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0264 WOODSIDE ROAD
zuew �l � e UPC 12543 No. 53LOR HASTiNGB 10N CAPE COD INSULATION 7qb- El N® IIS11TTI OUTTI I3) INS nY lOAM SUSY.N D70 1 A1i3 OUt110f IN7U1'110N CIIlIN07 1-800-696-6611 Town of Barnstable CD Regulatory Services o Building Division 200 Main St Hyannis, MA 02601 Date: q co Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance .Institute '(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements, Property Owner Property Address Village CX1A4A oZ(o GvcoDS�02 � Insulation Installed: .Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) (X) ( 3r ) ( ) (.,< Slopes d ps1,L (x) ( ) ( /° Floors ( ) ( ) ( ) ( ) ( ) Walls at( 6VO r �'O rAjeo/ _ Sincerely 2Hr E ssi r, President Ins ation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a� I TOWN OF BARNSTABLE 0q Map Parcel � Application # Health Division' LG16 JUL 22 ;)t.j 9: + O Date Issued, 77h6�/ 4 Conservation Division Application Fee QQ Planning Dept. Permit Fee U5 - Ob MVISION Date Definitive Plan Approved by Planning Board Historic- OKH _ Preservation / Hyannis Project Street Address ZdZ2,n led Village �/1; 1T/� Owner 1 4 .wee efdrel V& Address10, Telephone T/,y17_ :7;f Permit Request 1,44f75VI 9"4,46e,P io �4^Jl Sq le zkzee Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation j �' d, d Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes XNo On Old King's Highway: ❑Yes "o Basement Type'' ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - - Name/',9^ Pe //. Z'(2,Alz- Telephone Number Address ,�O�eA/Z�tl �ie License # ��2�fDuT Home Improvement Contractor# J -�-3!.S-L'7 E m a i I M i ikL,,1(0 -yIv9,41�A14 GJa Worker's Compensation # /I✓� zy/9,40 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ,1 .y SIGNATURE DATE S , f FOR OFFICIAL USE ONLY I APPLICATION # t DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE f "OWNER- DATE OF INSPECTION: F FOUNDATION k FRAME INSULATION FIREPLACE r k ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL Ff 7 GAS: ROUGH FINAL FINAL BUILDING DATE.CLOSED OUT ASSOCIATION PLAN NO. w The Conamonivealth of Mtassachusett s Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114.2017 www,mass,go v1dia ;;. -Yorkers' Compensation Insurance Affidavit: Bullders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, A licant Information Please Print Le ibl Name(Business/Organization/Individual): el" Address:.-- l City/State/Zip: 'r•, / �� /� 2 Phone #; i Are you an employer? C eck the appropriate box: Type of project (required): I.Z-t am a employer with employees(full and/or part-time).' 7. 2.0(am a sole proprietor or partnershil)and have no employees working for me in ❑ New construction i any capacity.(No workers'comp, insurance required.) 8.'D Remodeling l.[]1 am a homeowner doing all work myself. fNo workers'comp. insurance required.)1 9. ❑ Demolition t r i 4.[][am a homeowner and will be hiring contractors to conduct all work on m roe il ensure that all contractors either have workers'compensation insurance or a e sot I will ❑10 Budin g ad diti0n Proprietors with no employees. I l,(] Electrical repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑Plumbing repairs or additions These subcontractors have employees and have workers'comp. insurance.t 13. Roof repairs ' 6.p We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.(No workers'comp.insurance required.) 14'( Other_/ Any applicant that checks box rYl must also till out the section below showing their workers'compensation policy information. r Homeowners who submif4his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.^ J lContraclorstlial check this box must attached an additional sheet showing the name of the subcontractors and slate whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. l ant an eniployer that is provlrling workers' compensation Insurance for my employees', Below!s the policyand 'ob site inforntah'on l e — Insurance Company Name: Policy N or Self-ins. Lic. 9: —� Expiration Date: J-7 Job 3ke Address.-J6 Attacli-a copy of the workers' Failure to secur compensation policy declaration page (Showing the policy num p ber ar�e� ati ) to . Failure coverage as required under MOL c. 152, §25A is a criminal violation punishable by a fine up to$1500.00 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. A copy 6f.,this statement may be forwarded to the Office of Investigations of th coverage verification. e QIA for insurance A /r!o hereby certify under the paints aru(penalties of perfury that the l"fort tuction provided abov e 4Y true and correct Signature: i Phone Official use only. Dq.,hot write In tlals area, to be completed by city or low/a ofJtclat City or Torn; Issuing Authority (circle one); Permit/License # I, Board of Health 2, Building Departmen.t 3, Ci(y/Towu Clerk 4, 6, Other Electrical Inspector S, Plumbing InspectorT Contact Person; Phone#; I Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS•100988 Construction Supervisor t. HENRY E CASSIDY��` 1. . S SHED ROW WEST YARMOUYN •2' +Z � :-. ' 1 Expiration: Commissioner 11/11/2017 �� �p vcr�ear�� �I� . Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement CO.-tractor Registration Registration: 153567 ' Type: Private Corporation Expiration; 12/15/2016 Trq 259188 CAPE COD INSULATION, INC '. HENRY CASSIDY ---- 18 REARDON CIRCLE 80. YARMOUTH, MA 02664 .'Upda.te,Address and return card, Mark reason for change, $CA I !+ 20M05/11 [� Address El Renewal Employment (] Lost Card (exe 0,7707ao-mverf-44 010106wd«crcdeerd \ •Office of.Consun)e,,Arfnirs& t,,,sines,Regulntlon License or registration valid for individul use only OME IMPROVEMENI''CONTRACTOR before the expiration date, If found return to: egistration: '1.53557 Type: Office of Consumer Affairs and Business Regulation ;j xpiratlon;::1'21;1:5120:1:6 Private Corporation 10 Park Plaza •Suite 5170 Boston,MA 02116 CAPE COD INSULAT:I'QN:;:INC%..; HENRY CASSIDY 18 REARDON CIRCLE` . :,•' SO..YARMOUTH,MA 02664 Undcrsecretnry valid wi 'it sign e I CAPECOD-27 DEATON ACORO° CERTIFICATE OF LIABILITY INSURANCE DATE 7/5/2016 /5/2 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 Barbara DeLawrence Rogers&Gray Insurance Agency,Inc. PHO NAME:NE FAX 434 Rte 134 A/c No E t A/c No): South Dennis,MA 02660 ADDRESS:bdelawrence@rogersgray.