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0037 RIDGE ROAD
I i 0 0xbw NO. 1521/3 ORA MAN N use. 18t FSSE13M i COO Op7HE Town of Barnstable *Permit# ° Expy : PERMIT Regulatory Services Fee ee n �dmte KASEL _. ,; 2 1 Thomas F. Geiler,Director CO) T ! -IN OF BARNSTAB � Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESMENTLA_L ONLY Not Valid without Red X-Press Imprint Map/parcel Number-ZI U I ou Property Address l(a !7/Ld Residential Value of Work 3 W U- Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,IAI C ��q `7 /� Vyr Contractor's Name G ' G G c9 _ T G _ Telephone Number -4ome Improvement Contractor License#(if applicable)_ � 3 (e �onslrucdon Supervisor's License#(if applicable) r✓�[j (� ]Workman's Compensation Insurance Check.one: ❑ I am a sole proprietor ❑ I am the Homeowner [} I have Worker's Compensation Insurance isurarice Company Name L✓ 1yC,Y C11 L 'orkman's Comp. Policy# �/\/ �a — (Cj' 7j`? 2 �� ��4�9 [ opy of Insurance Compliance Certificate must accompany each permit :rmit 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 ��I&L ✓h�=urn #of doors_� v [� Replacement Windows/doors/sliders. U-Value S ( .44)#of windows *Where required: Issuance of this permit does not exempt compliance With other town department regulations,i.e.Historic,Conservation,etc. Property Owner must sign Property Owner Letter of Permission. A copy of th ome rovement Contractors License & Construction Supervisors License is regni I NATURE: 2 PFTT.FCIF(1RhAC1F�nilrii�v rr....it fi.....�lL' � orcc a.... 6/13/2011 5:51:09 AM PST (GMT-8) !'HUM: insurancevisioris.com--Iv: iwbi /00000 edye: _ OL l-) DATE(MM/DD/YYYY) ACORD, CERTIFICATE OF LIABILITY INSURANCE i 6/13/2011 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 endorsements . I PRODucER-FRANK L HORGAN INS AGENCY INC CONTACT NAME: 44 BARNSTABLE ROAD PHONE IAC.No Exil, 508 775-5830 F A/c No): 5(_08)I%5-6688_ HYANNIS, MA 02601 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NA_IC A wSUHERA: LIBERTY MUTUAL GROUP INSURED CAPE & ISLANDS CONSTRUCTION COMPANY INC wSURER PO BOX 210 INSURERC: CENTERVILLE MA 02632 ---- - INSURER D: INSURER E: wSURERF: COVERAGES CERTIFICATE NUMBER: 10385984 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 WITI I RESPECT TO WI IICI I TI IIS 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. _I INS" ADDL SUBR POLICY EFF POLICY EXP LIMIT'S LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY GENERALLINBILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ CLAIMS-MADE1-1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY GENERAL AGGREGATE $ GEN'L AGGREGATE LIMrr APPLIES PER. PRODUCTS-COMPIOP AGG $ POLICY PRO- LOC .--- $ —_ Fj OM AUTOMOBILE LIABILITY (Eaa a.dEenOISINGLE LIMIT $ ANY AUTO ' BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS $ NON-OWNED PR PE71DAMAGE $ HIRED AUTOS AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ $ A WORKERS COMPENSATION WC2-31 S-377540-011 5/7/201 1 5/7/2012 ,/ TORY LIHIfTS ERI AND EMPLOYERS'LIABILITY Y/N ANY PNOPRIETORIPARTNERIEXECUTNE LNJ N/A E.L.EACH ACCIDENT $ 100000 OFFILkKIhIEMtlER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 It yes,descrbe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If nrore space Is required) ICI Workers Compensation Insurance: Part One of the policy applies only to the Workers Compensation Law of the State of MA. 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 200.MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE Jeff Eldridge 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ••ERT NO.: 103859a4 Anna Chandler 6/L3/2011 5:46:22 Ara Page 1 of I eh Ls certificate cancels and supercedes ALL previously issued certificates. i The Commonwealth of Massachusetts Department of Industrial Accidents i 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): . t1_1 Gt Address: /L���C. PC City/State/Zip: )j 4 v w I.; /� � L� Phone.#: Are you an employer?Check the appropriate box: Type of project(required):' 1.[ I am a employer with .4. ❑ I am a general contractor and I have hired the sub-contractors 6. ❑New construction . . employees(full and/or part-time).*. 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.M 3)S -3 27 Expiration Date: Job Site Address: � ��I�L s _ s L City/State/Zip: �e 1/h e/4 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 'olator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the WA for ins nce coverage verification. I do hereby certify unde the a' sand pen ies of perjury that the information provided above is true and correct. Si ature:. ` Date: Phone#: f J Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): .1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and 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 p&son.in the service of another under any contract of hire, express or-implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability ConVanies*(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit./license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related io any business or commercial venture (i.e.a dog license or permit to burn leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance-for your cooperation and should you have any.questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. The Commonwealth of Massachusetts ]department of Industrial Aeeidents Office of Investigation 600 Washingtoh Street Boston,NIA 02111 Tel.#617-727-4900 ext 406 or 1-$77-MASSAFB Revised 11-22-06 Fax#617-727-7749 www.ma.ss..gov/dia r : EARM NI Town of Barnstable 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 AV t(\ ,as Owner of the subject property hereby authorize Ct Iu a.l-XS1-,-,ds lb4rv'�' (�� . to act on my behalf, in all matters relative to work authorized by this building permit application for. e (Address of Job) J11 AAA L 'aell Signature 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\deoollik\AppData\Lmal\Mcrosoft\Windows\TemporarylntemetFiles\ContentOutlook\DDV87AAZ\E PRESS.doo Revised 072110 " .�. iV1asN.►chuscttN' - Dcl►artmcnt of Public Sal'cth Board of Buildinl- Re!-ulations and Standards Construction Supervisor License License: CS 74660 JOSHUA X KOURI , PO BOX 210 CENTERVILLE, MA 02632 Expiration: 2/12/2013 ('ununissiuner Tr#: 12106 C `V�omrirrlModeca!� 4y✓�'Lc[oiaci<. U Tce of Consumer Affair:.;'c_B sines Itegulat!nn: -=- HO AE IMPROVEMENT('0,4TRACTOR ' Regi:stration: 1,65936 Type: - Ex ►ra lon: -:41912Q12 P• i -\ Private Corporat;o- CA 8 ISLAND CCiNGT!0, t-TION cO_I:4'C f iOSHUA KOURI 1_ ;_,7 Ti I'I 55 ELM AVE. t ,AF2 601� �1' c HYANNIS, MP:02 • •i_ Cyr?drrsccretary +�. Massachusetts- Dcl►artntcnt (it• Public Sat'ct� Board of Building Reaulatiuns and St:utdards Construction Supervisor License License: CS 74660 JOSHUA X KOURI ' 1 PO BOX 210 I CENTERVILLE, MA 02632 I ' I " I Expiration: 2/12/2013 Commissioner Tr#: 12106 License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ' Boston,MA 02116 I' of ealid without signature ICxQ�[0 �pIKE l Town of Barnstable *Permit# Expires onth fro issue dale Regulatory Services Fe 1a6J q. �O S irk % Thomas F.Geiler,Director ATfD MAr r C 4 .-W ���f Building Division 7-o Tom Perry,CBO, Building Commissioner ry�,� .