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1721 MAIN ST./RTE 6A(W.BARN.)
0 cJ�RECYCL��Co i UPC12543 �o 'No. _ HASTINGS,MN � f e Spy— +77-- 33 33 5 _ m AGRIBALANCE" Company Name CAPE COD INSULATION 1-800-696-6611 Phone Number 06-24-2016 Keith Dacey Installation Date z 1721 Route 6A, Barnstable PA86001543 J Jobsite Address A-Side Lot#'s D Z e-Side Lot#'s P3037313116 H Permit Number A O U Thickness TotaIR-Value ximate Sq. Ft. 11J on • l • 4u 3% R-15 360 square feet Walls 9.o R40 250 square feet Attic Garage Ceiling Walls co Intumescent Coating Used Location Thickness Covet-age Rate 00 ti Blazelok TBX Attic and high walls 23 mils wet 15 mils dry m LO m cn m m WWW.Demilec.com E M I L E C 4 f Y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I Parcel Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee 5 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address F't Al S 7- Village W. A R-JN S 7?4 f3LL Ale Sr' Owner d N KRA 4S 17 Address a I t-1A-Q, l ST• A1zNSTARle- Telephone 6 3,C o a// S 0 ce I/) 3 y7_ S f3 S/- '7a. ?a Permit Request R -"a t?tt S h ee7—T4 Yc k .?-ry J fi r o-o c' Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 53 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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new BV/LDINGHalff: existing new T. Number of Bedrooms: existing -new Total Room Count (not including baths): existing APR 052016 First Floor Room Count UVVNHeat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric I ❑OthOer AR%7-A,E •� 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 �� is'�✓� �%�''�2!�A Telephone Number �Q� °16 / -` 77 Address L�A'IL i License # C 6 tl"2* 7 g Ru clC L A-NJ- 1-4,A- 0-1 3 7 a Home Improvement Contractor# N O V 2 7 Email 4A-uff d/7@ t s,�j- Worker's Compensation # R a W C 6 3 1. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 0P St T-2�, 0-0N 0, T7z�ucTioi✓ J4r,,v 10S77 -0 L- SIGNATURE DATE FOR OFFICIAL USE ONLY � APPLICATION# i DATE ISSUED r MAP'/PARCEL NO. Y ADDRESS "' VILLAGE OWNER - e w f+• 1r v 's DATE OF INSPECTION: ° ' FOUNDATION fi •i r�y FRAME A INSULATION r• y FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL: t GAS: ROUGH FINAL '.• S FINAL, BUILDING 5% t f Y DATE:CLO.SED OUT ` �:7 r s' ASS_•QCIATI.ON PLAN NO. a - I MULTI-STATE RESTORATION, INC. FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT Kk)4 ,herein referred to as "Customer", authorizes MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any and all necessap cleaning and cons ctiPp on�.,�ervices on C� st mers'property Telephone and with respect to items that need to be cleaned at a remote location,to ren3ove and LA f 7' clean such items as necessary. %cy Customer authorizes '�" Insurance Company,herein referred to as "Insurance Company",to directly and solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- STATE,to endorse Customers' name,and to deposit Insurance Company checks or drafts for MULTI-STATE services.Customer agrees to pay Customers'deductible in the amount of$ that applies to this claim. • If the loss is not covered by insurance,Customer agrees U ay thehotd amount to MULTI-STATE upon receipt of the invoice. Signatur of Ow r It is my understanding that the services to be performed by MULTI-STATE will be limited to those,which are authorized by my Insurance Company. ri L f° ;l Insurance Company Name / ��y r A r- Policy Number Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional remarks: bi r I have read this doc ent and c pletely understand and agree to same. Signature ! Date (J,N N tAS Printed Name P.O. BOX 2210•MASHPEE, MA 02649 .866-921-9111 •FAX 774-238-4422 Teta�t QreEerre 00 Wmhh3yfvn Srest ffastm;M i 02M wFs�tu r�gv�rFur Wcwkeine CumpeusafgmIssarance Affida Roder-fGairfFatfi�ecfricbmsnumbers Applk=t Infurmation Meas-eFrinf it y Name(Susie l _ : /�1 ([t!7 i SAP 2e STO zf;e ? e A o . NrcaLe-=A 'S WWI 4atyfsfat>?l'lsp: AI q-. � Phfln e - 7 7 3 3 3'3 Amyau =employer?Chwkdu�gpprapriafeba= T o£, a ecE I.9 I am a i vrifa �4_ ❑ I aat a ge l rnntractur�I 3�' PF.3 ('�M�= �s � .�—* havahkedfhe�. 