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company INSURED INSURER B:SafetyInsurance Company 39454 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURERD:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR CBP8263063 04/01/2016 04/01/2017 PREMISES Eaoccurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JEST LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B ANY AUTO 6232707COM01 04/01/2016 04/01/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LIAB CLAIMS-MADE EXCI0006635001 04/01/2016 04/01/2017 AGGREGATE $ DED I X I RETENTION$ 10,000 Aggregate $ 2,000,000 WORKERS COMPENSATION PER TI- AND EMPLOYERS'LIABILITY STATUTE I ER D ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCE00431902 06/30/2016 06/30/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED_REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 'own. of a rnstable z RegWatory Sewices atAss RklardV.Sca1'i;.Director. ' Ridlding Division Tom Perry,Building:GbmmisstoImer 200 Mam Sheet Hy=xs,MA 02601 www town.bar ubMema ns Office: 508-862-4038 Fax.508-79"230 Prflperty 4wneT must Compkete:and$ipI is Section if U.-M.Z-ABuilde3r � J ��R t,J da.� ,a�Oavuer..of:tlie'sii�jecrProperrY hez+cbyaauito=ize Q- t,D ��!S�l�c.,l i a-� to 4Lcc;on:mpbel�al£, in-A Man=ml-aiv+e to work mnhorized by this building pemmit application for. (Adaress•of-jo�) `*Pool fences and alarms are the responsi of the-applicant:. P.06h atE u6t.to he filled orutf=d lieforefeaoe is:imuUed and all final. inspections ampedormed and accepted. i of Owner "Vf Applicaut I!D C/�-►2c�d �l ��fk�� Phut Name Pffit Name s a74 Date QTOPM&OWNWERMMOMMI:S 40 ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map— Parcel V I I TOWN Or BARNSTABLE Application'. T� Health Division i0` Nj: t Date Issued,' ? 3J & � �� •i � d f��6 9: 07 � , Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic Historic - OKH Preservation / Hyannis Project Street Address Village1, /�i2�� Owner , -r!d�� /�i�/�✓�A Address Zf ,w : Telephone J78 7j� Z Permit Request /I fy!oy i/2 11.a f Al s.f'kill 9 44?Z e If&S.S i <;Q/ 44Z!� i� -Z'Si6 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 2-G o d, 0 Construction Type /G11�//��4 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family jy Two Family ❑ Multi-Family (# units) Age of Existing.Structure Historic House: ❑Yes $4No On Old King's Highway: ❑Yes No Basement Type: 0 Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing • New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name G/�PL° ll�,��� y/� a� Telephone Number Address /�G� /fic/D�O l'/i AD License # Aim v v-f Home Improvement Contractor# /,3_5'G Z Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY ` APPLICATION # DATE ISSUED 'MAP/ PARCEL NO. ADDRESS VILLAGE . ti OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL } GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i. Massachusetts Department of Public Safety Board of Building Regulations and Standards License; CS-100988 Construction Supervisor HENRY E CASSIDY . . 8 SHED ROW •r�w jQ� ,::-:,�s�, WEST YARMOUTH�1 • `2' � �' �^ 0 Expiration: Commissioner 11/11/2017 i . Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 . Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY -- 18 REARDON CIRCLE - SO. YARMOUTH, MA 02664 x'Update.Address and return card, Mark reason for change, SCA I {i 20M.05r11 [] Address Renewal Employment Lost Card exe%'7141401uve eel,01QA11Jd«0%1edeTd -Office of Consumer Affnirs&Business Reguintion License or registration valid for individul use only OME IMPROVEMENfCONTRACTOR before the expiration date. If found return to: egistration; 1:53567 Type; Office of Consumer Affairs and Business Regulation j xpiratlon; :_:;1.21:1:5120;1.6 Private Corporation 10 Park Plaza-Suite 5170 �,. Boston,MA 02116 CAPE COD INSULATfQN:;iNc:. . HENRY CASSIDY 18 REARDON CIRCLE` . S0. YARMOUTH,MA 02664 Undersecretary qN- valj1dwi t sign e The Commonwealth of Massachusetts = Department oflndustrialAccidents ' a I Congress Street, Suite 100 Boston, MA 02114-2017 www,mass,gov/dia ll'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, Applicant Information TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le ibl Name (Business/Organization/Individual): l%�i�G� Address:- 2 Ci /State/Zi �' P: / /��b Z Phone Are you an employer?C eck the appropriate box: 7[�] oject(required): I.�t am a employer with _employees(full and/or part-time).' 2.�l am a sole proprietor or partnership and have no employees working for me in construction any capacity.[No workers'comp. insurance required.) odeling 3.[]l am a homeowner doing all work myself [No workers'comp. insurance required.)t 9. ❑ Demolition 4.a I am a homeowner and will be hiring contractors to conduct all work on my property. l will 10 [1 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.[]Electrical repairs or additions 5.0 l am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.[]Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.❑Roof repairs 6.®We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.(No workers'comp. insurance required.) 14.[ Other Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit-3his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 information city employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins. Lic. Expiration Date: v Job Site Address: 6�'„ e Attach a copy of the workers' compensation policy declaration page (showing/Sthe policy nu bl and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of.,this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sienature i �/2 �/ / Date Mz, Phone# Z Official use only, Dq Arot write in this area, to be completed by city or town offlctal 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 L,6ther . tact Person: Phone#: i �r CAPECOD•27 TQUIF CERTIFICATE OF LIABILITY DATE(MMIDD/YYYY) ,y TY INSURANCE 4/27/2016 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 POLICIEZ 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 pollcy(les)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 NAME; Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 ( AIL E Arc No: (877) 816 2156 South Dennis,MA 02660 E-MADDRESS:Mall@rogersgray.com INSURER�Sj AFFORDING COVERAGE NAIC 11 INSURER A:Peerless Insurance Company INSURED INSURERB:Safety Insurance Company 39454 Cape Cod Insulation,Inc.: INSURER c:Endurance American Specialty Ins, Co, _ 18 Reardon Circle INSURER D:Atlantic Charter Insurance Group South Yarmouth,MA 02664 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE IN50 D POLICY NUMBER MMIOD MM/OD� LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR CBP8263063 EACH OCCURRENCE $ 1,000,C UAMA 5E TO RENTED 04/01/,2016 04/01/2017 PREMISES Ea occurrence $ 100,C MED EXP(Any one person) $ 5,C PERSONAL&ADV INJURY $ 1,000,C GEN'L AGGREGATE LIMIT APPLIES PER: X PRO. LOC GENERAL AGGREGATE $ 2,000,C POLICY D OTHER: PRODUCTS•COMP/OPAGG S 2,000,C AUTOMOBILE LIABILITY $ CO 81 ED SINGLE LI TT_ $ 1,000,C ALL OWNED SCHEDULED B Ea eccid ANY AUTO 6232707 COM 01 04/0112016 enl 04101/2017 BODILY INJURY(Per person) $ M _ AUTOS NO AUTOS BODILY INJURY(Per accident) $ X HIREDAVTOS AUTOS P P R Y D G $ Per eccidenl X UMBRELLA LIAB X OCCUR $ EACH OCCURRENCE $ 2,000,C (,` EXCESS LIAB CLAIMS•MAOE R/O