�} . : 200 Main Street,Hyannis, MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 1 (� 4 Property,Address [Residential Value of Work 2;A2 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /v tzk / e s 1^,C, d, Contractor's Nam eJ���r I� t L O /n.L Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)�T 0 kworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance .Insurance Company Name ` ,1.� L IL J-16c4• I or Workman's Comp. Policy# 3j C -3 ZZ-7 15�_- Y a I Copy of Insurance Compliance Certificate must accompany each permit. Permit 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 #of doors [.} replacement Windows/doors/sliders. U-Value (maximum .44)#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. I A copy of a Ho a Improvement Contractors License&Construction Supervisors License is I re uire . SIGNATURE: i VZ Q:\WPFILES\FORMS\buildin permit forms\EXPRESS.doc Revised 0701.10 i A The Comuromvealth of Massachusetts Department of Industrial Accidents Office of Investigations 660 Washmgmw Street Boston,MA 92111 : nwtxmass.gov1dia Workers' Compensation Insurance Affidavit: Bmflders/Contractors/Etectiicians(PbiLmbers Applicant Information Please Punt I*M'bh Name Address: 0 / CityfState/25p: r �,,�G -�— 1/� Phone#- c9 Are you an employer?Cheek the appropriate box; Type of project(required): 1-Wam a employer with 4. ❑ I am a general contractor and I employees(fall andlor ). s have hired the sub-cmtcacthrs 6. New construction 2-❑ I am a sole proprietor or partner- listed an the attached sheet, 7. ❑Remodeling ship and have no employees 'use sob-contractors have 9. ❑Demolition woddng for mein any capacity. employees and have wags' [No wodla! s'camp.insurance comp-insmance 1 9. ❑Building addition required] 5. ❑ [fie are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself [No workers'comp- right of esemptton per 1Y1GL 12.❑Roof repairs insurance required.]r C. 152,§1(4),and we have no employees.(No workers' 13.❑Other comp.insurance required.] •Any app&=that checks bane#1:nmsi also fill out the section below showing rhea wokeas'compensation policy inf raxtia Y Homeowners who submit this affidavit indicating they ale doing SH wad and then hire outside cortmacmrs mast submit a new affidavit indicating such kAmt accmrs that check this boa must attached an addition, sheet showing the name of the and 6091E whether or not those entities have employees. If the sub<anttactors have employees,(hey must provide their warkkers':comp.policy,number. I am an employer that is providing workers'compeusWivn incurim for my amployw-% Below is thepoiicy and job site informaden. ) J Inmmance Company Name: Policy 9 or Self--ins.Lin#. e — /15:--72 77 Cr floc Expiration Date: Job Site Address: 4e,Vk 4er - D�l CityfStateZip: Attach a copy of the workers'compensation policy d colon page( the policy member 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 file 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 Im-estigations of thee•DIA for= pro crnrerage verititation- I do hereby cepW y under the pains d pen ofpedwy that the information proe►ided above is > an correct Date: v� Phone M " 0,acia1 use only. Do not!mite in this arm a be completed by city sr town officiat City or Town: PermitlLicense# Issuing Authority(circle one): . 1.Board:of Health 2.Building Department 3.Clty(Fown Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 6/13/2'011 5:51:09 AM PST (GMT-8) b'RuM: insurancevisioris.com-'i't-1: J.Duo/ Iz)D000 rdye: _ 01 17 DATE(MM/DD/YYYY) AC�RO CERTIFICATE OF LIABILITY INSURANCE F6/13/2011 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. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WANED,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 endorsements . 1 PRODUCER-FRANK L HORGAN INS AGENCY INC CONTACT NAME: 44 BARNSTABLE ROAD PHONE o 1 508 775-5830 I-AA IAIC.No: S( o8L7 5-6688 HYANNIS, MA 02601 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC q INSUKERA: LIBERTY MUTUAL GROUP INSURED CAPE & ISLANDS CONSTRUCTION COMPANY INC IN,u,ERB: PO BOX 210 INSURERC: CENTERVILLE MA 02632 INSURER D: INSURERE: INSURERF: COVERAGES CERTIFICATE NUMBER: 10385984 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. NOTWff11STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITI I RESPECT TO WI IICI I TI IIS 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. AOOL SUER POLICY EFF POLICY EXP INSR IYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MM/DD/YYYY LIMITS GENERALLUIBILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occ wrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILII'Y IEOe accidD SINGLE LIMIT eenI $ , 1 ANY AUTO BODILY INJURY(Per person) $ i ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-0WNED 1 HIRED AUTOS AUTOS Per ae idenl $ _ $ $ UMBRELLA U 13 'OCCUR EACH OCCURRENCE $ - EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ $ I A WORKERS COMPENSATION WC2-31 S-377540-011 5/7/201 1 5/7/2012 ,/ TORY L M S tnl sA AND EMPLOYERS'LIABILITY Y/N ANY PNOPMETOR/PARTNERIEXECUTNE E.L.EACH ACCIDENT $ 100000 OFFICEWMEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under E.I DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if nmre space Is required) Workers Compensation Insurance:Part One of the policy applies only to the Workers Compensation Law of the State of MA. 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 AUTHORIZED REPRESENTATIVE Jeff Eldridge r/A ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD -EFT vo.: 10385984 Anne chandler 6/13/2011 5:46:22 AN Pages 1 of 1 LhLs certificate caner Ls end supercedes ALL previously Lssued certificates. c a i i°v J Q p u.0 0 _ p (D N LLF co X N 2�; .'tF _ U Q X cr i n J O W p O 4-�.. —ti��frs'T�._ :� �A�7•LT 11 f.�.jl � J" }. oLConsumer A , HO 1f+ir..^ Bus+ncss Rc9U HUon gE IMFRQV .Regitration. EMENT.CG TRACTOR — s 165936 Expira°�� 1012 Type: CA Private Corporatto• ISLA & ND ,.1 55 ELAp HYANNIS MA 0260.1` _ 'Y -ice--> - l:' 3r.:sccrciary i J Regulatory Services Thomas F.Geiler,Director v w 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 as Owner of the subject roe //�� 1� ,� . 1 property rty hereby authorize CipC 91 �S�"AIS 0WAScI-f-11- . (�o to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners.License Exemption Form on the reverse side. C:\Users\decoUik\AppData\1.00al\Miorosoft\Windows\Temporary Internet Files\Contentoudwk-\DDV87AAZ\EXPRESS.doo Revised 072110 i Town of Barnstable *Permit Expires 6 n is jrom i date Regulatory Services Fee X' b-rnBM Thomas F.Geiler,Director 008 Building Division 70 BLF Tom Perry,CBO, Building Commissioner TOWN O BAR�STA 200 Main Street, Hyannis,MA 02601 www.towri.barnstable.ma.us Office: 508-862-4038 . . Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number t� Property Address � ll� \\� \ 4 o��,\ C�\�'k \� 'esidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address CA, Contractor's Name ��� \ a amsT �1 Telephone Numbe � ZA Home Improvement Contractor License#(if'applicable) 1001 LIB -)QWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name• (1 Cjc Workman's Comp. Policy# �9�(� (�j`1`h�(Qa Copy of Insurance Compliance Certificate must be on file. Permit 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 ❑ Replacement Windows/doors/sliders..U-Value (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 t e Home Improvement Contractors License is required. SIGNATURE: Q:Forms:bu ild ingpermits/express Revised 123107 i Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT PO" S T OWN THE PROPERTY LOCATED AT73t '*4 IN , MASSACHUSETTS. aC-� 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: 3 7 �1`cp�e U`8a-� OWNER'S TELEPHONE: !T 3 7 ` T P/0 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: I RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: i i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t 600 fflashington Street Boston, MA 02111 wlv►v.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Ndi17e (Business/Organizatiot>1lndividual): Address: City/State/Zip: !!b Phone #:-:5C5g-. y q—nls" Are you an employer?Check the appropriate box: Type of project(required): 1I am a employer wit 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub contractors 6. ❑New construction [2.01 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12 Roof repairs insurance required.] t employees. [No workers' comp. in 13.LJ Other p surance 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 this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. • C� �t ���-r� ������ „prvviumk workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Mtn Policy #or Self-ins. Lic. #: , x-:iC(o") I- ,�va. Expiration Date: S Job Site Address:13 City/State/Zip:(o 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 i surance coverage verification. 7do by certify ender t e n and penalties of perjury that the information provided above is true and correct.: Date: CR I IL Phone#: SiI [[fcial use only. Do not write in this area, to be completed by city or town official or Town: Permit/License# ing Authority(circle one):oard of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector thertact Person: Phone M r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to(his 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 enwloper is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(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 numhPr nn tha nnnrnnrinfa lino City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406 or 1-8,77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwlv.mass.gov/dia Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration elate. If found return to: d!111, hoard of Building Regulations and Standards Registr.4110; 100740 One Ashburton ('lace 12m 1301 pl'Pd tS 70.--�23/2010 �` Boston,Ma.02103 p lement Card CAPIZZI HOME M ( :v:.-MNT1ry t� RY GUSTAFS©ty.;.��,�_a 1645 Newton Rd. Cotuit,MA 02635 Administrator No vali itho.t nature Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 B i rthd a te: 11/29/1975 Expiration: 11/29/2008 Tr# 6430 " Restrictlon: 00 GARY GUSTAFSON 8 SHORT WAY SANDWICH,MA 02563 Commissioner Client#: 47298 CAPIHOM DATE ADORDrM CERTIFICATE OF LIABILITY INSURANCE 06/12/2008YYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ' Rogers &Gray Ins. -So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1601 - South Dennis, MA 02660-1601 --_- _ INSURERS AFFORDING COVERAGE NAIC# INSURED I:NSURERA. NGM Insurance Company I Capizzi Home Improvement, Inc. I IINSJRF,RB American-Home Assurance 1 Capizzi Enterprises, Inc. 1645 Newtown Road ----�-- - —-- - -- i;NSURER D i Cotuit, MA 02635 j INSURER_ COVERAGES 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 wHCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TI-''E?OL!C!ES DESCRIBED HEREIN IS SUBJECT TO ALL THE 7 ERr.1S EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN;MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' OLICY EFFECTIVE !POLICY EXPIRATION LTR NSR P TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE(MMIDO/YYI _ _ LIMITS A i GENERAL LIABILITY -MPB1075H 06/08/08 06108/09 _FAC61OCC,HRENCE s1 O00000 1 X COMMERCIAL GENERAL L!ABcL 7Y DAMAGE TO RENTED PREMIScS(E o « •n s500 OOO CLAIMS MADE 7 occciR. VIE':EXP(Arty one person) S10,000 0 ERS,,NAL&AOV INJURY $1 OOO 000 GENERAL AGGREGATE $2 000,000 HGEN'L AGGREGATE LIMIT APPLIES PER !-RODUC TS-COMPIOP AGG $2 000,000 POLICY 7PRO--JECT i _::C� i --- AUTOMOBILE LIABILITY 'COMS:NEO SINGLE UMI1 ! !ANY AUTO I;Ea accnenl) !$ ALL OWNED AUTOS i 60DIa.', :N.URY _�--- ! ) I SCHEDULED AUTOS (_e,oersOn -- $ HIRED AUTOS BOW Y:NJURY I$ ! NON-OWNED AUTOS °Gr acuoenq — -- 'F'ROP@ DAMAGE cc,ce j :Pr,acenl) S GARAGE LIABILITY 1�AU 0 ONLY•EA ACCIDENT $ ANY AUTO EA ACC $ 07,1ER 1 HAN i AU'O ONLY AGG S A EXCESS/UMBRELLA LIABILITY ,CUB1076H 06/08/08 .06/08/09 LEACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE ;AGGREGATE _ $5 000 000 DEDUCTIBLE $ X RETENTION $10000 ) $ B WORKERS COMPENSATION AND .WC6716562 12/25/O7 !12/25/O8 !XT;•.vcY�Aiu• oTH• EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECU''IVE ^_ EACH ACCIDENT S500,000 OFFICER/MEMBER EXCLUDED? E If yes,describe under DISEASE-EA EMPLOYEE $500,000 ,-- SPECIAL PROVISIONS below _--- _. DISEASE-POUCY LIMIT s500,000 OTHER —'-- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT;SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable !DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN 200 Main Street I 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. 1 AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S36540/M36539 KW ACORD CORPORATION 1988 I DURABLE POWER OF ATTORNEY I, Thomas W. Guest, of 37 Ridge Road, West Barnstable, County of Barnstable and Commonwealth of Massachusetts, hereby appoint my son, Mark S. jGuest, my agent to do the following.things for me and on my behalf: i1) Pumose of this Power of Attorney. I intend this to be a general power of attorney. I shall specify certain acts which my agent is authorized to do in my behalf, but this is not intended to limit the generality of this power. I intend that my agent shall have the power to exercise or perform any act, power, duty, right, or obligation whatsoever that I now have, or may hereafter acquire the legal right, power, or capacity to exercise or perform, in connection with, arising from, or relating to any person, item, transaction, thing, business, property; real or personal, tangible or intangible, or matter whatsoever; 2) To Collect, Enforce, and Manage Assets and Claims To request, ask, demand, sue for, recover, collect, receive, and hold and possess all such sums of money, debts, dues, commercial paper, checks, drafts, accounts, deposits, legacies, bequests, devises, notes, interest, and retirement benefits, insurance benefits and proceeds, securities, any and all documents of title, claims, personal and real property, intangible and tangible property and I property rights, and demands whatsoever, liquidated or unliquidated, as now are, or shall hereafter become, owned b due owing, y, or g, payable or belonging to, me or in which I have or may hereafter acquire an interest, to have, use, and take all lawful means and equitable and legal remedies, procedures, and writs in my name for the collection and recovery thereof, and to adjust, sell, compromise, and agree for recovery thereof, and to adjust, sell, compromise, and agree for the same, and to