6- Newer n eaaspioyees{€alI andtorpazt-f�e�- _ ❑ I am a sole proprietor orpartner- listed on t�attached sheet 7- ❑R PT"-"'��irtg sbig and have nn employees These snb-oonkactou have g andhaveswos��' . x�vot3�.ng for mE m assy capacity �Fky� $ 4_ �$nildmg a dddion [L-Vo wot��'comp_in4ruau Comp_kMnM� 1 j_ We are a cotporafiam=d ifs 10-0 regans or addifiow 3_❑ I am a htrmt rner daing ail vvoaf: offft.ers have a ur-ised their 1 f-0 Plumbing aepaus or additions MY-01f 1No"wc6Mta'Comp_ rsght ofememgfiosaPer ltfC�. 12-0 RDof repa c-152.§1(4},aadwel�axo y r xicrrrAn re d_I•F 13�Ofizel employees-Wu wodc=' Comp-msarance req-i ej 'dayffiPS thatchecksbact1trstalsofU1ontthesectionbelo-w&o 633Ziiieawn3ces'---tiauporic}-fn tac S4met]waeiS air,snbmfEt Sus Effi&:;.in r $diry am doing=IItc^ fn�hire ostsifT�contlacr=most sober s aec�sigd3eit it'"' sarh is*.$17,11 this bmC IDait S tEri, a xriditi—y7 ShQE'Y dusting the Lmne of 612 rz iE=dSWEVrbPtlel Dc=t fmH E - Moyers_ 7f the th%!y ffinI P=Vi&the tamp.p oF-Y m33bet izlri ari'arnpInyer ilirrtis pt�rt trArkets'eArisrdinzt iruzrrrcacs for ttzy ett�tDyess. Beiorr is thepu&cp cued job sits amminrr,ccmpanyNa Z- /'/ �u PuRcy 9 ar Sr1f-far.Tic-� WC (0 3`I's�J ( �xgiratiuffI?ate. 7—1�e-l G za>� 17d� r M N Sr. c�gfStafelLp_.w� ,Q A-2K j,/ d le Attach a copy of the varkers'campensatinn polirI-d=hrstion page(shuwiug the policy nuoober aad motion date): Fzpnm to 152 can lead to the imposition ofC-iminal peta216 Sofa fine up to$L50D_OD andlor one-yearim as well as c ivR peszal(ies in$ere form of a SMF WORK ORDER-and a fine of up to S250_00 a day against the violator_ Be advised that a copy of this staeoent may be foa-warded to,Ifie Offir-of InvieuEgatioaia of Vie DIA for ine -e;coverage v=iE Wi=- 1 efA hengiy Certify:cFider �eptdus�u dpeuai�iss Afgerjurp thatffte uzfArntcdiat:pt asdclts�d abatTe is h ua and cnFxBcf PfiDnei#- .7 A6! -5917 62fficW mM an£y. I1c rraf wri&in fkis area,&ba campieW blZ cd3.ar lawn AffZciAL City or'Fowu: Pf•Meuse# fssmr�g�-nSht�rttg{CQCIC 4IIe�: . _. LDotedofHealff, 2.$mangDepatnmt I C igff wnO=k 4_Elec ncaIEaspmti r 5.PfanabmgIuspector fi.C WILcr Ca>�ct gt;rson: Phone#; . 5 Masca� General Laws chapter 152 requites all employers to provide Wormers'compensation for their empIoy=s% PrrcS�b this stage,an enplayee is denied as -every peasan in the service of another under any contract ofhne, exprrss or implied, oral or written. , . An anprcyer is defined as 4an individual,paxineashin,assocation, corporation or other legall entay,or any two or more of the foregoing engaged in a joint uprise,and iacbzding the Iegal representatives of a dexeased employer,-or the received or trustee of an iad'ividual,partnership,association or other legal entity,employing em e;.ploye However the owner of a dwelling house having not more than fin ee apartments and who resides therein,or the occupant of the dwellmg house of anothrr who employs pemons to do maintenance,construction or repair work on such dwelling house or on the grounds or bolding appurtenant hereto shall not because of such employment be deemed to be-an employer." MGL chapter 152, §25C(6)also states thst"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,MM chapter 152, §25C(7)states`Neither the commonwealth nor any of iispolitical subdivisions sha11 enter into any contract for the performance of public work until acceptable evidence of compliance with the in once rec u ments of this chapter have been presented to the contracting authority." Applicants Please ill out the wormers'compensation affidavit completely,by chec-ming the boxes that apply to you situation and,if necessary, supply sub-contrac`or(s)name(s), addresses)aad.phone numbers)along with their cerencaic{s) of insurance. Limited.Liability Companies(LLC)or Lim tedLiabiZrty Partnerships(LLP)with no employees other than the members or partners,are not required to carry wormers' compensation insurmce_ If ai.LLC or LLP does have employees;a policy is requites Be advised that this affidavit may be submitted the Department of Industrial Accidents for confrmafion ofinsnrance Coverage. Also be sure to sign and date the affidavit. The afdavit should be retuned to the city or town