EX010006636000 04/0112016 04/01/2017 10 0 AGGREGATE $ DEDEC) 00 X RETENTION$ Aggregate WORKERS COMPENSATION $ 2,000,C AND EMPLOYERS'LIABILITY YIN STATUTE VER D ANY OFFICER/MEMBEREXCLUDED9ECVTIVE ❑ NIA WCE00431901 0613012015 06/30/2016 E.L.EACH ACCIDENT $ 1,000,0 (Mandatory In NH) IInys,describe under E.L.DISEASE•EA EMPLOYE $ 1,000,0 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 1,000,0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHIdCes (ACORD 1ol,Additional Remarks Schedule,maybe attached It more apace is required) Workers Compensation Includes Officers or Proprietors, Additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holcle CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Bill Swanson Builder THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 50 Camelot Lane ACCORDANCE WITH THE POLICY PROVISIONS, Brewster,MA 02631 AUTHORIZED REP RESENTAT17VE G ©1988.2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Town of Ba rnstabbe z Regulatory Services s kith" V.ScAbbwWr. $aiming Division Tom Perry,Binding Commissioner 200 Main Stre4 Hyannis.MA 02601 wwy town.barnstab"=us Off= 508-862-4038 Fax 508 79"230 Piopexty Owner Must Completeand.Sign This Section IfUsin .ABuilde3r L T 0"Idd.4-1 ;a$OMer of.ehe SalectProPUty ��""� /� .-�( —r0-aCt:.,b1*xy,bP-b4. h,,byautlioiize C4Q- 00 -T S V,,LL in an.=UM relative:to work authorized by this buflding permit application for. (Ad&-ess-of job):, Pool-f ences and alarms are the r esponsibky of tie appka= Pools axe uot.to be filled or.utgized before fice is:-iustZed and all final. inspections are performed and accepted. i o Owner f Applicant J n r Print Name Punt Maine S a 7(' Date Q PORMOWNERPBRM LONPOOLs $S R Town of Barnstable *Permit KwAis 6 months from issue date rT Regulatory Services 81013 p. Thomas F.Geiler,Director i63¢ TQ trta+ . F BAR Building Division NSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number r/ Property.Address 0/ce`1 pool /Z:)L, Resider",l Value of Work 4` ��u• Minimum fee of$35.00 for work under$6000.00 _ Owner's Name&Address •Y •'2(o�( kJ ov�Js ��� �2. •1�' ��r-zNs-r��c.c�, i✓�� o z6 y� Contractor's Name rJ � b�/(/ Telephone Number Home Improvement Contractor License#(if applicable) J 40^37-31 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Checkone: sole, proprietor am.the Homeowner fiave,Worker's Compensation Insurance Insurance Company Name j4[�e_ Workthari's Comp.Policy#, DO I,12&o1 zoll? Copy,of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) A]I.construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going.over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value 3 (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must s• Property Owner Letter of Permission. copy of the om provement Contractors License&Construction Supervisors License is req r SIGNATURE: C:\Users\decollik ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 i anara at!ju,,aIng r<aguaatiors anc9 52an a-cis = vam of c ousnmerAImas&BnsmC13 ttcgutation i C on%tru:Lion Super.i%or tiOIItE t!I&PROVEMdYT CONTRACTOR €tense: CS-093716 = _ n 163732 Type: ° - Eapka6on: :71172013 Private Cotpc RYAN CAMPBEI$ - P.A JGAIIIlPBELLSVERPRISES INC. 126 BAY RIDGE DR S DENNIS MA 02'660` RYAN CAMPBELL 126 BAYRIDGE DR_ SOUTH DEt�4VlS,MA 02660 ad�larp. r^.r„s sssa 04%06/2014 License or regi�tion valid for in dnl use onry to before the expiration dstttsuanf d Baseness gegilatiou office Cnnsum��0 10 park Plaza- _ Bostop,MA 02116 of wa signature r 2 1 t i i i T 9 From:Michelle Connors FaxID:OLDE CAPE COD INSURA Page 2 of 2 Date:5123/2013 01:23 PM Page:2 of 2 RACAM-1 OP ID: MC 'a`oRo� CERTIFICATE OF LIABILITY INSURANCE F05/23TE(MMfDDfYYYY) N 3 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 Phone: 508-255-8000 CONTACT Kerry Insurance Agency,Inc. PHONE FAX Scoff Kerry Fax:508-240-1860 NAM E: , A/c No): PO BOX 1945 E-MAIL North Eastham, MA 02651 ADDRESS: W.Scott Kerry INSURER(S)AFFORDING COVERAGE NAIC 2 INSURERA:ASSOCIated Employers Insurance INSURED R.A.Campbell Enterprises Inc. INSURER B: ,.Ryan A.Campbell 126 Bayridge Drive INSURER C South Dennis, MA 02660 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUB POLICY EFF POLICY EXP LTR TYPE OFINSURANCE INSg WVp POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ A COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR. MED EXP(Anyone person) $1 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY NJURY(Perperson) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peraccident $ UMBRELLA LIAB OCCUR - EACH OCCURRENCE ' $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILI TY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A 5009706012013 01/11/13 01/11/14 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? El(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,00 If yes,describe under 500 00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Carpentry Ryan Campbell elects coverage under this workers compensation policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept AUTHORIZED REP RES ENTATI V E 200 Main St Hyannis, MA 02601 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 05/24/2013 FRI 7! 53 FAX ®001/001 A' (r4 1 , 7- 9:3,,;t 6 r a � 0 ESTIMATE Donna&Jell' Patio door: o Remove existing patio door and install a header and flaming for the new larger patio door. All materials and labor included except fiyr the painting of any trim or wails. The door shall be Anderson patio door as shown by homeowners Home Depot printout. "Total Door project: $3,800.00 Bulkh"d: o Remove the existing bulkhead and install a new Bilco steel bulkhead door. Flash and cement:to the house and fioundation. • 'Total Bulkhead projcct: $1,100.00 rotai project: $4,900.00 Home owner signatured—.0- ,���1...��_..� _ Date: .' Contractor Signature: _ t�<ite: Z� 13 --... i 77te Con mnweda of Massachwe& Deparnt of bidustdd Accidents Oiwe of brpestigations ,600 Washington Street •' Boston,MA 02111 www.H=gov/din Workers' Compensation Insurance Affidavit:Builders/Contractors/Eiectricians/Plmnbers APPUcant Information J PIease Print Legiblv Name(stsir1Md0r9an;MLionAn&MdvaQ: .4• Address: City/Stu aup•, , ,I�w�tn�S 1'YI f D b4hone#: 77 '-Zl Z�33Z f V Are an employer?Check the appropriate box♦ Type of project(required):1. I am a employer with Z - 4. ❑I mn a general contractor and 1 [3'. employees(M and/or part-time)« have hired die sub-c�actors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t ?. ❑Remodeling ship and hm no employees These sub-conhuctals have B. ❑Demolition worlding for me in any capacity. worine comp.insurance. 