make execute and deliver for me, on my behalf, and in my name, all endorsements, acquittances, releases, receipts, or other sufficient discharges for the same; 3) To Deal With Personal Property. To lease, purchase, sell, exchange, and acquire, and to agree, bargain, and contract for the lease, purchase, sale, exchange, and acquisition of, and to accept, take, receive, and possess any personal property whatsoever, tangible or intangible, or interest thereon, including, but not limited to automobiles, trucks or trailers, on such terms and conditions, and under such covenants, as my agent shall deem proper; 4) To Deal With Real Estate To maintain, repair, improve, manage, insure, rent, lease, sell, convey, subject to liens, mortgage, subject to deeds of trust, and hypothecate, and in any way or manner deal with all or any part of any real or personal property whatsoever, tangible or intangible, or any interest therein, that I now own or may hereafter acquire, for me, in my behalf, and in my name and under such terms and conditions, and under such covenants, as my agent shall deem proper. To sell and convey any and all land owned by me; 5) To Establish and Amend Trusts To establish trusts on my behalf, on terms which my agent shall to his or her belief understand to be. my wishes for my estate, and to amend any trust established by me; 6) To Fund Trusts i To transfer money, securities, and other property to any trust or trusts which I shall earlier have established; 7) To Execute Disclaimers To execute disclaimers on my behalf under Section 2518 of the Internal Revenue Code or any comparable section of any state statute; 8) To Deal With Brokerage Accounts With respect to my brokerage accounts, to effect purchases and sales (including short sales), to subscribe ,for and to trade in stocks, bonds, options, rights, and warrants or other securities, domestic or foreign, whether dollar or non- dollar denominated, or limited partnership interests or investments and trust units, whether or not in negotiable form, issued or unissued, foreign exchange, commodities, and contracts relating to same (including commodity futures) on margin or otherwise for my account and risk; to deliver to my broker securities for my account and to instruct my broker to deliver securities from my accounts to my agent or to others, and in such name and form, including his own, as he or she may direct; to instruct my broker to make payment of moneys from my accounts with my broker, and to receive and direct payment therefrom payable to him or her or others; to sell, assign, endorse and transfer any stocks, bonds, options, rights and 2 warrants or other securities of any nature, at any time standing in my name and to execute any documents necessary-to effectuate the foregoing; to receive statements of transactions made for my account(s); to approve and confirm the same, to receive any and all notices, calls for margin, or other demands with reference to my accounts(s); and to make any and all agreements with my broker with reference thereto for me and in my behalf. The power granted herein shall apply to brokerage accounts with the following brokers: and any other brokers with whom I may have accounts from time to time. I authorize my agent to execute on m behalf an powers of attorney 'Y YP ym whatever form which may be required by any stock broker with whom I have deposited any securities; 9) To Deal With Securities. To buy, sell, trade in, hypothecate, and otherwise manage any securities, domestic or foreign, whether dollar or non-dollar denominated, including, but not limited to, stocks, bonds, and options, which I may own, and to sell all or part of such securities and purchase other.securities; 10) To Make Contracts and Give Releases To make, receive, sign, endorse, execute, acknowledge, deliver, and possess such applications, contracts, agreements, options, covenants, security agreements, bills of sale, leases, mortgages, assignments, fire and casualty insurance policies, bills of lading, warehouse receipts, documents of title, bills, bonds, debentures, checks, drafts, bills of exchange, letters of credit, notes, stock certificates, proxies, warrants, commercial paper, receipts, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, liens, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be necessary or proper in the exercise of the rights and powers herein granted; 3 I 11) Bank Accounts. To deal with any bank accounts or certificates of deposit which I may own, to withdraw funds from such accounts, to pledge such accounts, and generally to exercise control over such accounts, and to establish new accounts; 12) Life Insurance Policies. To deal with life insurance policies and annuity contracts, to change the beneficiaries, to assign the policies, to surrender and borrow against the policies and to exercise all of the incidents of ownership in any life insurance policies or annuity contracts I own; 13) Medical Care. To make decisions as to acceptance or rejection of medical treatment, to engage and dismiss physicians and other health care personnel, to choose where I shall receive medical treatment and to arrange for my admission to and discharge from hospitals and other places of treatment, and to do anything in connection with my health care which I could do personally. If I shall have executed a valid Health Care Proxy this provision shall be inapplicable; 14) Tax Matters. To represent me in all tax matters; to prepare, sign, and file federal, state, and local income, gift and other tax returns of all kinds, including joint returns, claims for refunds, requests for extensions of time, petitions to the Tax Court or other courts regarding tax matters, and any and all other tax-related documents, including, but not limited to, consents and agreements under Section 2032A of the Internal Revenue Code or any successor section thereto and consents to split gifts, closing agreements and Form 2848,.and any other power of attorney required by the Internal Revenue Service, any state or any local taxing authority with respect to any tax year between the years 1985 and 2020; to pay taxes due, collect and make such disposition of refunds as my agent shall deem appropriate, post bonds, receive confidential information and contest deficiencies determined by the Internal Revenue Service, any state, or any local taxing authority; to exercise any elections I may have under federal, state or local tax law; and generally to represent me in all tax matters and proceedings of all kinds and for all periods between the years 1985 and 2020 before all officers of the Internal Revenue Service and state and local authorities; to engage, compensate and discharge attorneys; accountants and other tax and financial advisers and consultants to represent and/or assist me in connection with any and all tax matters involving or 4 in any way related to me or any property-in which I.have or may have any interest or responsibility; 15) Safe Deposit Boxes. To enter any safe deposit box which I may have leased; to add property to the box or take properly from the box, and to surrender possession of