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HomeMy WebLinkAbout0034 FAIRHAVEN LANE 4 S a � F _ r .7 f i I -2�-SAS tNE Application number................................................ 4► BUILDINIr nPr Fee ......... s:...`....................................................... "" Building Inspectors Initials... ... TUbv1,4 Date Issued....41 Map/Parcel........`��.1 o 3 �d0 2 R F TOWN OF BARNSTABLE 1 SCANNED EXPEDITED PERMIT APPLICATION: MAR U 5 2020 ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION a Address of Project: 3� /-�"iq f✓,YW&t1 -/VLAK,S 4'—T NUMBER * TREET VILLAGE Owner's Name: 09-i� Phone Number , 60P Email Address: ZdvZ 44 Ce11 Phone Number Project cost$ l�-jd�— Check one Residential Commercial i OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a buiil�lddi/ing permit in accordance with 780 CMR Owner Signature: %�Ll Date: Z Z2 �LLZz� TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Doors (no header change)# ❑Insulation/Weatherization 0 Roof(not applying more than 1 layer of shingles) ❑ Commercial Doors require an inspector's review Construction Debris will be going to ❑ Certificate of occupancy with no constru tion(complete below) Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit) CONTRACTOR'S INFORMATION Contractor's name 6"J,4 4,,t,t.(/ e-c.-, Home Improvement Contractors Registration(if applicable)# S Z (attach copy) Construction Supervisor's License# 10 q 16, � (attach copy) 41 Email of Contractor 't-G-A &Jg -Pj onenumber,// '4 �-' �• ���d� ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER.................................................,.......... *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. 01 Pau pose of Event -a;Ched10ohe: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model /I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit app oicados are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers . Applicant Information Please Print Legibly Name(Business/)rganization/Individual): cP Address: 4_1 City/State/Zip: Phone #: 7A? Are you an employer?Check the appropriate box: Type of project(required): 1. 1 employer with / 4. ❑ I am a general contractor and I �L am a em to p y 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me l 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 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[1 Other comp. insurance required.] *Any applicant that checks box#I 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. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: f� Policy#or Self-ins.Lic.#: VCC— SO&SGI SY 9 �4- Expiration Date: Job Site Address: � - � City/State/Zip: /1 Attach a copy of the work rs'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under theTp *ns and penalties of perjury that the information provided above is true.and correct Si afore: Date: d 2-A /2 6 Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing,agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." 1. 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 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 to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons`riTm0rvisor t. C0,4107 �' .,k �yc�pires:0812512021 CARLOS H FrGUE1F�0 20 CAPTAIN 140YES R rj SOUTH YARM�UTFt 64 Y Commissioner '" -- _. • .T/�e �.i�v�aoivaea�o�✓//6�ac�eu�ell. .. .- ..,,,. l Office of Consumer Affairs&Business Regulation i HOME IMPROVEMENT CONTRACTOR TR uiskaE norooration e �xoiration �3792 01/07/2021 C&F REMODEU�NG{C % a i�1 CARLOS H.FIGIlEIRQAs:= _-. 20 CAPTAIN NOY�S;RD�..„�` U S.YARMOUTH;MA`02604 Undersecretary Registration valid for-individual use only before the expiration date.,If found return'to: i Office of Consumer Affairs and Business Regulation 1060 Washington Street Suite 710 Boston,MA 02118 P ' Not valid without'sigrtature ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/02/2019 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 have ADDITIONAL INSURED provisions or 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 Deborah Kelly NAME: Leonard Insurance Agency,Inc PHONE (508)428-6921 FAX (508)420-5406 A/C No Ext: A/C No): 683 Main Street E-MAIL deborahk@leonardagency.com ADDRESS: Suite B INSURER(S)AFFORDING COVERAGE NAIC 0 Osterville MA 02655 INSURERA: Alain Specialty Insurance INSURED INSURER B: The Commerce Ins.Co. 34754 Carlos Figueiroa,DBA:C&F Remodeling Inc. INSURERC: Associated Ind.Of MA-ARWC 26158 INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL195203710 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 AUUL bUtSK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE To RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any oneperson) $ 5,000- A CIP383515 04/18/2019 04/18/2020 PERSONAL&ADV INJURY $ 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY El PRO ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) s 250,000 B OWNED SCHEDULED RVM277 01/18/2019 01/18/2020 BODILY INJURY(Per accident) $ 500,000 AUTOS ONLY Ix AUTOS XHIRED NON-OWNED PROPERTY DAMAGE $ 250,000 AUTOS ONLY AUTOS ONLY Per accident Medical payments $ 10,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY STAT YIN N UTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WCC-500-5018589-2019A 04/30/2019 04/30/2020 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road AUTHORIZED REPRESENTATIVE C''`� J Mashpee MA 02649 �L.1� ilKL3 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Y Application number./.... ..I..... .......... .... Issued... ?.l? ,� a v Date Iss ......... �R JUL 24 2Qi9 �. .��� t 1. ..... 39 1� - Building Inspectors Initials..... ............... �a fOWNO� 8ARNSIARLF Map/Parcel........fy9....d. ....... �, ............ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDWG/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 3H -rc►-�r l &Vt,1 !_n, NUMBER STREET VILLAGE Owner's Name: �Kp /�,, Phone Number d t,- q Lfr-I-tco y U I Email Address:��rbsk; edol ., Cell Phone Number Project cost $ oZ�/ Z — Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: 5 e p A- ,,4-�a Date: TYPE OF WORK Siding Windows (no header change)# /S 0 Insulation/Weatherization Doors (no header change)# Commercial boors require an inspector's review Roof(not applying more than 1 layer of shingles) / n Construction Debris will be going to GI i s4f--/?