9. ❑Budding addition [No workers'comp.insvranc o 5. ❑ We are a corporation and its ce9uind] officers have emmased$heir 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work tight of eruption per MGL 11.0 Plumbing repairs or additions mysem[Now It camp. a M 11(4),'andwe have no �❑gods t aP [No wcs' gyp.insurance requirv&] 13.0 Other _ *Any qV icant#Mchcdm bcaft unwatw®om8icsia b wvs wwjqg&cirvodz&MMpcMMfiMvdiCY t Homeowom v&o submit this @M&vR hAcsft dity ere doing ally o*and d=tie oOW&cm*actm mastsubmitanowat5dava indrea ft sucih. kbwMann datdeek dds box must a ao aditmd shcdsbowir g the mendtbo and tbur worlmrs'comp.poky i&nafiaa. ram au ern AUw that is providing workers'cm remsarwn lnsuranaef+or my mrfoyem Below is&e polcy and job site Woftatron. InsuraMM Company Name: /i Policy#or Self-ins.Lic.#: -, 9 7Duo D 1 W Z/ Bxpkation Date: /— !I — / Job Site Address• . 0 L >Qb�- 2 (may/Sp: r/� �{, IV l Attach a copy of the workers'compensation policy declaration page(showing the policy camber and expiration date). OZ4�' Faihire to sere coverage as regained 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 farm 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 the DIA far-insurance coverage verification. I do hereby and penalties ofperjoy that the Information provided above Is ttue and correct si Date: Phone ? -3.3 Z l Djcld use only. Do not write in this area;to be bonrpleted by c8y or toRn offut d City or Town: Perm�i►rase# Iming Autflority(circle one): 1.Board of Healtfi 2.Building Depart rent 3.City/Town Clerk t Electrical Inspector 5.Plumbing inspector 6.Othet< - Camttiet Persons �& : ofn+E L 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 as Owner of the subject property hereby authorize (./r to act on my behalf, in all matters relative to work authorized by this building permit application for: 21�y AbrJW-ID&f 4D2 (Address of Job) Signature of Owner D to Print Name If Property Owner is applying for permit,'please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 n�a G�a..�5 e� ��k } J�`ti`-�-�--� ., ,: ao ma Town of Barnstable *Permit# Exphres Regulatory Services 6 months on?issue e 91639.MASS � 60�' Thomas F. Geiler,Director prED MAi 6 70 Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 f>-0 www.town.bamstable.ma.us Office: 508-8 62-403 8 Fax: 508-790-623 0 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprints Map/parcel Number'? (� `A UV t Property Address CZ(o 1 0 64 S 4j,_ Residential Value of Work 3� 600. 0 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address�DflYlq _7,tp q Ion s 1 n ill�4s ►4rz�s S;►`t c- Contractor's Name C(, . WI Telephone Number_?Iq'2l 2--3 3 2 i Home Improvement Contractor License#(if applicable) 3 �� Construction Supervisor's License#(if applicable) 92'? L4 6orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I the Homeowner I have Worker's Compensation Insurance Insurance Company Name . Workman's Comp. Policy# �j CGp9`7b(pQ/ZD// T 0\N 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 • 3 (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 Owne m t s' Property Owner Letter of Permission. py of th a provement Contractors License& Construction Supervisors License is re r SIGNATURE: Q:IWPFILESTO Slbuil permit forms\EXPRESS.doc Revised 0701 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations k9i 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyiblv Name (Business/Organization/Individual): /�P7 Address: 1 Z-Cv t dll ,, J City/State/Zip: Phone #: 7 7 —Z Z"33 2 Are yQu an employer?Check the appropriate box: Lr� Type of project(required): 1. I am a:employer with 2 4. � I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp,insurance.# 9• . Building addition required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.2Other Ir 0 W S 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-contractor;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.Lii""rc. 4j#: Oo q 7o(p 0/2 Expiration Date: I I Z Job Site Address: LU! `( d U ;� 02� �S� � J City/State/Zip:bl)eS� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here and a airs and penalties of perjury that the information provided above is true and correct. Si afore: z Date: Phone 7��1- 1 2 3 J Z 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#: 09/15/2011 00:00 5082401860 KERRY INS PAGE 01/01 OP ID: KC coRa CERTIFICATE OF LIABILITY INSURANCE DAT09115D/VYY1� ` 09 15111 AJIS 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 111E 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, sub)ect 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. PRODUCER rJOB-zSrj-8(IfIO CONTACT Kerry Insurance Agency,Inc. HOE` Scott Ke 508-240-1860 PHONE PAX rry IIC.No E±nt• AIC N® PO Box ;zs E MAIL aSe North Eastham, MA 02661 PRODUCER W.Scott Kerry usroMER ID-X RACAM-1 INSURER(S)APFORMINO COVERAGE NAIC# INSURED R.A.Campbell Enterprises Inc. INSURER A;Associated Employers Insurance Ryan A.Campbell INSURER B 126 Bayridge Drive South Dennis, MA02660 IDISURERC: IIISURER D: INSURER E: IN COVERAGES CERTIFICATE NUMBER: REVISION NUMB : THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE D 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 DESCRIBE[) HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADUL TYPE OF INSURANCE b POLICY EFF POLICY EXP .WaLIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY P _&(Me occurrence $ CLAIMS-MADE 0OCCUR MED EXP(Any one ereon $ PERSONAL&ADV INJURY S GENERAL AGGREGATE $ GEN-L AGGREGATE_LIMB APPLIES PER: PRODUCTS-COMP/OP AGG S POLICY D PRO.-JP-CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE,IJM(T $ ANY AUTO (Ea accident) BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per oocldrtM) $ SCHEDULED AUf06 PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ 3 UMBRELLA UA9 OCCUR EACH OCCURRENCE $ EXCE53LWBH CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WCSTATU• On' - AND EMPLOYERS'LIABILITY Y/N x BY LIMITS I ER A ANY PROPRIPTOWPARTNEWEXECUTIVE 5009706012011 01/11/11 01111112 E.L.EACH ACCIDENT S 100,00 OFFICERMEMAER FD(CLUDED7 r N/A (Mandatory In NH) EL.DISEASE-EA EMPLOYEF $ 100,00 $ dc:orlbe under F QEERATIONS below E L D SPEASE-POLICY LIMIT S 500,00 J 7- M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional[ Ramirks schedule,IF more space Is required) (j� ! C=T•T Residential Carpentry -o C) ;Ryan A. Campbell elects coverage under this workers compensation policy. a CERTIFICATE HOLDER CaNCELLATION v? SHOULD ANY OF THE ABOVE DI-CRISE:D POLICIES BE CANCELLEOO-BEFOREE THE EXPIRATION DATE THEREOF, NOTICi WILL Bg_DEUVMM IN Town of Barnstable ACCORDANCE WITH THE POUC"PROVISIONS. Building Department ALITHORIZEOREPRWENTATIVE 200 Street Hyannis, MA 02601 ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 1 .+1 ttl fall 11 U,l l-L i.l— t/t,l tll l+++l+al +++,+ u+r i+>_ •aa+�: — — _ --- l.la '� Sr►a'rti-c,t•b'iliitlin;,j Rc��vlati+rn. anti �tcrnrlart;.'. tom. ��►`eiar'�'�iun�i��'aa��b���r��g'�t; HOME MP CONTRACCOR i License:: �SVI 6 ~. . _ --� Reg'tstra6oir. .