the box and terminate the lease if my agent shall deem it appropriate; 16) Mail Boxes and Mail To enter any mailbox leased by me; to instruct that mail be forwarded to another address selected by my agent and to surrender any leased mailbox; 17) Power to Do All Necessary Things I grant to my agent full power and authority to do, take, and perform all and every act and thing whatsoever requisite, prior, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as I might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that my agent shall lawfully do or cause to be done by virtue of this power of attorney and the right and powers herein granted, 18) Powers Not Intended To Be Limited This instrument is to be construed and interpreted as a general power of 1 attorney. The enumeration of specific items, rights, acts, or powers herein is not intended to, nor does it, limit or restrict, and is not to be construed or interpreted as limiting or restricting, the general powers herein granted to my agent; 19) Choice of Conservator or Guardian. If it is necessary at any time for a court to appoint a conservator for my estate or a guardian of my person or estate, I nominate my agent, Mark S. Guest, to serve as such conservator or guardian; 20) Power to Remain In Effect. This power of attorney is intended to remain in full effect notwithstanding any subsequent disability or incapacity on my part; 5 21) Expiration. This power of attorney shall not expire or become stale upon the passage of time but is intended to continue in force until revoked by me; 22) Counterparts and Copies Valid I execute this power of attorney in a number of counterparts, each to be valid as an original. In addition a photocopy of this power of attorney shall be deemed to be as valid as an original; 23) Other Powers of Attorney Revoked In executing this power of attorney, I hereby revoke all other powers of attorney which I have executed earlier, except such as have to do with signature powers over savings or checking accounts; 24) Appointment of Successor Attorney. If my son, Mark S. Guest, shall be unable or unwilling to serve as my agent under this instrument, then I appoint my son, William T. Guest, to serve as such agent. Inability of my agent to act shall be evidenced by a certificate disclosing his or her death or by a certificate of a licensed physician to the effect that he or she is unable, for reason of physical or mental disability, to act. Unwillingness to act shall be evidenced by a statement in writing, acknowledged before a notary public, and attached to this document; 25) Protection for Third Party Accepting Power of Attorney Any person;firm, or corporation shall be entirely protected in relying upon this power of attorney or any action taken by my agent pursuant to this power of attorney, and I, or my estate in the event of my death, shall hold harmless any such person, firm, or corporation so relying upon this power of attorney or any action taken by my agent pursuant to this power of attorney; 26) Designation as Personal Representative Under HIPAA. I grant my agent the following powers, status, and privilege in order to enable my agent to obtain all protected information with respect to my health under HIPAA (The Health Insurance Portability and Accountability Act of 1996.) I intend that my agent shall be able to obtain all of my health information, since I anticipate that my named agent shall be obliged to make decisions related to my health care, including, but not limited to the payment of 6 expenses for my care. I declare that I consider all of my health care information to be relevant to such activity on the part of my agent. I direct that my agent shall have such authority to act on my behalf in making decisions related to health care as shall entitle him or her to receive protected health information under EUAA in the. status of my personal representative as that term is used under EVAA. In addition to, and not in limitation of, the foregoing designation of personal representative, I intend this provision of this durable power of attorney to be valid authorization for my agent to receive all of the health information that my agent in his or her sole discretion shall deem relevant. My agent shall not be obliged to state a purpose for the request of such health information, and his or her request alone shall be presumed to be based upon a valid reason. I intend that any provider of health care services, including, by way of illustration and not of limitation, any physician, surgeon, dentist, nurse, physical therapist, chiropractor, psychologist, hospital, nursing home, or assisted living facility, shall be entitled to accede to the request by my agent for protected health care information. The authority granted under this Article 26 shall expire in five years from the date I sign this durable power of attorney. The reference to "agent" in this paragraph shall apply to the named agent and any alternate or successor agent. I understand that I may revoke the grants made in this Article 26 at any time by revoking this.durable power of attorney. I intend that the grants under this Article 26 are not a precondition for any treatment, payment, or enrollment under any program or protocol of health care or payment therefore. I understand that health. care information under this Article 26 may, once released to my personal representative or person to whom this authorization runs, be later released by such personal representative or person to whom this authorization runs. 27) To Make Gifts. To make gifts of my assets to such persons and institutions as shall appear to my agent to be consistent with my prior pattern of giving, or as shall be appropriate to reduce or eliminate Federal or State estate or inheritance taxes on my estate, or as shall be appropriate to reduce the exposure of my estate to nursing i 7 home expenses. This power shall not authorize my agent to make gifts to himself or herself. If such power is granted, it will be provided in Paragraph 28; 28) To Make Gifts to Himself or Herself. I specifically authorize my agent to make gifts to himself or herself, directly or indirectly; To be signed on ly my if this power is granted.) 29) State Law To Govern. This power of attorney is to be construed according to the laws of.the Commonwealth of Massachusetts. WITNESS my hand this Q-4 day of December, 2007. Thomas W. Guest COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. December�, 2007 Then personally appeared the above-named Thomas W.. Guest and acknowledged the foregoing to be his free act d deed, before me, I A. Anthony 20-1 Public :y yP ssion expires: "G .4 k , 2013 PUe�:•'O c11f n g THE T TOWN OF . BARNSTABLE I33 AHB9TODLS, i 16139&- �Fa YPY a' . BUILDING INSPECTOR APPLICATION FOR PERMIT TO 4v ............................................ ...../................................................................... TYPEOF CONSTRUCTION .................... ........................................ .................:............. t TO THE INSPECTOR OF BUILDINGS: , The undersigned/hereby appli syfor a p~rmit according 'to the f�Aall�wing information:/ Location ..........