPECTION: FOUNDATION O .FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH; FINAL _ FINAL BUILDING F 1 DATE CLOSED OUT ASSOCIATION PLAN NO. r Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia davit: Builders/Contractors/Electricians/Plumbers Workers"Compensation Insurance.AM Applicant Information 4 Please Print Le 'bl Name(Business/Oro nizationdndividual): . Address: city/S.e/ G Phone.#: AV re an employe . Check th appropriate bog: Type of project(required):. 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction . employees(full and/orpart-time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' y p tY• $. 9. ❑Building addition comp.insurance. [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11. Plumn •3.❑ I am a homeowner doing all work thi ❑ big r. epairs or additions myself [No workers' comp. right of exemption per MG 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 warkers'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 Iam an employer that is providing workers'compensation insurance for my em loyees. Below is thepolicy and job site information. Insurance Company Name:Policy#or Self-ins.Lic.M 6 U c 77 Expiration Date: 1111eF Job Site Address: / City/State/Zip: C,70 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 I)IA for' e coverage ve-Vification. I do hereby certify:ender p ti of p 'rcry that the information provided aftKis tgie and correct: Signature: Date: V dcv Phone#: Official use only. Do not write in this area,to be completed by city or town ofciaL 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#: 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, §25g7)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 ins ranee 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-contractors)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-hMrance 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'aumber. 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 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 Depaitnent'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 ext406 or 1-877-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia I OfTMEtaY'Y Town-of Barnstable yP °� Regulatory Services + sasN . _ Thomas F.Geiler,Director �� te39 •�� BuildinQ Division �rED MA'S a b - . Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 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 Estimated Cost Gib address of Work: Owner's Name: + Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 OBuilding not owner-occupied ❑Owner 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:f PENALTIES.OF PERJURY I hereby apply or a emit as the agent of owner• -- pGGell07 Date Contractor N Registration No. OR Date Owner's Name Qf0=:hcmea.fndav 03-07-OT 03:12pm From-AIG +973 331 8599 T-875 P•001/002 F-696 CERTIFICATE •I 'Y376.200 .. I. I.; '1' '.�i+.'':.i'1'*:•t:'�x:':•:.d�•t'E�:KI?� "rii•J�==:�.:v�ri.•,ls:;t,. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Edward A Grazul Insurance HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 4527 Falmouth Road Po Box 337 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Marstcns Mills, MA 02S48 COMPANIES AFFORDING INSURANCE INSURED COMPANY A GRANITE STATE INSURANCE COMPANY I' Hayden Building Movers Inc Po Box 495 Cotuit,MA 02635-0000 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELMI HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 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. I Co 1 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE A613 ORXERSCO�MPENSAT10N EMPLOYERS'LIABILITY LIMITS THE PROPRIEYOR! AFYNER6rEXECUYIVE OFFICERS AAF: 860277 INCL 1]F.XCL 0 8 2/0512007 2/06/2008 ATUTORYLIMI?S COverege APplitm Ic MA OpenoWns Only, • CHACCIDNT $ 100,0001 DISEASE POLICY LIMIT $ 500,00 DISEASE-EACH EMPLOYE $ 100.000 DESCRIPTION OF OPERATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN: BLDG DEPT EXPIRATION DATE THEREOF,THE IBSUINGCONIPANY WILL ENDEAVOR TO N'AILIn 200 MAIN ST DAYS WRITTEN NOTICE YO THE CERYIFICAYE HOLDER NAMED TO THE LEFT,BUT HYAN NIS, MA 02601 FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPREB'cNrATIVES, AUTHORIZED REPRESENTATIVE t { _I fl x - ry F" co ^J i` CIO rn BOARD OF BUILDING REGULATIONS License:.CONSTRUCTION,SUPER�/ISOR Number+CS 016161. Birthdate 09/-471945 t az Expires: 09/-- 2007 Tr.no 4359.0 p? R6tricted-00- I r ROBERT F .HAYDEN � 4 , 60CHEOH.ROAD / 1 COtUIT,"'MA 02.25, `� Commissioner n ,tea-•---•.,.,- -\ Board of Building Regulations and Standards i — HOME IMPROVEMENT CONTRACTOR Registratio�,n�_106207 } Expiration' /2008 I Typvate Corporation l HAYDEN BLDG MOVE-RSi.INC: .Robert Hayden PO BOX 496 COTUIT Mills, MA 02635 Deputy Administrator 'i r - - .rite: 7/25/2007 Time: 2 :00 PM To: OnTarget Screening @ 915084204474 On Target Services Page: 001 TULT.Ed 1 T.00gft e8 99 Enterprise Avenue �nenue www.ontargetservices.com #ilia