�a4g 9 Ply/P/i CONTRACTOR'S INFORMATION Contractor's name (�t�an `7�n�;so✓� - So,.k�.2�n We,J Fr`s (nn4 4f'n c ow S Home Improvement Contractors Registration(if applicable)# 17 3 2-1A_5 (attach copy) Construction Supervisor's License# b j S 7 01 (attach copy) Email of Contractor Phone number 1101— z z R -�fW ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS/IV A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATIONNUMBER ..............................................I............. *For Tents Only* Date Tent (s) will be erected Removed on number of tents total Does the tent have sides? Yes No of yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location (s) of each tent If food is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXE1bIPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, speck inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT9S SIGNATURE Signature Date 7—24 -15 All permit applications are subject to a building official's approval prior to issuance. Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal B Andersen of Southern New England y g Elaine&David Kelley L;X Legal Name:Southern New England Windows,LLC 34 Fairhaven In RI#36079, MA#173245,CT#0634555, Lead Firm #1237 Marstons Mills,MA 02648 WINDOW N 10 Reservoir Rd I Smithfield,RI 02917 H:(508)428-1400 Phone:866-563-2235 1 Fax:401.633-6602 1 sales@renewalsne.com Buyer(s) Name: Elaine & David Kelley Contract Date: 07/10/19 Buyer(s) Street Address: 34 Fairhaven Ln, Marstons Mills, MA 02648 Primary Telephone Number: (508)428-1400 Secondary Telephone Number: Primary Email: farboskip@aol.com Secondary Email: Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document, the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this "Agreement"). Buyer(s) hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $24,982 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $12,491 Balance Due: $12,491 Estimated Start: Estimated Completion: Amount Financed: $24,982 6-8 weeks 6-8 weeks Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: Deposit by Greensky, permit in Barnstable. Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 07/13/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Ren "I By Andersen of Southern New England Buyer(s) ,�j� �liu�Vr�L /[il-�I�t� `�•+�-d I'r 1-�yl�r Signature of Sales Person Signature Signature jim passanisi Elaine Kelley David Kelley Print Name of Sales Person Print Name Print Name UPDATED: 07/10/19 Page 2 1 12 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home ImprovemeftCiantractor Registration - - _ Type: Supplement Card - Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS,LLC= ~'.; . = Expiration: 09/18/2020 10 RESERVOIR ROAD = SMITHFIELD, RI 02917 - - -OS/17 SGl 1 0Update Address and Return Card. 20M�� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Reais�ion.. Expiration Office of Consumer Affairs and Business Regulation 113245,= 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON� _ ��2 10 RESERVOIR ROAD - U SMITHFIELD,RI 02917 Undersecretary it. without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constru_< T6nSu,perwsor CS-095707 pY,=`- :_ ' Eppires. 09/08/2020 BRIAN D DENNISON Rai 8 BLACKWELL-DRIVE ... ; CHARLTON MA 01507 i Commissioner The Commonwealth•of Massacisuseas Department of Industrial Accidents I Congress Stree4 Suite 100 Boston,MA 02114--2011 www nrassgov/dig R"arkers'Compensation Insurance Affidavit-Builders/Contractors/Etectriciaos/Plumbem TO BE FILED WITH THE PERNitIT4YG AIJTHORrrY. Apolicant Information 1 'Pleaase Print Leeibly NaMe(Business/0rganiration/lndividual): � (zfh e f, N Leu) (�j121• 4 1 /A JID f Address: U ��er, voLL—-LZIA - City/State/Zip:SM 1-Hi-6 dd,1?! OLQ /7 Phone k 40/—ZZ r— ? ff04() Are you an employer!Check the appropriate box: Type of project(required): 1. I am a employer with ;ZO'f'employees(full and/or part time).• 7. ❑New construction am a sole proprietor or partnership and have no employees working for me in 8: Remodeling any capacity.(No workers'comp.insurance required] ❑ 3. 1 am a homeowner do all work m 1£ 9. ❑Demolition ❑ doing yse (No workers'comp.insurance required.]� 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my PtopenY• l will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietars widt no employees. S.Q[am a general contractor and f have hired the subcontractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insuance.t 13.❑R f repairs /� 6. %are a co radon and its officers have exercised their right: 14.ter A,J l n 6&t✓ ❑152,61(4).and we have no employees. o workers'comp. of exemption per MGI,c. IN ksuranco required.] •Arty applicant that checks box#1 must also fiU out the section below showing their gmtkers'compensation policy infbrmatioa t Homeowners who submit this affidavit meeting they are doing all work and then hire outside conttacmns must.submit a new affidavit indicating such. Vontractots that check this box must attached an additional sheet showing the name of the sub-contoftfs gad sbmwhether or not those entities have employees. If the sub-conuacwts have employees.they must provide their workers'wmp.policy member. I ant an employer that is proWding workers'Compensation insurance for my ensployem Below is the policy and f ob site lnformagon. 11 tQ Insurance Company Name: `f i reA w /7.s wa/l ►(,— (,O - of W(�.. (�. a . Policy#or Self-ins.Lic.#: UC,g31 S37c2 Y2-6?7 Expiration Date: �—2.D LO Job Site Address: .i`>' 1;rl7aV e.,, /J, City/Stamp:A /'I, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c- 152,125A is a criminal violation punishable by a fine up to S 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 violatot.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verif bation I do hereby ce underthe p penalties ofperjiuy that the infornsaden provided above is byre and correct Date: 7—Z — P11one#: <!nl O leial use only. Do not write in ddy area,to be completed by city or town qok? aL 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#: A` DATE(MMIOOf'ry") V CERTIFICATE OF LIABILITY INSURANCE 12/28/2018 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 terns 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: CoBiz Insurance, Inc.