�.v........��/ ®.y �, �V�: % 2........................................................1 -S L ........................................................................... ..... . .... Proposed Use .f. 7-rAol.&...... /.e4/S'.................................................................................. Zoning District .......6�� ,� r �r yl.� , . r.....................................................Fire District .�� !/l/� ...�........ Nameof Owner ��,�w..... ...............Address .................................................................................... A Name of Builder .......'.............................................................Address .................................................................................... Nameof Architect ....../...........................................................Address .................................................................................... Number of Rooms 'flTu� ( � `.. .ULLC.�LL�� Foundation ......... .... ............ Exlerior .c ;r .C. ... ...c�. �! �v...r.............Roofing ...��> Ib ........................................... Floors .../.��.6..4.P.................................................................Interior s A... . .. ................................................. Heating . . .. ....... A ..:...........Plumbing ........4......4 ... +�J TI S.................................... Fireplace .................1................................................................Approximate Cost'1..� .6°� .: .. ......................................... Difinitive Plan Approved by Planning BoardQ ____19 i Diagr �I��T�iK11 pQF PRO�I131i'd�- , �,A St�y�`RE mpad5 A'gE DISPOS +�- ST Og�SANITARY WATER SUPP p�',jED LER �,U AND DRAINAGE HE 3 5��� SEo �NS�AL 1�.Mp / ��(S D �c. OF BARNSTABI-E, TOWN p�RM11. PAD BOARD OF HEALTH t9F LU,- ,ti� Zxe 1 hereby agree to conform to all 'the Rules and Regulations of the Town of Barnstable regarding the above construction. Name C-' 3 �.. �`....................... Thoms, Edward J. No Permit for ,,,one s tory, f ............ family dtreling-�ara�e : , Location ................................ Zest Barnstable ........................................................................I...... Owner Edward J. Thoms .................... ......................... Type of Construction ...... rame ............................... ................................................................................ Plot ............................ Lot .........#17................. i Permit Granted .......March 5 ..... .....19 70 .............. . Date of Inspection .....................................19 Date Completed ...,< ..................................19 7 d PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................... ............. . ................... ............................................................................... ` Approved i ....................................................................... ... 1 1 I 30 ep ro � r7 . +y 1 �� � ' � �.i,t'=_ •r .t%.tC.�?a4i�k43.�'k4.7�tli?�.`ti��;�sg�Y�.43 "�.�i� ��wAk � ,ci �' 'ir2. tL4 t t 1 , Asse is map and lof number .:.... �.. ...... SY8IMT BE • I 14 .. i� WITH ARTICLE N STATt Sewage Permit number ...... ..: .. . �... ..A' SA ITI Y N= T IN Er TOWN OF tARN'g ln E BJBBSTABLE, i 1639- Y BUILDING . INSPECTOR G PY a APPLICATION FOR PERMIT TO CiP..,f2Tl1Ff Gl..... (..<`'lS.l.(��1.. .. .f�0�(Y.f..�1?! �.!l f....... TYPE OF CONSTRUCTION %2'! ................................................19........ TO THE INSPECTOR OF BUILDINGS: The unde�si..necl hereby applies• for a permit according to the following information: Location �yL..ew......W. ....(���.1�/�.,�.��-�f�4�......�GLi.a.....>�.li.�.a.8.............................................. ProposedUse ............................................................................................................................... ZoningDistrict ............................................................:...........Fire District ...................................... .........Address 1... .C...:C....... .. .. .7........................................... Name of Owner�l..�../.?.?.�„�....1,�/.....5�.�/1...`L..�� � �y Name of Builder l�/'.y/a! i?'J...(/l/ ��!/LfS`...............Address ... !.."....:-.............................................................. Nameof Architect ...................................................................Address .................................................................................... Numberof Rooms ..........`.......................:..............................Foundation .............................................................................. Exterior .../'/. ... ..�1..!?/ ........................................Roofing .. N'��!................................c.......................... / // Interior�� Floors .Nf�.0..0..4 ..........................:......................................... i�/v ........................................................ Heating ��lll.!.�?... �/c,..�.L�lr✓1'�r-�•• Plumbing ,rl `� .................. Fireplace .... . . ..................................................................Approximate Cost Definitive Plan Approved by Planning Board ----_----------____-----------19________. Area *.�./�0.�: ........... Diagram of Lot and Building with Dimensions 2ea, Fee C...................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the T f Barnstable regarding the above construction. NaG �.1 ....... / ✓!•••••.......................... Guest, Thomas W. 4 17688 ... Permit for add to sin e ..... it .............. ........................ ..l... !...family..Xdwel ling.................................... Location Bldgs..Road................................ .........................West... a rns.ta bl..................... t Owner ..........Thomas..M...Guest...................... ; Type of Construction .........,frame ..... ...................................................................... Plot .4....................... Lot ................................ Y Permit Granted ............Mg....12...............19 75 1 Date of Inspection .... ...... .......................19 Date Completed .. .... t p 7.......................19 !. PERMIT REFUSED ................................................................ 19 �t( ............................................................................... } ................................................................................ ...................'... ....................... ....................... . .................. .............................. 17 Approvedn.............................................: 19 ; ........ ........... ...................................................... , f I . I ..................... ......................................................... 7 1 Assessor's map and lot number Sewage Permit number 7 TOWN OF BARNSTABLE HAHH4TADLE, i 1639. BUILDING INSPECTOR �o May a' APPLICATION FOR PERMIT TO .... ......:.: %..................'