SQ'rV%¢�'S Gardiner,Mine04345 Y te 1800-598-0628 fax 207-58N302 a-mail: smenII ag@ontugeLwvices.com Date/Time : 7/25/2007 2:00:04 PM To : BOB HAYDEN Company'. HAYDEN BUILDING MOVERS Tel.: (508)-428-6380 ext. Fax: (508)-420-4474 ext. This message is being sent in response to your request for underground cable location.The following represents a list of responses for the indicated member.These reponses only pertain to the specific member. Ticket : 20073006355 Place : BARNSTABLE, MASSACHUSETTS Address : 367, PLUM ST 1-COMCAST CABLE-SEMA AREA Ticket Screened on 0712512007 This ticket is clear of conflict and has been screened by un ll arget UL11ity Services If there are questions regarding this transmission or if you arrive at the site and have a question about the markings,please call 1-800-598-0628, extension 3347, during normal business hours, Monday- Friday between 7:00 and 4:30 I 4 46 DATE : 07/25/2007 FROM : INNOVATIVE DATA MANAGEMENT, INC 146 Orange Place MAITLAND, FL 32751 PH : ( 407 ) 539-1390 Fax : ( 407 ) 539-1739 TO : HAYDEN BUILDING MOVERS FOR: BOB HAYDEN TICKET STATUS TICKET - 20073006355 STATUS - CLEARED OF CONFLICT FOR VERIZON CITY - BARNSTABLE IN COUNTY LOCATION - 367 PLUM ST i JUL-31-2007 TUE 01 : 19 PM KEYSPAN ENERGY FAX NO. 508 394 5019 P. 01 7 Energy Delivery 12 Whit 12)Whites Path South Yarmouth,MA 02664 July 31,200T Til Wham It May Con=,U, '�'fri le is as JO raacrfirVE _tie are mca uuderground nattn'al gas ftailifi s to the �3k s , &xa . pc ty� This was confirmed by our r�Udive on July (cim bt:rcai±wd dire dly at 5W760?484 should there he any further S,ir�, °lye R pat ia W )n (1,c alstairtiom Coondimdar,(rape Division •Town of Barnstable Regulatory Services L WLC&^B Thomas F.Geiler,Director ATF �So*1 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 509-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section If Using A Builder I A." 2 air as Owner of the subject property hereby,authorize /,�L.w+� z, to act on mY behalf, in all matters relative to work authorized by,this Molding permit'application for, . Address of Job) -Sign o Qwner D Print Name QFORMS:OwNE-RPERMISS ION i �W r � I' � � O II �v I� \�� V � � � \ I �' . i �BU✓LDING� GENERAL Q CONTRACTORS RESTORATIONS Q� SHORING a 6nJ l'I,4SS-42 HAYDEN BUILDING MOVERS,INC. ROBERT F.HAYDEN - PRESIDENT Mailing Address: Shop Locations: P.O.BOX 496 84 INDUSTRY RD. MARSTONS MILLS COTUIT,MA' COT (Adjacent to Cotuit Landing) 02615 Shop:508-428-6380•Fax:508-420-4474•Cell: 508-364-6387 a�6 � L�i „e L f I I ✓ ` I � o I II I II - �� - ;; � _ ' , �. �\ •. � • ` � � , • .- � , !� \ '', � ` .. ,, � - � ` l `\`� \ � , •� • , '. ^� � �' )`- z_• ` ,\ � .,�c ,may_.', 1 _ \ \ � \ _ 'L ,\ - � �y � �• �, _ ` ^ '\ •� _ • ^'� -� ,\ ' ,\ _ � �- \ _ . . • � _ \ \ e � ,� �y .,_ a. _' � �` � 1 � r �` ` `\� � � �\ 7814418721 NSTAR SUM SW3024 09:16:40 a.m. 08-03-2007 1 !1 S ,AR One NSTAR Way EL ECTR/C Westwood,Massachusetts 02090 GAS August 3,2007 Robert Hayden Hayden Building Movers P.O.Box 496 Cotuit MA 02635 RE:Electric Disconnection Lead Times 367 Plum Street,West Barnstable MA To Whom It May Concern: At the request of Robert Hayden this letter serves to inform the typical duration of a work order request for a temporary service disconnection.Provided all information is completed accurately at the time of application,the.typical NSTAR commitment date for completion of a simple disco nnecYreconnect work order will be 22 business days from the initiation date.If the service fee is paid at the.time of initiation,this would advance the project by approximately 10 business days.In situations where the fee is paid in a timely manner and there are no complications,the service disconnection can be scheduled approximately 1.5 to 2.5 weeks from the initiation of the work order.Please keep in mind that the total time to completion on an individual project is dependant on a multitude of factors and NSTAR makes no firm commitments to any project being completed prior to the committed due date specified at the initiation of said work order request. If you should have any questions,please call me at(781)441-3334. Justin Reih1 Customer Service Engineer HAYDEN BUILDING MOVERS, INC. P.O. BOX 496,FALMOUTH AVENUE,COTUIT MA 02635 TEL. 428-6380 WHEEL WORK A SPECIALTY REFERENCES,INSURED,BONDED � ool X-ji . c�r7- � � rZool _ QTt�ri � ��� i!rl�vQlil�. / l..z J ^ 7 ire HAYDEN BUILDING MOVERS, INC. P.O. Box 496, FALMOUTH AVENUE,COTUIT MA 02635 TEL. 428-6380 WHEEL WORK A SPECIALTY REFERENCES,INSURED,BONDED / (/ G l ulpe e 72('--4 00 Ole /��� ��� I NOIaIMO Z :I I WV I - OnV LOOT 318ViSi0`�V€i :.10 11'0 _ r y. � e iLDING�O GENERAL L CON IDS RESTORATION6 :. SHORING 6nJ ss • _ . ate � _ _ . . . �.._ . HAYDEN BUILD ING MOVE ROBERT F.HAYDEN MajWg Address: PR.FSIDENT P.O.BOX496 COTUIT MA Shop Locations: 02635 84�USTRY,RD.. 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