-CO PHONE FAX 1401 Lawrence St., Ste. 1200 0 • 303-988-0446 AIC No:303-988-0804 IL Denver CO 80202 ADDRESS: COMail@cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC q INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER a:FiremenS Insurance Company of WA D.C. 21784 Southern New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURERD: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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 ADDL S BR . POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER iMMIDONMI imwDDNyyy) LIMITS A X COMMERCIAL GENERAL LIABILITY CPA31 S8728 1/112019 1/112020 EACH OCCURRENCE $1,000.000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence $300,000 MED EXP(Any oneperson) S 10,000 PERSONAL 6 ADV INJURY $1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.000,000 X POLICY❑JECT LOC PRODUCTS-COMPIOP AGG $2A00,000 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1H/2019 1/1/2020 COMBINED MANED SINGLE LIMIT accident) $1 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per,.,7 $ A X UMBRELLA LIAR X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,OD0 EXCESS LIAR CLAIMS-MADE AGGREGATE $IS.W0,000 DED I X I RETENTION$ $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X IPTEARTUTE I ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? ❑N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEj$1,000,00o If yyees,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 51,000,000 C Pollution Liability 7930073340000. 1/1/2019 1/1/2020 Each Occurrence $2.000,000 Claims-Mada Policy Aggregate $2,000,000 Retroactive Date 06120/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES'ONLY AUTHORIZED REPRESENTATIVE l� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD _1- A( } .Pot. 14 . . . t � I .dot r s l9a Ahauen 4 360LI I � .('o z 2 N } i � Ll0 �w i dzt 0 1_l Sr. lot, 0 1 The low4dation i4 located as 7!o _ I� -hoovn and *ee t4 .the setback tiecyuihence vt& o the Down o� 13a�►vstab.Ce. I I �a.te 12-�-47 t —Pot 3 Site /flan o j .(and i i Mars ton Mitt&, MA 9oti dues Anfi i pod t i, s 13e inf tot r S ad, shoe in bk. 487 pg•.66 Scate 1 "-50 1 (date 12-4-97 + ,qt t Cape Cnj i.nee ;Aq a 4 Pa tb o' %?d. ldga mi i, MI? 0260 r ,..:.. . . r r . ao iiihry L3 �. ! i No. �1 o-� �v+�1c+T+-.0 is�t:y3+r^w,.'pp.4w•.•"*,;V:ti�ktt''" .. "=- -'-�"." �'•y"•"�•` =y,r�-'.dLr''Ya.�a,,�iiif9/:.•!�r'�.. `Semi+ ,n'... :_ ....�. „.;.. .•'.+.,t, The Town of Barnstable BARrISTABLE. ` Department of Health Safety and Environmental Services MASS �► /039. �0 RFD MA+p Building Division 367 Main Street, Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice j i Type of Inspection Av A- i I Location Permit Number a i Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: cee -5 TC�i ♦ �J �d Yl Or/,,v 1),9aA -r-, / rtiUP?!� i 54. n, G ivS.e 54- r o , .� .a 4 W 49 All oc. ,1 `\n 9�/I4 c k c. 7-� (`f J A )0 p CX J I�� 2 a?iA-r- r-v c, Please call: 508-790-6227 for re-inspection. Inspected by C ,� Date IQ k-- V I� RECEIPT N U M B E R DATE C IQ 3 RECEIVED FROM I I 1 am 7)Qf) N Address D UARS FOR 1'1 N ACCOUNT HOW PAI y BEGINNING BALANCE CASH c AMOUNT CHECK - PAID m p MaoE w U t889 .S.A. BALANCE MONEY i WilsoNoneS. DUE ORDER l IJ1` BY L 77 OGOG L_tV�L . 41 4, Ce o:.'.J c..:.c I I c.s C_,- .• '.. rI Rw c.i as 'i-Yi r> J.".J f:•_L•_•'_::4 ,L E CJSE A CjAS 13AF.M C 44S 4 -- i .: •3uT TP . _ 4t.-O .-77 0'i!{ Use 2-8,x4 galleys 1 1 . with: 4:.:. of: <8" p o Bs c W�4 SroLl� a Gy all; around units. ®d,����� G A LLEyS. . Note-:- work to conform • 1 � to the;-minimum requireinentl s _ _-_ ..._ ,z5- of Title V Site Plan of Land in Marston Mills, MA For James Antiposti Being lot 15 ass shoian---in bk 487 pq 66 ii - Elevations are on NGVD Date Agent Barnstable board of Health _._.._ Scale 1"•-50 ' Date 12-23-97 All Cape Engineering 49 Harbor Road Hyannis, MA 02601 -(IF �4 OBERT Pit. �•� !„`'� .< FITZGERALD CIVIL No. 39791 - 011, - -t 7 ONA T, L71 • r-j ' I .`� .—_-.—._______. __-_�_._.T.._ , _.. .._..._,_....��__.__.__. ._,._._...__-__-...._.�.—... .. ....- ---•-• ---- Map 149 pc 1 3 3-2 i `..._...._ .. Test pit 4P-8280 Wit Ed Barry: . . : Made 9-1 -94.._! .._ _. T No water encountered' . Pert . less 2 min perl" L a-r /SSAr v D j' 4 04- 5F 4 2 t � 30 1 Soo C,rr o , I..: � I"Zof>oillt) ILI 144 410.0 f ( S 7' 1 y Septic design No. bedrooms 3 i ; I Req . leaching 330 gpd Req . tank 1500• gal .--.. -- —. — Leacchin2 12 x =3 0 x . 7 4= 2 3 7 .0 Fairhaven Lane 40 wide 7-5-x2.=151 x. 74 = 112 . 0 4 l 'Tel,'Tel, Tbtalleaching 349 .0 gpd , I i Profiles no scale .� STZ ..i......: n -- $ T _tr-� —I�-.Pay,, Sruncsz`' i!.i.'•_:1 II �V 1 t i 4 M G G Q G .c, _n TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. • DATE �5 1 1 I qg JOB LOCATION 1Y) Number Street address Section of town "HOMEOWNER" � i I ►\jO-V1 LSCI).Ugo- �Q.Sb Name Home phone Work phone . . PRESENT MAILING ADDRESS RL4 Ecj �L—an P, City town State Zip code The current exemption for "homeowners" was extended to include owner-occuni� dwellings of six units 'or less and to allow such homeowners to engage an in. dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to rE side, 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 structure: person who constructs more than one home in a two-year period shall not bE onsideied a homeowner. Such "homeowner" shall submit to the Building Offic n a form acceptable to the Building Official, that he/she shall be resnons or all. such work performed under the building permit. (Section 109. 1. 1) he undersigned "homeowner" assumes responsibility for compliance with the S uilding Code and other.' applicable codes, by-laws, rules and regulations. he undersigned "homeowner certifies that he/she understands the Town of arnstable Building Department minimum inspection procedures and requirement nd that he/she will comply with saiA procedures and requirements. IOMEOWNERIS SIGNATURE KI), PROVAL OF BUILDING OFFICIAL ote: Three- family dwellings 35 , 000 cubic feet, or larger, will be required 0 comply with State Building Code Section 127. 01 Construction Control. i • HOME OWNER'S EXEMPTION - The code state that: "Any Home Owner performing work for whichz;a. buildin permit is required shall be exempt '-from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that Home Owner engages a person (s) for hire to do such work, that such Home 0- shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuminc the responsibilities, of a, supervisor (syee ;Appendix- ( , Rules and Regulation for . licensing Construction Supervisors, Section 2. 