...........: .. ............................:............................... TYPE OF CONSTRUCTION .................: .:.. ......................................................................................................... ................................................19........ TO THE INSPECTOR OF BUILDINGS: The ,uAdersigned hereby applies for a permit according to the following information: Location ..... .. . ... ............ <. ............................ ` ................................................. ProposedUse ..:...... " .:.......................................................................................................................................... Zoning District Fire District ....................................................................... ................................................... Nameof Owner :...,. .... ..Address ........................................ ........................................... Name of Builder ..................Address .......:.:.......... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..........:.......................................................Foundation .............................................................................. .......:. Roofing .......: Exterior < ....:.... �...::.. ..:...................................... g ......:.... .............................................................. Floors ......................................................................................Interior ..........:......................................................................... Heating ..........Plumbing ... .................................................................. Fireplace .....................................................................Approximate Cost ...: ....... ..................................................... ................................................... Definitive Plan Approved by Planning Board ________________________________19________. Area ..s..................... .................. Diagram of Lot and Building with Dimensions J2n ;�" Fee .............. ............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................................... ...........%.............................. Guest, Thomas W. (o 17688 add to single No ................. Permit for .................................... family dwelling ............... ............................................................... Location 51 Ridge Road ................................................................ West Barnstable ............................................................................... Thomas 'W. _Guest Owner ............................... frame Type of Construction .......................: ................................................................................ Plot ........ ................... Lot ....... ...................... Permit Granted ......../, ily...12. ............19 75 Date of Inspection . .................................19 f Date Completed .)....................................19 PERMIT 'REFUSED ......................... 19 ............................. / ......................................... f.. ..... ` ......................................... / �.................................................... Y Approve• ................... ........ ................... 19 ............................................................................... ............................................................................... THE Sewage Permit number v�U House number ----'_—_--------------��` / ' NAGIL ;or, 1639- �������' ��� � � � �� � � �� � | J� ��� ��' 1`� ��"�C ������JKY��"� �� ]� z����V ����� ' ' BUILDING 0N �� N ��� N �� � ��������� �� ' . ���� N N-00 N �� �� INSPECTOR ���� ��0m 0 N� �� l/ __ _ - ---- - -- ~- - -- .- ~ ~~ .~ ~ `~ ~- � ^APPLICATION FOR PERMIT .��. .............................................. TYPE OF --. !%�. --r--�---.----"-----..---_---.-----'- � —. ----..l��—.. TO THE INSPECTOR OF BUILDINGS: The. undersigned hereby applies for o permit according to the following information: Location ...... ..������r����--_-----------.. � ProposedUse ...... .....------------------------------------------------- . Zoning District ------.-----------------Fine District .........................................:.................................... Nome of ^= /~~~� —»��f� .............Add'~^�3 ! Nome of Builder -----------------A66nsss ------------.---...—.--------.. ~ / . Nameof Architect .................. ..............................................Address ---------------------------- ~- ^� _ Number of Rooms ----------------------Foun6otion���n����z.�.z.���,/ .................................. Ex/e,iu, Y---'RooGng ,���� ------- F|oos ' 'n( --------------------.]nte,iov ---------------------------- Heating .-----------------.F1om6ing ...... ...................................................... ' AP- Fireplace ' ��--------------------.App,oximo^eCos- / ........................................... Definitive Plan Approved by Planning Board (- lg Area ......... ) ...... {-,�_`_ Diagram of Lot and Building with Dimensions Fee _____ ....................... | SUBJECT TO APPROVAL OF BOARD OF HEALTH *° /-r/' ^/ /^'c t-y' 4?gp,~�r~v. OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the To<vrt of'Barnstable regarding the � .\ ' ' � | . � � - ^ ` above =_=� .... ............. ........................ ...... ................................. _ GUEST, THOMAS W. < A=216-64 No ..23594 permit for „ADDITION Single Family Dwelling ............................................................................... Location ....37 Ridge Road . .......................................... West Barnstable ............................................................................... Owner ..,Thomas W. Guest ................................................... Type..of Construction Frame ................................................................................ Plot ............................ Lot ................................ Permit Granted O.ctober. . . ....27. .,.........19 81 .. .. .... .... .. . .. . Date of Inspection .............................:......19 Date Completed ...........:..........................19 I p c Assessor's map and lot number 01/1' d. �..- :. .............. I / / Bpi THE Sewage Permit number ......Q.`...:.. Z E9E33TLELE. i House number .................................................................. ....: v Mae& 'F0 MAY a TOWN OF BARNSTABLE BUILDING 'INSPECTOR APPLICATION FOR PERMIT TO ............................................. TYPE OF CONSTRUCTION ........11�1. 1�......................................................................................................... ..... G ....................1 9..... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location �.7...11,1 �zlG..I../ram....... Gl f�... :1 /tic ....iF� ...Cy r.��............................................ ProposedUse ..... �r...................................................................................................................................I......................... ZoningDistrict ........................................................................Fire District .............................................................................. � l� °�T ................Addres Name of Owner. . s�.