-163732 Rc-stricted to: — iraffam' . - Tr# 2WX ration RYAN CAMPBELL RA CAMPBE RISES INC. 126 BAYRIDGE DR RY%W BELL S DENNIS. MA 02660' OUTH DENNIS.NSA 02660 adeisecrem pir iation f,muni..i+mer Tr-`: for vidul use }` License or registration validtf foundtreturn to* ,,,� u aho►►:: before the expiration da ulation f me Bdsiness eg Consumer Affairs and Business:Reg. office of`onsu TRACTOR office of Cons HOME IMP EMENT CO TRA Type:) ! Suite 5170 Registratio :A. 6373 o;.a I 10 Park Plaza- Private Corpa , , Boston,MA 02116 Expiration: 'PT MPBEL•LtEN�ERPRSE INC. RYAN CAMPBELyr go _i w►th tsignature of v 6 BAYRIDGE �� 1., 12 U ndersecretary .)^, t SOUTH DENNIS,MA%6 %'%i - • r _ v ' 7HE � Town of Barnstable Regulatory Services a+RivsTr+a Thomas F. Geiler,Director 1639• �� �p r Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit W00dS (4CkII - JAje-4 'ZA-r�-PTTA(3&C (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and acc d. Signature of Owner Signature A licant .CA-Ps-�,u�1 Print Name Print ame I Dat Q:FORMS:O WNERPERMISSIONPOOLS THE Town of Barnstable . 0; Regulatory Services * i gnaws ABLE Thomas F. Geiler,Director o 39. p•0� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occu ied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides.or intends to reside, on which there is,or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1.-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt OF THE r Town of Barnstable Permit# Erpires 6 months rom ssue date regulatory Services Feel Y +� BARNBTABLE, v� i639. `0� Thomas F. Geiler, Director oT fD MAt A Building Division Tom Perry, CBO, Building Commissioner 1� 200 Main Street,Hyannis,MA 02601 VWw.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Nerd X-Press Imprint Nlap/parcel'Ntunber.-_tom` Z) l Property Address _ / le v f d-D Residential Value of Work (n Minimum fee of$25.0U for work under$6000.00 Owner's Name & Address r'/7(0 r��J Contractor's Name 9ZCi GOryJ7 //VL Telephone Number' S�� 77(0 Home Improvement Contractor License#(if applicable)__��� r� Construction Supervisor's License# (if applicable) _ -❑Workman's Compensation Insurance _ � - v"W Check one: � t� S F; olt � ❑ .I am a sole proprietor ❑ I a*m the Homeowner OCT 3 20�� �I have Worker's Compensation Insurance �a ,F -TOWN (fir i3,ARNSTASLe Insurance Company Name G: Workman's Comp. Policy# C-3 77 Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) c�/?? 19-111'te-roof(stripping old shingles) All construction debris will be taken to G t�l' Fi'' b= __ ''`- A-( �Cf ❑ Re-roof(not stripping. Going over existing layers of roof) _- r--- ❑ 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,is e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. A.copy of the Home Improvement Contractors License is required. SIGNATURE: Q:'W111-1LE.S`•.FORMS\bui[ding pennil forms\EXPRE S.doc Revised 100608 ' The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations 600 Washington Street <` Boston,MA..02111' Y � www.mass.gov/dia • Workers, Compensation Insurance Affidavit: BuUders/Contractors/Electricians/Plumbers A licant Information12 Please Print Le ibl Name (Business/Organization/ludividual): . �C�2 LT GO f ~e— •Address: 3 f C(H l LTG Ce ' City/State/Zip: ( /�,�,t��u t 1LC /V a Phone.#: AFu an employer? Check the appropriate box: ype of project(required):. 1. am a-employer with 4. I am a general contractor and I _ 6. []New construction . employees(full wd/or part-time).* listed hired the sub-contractors listed on the.attach ed sheet. 7. ❑Remodeling 2. I am a'sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑Demolition '�rorking for me in any capacity. employees and have workers' 9 Building addition [No workers'comp,insurance comp. insurance. 5 We are a corporation and its 10.❑Electrical repairs or additions . required.] ' 3.El am a homeowner doing all-work . officers have exercised their 11.[]Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.0 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 Name; Policy#or Self-ins.Lic,#: Expiration Date: Job Site Address: �a y Gf00 D�J'� /� - e/ , ty/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 tip 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 CIA for insurance coverage verification. I do hereby certify and a pains-a ena ties of perjury that the information provided above is true and correct. Si afore: Date; O O _ Phone# C 7LE 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/Tortvn Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.. Other Contact Person: Phone#: 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 hiie, 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 othei 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-.I 52, §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 cornplianee with the insurance requirements of this chapter have been presented'to the contracting authority." Applicants Please BE out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contzactor(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 ibis 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 additiob,'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. Anew 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 DepaFtmenfs address,telephone-and fax number:. e CO.MMORWWth Of MassarhUSQetts She artmzemt Of kdiis iai Accidents Office of 11awstigatims 600 Washington Street TeL #617-727-000 ext 406 or 1-9 77-MASSA.FE Fax#617-7227-7749 Revised 11-22.06 . Www.rnass.gQvfdia • isfandSiding andRoofing a .- N ' 3 ii. a division of RLTConstnxtion,Inc. Proposal To: October 20,2008 Jeff&Donna Carinda 264 Woodside Rd. W. Barnstable, Ma. We are pleased to submit the following specifications and estimates for re-roof. Remove existing shingles and flashings. Install aluminum drip edge and pipe flashings. Install 3 ft. ice shield to eaves, valleys and chimneys. Install 15 lb. paper to remaining roof. Install 30 yr. Certainteed architectural shingles. Clean up and haul away debris. We hereby propose to furnish material and labor- complete in accordance with the above specification, for the sum of: $6,900.00 PAYMENT TO BE MADE AS FOLLOWS: Payment in full due upon completion All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owners to carry fire,wind damage and other necessary insurance. RLT Construction,Inc. carries Geueral Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request. ACCEPTANCE OF PROPOSAL- The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the rk as specified. Payment will be made as outlined above. Date of Acceptance: Signature Ac Start Date: Signature 31 Manni Circle Centervdfie, Massachusetts 02632 7efeephone 508.420.5243 and.508.833.5249 Fax 508.420.1776 Enmdcaperoofer@caperoofer.com 03113 -AM - I ATFORD 2420 LAKEMONT AVE STE 100 