15) . " This lack of awarE often results in serious problems, particularly when the Home Owner hires unlicensed persons. _ In this case our Board cannot proceed against the inlicensed person-'as" it would :with licensed Supervisor. The -Home '•Owner ac as supervisor is ultimately responsible. To ensure that the Home Owner is fully, aware of his/Hier responsibilities , . ^:-=Unities require, as part of the permit I application, that the Home Owne. ..atify that he/she understands the ,responsibilities of a supervisor. On ..ist page of'this. issue is a form currently used' by !several towns. You ma: care to amend and adopt such a form/certification for use in your communit_ • J 1. . • �11�`nI MOWY CONMVAUON APPUCAITON FORM FOR LDW-RW REMDMCMAL NEW CONSTRUCTION awax. • b�af� Cpt�lt#tlaq�(ab!/�b�OAOk . ❑ PrmrkW"Pie OMN ts lh�aad hum!Hobe DRW Paokw(A i Nusb M* ((+or b =d.ISM&*1,0 ba d vdbW gW Mj*fiw't'sWJ53.tba' a. Grow WOO Am woo bArmtbae b. GtambS RA Am Plow Rrvrr w Rc 0. obatft (loo a b*a)r•„�% b, Bout"WWI d, i)baag luwabu0 L .. -- L Sb b Pent $.,...,..,_ [� Cempawwt Prrlbs ' and*iwtes "Q,tea be WmW'w moo*""bdfd AP ORW Cblma s Zone(*am nom ) it Zoo 12 p Zaas 13 p Zone la At&7M&4%VWorbrl4 dRm Awsoft J.tone NPAC TM*- 9 Ww , �1 AGO*S* . Amoh Omplima Jts w and AMpmd=CWdftPbWft p CM 0 A ftch Maw Rqftwed Anhb d of 13 &w A App kodw Appw a b3 pow otApFomb Applicadon LkmW Q Dme of Mai: Raawa(a)!br Dotal: (peovjdo aaosn detw*if am"+w*Rd" man gum TO d L119 V99 209 uOL"4QLnsul XuOL00 `d05 =01 66-8Z- LnC I2-o t 14 � r� • /.74.00 . s 1 i 1 �oo•a � b .C'o-t I S � 9aiAAwen a360LI 41 .('ane .Co-t 2- . 61'= N 40 rev de cv hqua4. o o o I `7he jounda ti.on i4. tow ted ate. ' 4hown and meet..*.the 4e,6ac,- tiequ4Aexent4 o� the gown o f I � 13aicn.�.tab,Ce. , l '3ate- 12-4-97 174.ov the ahaded area •cam the paopoaed _.. ._ .... f addition. Date 7-26-99 Xo•t 3 I I 4 E ( t 1 Site. Pan o j •X and in Marston M.i,1&, Mq goat Kahen Scan_ i3e•i -Cat 1 S a4 shown in ble- 487 pg 66 i i Sea.Le I"-SO I . date 12-4-97 Keu. 7-26-99 .9.LC Cape En-nem i n L!9 l � f t i 1 �"E A 'Y The Town of Barnstable BARNSUBM 1 ¢ 10�' Department of Health Safety and Environmental Services tEo '' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair;modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. ;. Type of Work:hack,11 folon Estimated Cost SW, M) Address of Work: _��q fr+-u\)en i 11S M[4 Owner's Name:�__n f r( Date of Application:-% G1Q I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied MOwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. Date O er's Name q:fomis:Affidav a Commonwealat of Massacituseas --- Department of Industrial Accidents = OffiCC 011MOSIf92MRS 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name location aLA F:U� es L_0_�le— city t M MA phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workin in anv ra acity ❑ I am an employer providing workers' compensation for my.employees.working,on this job..::::::::.:::..:.:::....:::::.::::.:.:::.:::.::.:.:.::::.::.:::::.::::.: iL•+:::::::::`:ill%4i:!v:4iiii;:i}...•.:-.::::Si:::::y:::i:i:::::::�i::ii:::v;ii:{:iiiiii:i i:iiiiii':i:Ji:iiiiiis::::ii iiiiiiiiiii::isisi::'::!:i::::::i:::iii i:iC . ......... :i;>:};:;:; U. :.:::'.:is iii:'.:•:''il:::.:ii':':iii:.i:.::.i::i.�::•v:�i:i•:}::.:':::....:'::i::ii::i::i:'v:i::::iiii:i::' '.:: .:.:.:ii:;'.::�'<iiiii ti�'i': i address;;'`<'> :. ::......::.:.: :.. :.:.. :. .: . ::. :::::::.;::::::.::::::.: s 33 "y ' ::;:::;:;>.::::'�;:�:;:::::;:?:::;::::<:r:::;::::::::iii::;:::::;:;:::;i::;::::::::::>::ii:>�::;::;:�i::i::.;:::;::::::;::;:::'.;:::::£'�; �:::;:.;:.:>;'�;;:.:;:::...::::..::.:::::..�::::::::::::::;:::::::.�.;':.�:::::.:.::::::::::.�::::::. NOX rI am a sole proprietor,general contractor,or omeown circle one)and have hired the contractors listed below who - have the following workers' compensation polices: .::.:.':::::::::.':..:•.ii..:.:ri:::::.e.•::i.:�.s:.:..:.i:s.i:.:�.:::::::':::?i:.::::'::i i:::.i:.::::.:•i.:i i:i si?iiy:::.:v:i.:4L:.vvi6i�ii:ii.:�i'.::.i fi.?:.i i:i':..:i:i'i`i�ii-.�.i i;:.!ii;•T:;iyi:is:ii:ii:i:i:;i::._:::;:.••.:i,...i;:?C:::•i::i:s.i•F:::ii�•s':i::i::i i:i:ijiitii:::ii.ii:i::i:::::::?4i:::5i::4.:':�•ii'::i•::::?:.•.��i?i4`i:+:•i•::.i::'i::ii:::::::::•:i:::.:::,•ii.::i�'i:•:i�':.i:�:.:'.ii::: .. :. v i 4•: 64. .. { � ....$..'. .:.:.:comaanvname. . : . . }ii? ?iiii: . .. . . ::. . . �.F...i.i.:iiii :`:{}i:i:f.i.:C.> : :..i � ad .:.. >...:.. ? ::}•+•.;�'•:+:?ii::•ii:::• '•''?i:':;:i::ii:i:�i?C;ii:i:tiv}i':::'?:v }':: <`> »` ............................. ............. ......::::::::::...... .: ...::::..<: .... ................... .. ......... ...... .. .. .. .... .,.. .......:.�:ry ii:•iii:4ii}ii:4ii ::. ..: :�:A•iii .i::::oS:ki;::ii:tii!i�i ....... ..... ..: ::: .. �} J{ v v.�:.......:. v: :. .:::. v::.:w:v.��.:•:.:::.. iii':•`:hi:::�.:::,:;ii::'•i:::ii:�ii:i:!+::�:+i:^i+iiiii:<••::C:}i: t1�t:V��:;i::::i.`� �::-::tt;,v:v}:•..�?�:L:': •:,�-:.-..:.$':.:•::`:'i::'::.':':�<:i:;:i`ii}:2:j::i;Xi;i: `:' camp env n '�{ € x. C : XX 01. s address• ....X. t ................:....... ............ ................................ .::::::::::...........:::•::::•: ...r... .. .. ::•.:•::::::::.�. ::.. .. ...... nsarance:co:i::.:.. .:.. :::.::......:: ::.:::....:.::...:. .:.:. :.::. ... . . ....... ... ... . ........ olicv#�� '.;:., .......... .... .e�.�•.,;;..::;.; ::>:;:;': ..;>:?:'>::`:<::«:;::::::: Pg& 0:0 �/. Failure to secure coverage as required under Section 25A of IM 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby cerd the p ' and penalties of perjury that the information provided above �is trzw and ccoo�md 4111A Signature Date 111_L_l<l - — Print name M VX1 \��\a Phone# official use only do not write in this area to be completed by city or town official dty or town: permit/license# ❑Bufiding Department ❑Licen�g Board ❑dueekif immediate response b required ❑S�r•••�men's Office _ []Health Department contact person• phone#; 00ther (revised 9/95 P1N Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any coatrart of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association,corporation or other legal entity, or any two or more of the foregoing.engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone'numbers-along with a certificate of insurance as all affidavits 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to'fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pemiitllicense member which will be used as a reference number. The affidavits may be remmeii io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. ] Y The Department's address,telephone and fax number: y The Commonwealth Of Massachusetts Department of Industrial Accidents Me of InvesugauOnt 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 • -+Ji..'72iy ')..i^k';!