��cr.�c�� .14!. G/. .... Name of Builde��4/• i7 ..�.................................................Address .................................................................................... Nameof Architect ..................................................................Address .........................,y......................................................... Number of Rooms ....`.............................................................Faundatian� ................................. Exterior .............Roofing �J��r�l.�!'liy�� .�c:�.................... Floors ../e/w ...................................................................Interior .................................................................................... Heating .....................................................Plumbing ..... ..�1.,.f'�.C ...................................................... Fireplace ..............................................................Approximate Costv........................................... . Definitive Plan Approved by Planning Board 1-'�',_�t j_'_---------------19 ____ . Area ........1,..?56....... .....-.... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF/HEALTH /�73 / z ,D OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the T n f Barnstable regarding the above construction. . . ................................ ' GUEST, TBOMAS W. ! ` 23594 ADDITIONNo ................. Permit for .................................... . � Single . ''I�aod'ly Dwelling ' ______.. / ~ ' l 37 Ridge 8d. - Y ---'— —~--^'~------^--^------ ' West Barnstable `) ____.______________________ ` ^ " � Thomas W. Guest ' vOwner .................................................................. n ' , Frame � Type of Construction -------------- l -----------------^--------' > P|c� —'---'.---. �� ................................ ` ~ Permit Granted --..{}������`.2.T. V 81 , Date of' Inspection ....................................lg ' Dote Completed .......... —.---lq ' ' ' . . ' � ^ / ^ ` ~ ' ^ ' / | �\ Ofice Use Only*l� 7-lie Commonwealth of ]Massachusetts PemutNo. Deportment of Public Sofe-ry Occupancy&Fee aecked BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12.00 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Work to be performed In accordance With the Maa"achusetu Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date )Q--61 ^ L� TOWN OF BARNSTABLE To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Number) ',: = ` .two+' ^ 06-ner or Tenant Owner's Address Is this permit in conjunction withhaa building permit: Yes ❑ No D�(Check Appropriate Box) Purpose of Building ility Authorization NO. 27 a Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters A` New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity t Location and Nature of Proposed Electrical Work 2 �� No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA Above In- No. of Lighting Fixtures Swimming Pool grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners I FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devices No. of Disposals No. of Pumps Total Total Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal D Other Connection No, of o. o Low Voltage No. of Water Heaters Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current liabirlity Insurance Policy including Completed Operations Coverage or its ubstantial equivalent. YES NO[] I have submitted valid proof of same to this office. YES If you have checked YES, please indicate the type of c verage by checking the appropriate box. INSURANCE E],-'BOND ❑ OTHER ❑ (Please Specify)_] 6,:==d-,OL-2�_ r-..;, --?— " (Expiration ate Estimated Value of Electrical Work S / Work to Start Inspection Date Requested: Rough Final / Signed under th penalties of perjury: FIRM NAME Cr Lt/t��P- LIC.-NO,Z/ V Licensee 1 /j h l C3 Signature LIC. NO. // Bus. Tel. No. Address /� r%��• ��i�Z�� Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent b�QyO�TMET��`a TOWN , OF BARNSTABLE 123AR35TAIL 0A86. '639. BUILDING . INSPECTOR APPLICATIONFOR PERMIT TO ............................................................................................................................... TYPE OF CONSTRUCTION ........................................................................................... ............................... . ................................................19........ TO THE INSPECTOR OF BUILDINGS: i The undersigned hereby applies for a permit according to the following information: Location'..z ..4-12 f ....... .... ....................................................... .....................7...... ProposedUse ....................................................I......................... ZoningDistrict ........................................................................Fire District ............................................................................... Name of Owner1,—'7-.�-..-0.. ......................Address 1141W.. .. ....... Name of Builder %---. .............Address "57.177.0.e!?.d (�t4 dQ Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .257........................................................Foundation . .......................lwle.......................... Exierior ................ .. ......Roofing ...... ....... .. ......?.9. ...... z................. Floors ...... .................................................Interior r, ..... ............................................... Heating .................................................Plumbing ....................................................... Fireplace ... ....... ......................................................Approximate Cost .........?...... ............................ ........ Definitive Plan Approved by Planning Board ----------------------------- SIP Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH o Ld < O 0 < LLJ .4 Mao o u > K:Mr X Cl- < iY LL- 0 c 0 0 cn N :D -j Ul W C W --D Ld < -:) C J.J.-— - . r- cr) LLJ L11 — Ln Ld Z < 61'--- 4 , 0 0 z I't >- cl� < F- CY U.5 - M� J [If Z < LLI < tl < I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..... ... .................. .... .. .*...................... ................... \ Tbmms^ E. J. & M. F. f one ' ^ No -�:���—. �rmhfmr ---.—.��"^�---.. single family dwelling .—.-------.-----.--..-------- ` ' � l I���ue Road Location_ .--.----.---.—.,.~..-----. West Barnstable ~'---^-----------'^'---------' � E. u J—` —&—M—�—F.—T—~'"—m—" Owner ^-- ---` frame Type of Construction .......................................... ' ' 1 ----.—.—.—..--,.--.—.----..---- #r7 Plot ............................ Lot ................................ l . ` ` rernnr Granted ' - ~ = uo/a of Inspection Date n�� ~�= -- --l~ —�~'~~ Completed —°"..... ^ � . PfRmmx R6UwED '----''.-_.---------.---.. lA .................................�--_-----------.. __--.— ----.-..--.----,.—..--.—.-. -,^—.^ —.~~..---...—,....—_.—.._.,--- / .�----..----.---.---...—^—.---.—. ' . � Approved _--------------- lq ' + ' ` ' --------------'--^^^--~---^—' : � ^ ` --------------------^--`'^^~-' / ! - ' ' . ' ' '