ORLANDO FL 32814 CP 01 6640 G6640POS 08278 03113 - Pl TOWN OF BARNSTABLE ATTN: BUILDING DEPARTMENT 200 MAIN STREET HYANNIS MA 02601 REINSTATEMENT NOTICE Please take notice that the Policy designated below has been reinstated as of the effective date of the reinstatement stated below,notice of cancellation heretofore issued being hereby withdrawn as null and void. 5 :A� Y :> POLICY NUMBER:(6S60UB-1051 C04-5-07) ISSUE DATE: 10-03-08 NAME AND ADDRESS OF INSURED PRODUCER OR AGENT R L T CONSTRUCTION INC EDWARD A GRAZUL INS Y f8Y2K 31 MANNI CIRCLE v. ISSUING OFFICE CENTERVILLE MA 02632 ORLANDO DA HTF.D 05G EFFECTIVE.DATE OF THIS NOTICE VEHICLE IDENTIFICATION 10-20-08 (Comp'ete forAao Policies or overages Only) LOCATION J (CoinptetefirFire Policies or Fire Coverages ONLY) WRITTEN.NOTICE IS HEREBY GIVEN TO YOU AS: ❑X THE PERSON TO WHOM AN INSURANCE CERTIFICATE WAS ORIGINALLY ISSUED OR A BANK OR FINANCE COMPANY; ❑ AN ADDITIONAL INSURED UNDER THE TERMS OF THE POLICY; ❑-A:'1VIORTGAGEE - ' THIS NOTICE IS GIVEN ONLY BY THE COMPANY OR COMPANIES WHICH ISSUED THE POLICY DESIGNATED ABOVE. Page 1 of 1 CN003C0394 RightFax C1-2 4/23/2008 8 : 58 : 36 AM PAGE 3/003 Fax Server ACGRD. CERTIFICATE OF INSURANCE DATE(MM\DD\YY) 04-23-08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE " EDWARD A GRAZUL INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO BOX 337 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE MARSTONS MILLS,MA.02648 COMPANY 28Y2K A HARTFORD GROUP INSURED COMPANY B R L T CONSTRUCTION INC COMPANY 31 MANM CIRCLE C CENTERVILLE,MA 02632 COMPANY D COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING -ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WrTH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - .CO POLICY EFF POUCY.EXP LTR TYPE OF INSURANCE. POLICY NUMBER DATE(MM\DD\YY) DATE(MM\DD\YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY. $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one tire) $ MED.EXPENSE(Anyone person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULE AUTOS BODILY INJURY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH(ACCIDENT$ GREGAT" EXCESS LIABILITY UMBRELLA.FORM EACH OCCURRENCE 1 OTHER THAN UMBRELLA FORM AGGREGATE 1 WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-1051CO45-07 12-24-07 12-24-08 STATUTOR,Y L)MITS THE PROPRIETOR/ EACH ACCIDENT $ ... 100,000 PARTNERS/EXECUTIVE X INCL DISEASE-POLICY VIMIT 'T$ - 500,000 OFFICERS ARE: EXCL DISEASE-EACH EMPIiOYEE ;$ ::. 100,000 OTHER ~ DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF BARNSTABLE -EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 _ 'DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT . ATTN:BUILDING DEPARTMENT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY 200 MAIN STREET KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25-5.(3193) Raman Ayer I -777 ��� a„ ,�,u� •- ,. iYIassachusetts- Department ot',Public Sakti-' _ Board oftBuilBing'Regulatiofis and Standards Boat(1 of:BUildin!� RC!�ul:Iti0n5 and Standards HOME IMPROVEMENfiCONT �--' Construction Supervisor S ecialt License_ RACTOR p Y Registration: 13 tio License: CS'SL 99910 :_ T�•t 4286 Exp-*- ri: 0/22/2009 Restricted to: .RF,WS Ir i .� Tr# 133426 ;.� Type RONNIE TAYLOR: RLT CONST. INC QWKYSLAND SIDING&ROOFIN 31 MANNI CIRCLE RONNIE TAYLOR CENTERVILLE, MA 02632 1 31 MANNI,CIRCLE 4n CENTERVILLE, MA 023621" i • - Administrator '. ��- �' '�'' • r... �� Expiration: 10/26/2011 �:-� CommissionelT rn: 99910 License or registration valid for individul use only before the expiration'date::Iffound,return.to: ' Board`of Building Regulations and Standards' One Ashburton Place Rm 1301 '.Boston,Ma.02108:`- F` of valid without signature. I • I Assessors map and lot number ...I�S .� 1 f t o.. C;... THE. K SeWcSge Permit number ....4. ...9 g ............................ IISTALLEi3HaHa9TaHLE. ' House number v NAM ........................................................ i6 \0� i YAY I� TOWN 'OF BARNS���� �ABL�E BUILDING INSPECTOR o � - o APPLICATION FOR PERMIT TO ............................................................................................................................. TYPEOF CONSTRUCTION .............................................:....................................................................................... .................1 ..19 2 s TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ��!. ....CC?Ot..41................r..W:....ff7Q!W{,/�$(� v"/A................................................................:......................... t ProposedUse ......... �� 4! / ..................................................................................................................... Zoning District ................Fire District W...: 'lK�` � / _ �/.. r�/ /fName of Owner � � .. ....C.) /, affl".................Address .4K!7 b(IYXJJ�Sf��A4� .. C�l!1v lbr M"d ..... . . .... ..................... . r� i Nameof Builder ...................( ..................................Address ................................&/4��................................... Name of Architect v4/'�l�s'.d � .736, '.`.^q. 4�F Address ��f(..... ��r ..`.....f.....IS.�.!D�G..... .. /"�/r� V ........................ Number of Rooms ....... .. ..�J..Q...�....................................Foundation ........ ..ULc9?ACC,Q...�Y�,(�..:............................ Exlerior ... .......................................Roofing .......... .. ...........Cr""J... .........................,. W Floors / ..... ' �/ .........................................Interior .. .. u!iJ�.. �r2 ..... .. . ........... ... ................................. l.' Heating v...........................................................Plumbing ..... T.! .: Fireplace ........ ®(� I�Tl�sd ....................................Approximate. Cost �.. qe--D..u..`�... .......I................. A Definitive Plan Approved by Planning Board -----------_------_-----------19_______. Aread.....��D..Q........ Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH t � � ° to �55%�� � �si'rvc> ,)CIoLc boy l � 1 a OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the T n of Barnstable regarding the above construction. Name .... .. .... ............ .......................... . .Construction Supervisor's License .................................... CARINDA, JEFFREY F . No .217.7 9 2... Permit for ADDI 0 IN .. ....... .................................... Single Family Dwelling........ ...........:.............................................. Location ....264 Woodside Road ............................................................ West Barnstable ............................................................................... Owner .......Jeffrey. . ...F......C.ar.i.nd.a............. .... ......... .. . .. .... .. .... .. Type of Construction ..Frame................................ ....... ............................................................................... Plot ............................ Lot ................................ , Permit Granted .....Apri1 ...............23 ....................19 85 Date-of Inspection ................ 19 Date Completed ......... Assessor's 'map and-lot number ../.. .. ...../. J .. . ?NEtO v Serge Permit number ............................................7.1.......... Z BABESTABLE, i House number ... .............................................................. 90 NAM pow 1639. `00� r£0 TOWN ..OF BARNSTABLE BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ..........................................................................................................................:.. TYPEOF CONSTRUCTION ........................................................................................................'............................. .................4.41.tL- r , ..19 �r e TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: /_ Jay,, [p-�,, �` /� /' / r Location �coq u!(w !6.�:...p.,.Ix)..... (U, L� �"1�( VZ&(pG'" ............................................. �.......................................................` pnv t NProposed Use ......... ............ ............................................................................................................................................ Zoning District ........................................................................Fire District ........ TU�� ............................................................ Name of Owner .................AddressT ........ Name of Builder .....................Address ......................................... Name of Architect ..........�.....Q....................�........,q,.. ?`� Address �. J' �g Number of Rooms .......TJ.. .. ....................................Foundation ,OT.c9tC3.... (iF P.f. ..................... Exterior t.N L%iv 11��1 �... .............................. .�./.............................................Roofing .................................... : aig1`. W� ............Interior ..`::�.. � Floors .......o.... 1......{................................................. ..................................,. ,................................... �� 4-Va i� .Heating ...,�'L (ci............................................................Plumbing ..... . ...............:.....................,................................... f l �� / Fireplace ........ 1.. !.Q ...... .................................................Approximate. Cost �(,,�1�� J �� f Definitive Plan"Approved by Planning Board -----------_------_------------19_______. Area ................................V. Q........ d� Diagram of Lot and Building with Dimensions Fee /- SUBJECT TO APPROVAL OF BOARD OF HEALTH 36�`Co9 S . la� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... .! ..:.......• G1�7'vf ............. Construction Supervisor's License .................................... CARINDA, JEFFREY F.. A=128-11 No ..?17792.. Permit for ADDITION ..2:7 792 .................................... milX Dwelling .................. ...KC Location ....2.6.4...W0.0ds.ide...Road ..................... ....... ....... ..... .... West Barnstable ............................................................................... Owner .........Je.f.f.r.ey.. n.d.a.......... .... .. . .. .. Type of Construction ........Frame,,,.,_ ............................................................................... Plot ............................. Lot ................................ Permit Granted ......April -23, 85 .. .. .........................19 Date of Inspection ....................................19 Date Completed ............... ......................19 r BARNSTABE.B COUNTY HEALTH DEPARTMENT BARNSTABM MANS. 02680 tc�crMONcs 362-2511 . Ext. 331 r Date: ' December 3,, 1974 Too Mr. Jeff Carinda 297 West Main Street Hyannis, Mass. 02601 On the basis of.a sanitary survey and a laboratory examination on the sample of water taken. from a .. ....well. . . . ..... .. . . . .... .located. on the premises of. . . ....4Vff.Qji,:Vir:da.,. ... . . .. . . . . .. ... .. . .. .. .located at Lot 28 Woodside Rd; West Barnstable December 2, 1974 ' . . . .... . . .. .... .. .. ...... . . . . ..... .. .... . . .. on .. .. .. . . .. . . . . .. .. . . .:. (Place) (Date) this supply is approved for domestic purposes at the time the examination .was made. ' If you wish further informationL regarding this supply, please contact us .at the County Court House, Barnstable, Massachusetts (Tel- 362-2511 Ext. 331), aril we will be glad to assist you in ariy way possible. Signed............. ... . :..`:'. .......0. Public Health Sanitarian Assessor's map and lot number .I�.°7 /..RZ..:7°..�..�1� �/�• �'� � "S 7 �` c ?,CSYT� 7EE ��.� .:a ..:.:; . Q y " :fir uu Se tage Permit number ............fl..................................:........ <. . w. �QOFTHEro�o TORN OF BARNS' ` ` '" ..::. i BAHHSTODLB, i `y 1639- BUILDING INSPECTOR � .r�e l ..�a. .� t�..��.�u...:........................... APPLICATION FOR PERMIT TO ...... .................. TYPEOF CONSTRUCTION ......... . ....... .:................................................................. ....... ...... .........197 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / Location ......... .O..T... ' : ....�rL�.O..U.[ . .. ..RL�. •.j...GL��.S ...J...t �l!t .SL. .4�:......................... '2 Proposed Use .......11Y`l..U. `e... !!t� �.l.�Yt. Zoning District .............../..1.,.°.. ........................................Fire District ........... 3../.......... -.............. `" , Name of Owner ..Ltt e art°>7.�&Address ..c �t� �?....�....�.. ............. ..... 9.7............�. ...... tt 11 c Nameof Builder ....................................................................Address .................................................................................... Name of Architect ....Address .............................................................. .................................................................................... Number of Rooms ............... �...... ....................................Foundation ....... .V-!" " .................................................... Exienor .............. Roofing ........r . .. ......,.................................. Floors ................... (/4/•��`: .....�� ..... ...........................Interior .......... ..... �'.. ... J�............... ........ . : ...... c Heating ........6v!:1...:. ..... vl/�"°•••• -...............Plumbing ..... .... r�..... ...................................................... ............Approximate Cost � . Fireplace ................. .... ................ ,p . ....... Definitive Plan Approved by Planning Board -----------_______-----------19_______. 1 Area .......�.�.:�...1..- ............... Diagram of Lot and Building with Dimensions Fee ` SUBJECT TO APPROVAL OF BOARD OF HEALTH � K 34 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . ...... ....................................................... Jeffrey F. Carinda No ..... Permit for ........Dwelling.......... j .. .u.q. ................................................ Location .Lsk .T aQl1S.�.d�..�d....................... ....................W......Barns table................:............. Owner .....Jeffrey...F.....CarlAda..................... Type of Construction ......:. YP /.w,oad..Fsawe.......... a Plot ......128............... Lot .............. .............. Sewage 480 Permit Granted .De ber..............5......19 74 Date of Inspectiori . ...:........ .......... ........ � ' / 7 Date Completed ..f�1..�/�.5.. ......... ... PERMIT REFUSED ................................................................ 19 ' ................................................................................ ................................................................................ ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... Assessor's map and lot number ........ ;2 V tf S*ag e Permit number .......... .......................................... TOWN OF BARNSTABLE 33AUSTIaLE, MU& 1639- BUILDING INSPECTOR Ar. // f--z T;f-,t1 APPLICATION FOR PERMIT TO ..... ..........1.! ..... f... ............................................. TYPE OF CONSTRUCTION ......... ...... ................................................................... ................................................ 197V TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following inform-ation':' Locationr ......... .. .. ........................................................................................................................................... r r Proposed Use ........... 4 . -,.... ... .. 'C4 ....................... .... ........... ............. .... ZoningDistrict ........................................................................Fire District ............ ................................................................. ..........................?.. ....... ................................................................... Name of Owner L-1 r eU... .....(.-.�r!�:.!.,?.1).dA--Address It t Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ........—.7....................................................Address .................................................................................... Number of Rooms ................4/ ...................................................Foundation ........ ......................................................... -ior ..............Exiej ........................... .................................Roofing ............................g? ................................................ ......... . Floors ............................................................Interior ........... ............................................................. K4 .........Plumbing ..... ........... Heating ................. ......................................................... ..................................... Pd* Fireplace ............. .........................................................Approximate Cost ....... -7r)z.............................................. Definitive Plan Approved by Planning Board -------------------------------19--------- Area ....... 41......-J/ ) . ................ Diagram of Lot and Building with Dimensions Fee ................ ....................... SUBJECT TO APPROVAL OF BOARD OF HEALTH N 1-1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................ » Jeffrey F. Car1oda ^ o ..... Permit for ....Dnll1Pg.............. ' .......'.' ��' —''*�' .--------------- . �*^e \ Location ...... Ai.d.9..Rd................... ..................W.^..Ba.=NtAb.le.----------. ~ Owner ^Jeff rey.. ......................... �wp� �ra�e � Type of Construction -- --—--—------ � ................................................................................ Plot ..12-a------. Lot .....I1....................... Sewage 480 . . � Permit Granted ' '5.----'lV74 Date of Inspection ------------lA _ Dote Completed ------------'lg � � PERMIT REFUSED � � -----_--------------'' 19 --------------------------. . � ~-------------------------.. � | '—'-----------'--------'^----' ---------------.------.----. . . ` Approved ................................................. lV ' � ' | ----------------------~---' � | ------------------------'`—' � ' r FEE TOWN OF BARNSTABLE, MASS. Q ab�!-9 19 0 UA•� THIS IS TO CERTIFY THAT A PERMIT IS HEREBY GRANTED TO Ri p _ ._.........._................................................____............................................................................................. ..........._........................................................................................ _.._ M O .0 _. (PROPERTY OWNER) (ADDRESS) 17 tia TO ...........................................................__..........................._............................._ EI3b (BUILD) ( ER) (REPAIR) d O h s� Dr a M M (TYPE OF BUILDING) (APPROXIMATE SIZE) O p ♦r opLOCATION ........................._..................................................._........................_..._ ..._........................................................................_................................_.__._..__•_ y (STREET AND NUMB (VILLAGE) CcNAME OF BUILDER OR C O N T TOR __---____----___---_-----------_--------_...._........_................................_...._......................................._........ .... _...._ A °7 °1R APPROXIMATE COST ... ..........__............. � b d eoce I HEREBY AGREE TO CONFORM TO ALL THE RULES AND REGULATIONS OF THE TOWN I OF BARNSTABLE REGARDING THE ABOVE CONSTRUCTION. o m �.0 O a U 03 _Y__........_.._.._.....__.._._................._......_............................................................... _......................_.........._.................................._.............................................................................. VJ O h (OWNER) (CONTRACTOR) O O O d Q .......... ..........-__._.._..... _........._..........._...._._.__._........_...................................................................... ABUILDING INSPECTOR Subject to Approval of Board of Health. ___ [J v'� . / / !� /� / /, _,, 4 L TO!,-TN OF BARNSTABLE BULK RATE . COUNCIL ON AGING U.S. POSTAGE PAID 198 SOUTH STREET NON-PROFIT ORG, HYANNIS, PIA 02601 PERMIT NO. 2 �r y y / � g - � � fi _ , ,i t"'� �i ` ��� t � c i _ ,. ' - , ., __i�%