`'".' ar 4 t ,.'i a 2WZi,D•�S�.yi�1'.�:.,a L?'.c,_.v�:r• r�'ytsj`I 9.Ysit..r<' .iq'. y.w,<.. ►- .-.� �-�.�.�.._w..� .. r.-yit,cy'1T�1-:/�1'�:Re'.'tF'io^1.+.+.-+^ The.Town of 'Barnstable INE T B,RMA..LE. Department of Health Safety and Environmental Services °rFo �• Building Division 367 Main Street,Hyannis,MA 62601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection Location -) A-I'd Permit Number Owner Builder &A"e-A One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: U, T-7�Y- 1 l� C-e t ( LA c U 4 CS T li e 1W0 f 1 Please call: 508-862-4038 for re-inspection. Inspected by Date 6 ,� � .. �� .I � � � �, _ � - � � � _ -� i�� � � �� _ [� uY��su�+vx1 �jp,�yT PIBc�l.rr7nwl - LE GY fy��lYo of �a...�.w✓ "da fy�y(____ _ _ m �s�s 7�d� .,� ,� /otg ® MP i4iisi.�aGt ® �Iyt _ • �T ` u �I T ° of p► x i?SiaK.Cot.. d r Y" a�nrtn... �� J Flr-Ldp MWOFAJ 41. 4tfuVf� �. Cowl[.�Dlr LAS& �n wfuff y-p••1 c 31 3�•6 y © Ova)pol,c&AL 0I.t v l,Aro ado GW 'Le �?pA PC N" A Wm . INCfvA) - ji sm ceAul� Pwc6 rep r- e a wAw Ylras"xr• ccor. 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E ]�i iK OPDR - i Of MIX e �ooc MAScheck COMPT.TANCE REPORT 4ot Massachusetts Energy Code Permit MAScheck Software Version 2 . 0 Checked by/Date CITY: Hyannis STATE : Massachusetts HDD: 5973 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 7-28-1999 DATE OF PLANS : 07/28/99 TITLE : PROJECT INFORMATION: 34 Fairhaven Dane -- Marston Mills,MA COMPANY INFORMATION: Colony Insulation, Inc. PO BOX 189-- Cataumet,MA 02534 508-563-6049 NOTES: 266 Joe Thompson Road -- West Barnstable,MA 02668 508*428-5736 COMPLIANCE: PASSES Required UA = 230 Your Home = 225 Area or Insul Sheath Glazing/Door ;," Perimeter R-Value R-Value U-Value ----------------- - -------- CEILINGS '786 30.0 0 .0 28 WALLS- Wood Frame, 16" Q.C. 1080 13 . 0 0 .0 89 GLAZING: Windows or Doors 171 0 .400 68 GLAZING: Skylights 7 0. 600 4 DOORS 41 .0 . 350 14 FLOORS: Over Unconditioned Space 678 30. 0 22 HVAC EFFICIENCY: Furnace, 82 . 0. AFUE COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or coo] the building shall be no greater tha "'�25% of the design load as specified in sections '780CMR 1310 d/J4 .4. Builder/DeWi gner /' Date f0 ZO'd L119 V99 809 uOLgvLnsui XuOLOO d05=01 66-8Z- Lnr i MAScheck INSPECTION CHECKLIST Massachusetts Energy Code - MAScheck Software Version 2 .0 DATE: 7-28-1999 Bldg. Dept. Use CEILINGS: [ j 1 . R-30 Comments/Location_ WALLS: [ ] 1. Wood Frame, 16" O.C. , R-13 Comments/Location - WINDOWS AND GLASS DOORS: [ 1 . U-value: 0. 40 For windows without labeled tl-values, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location — SKYLIGHTS: [ ] 1 . U-value': 0. 60 For skylights without labeled U-values, describe features : # Panes Frame Type_ Thermal Break? [ ] Yes [ ] No Comments/Location _ - DOORS: ( ] 1. U-value: 0 . 35 Comments/Location- FLOORS: [ •] 1. Over Unconditioned Space, R-30 Comments/Location HVAC EQUIPMENT EFFICIENCY: [ ] 1 . Furnace, 82 . 0 AFUE or higher Make and Model Number v - THERMOSTATS: [ ] Adjustable thermostats required for each HVAC system. AIR LEAKAGE: [ ] Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. Recessed lights must be type IC rated and installed with no penetrations or installed inside an appropriate air-tight assembly with a 0 . 5" clearance from combustible materials and 3" clearance from insulation. VAPOR RETARDER: [ ] Required on the warm-in-winter side of all non-vented framed ceilings, walls, and floors. I MATERTALS IDENTIFICATION: [ ] Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating EO'd LI19 ti99 209 uoLgeLnsuI OcuOLoO V09 :01 66-13Z- LnC and cooling equipment and service water. ' heating equipment must be provided. Insulation R-values, glazing U-values, and heating equipment efficiency must be clearly marked on the building plans or specifications. DUCT INSULATION: [ ] Ducts in unconditioned spaces must be insulated to R-5 . Ducts outside the building must be insulated to R-8.0. DUCT CONSTRUCTION: [ } All ducts must be sealed with mastic and fibrous backing tape. Pressure-sensitive tape may be used for fibrous ducts . The HVAC system must, provide a means for balancing air and water systems . TEMPERATURE CONTROLS: [ } Thermostats are required for each separate HVAC system. A manual or shut off the heating or automatic means to partially restrict and/or cooling input to each zone or floor shall be provided. HVAC .f;QUIPMENT SIZING; [ ] Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4. MISC REQUIREMENTS: [ ] Refer to 780 CMR, Appendix J for requirements relating to swimming fluids swimming pools, HVAC piping conveying fluids above 120 F or. chilled below 55 F, and circulating hot water. systems. ----NOTES TO FIELD (building Department Use Only)--------- I too d L119 b99 Bog u0L4vLnsuI -CuoLoO V09 :01 66-8Z- LnC- COLONY INSULATION, INC. S'eanaless Gutters r`'�} r` n n Box 189 C a,zim inlet, MA 02534 L np C` ,1 rl"el. 508/F)bri-6049 Fax 50H/564-61 l7 Proposal Submitte(I to: Phone: Date: 428-5736 July 28, 1999 Job Location: 34 Fairhaven Lane Marston Mills, MA we submit specifications and estimates for; lnsulatitrn: Addition Dcsc� I'r ttc R-Factor Flat Ceiling 9" Kraft Faced Fiberglas w/PVf,. R:30 Cathedral Ceiling, 8 1/4" Kraft Faced Fiberglas R;30 Basement Ceiling 9" Kraft faced Fiberglas R:30 Exterior walls 3 112" Kraft Faced Fiberglas R;13 VVC.n�O�A&C he�C�y'tO.CUI[ilSh:�l lte al::lziEl:l Ors::CaiYirjlClC iEl Co C:Wit ;.{bClVi)Spe:CI CN1�41t6;,far.:tIie su iP mound ...... ......... . :::.:. ..:: :.:::. ......:.;....:::::::::........... ... payment to .:::....:::::...:::...:.. ...... ..... . .... OPTION-V& ADDITION.1 ricett se crate!i Seamless Aluminum Gutters& Downspouts Installed Add $265.00 All material;s,;usranfeod to by ax xlxcili�Y1. .III wwk to he tnmplete,l in 8 workntanlik.-..,.niter sword ing to a9andard praetiw::. Any alteration o, �cviatian IYrnn.hove xpxilicauont:involving corn a?xlx.sill be eu..:utvd / T � only tipm w•iitlen orders.and will become an extra dtarge over and aMwc Joscp . D l C r. "Diddi the estimide ,VI aprecmenls cYnninecnt upon slrikcx,aocidrnts unhfa�:e / beyond our control.Owncr to carry fire.tuimido and other ueeessarr incur- Nrnc:This prup-&sl may he withdrawn by a/if*(of � anew OUT workers are fully eQvcmd by Worker's Compensation Insurance. awepted wilhin I U days. I ccrynaere oJ'Itupoxar The above price%,xpcofiicatrurn:and conditions Signalarc an:x3lixf8etory and are Ix;rchy accepted.YOU a-authorized to du the work its xpcufi d.Paynicil will b.:made as outlined aMwe. signature 50-d LTT9 ib99 209 uoL"teLnsui RUOLOO V09:01 66-8Z— LnU V KIuu Id lJ _ ; �-�s; _ --may...�_�;� ..���� �.�•• -�-.�,__.. .--- - - - sRON-T i;�EVA TIo�.I . E i GAPE PEAN5 fOR ➢AUL ANTIPA-Ti /o/Y�/ar FcuOK L�/��✓O rc 9n8y G.�eE ecwi: S/. NnaYm IY ow��n an: �•/l.yy SMS 8q.6MARCAI pAIOdE =040>04 77.-LG 7y oti..n�o xwx� I T ' I h REAR E!EVP.TIO/J T T"� i Imij ' IT, IT �y(iNT EIE Vo.7io nl _fU.�E ''/v �•o'• _ LEFT ESE VA non/ So'o'• 9 L'•o•• —_._____—.___ —.—......_.___—_ l4' a.. ;�� s• �! Cs Gi ;.5[� G � ,ram g0 I I i i I•I I Ow�V K.-J o.r i O iI _ wr. y r •� a' •e. OF A I DJ I 1T.o•� eVER o i F.19f I I IQ V i• I I.I Flr(D I I � ©9»off UaR Do eR I 'i! 'a 14 1� /ter FtooR I I I Foc FfLbR P�A.J ' �CALf lY`�l'-O•• - i � 4Kl occK U G U o H ' I i I i q a i I Fa s I i ti I su'•a .' _jE co�l�Ftoo�Pc�� f d 6aiLK I �i I x�l RiDo-Ey \ ixrO RAFTERS Q/L'OC i nro,.4 oLe 1[��•ll I•SIXA�T 11— Oltn y'CDr PLY, IL� ' R 3d SdsllLoti'olt 9,/y M1�Jn sDrP°r'r at y+-NES �xYS iw4 Y"PAC PP 11 c u : r �11 T S j ' I •IUS°LA�E All PER CODE ✓ 1` WrNOON EhTER�04 DOOR SGHE OUIE 9y1 y v.0E0. R, G✓y5 L,rE oTH R-3u �jtr all L•Ot r° a )a"OC. _3._ 1s,7. ' DDL To PLATE h 1� — ]•]r.P HEAD E,P - - DN ��' Y I L �T!•a �1...' 1-4 Ix5 LBOS. 7. v 5 W Z FADNT CMP 4•T.T.W DR,CK S.i0E5 WIC-SHrLILtf5 S"r.T.W. 9 I I i � .! lx4 SHOE 1vD FL. L 1n�o' IxiO HEADE2 P e o!. t 'L' /RT51a­CONC. COL. FILLED 7.L..0 AIf. WALL W� )6"x 8'4LNT. FooriN4 ,J30n So"n,o" PADS CAL — I L so.o.. . I•� Y-O�•N ILN CONC.t,/I.LI I WJ AL•XBYO�AT. FcoTING _ V•CGN(.fLAA tjblED 7D �.ax,iG IR7 J I I �,�iUdi�io'CO NC }/�(O COL. DOOR \I 4i J. I I PA OS ✓r/LLE,U(D \�\ I I I '•� Di Y R-e 0 0 0 r'I C'TN LCX [pyJ 1. L✓A LL 1)11-8'"CON r. 'C O Ifi NG Cj h � 1 ",CO. d•3" �91 lop �e } .a i 'J ngineering Dept. (3rd floor) Map Y Parcel L1,713 619Q Permit# House# . 4 Date Issued 2, — Board of Health(3rd oor)(8:15 -9:30/1:00-4:30) Conservation Office(4th floor)(8:30-9:30/1:00-2:00) W Q "I 1 TE UST BE Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SYS • - I LED � CIS Definitive Plan Approved by Planning Bbaidl'- 19_�2� �1'l IT . . NM 1C AND a TOWN OF BARNSTABLET N RE S Building Permit Application ProjecPee dress _3 Village:�. (_ ` CYr;2u. -�eY Owner Address Telephone 911C,6/11 9C Permit Requests„Z�,� g . First Floor /ZG'D square feet Second Floor T67Z7 square feet Construction Type_��� ,� Estimated Project Cost $ 47/) Q,! 9. O C Zoning District Flood Plain Water Protection Lot Size Grandfathered es ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(# nits) Age of Existing Structure AXOA/� Historic House ❑Yes No On Old King's Highway ❑Yes o Basement Type: 2fFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) y Basement Unfinished Area(sq.ft) 'Number of Baths: Full: Existing New Half: Existing New O No. of Bedrooms: Existing New Total Room Count(not inc ing baths): Existing New First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes o Fireplaces: Existing New Existing wood/coal stove ❑Yes o Garage:;Attached Det ed(size) Other Detached Structures: ❑Pool(size) (size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Numbe � Address !.e License# Home Improvement Contractor# `o ` 3/7 Worker's Compensation# a3 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO AS •�y► 0000l SIGNATUR DATE BU .D G PERM T DENIED R THE FOLLOWI G REASON(S) � sot FOR OFFICIAL USE ONLY _ Y _PERMIT NO. e . DATE ISSUED .a MAP/PARCEL NO. - ADDRESS VILLAGE OWNER .. DATE OF INSPECTION: FOUNDATION FRAME / f` INSULATION /Lrl ,.. , FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING- r 7 g4DUa - FINAL " F2 t , EE GAS: FINAL ` C%) FINAL BUILDINGv 2 R1 4t f"n DATE CLOSEDglgn 4 j ti ASSOCIATIO r, NO ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ' Map 1 4 Parcel W(�?-,_-S 4;7_X Permit# ff.�.Q,l� Health Division 7, f4l2 Date Issued Conservation Division �� �� � .R4� " Fee-,$'t 2s6 Tax Collector 1/,77 arc EE?J SYSTEM MiUST BE Treasurer INSTALLED IN COMPLIANCE Planning Dept. Al. 4• WITH TITLE 5 ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN REGULATIONS i Historic-•OKH Preservation/Hyannis5 Project Street Address ':;4 FQir b"e n 1A) 1 , 1 S ,. Village tc, - Owner r i(1 �� \��1�-�'1 �'yl Add ss Telephone I 1 1ADD--�q-s© -- Permit Request A ciao 4 i on �- I t wt. a A--tL O -_> el o�QQn...� IM pA c� ,O t�-S-Qf Square feet: 1 st floor: existing c,;M proposed _ 2nd floor: existing proposed Mof),e_ Total new ' ' S Estimated Project Cos Zoning District Flood Plain h)0 Groundwater Overlay Construction Type (I)CCA Lot Size I (p 1 CxC Grandfathered: ❑Yes ANo If yes, attach supporting documentation. Dwelling Type: Single Family M Two Family ❑ Multi-Family(#units) Age of Existing Structure t Historic House: ❑Yes %No On Old King's Highway: ❑Yes ANo Basement Type: ❑Full J8i Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Nme- Basement Unfinished Area(sq.ft) r­7 9J6 Number of Baths: Full: existing new Half: existing ftXhi?_ new Number of Bedrooms: existing new Total Room Count(not including baths): existing Is new_— First Floor Room Count Heat Type and Fuel: A Gas ❑Oil ❑ Electric ❑Other Central Air: XYes ❑No Fireplaces: Existing �_ New Existing wood/coal stove: ❑Yes )kNo Detached garage:❑existing ❑new size Pool:❑existing ❑new size ALf=- Barn:❑existing ❑new size A2one Attached garage:A existing ❑new size K,10M Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name r,c��,7 Q (� Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO JI SIGNATURE DATE J-4jq FOR OFFICIAL USE ONLY PERMIT NO. d DATE ISSUED MAP/PARCEL NO. ADDRESS- ` .' VILLAGE OWNER '. DATE OF INSPECTION FOUNDATION. OQ FRAME Ve INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH'r FINAL GAS: ROUGH, FINAL FINAL BUILDING l") DATE CLOSED OUT ASSOCIATION'PLAN NO. _24, ---= --_ o00 I+• � `_' � �J - � .i t. _ _^__ jam_ 1 ..' __.' ��i11N6C�4 Y -0 .. fig•: ^� _.— yGF SIn6 _Q o o - -o o a Q== a Mo _ n� a �Q _Q o -09-Ro Q D.II o BAY..91DE 6l�lLPING CcOwc. UIU • � —.------ — �' .. .:CENTE¢VIL.L6 //v�.SS. - REV'FE06 5GP B 7T EL.MVAT.IONS 6Bn19- c.op G ........:....... .. ......... iC'f�N���c'i2. Y GOLD.. ..� L _ _ I 5 _ i IEE .. 1 041. LLLLI I ' I I I 'BAYS 10E BUILDIMG CcIw4- - ---- --..------' I I I CCWTeMS/ILLE a -.sap ELCVA'T ION 3 Be-is GOF G Jv:::r.rZ tveeri ocai_ . - •` t 4 6 _ I�N. O b' L— O �. �. o..awc.. _ I xcwmN. b CI 2 ► e coat¢'6�aVj h— i+ i .\TGIF .2• Te pOep,. • C4 F.C. m4Dc4x .l'w -eewa.-0►meal' m 4�•v. 6�1 0� TI.O" '.O`' C�•(i� 7W. 11•(i� 91.0• ti.f.' ... BA`l91DE BUILDING Cc Imo.. .... . ' .CHNTSRV 11.1.tt //�A98. -. e o Eta 69 __.F..I.Q..�S.T_.....F.L_G o r'L. '. !/4"� II-oi1 ee . . . FiL A4 V� O., • •1 ,• co �1 ►�` 9 F1�P ! _ _ �SL•Q Ry.a/n r c: ..P� a 4 67 1 �• 61 s1 •• !fi C i k � ' —........... 1 BAY�I DG B i. ZE.NT ERV f f.l:6-- • ' �i,o o.�_p_�nl.i"s;:SMca _8771i/ t6.._ W r.)b\V S ':: IRIVGO WOOS t7N ..:'.':'..:ANI�EQSGIJ "GLAD' CAGE/nEi:ITS . o ¢IVGo 0.14. 50 811 •De • S-7 3641 30A 41^• (Zlvco 1935 •CsLA¢ Seca .. -e:.•-:..�......e... _. ....._ ... __.........-•----•--_._.- CD N fa 11.t1 6"x4'•ra•colic•wAp f 9s.orr.9bo�tcr�M.N-We �• 9Vs'I.ALA-Y CotFa —+ 9[e Al mow+*. t4"Y x le" FooT1NbS I �- it oI Vmwo rb. ,L - C0 NC W AL-L.I. BAYS DE G. L-- —— — —— — — — — — 0 1.....__..... 17�GM 6 T d, _�. I lo" 1'�" '' 7�•.V' -.�`•�.. / ._1,-o•CENTICRVIt_Lj�IN/�:e.SS•RN L 1 a o 14 0. .. A. ee — L :B&t tkukaWr.;-FOUWnATtall Sa-18 oF.6 1tSGC SHI kJa"t.S'.. -5F1�L'.TAol�:aaPla.oat_SHaNGtLS�...__. : _f'I td26G LQL: 0L•(WO06 CATWgL1f .... MB FA5G14'..- ._ , 1yg �16'• � IXa '� �fLY.\VITH VCNTS � � . aLLJ/AINuIN GUTTGrL.B. f�\VNSF<DUTS _ • xi 9NGCTn.00.t tD10.. " y I gut.='goAMO Tb Toffs of NINgOP1_'r-ASIUL�4 -;. � . t oil t.. STUn .. G?...:FI Pj MOM S I sU L./aT 10 tJ� 101411 F L R SI O I N C+ a CLa PT�jopnOf F2otJT. �•• p 5ulbFLc0rr C `SHINGL.f11 'SIt7C5 A RGdC, m.�r � FO.�GR::O►1 Cr '�. m ;/., S ri i 1Nil1a FL.CCR PI_Y .Sug�Lacrs n� G"�Ia+y26C.LA4 ._... _ ...... .. .. - OA Old >fAta►.Jia . Z■G.-51L'-t:.owJ.S164-ll♦j. •: .• �► .Ide,..•Qo LG.aJ T_�. - a I 6�y • L T-.:-COATIIJb .f�s6lt'r�l...:GtL/ar�tL• r LALL�t G'oL.. I a"CONUL SLAT :- bAY91DE BUILDING Cc1154, NT V _ C E 1 LL C AA-Aa'S6• �i�Cl . 4awc. i COMMONVvrrEALTH OF MASSACHUSETTS . � Q �. =_P DEFA I'- OF INDUSTRIAL ACCID..UM 600 WASHINGTON STREET BOSTON, MASSACHUSEIZS 02111 J.arnes.: Garnooel: ;ornnrssrone' WORKERS' COMPENSATION INSURANCE AFFIDAVIT IF (licenses/permince) with a principal place of business/residence ac (Gtylsmtemp) do hereby certify, under the pains and penalties of perjury,that: (J 1 am an employer providing the following workers'comper ation coverage for my employees wonting on this job. . 17 D/ Insurance Company Policy Number ( � I am a sole proprietor and have no one working for me.. (.J I am a sole proprietor, ncral contractor r homeowner (circle one)and have hired the contractors listed below who have the following wor ers compensation insurance policies: Name of Contractor Insurance Company/Poliry Number Name of Contactor Insurance Company/Policy Number Jame of Contactor Insurance Company/Policy Number 0 1 am a homeowner performing all the work myself. NOT1: .Plcau be aware twat while borneo-mcrs woo emoio-epersons to do mainteoaner. eoestruetioc or repair-ark on a d•niiint of not more than: three unit; in Woich the homeowner aiao resides or on the rmunc appurzcaant tbento art not etoerziJ+' considered to be cr_oiavcn under the Wor-kcn' Cornacnsauoo Act(Ga.C 152.sect. 1(5)). applieatioo by a homeowner for a lkzwc or permit may c-riccacc the ico status of am empiovrr under the Woritcn'Compeoution Act. 1 understand that : eooV of this stapc rnt will be forwarced to the Deoar:.•nent of lndusaial Aecdena' Ofncc of lnsuranQ tot cD�e wn.=—ion anc :ha: :a lurc to ieeure ca••eras:c as mcuircc uncle Srenon_5A of V1Gi 15: wire leac to the imonsiuon of ei.:JL pa;alues mpnsont c:.t of up to one ya:e ant avu penaiues in the form of a Stop WO-ic Oroe' and er sisone of : tint of are to S1 SOO.Ou and/or i a fine of S 100.c-; a day a€a:nst me. SUBCONTRACTOR'S INSURANCE ENGINEEER: BAXTER & NYE ENG: LIBERTY MUTUAL - WC1312595563023 FIREMENS FUND - S30MXX80564866 EXCAVATION & SEPTIC: DRISCOLL, JJ: U S F & C - 7708711916 ARBELLA - Q3N 088 130-01 FOUNDATION: BAYSIDE FOUNDATIONS: LIBERTY MUTUAL - WC1312201785044 COMMERCIAL UNION - ABR406267 CELLAR/GARAGE FLOORS: MICHAEL BROWN: AETNA - MP0023672849 FRAMERS: ROBERT DORRER: AETNA - 006C0022382785 TRAVELERS - BINDER22267 MICHAEL DUFFLEY: COMMERCIAL UNION - NBSF529312 ROOFER & SIDEWALL: JOHN MEE: TRAVELERS - 6NUB448K275894 AMERICAN STATES - 01CD1486783. MASON: SHERMAN, WAYNE: WAUSAU INS - 151200082284 COMMERCE INS CO - 561446 ELECTRICIAN: CHAVES ELECTRIC: HANOVER INS. - LHN2964649 MISCELL. INS CO - 0708878 91 1 PLUMB & HEAT: , WHITELY PLUMBING: FIDELITY CASUALTY- 28C884837393J TRAVELERS - 660365K1782COF9 ALARM SYSTEM: BALTIC SECURITY SYS: COMMERCIAL UNION - CB0743379 FIRST FINANCIAL - C400834 CENTRAL VAC: VACUUM HOUSE: MERRIMACK MUTUAL - SBP1608045 INSULATION: MAP INSULATION: U S F & G - 7711099924 AMERICAN STATES - 02CC326435-3 SHEETROCK: MEL REED: COMMERCIAL UNION - CBH557387 WORCESTER INS - CB817530 A IL INTERIOR TRIM: DAVID'S REMODELING: COMMERCIAL UNION - NBSF529312 DAVID BIK: TRAVELERS - 176K337-8-92 OAK INSTALLER: ROBERT BUDDEN: NORTHERN ASSUR. - NBF528652 PAINTING: '4 CAMPBELL PAINTING: TRAVELERS - 1680251K4083 AMERICAN POLICY - WWCC 186604 ROUSSEAU, AL MERCHANTS MUTUAL - 8CM0278570179 GARAGE DOORS: ALL CAPE GARAGE DOOR: COMMERCIAL UNION - CB94H573757 U S F & G - BSC140373112 STORMS & GUTTERS: ALUMINUM PRODUCTS: AETNA - JC89258880 MP0021014146 OAK FINISHER: AMERICAN FLOORS: TRAVELERS - 680666J6757 CARPET, VINYL & TILE: CARPET BARN: PHOENIX INS. - 6NUB476J652794 VERMONT MUTUAL - SBP6507393 WIRE SHELVING: CAPE COD CLOSETS: U S F & G - BSC146687024 APPLIANCES: KITCHEN APPL MART: HARTFORD INS CO - 067133R NEW LONDON - 1SR27039 MIRRORS & SHOWER DOORS: L & M GLASS: U S F & G - 0714349925 FIREMENS FUND - MXX80562243 LANDSCAPE & SPRINKLER: COY'S BROOK: CIGNA COMPANIES - C40216339 ARBELLA MUTUAL - ABR143850 DRIVEWAYS: NORTHERN SEALCOAT: THE PHOENIX - 387K530A MARYLAND CASUALTY- EPA18716945 Assessor's office(1st F#numb ' 2 - �-�— Assessor's map and lot ✓ c�T"tConservation(4th Floor) ����Board of Health(3rd flo8 '� Y4 ; asaSewage Permit number " 'y <� I,����' ?p rua Engineering Department(3rd floor): ` House number ' ��'®v,�� j®� •r/�� �-il°�.,,® Definitive Plan Approved by Planning Board 19 P1�q ��tf� �� /�j u APPLICATIONS PROCESSED�f O-9:30 A.M..and 1 00-2:00 P.M.only � o TOWN OF BAR S TAB LE/0 �� � BUILDING :INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION _ I OL 19 _ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies.for a permit according to the following inf mation: Location Proposed Use Zoning District Fire District v ,I Name of Owner Address-- Name of Builder Address Name of Architect Address _6_e�_ Number of Rooms L Foundation A?�, Wj Exterior r Roofing Floors �C""-- Interior t Heating Plumbing VC L��i 4Z&o4l Fireplace_l �rY 94't-11r.*G •Z Approximate Cost �— Area Diagram of Lot and Building with Dimensions 3©g' -- /_ '�� Fee �l �l�Ll • . } 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 �� ! >� • �� �s� Construction Si rpervisor's License 6Q S6 �I /M � L BAYSIDE BLDG. CO. 34 FAIRHAVEN LANE, MARSTONS MILLS r. No W -72 Permit For Two Story ` S. F. D. Location 34 Fairhaven Lane _ Marstons Mills s Owner Type of Construction Plot Lot Permit Granted ' 19 , Date of Inspection: Frame 19 Insulation 19 ` Fireplace 19 Date Completed' 19— IL t. I J. ":.,.. � i.?F: •.a-a..,,;j:wGi:.)+j� I it1r if?v: �4,,; ,,,,� ,i,;.-S' ti, -.,.1. >, r. a• �o v.;: � t, .x 're #. �"' :.Y 7"a` r�.t.. ii:;,. 4�.v '.�ti. �"�T-�� Y„ �,.37{�+ :ttk"fs+�,x,;;;t;"tt^*'ArrjtY Y34..-'$•fir �i r .y3� 'ii,��.'.�•.�� ��'%1 Y•-'a[i!X>�' _.�: �-xr ,� � r'�.Y.r'� r-�c r - \.f K - .� .5. y.;�L „1'tYy�.•!.. '� ,at-r' �S. .F a3 .¢`rt♦ �.• >,!?: w� �'S"2 �:�r.. 5R.M .3 .,s.°�- aL.-1 J 7: '1 '•r .r-:+.� ti. " t�. a•.t s 'l ,`.V �" _''� ��" q t I �"r s 1,. *a i� Y• 3�.�--�M � -tit" ?}�;1'�.^;. { ,S t i t� ',;, �. s. 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CO. AODRIESS DATE� OctG3A 19 94 PERMIT NO. Centerville #005645 ✓ PERMIT TO g ( 2 1 STORY Single Family (DWelllric (CONi R'S LICENSE) Build Dwellin UMBER OF WELLING UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) AT (LOCATION) Lot #15, 34 Fairhaven Lane, Marstons'IMills ZONING ,, ONINDISTR , RF (NO.) (STREET) BETWEEN AND (CROSS STREET) (CROSS STREET) LOT SUW' (VISION LOT BLOCK SIZE BUI DING IS TO BE FT. WIDE BY FT. LONG BY FT. IN /NO LL CONFORM IN CONSTRUCyIO �� � �` � ` �� TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: Sewage #94-582 VVOLUME 11r 2 $Q. ft. ESTIMATED COST 125,000.00 FEE MIT S174. •75 .,�. (CUBIC/SQUARE FEET) / oviNER Bayside Building Co. ADDRESS Center v a BUIL �W �/� � ram. � . P_E_iRM I T TOWN OF BA,R,N�Sd?ABLE MASSA.>�IUSETTS A=149 3 ' 2.. -• /! •DAZE 0� 3'� 19 94 P�ttMIT NO. Ni 87072 APPLICANT �.•KB'a .S1Cle Bldg. Co. �'" ADDRESS entery11'Te #UQ . •� q�\�,,: • (N0.) (STREET) (CONTR'S LICENSE) PERMIT TO '.Build ++welling ( 2 ) STORY Single FF'alttfly DwellingpWELLR OF NG UNITS (TYPE OF I1APROVEMENT) N0. (PROPOSED USE) t Lot #15, 34 Fairhaven Lane, Marstonst.M s ZONING KF AT (LOCATION) DISTRICT �,. •W' (NO.) (STREET) 1 /BETWEEN; AND t (CROSS STREET) (CROSS STREET) .� LOT SU "DIV,IS10N LOT BLOCK SIZE BUt-DIN IS TO BE FT. WIDE BY FT. LONG BY FT. IN,�HE'GHT ND SHALL CONFORM IN CONSTRUC ION n /I'/ / H (• •�� .. .. � / C. �C,� /([ �,•^� Via,.-,^'� C l r( 1 G ��!. TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION �. r _ •- (TYPE) `•^QEMARKS: Sewage #94-582 lF •w'yAREA O'R 119�,2 i Cg. ft• 125,000.00 PERMIT// VOLUME ESTIMATED COST $ FEE $174•75 7//� � ,.' 1• (CUBIC/SQUARE FEET) S •OWN'ER A iBayside Building Co. ( =ADDRESS_ 'Tent f'.rVa% BUIL { _ t ;. THIS -PERMIT -CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OFNIOEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR PERMANENT LY"•ENC`ROAC HMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE O.F THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE'SUBDIVISION RESTRICTIONS. !MINIMUM OF THREE' CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE I INSPECTIONS S REQUICONSTRUCTION E WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ALL! CONSTRUC T.I-0N WORK: ELECTRICAL, PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERINP..STRUCTURAL QUIREO,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL I MEMBERS(R'EADY TO LATH). FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION BEFORE. �••-.. OCCUPANCY. POST THIS CARD -SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS; PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2 2 3 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 1 2 BOARD OF HEALTH OTHER SITE PLAN REVIEW APPROVAL I WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT.'WILL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. I PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. r q uOLE T. DATE: SEPTEMBER V5j,1994 P- TEST BY: WELLER&ASSOCIATES 1) WITNESS: ED BARRY, HEALTH AGENT I PERC RATE: <2 MIN/IN 11 ,� I I v 55,5 5l�Pf l— 3C7« • � I� ! To� � Goo � -wl.o I Iv:3" 1�" ------- \. ""77-- a U 44-,o - - I DAILY FLOW: (= ) BDRMS. x 110 GPD ='�A I _ SEPTIC TANK: I , �. USE: 150" GAL. PRECAST SEPTIC TANK I LEACHING FACILITY: USE: ( � ) 4' x 4' GALLEYS WITH L' OF STONE CAPACITY: 5ZZ.e> c+� pi �0 Of I-Al0 o,,r of s'raJ� atz�r� o � c EL. �,o.CX7 IN S�.?5 54,00/ 1C$oo ST c v m TM BUILDING SETBACKS SITE - SEWAGE PLAN FRONT: 30' FOR SIDE: 151 t"eT is 'F4►1z1 ►Jrc M o► s Hlu-->'m'N-' REAR: 15 �-�/r� l� �T PREPARED FOR DING INC. �',""�"�,`'� ;. 'BAYSIDE BUIL ,�'` r,,•., k, p��e of DATE: SEPTEMBERZ3 , 1994 SCALE: 1 7-2/9 WELLER & ASSOCIATES P.O.BOX 119 YARMOUTHPORT,MA. 02675 (508)362-8131 ; -. --- --------- -- ---- - 14r��� - - -- ,l�.�.ems' •} •fi.,,z-� a....., - 1 w , , —"r'�T -� / - r i l l! /''''. • . . • ., .. �� 1. •.. , ' - / , � A r -, , 1 ,I . �- s { ii . �i �l , ft /� r I, -� -' e> V . _' ,� , t , t 5 1 , l � r�� Y` . _ - . ,, 1 i + l 1 ti f F 1 G t > _ t, - , 1 . t I ... -... _ ' -- . _ s f X : - . „� r• ♦ i i { _t _ ! - - - t , __y . ._ f - k. 1d,N y� '— — -- — —-- , , . - . , . 1 _ _• - _ , ,. „ 14 . . -. . . . f 1 s 1 1 �. r E .. 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