that the application for the permit or license is being requested,not the Deparhnenf of Indnstrial'Accidents. Should you have any questions o-rdnZg the law or if you are required to obtain a vorkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self inc,r�nce license number on the appropriate line. City or Town.OffirdaIs Please be sure fliai'the affidavit.is complete andprizFtecl Iegdily. The Deparlmcathas provided a space at the boti . . of the affidavit for you to fill out in the event the Office oflnvestigaiions has to contact you regarding to applicant Please be sure:to fll in the pennit/lieense number which vrr7l be used'as a reference number. In adAilion,an applicant that must submit multiple pcm iW icense applications in any given year,need only submit one affidavit indicating current policy inf =nation(if necessary) and under"Job Site Address"the applicant should writ-,`all locations in (city or town).'A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided`Lo the applicant as proof that a valid affidavit is on file for foture permits or licenses. A new affidavit must be,filed out each year.Where a home owner or citizen.is obtaining a license or permit not related to-any business or commercial venue (i_e,a dog license or permit to bum leaves etc.)said person is NOT rex to complete this affida:7i The Office of Investigations would 1 ke to bank you in advance for your cooperation and should you have any questions, please do not hesitate to give tie a call_ The Department's address,telephone and fax number: at.Cammaawtea of Massachusf ib Depait ne t aflnditstdal.Aacxdents 4'>~of Tvv�tiului • ��a,sltm S`.tr� Ramon=M&G2111 Ta 44 617 727-4, at4�66 Qr 1477-MA&SAFE R=4 617-727-774-4 Revised 4-24--07 is ACOREP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03 31 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 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 NAME: STARKWEATHER&SHEPLEY INSURANCE CORP OF MA PHONE FAX A/C No Ext: AIC No PO Box 549 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Providence RI 02901 INSURERA: AmGUARD Insurance Company 2390 INSURED INSURER B MULTI STATE RESTORATION CAPE COD DI INSURER C: 68 NICHOLETTAS WAY UNIT G INSURERD: INSURER E: MASHPEE MA 02649 INSURERF: 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISESS Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC LtMtl- OTH- A AND EMPLOYERS'LIABILITY YIN R2WC639531 7/16/2015 7/16/2016 x ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 IT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 1721 Main Street(Route 6A), West Barnstable, MA CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 202 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I U/ce cparrvnzzo�rzcuetc�o�� /`tu�aac�cuietld Weg fe of Consumer Affairs&Business Regulation License or registration valid for individul use only E IMPROVEMELVT CONTRACTORbefore the expiration date. If found return to: Office of Consumer Affairs and Business Regulation istration::_440427'- = Type:. 10 Park Plaza-Suite 5170 xpiration:-:10= 5[_2017,;.,.A Supplement C:,:d Boston,MA 02116 MULTI-STATE RESTORATIOt���,�-INC;�CAPE COD RICHARD LAURIA 21 PEQUOT RD. MASPHEE, MA 02649 Undersecretary No slid M t ut signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards c�,ril5iriiidf)l �iijrei JiSirr i uc r+uurir'v License: CSFA-051784 RICHARD D LAUJtIA I 1 LEA.H DR = ' Rockland MA 02370 i Expiration Commissioner 64/01/2017 j i - V/ee �panvrnoar"cuea��o�C�/l/�aac�ccaeLGi € _._.._ rice of Consumer Affairs&Business Regulation License or registration valid for individul use only . E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: I ��°• Office of Consumer Affairs and Business Regulation egistration;=_1-_p427_ Type: I~;— 10 Park Plaza-Suite 5170 Expiration=�Q/512017 'L Supplement C :d Boston,MA 02116MULTI-STATE REST O -T`O3RAFN,C:,CAPE COD :N • RICHARD LAURIA { 21 PEQUOT RD. -� MASPHEE,MA 02649 Undersecretary No alid t ut signature Restricted-One-:and two-family dwellings or any l accessory building thereto, irrespective of size. I Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPs licensing information visit: www.Mass.Gov/DP5 . I 4'w• 'vs t V �1 j �1 -C 3 � a � �0 OQ �3ARNSTAB�E Vol OQ x s w � k o N O gvILD1N�' DFpT. 5 2016 TOWN OF gA�ySTABLE i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ^- Application # Q Health Division d�,ya� � Date Issued _I Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 7_ati1 /`'!A-ijo S� Village W. 6�}-2,�S r�/�(� 117-4 Owner J b)✓ Address /`��/ ��i✓ S� N'� ��+�L ,q, Telephone Permit Request Axe- o F Gyi9"lei S eg� /;X$ mod. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation-A3 $ 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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other �4 C s� '- Basement Finished Area (sq.ft.) Basement Unfinished Area(sq�t) Number of Baths: Full: existing new Half: existing ��' new o Number of Bedrooms: existing _new Total Room Count (not including baths): existing new _First Roor Roo 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 R0.7 gi ec Telephone Number Address aZ.l �� (,� 'O'r 129 License # S -7 8 pee ! D �-6 �q Home Improvement Contractor# 114 b 14 ,4 7 Worker's Compensation # DaL tV EcT' K of uo ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 0A) Sire CG ST/L4eC-ri o,u C7 S'Te,,t, SIGNATURE DATE oz �r FOR OFFICIAL USE ONLY S. a APPLICATION# s DATE ISSUED -MAP/PARCEL NO. . : Y ADDRESS VILLAGE OWNER DATE OF INSPECTION: 4 -'FOUNDATIONr' FRAME i INSULATION!- .?•'`•:r)% FIREPLACE �4 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL • FINAL {FINAL BUI'LDINGIL' DATE CLOSED.OUT ASSOCIATION PLAN NO. r' ' The Commonwealth of MassachasetLr Deparment of IndUsbzal Acciderc-its D,�ice oflrcyesfigatians 600 Washington Sweet Boston, MA 02111 www.mass gcT14 is Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunnbers A Re-ant Information Please Print Le ' Name (Business/orpai=ion/fndivifta):_4111111,L fit.t.Tl ,�T�—tom �ST�/ZA+r>► oN Address: vZ( Aco L9 city/state/Zip: l�'1�31�t/�C� 0'1 A- �� Phone [am an employer? Check the appropriate box:. a employer with� 4. ❑ I am a general contractorand I Type-of project(required):loyees(M and/or part-tmze).* have hired the svb-contractors 6• ❑New coast ction a sole proprietor or partner- listed on the attached sheet 7. ❑Remodelingand have no employees These sub-contractors haveforme in aII c act In 8• ❑Demolition mg y ap ty. emp yeesand have workersworkers' comp. Tnsr, comp,insurance.$ 9. ❑Bm7ding additionired j 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions a homeowner doing a l work officers have exercised theirPltmlbinlf [No workers' camp. right of exemption per MOLg rePaits or additions ance required.]t c. 152, §1(4), and we have no 12 0 Roof repairs �P�Y�s• IN workers' 13.❑ Other comp.ice required] . *Any applicant that chtch box#1 rm, also fill out tho section below showing thoff w ='compensation policy intvrIDahon FInmeown fir wire submit this afndavit i hcd a ng they are doing an wad;and than hire outside contractors must submit a new affidavit indick g y� CjiCtn, tCanhactars that check this box mast aYtacbod.,additional sheet showing the name of the sub-coatracto end stain whether or not those antities have rPDY = If ffic sub-contractors have employees they must provide their wad:ccs'°o¢3P.policy number. am I an employer that is providing workers'compensation insurance for my employees Below is the pofcy and job site in ormadom L lnsurance Company Name: Policy#or Self-ms. Uc.#_ 0.% wFe T-K -St-0 Expiration Date: 7— rob Site Address: / 7 N " 47 N Sr- City/State/Zip: W 64-4,V S T7�'4& /�C* Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Faihre to senate coverage as required under Section 25A of MGL C. 152 can lead to the impositi m of fine up to$1,500.00 and/or one-year imprisomnent,as well as civil penalties in the form of a STOP WO RDER and oenaltiesf fine Of up to$250.00 a day against the violator. Be advised that a c of this statement ma be Im'estigations of the DIA for insmmwe cov SPY y forwarded t0 the Office of erege verification. I do hereby certify under a pains qnd penalties o fP�l that the informadon provided above is free and correct Si Date- 14.2 Phone 9 X i-— T 9 6 Qf cial=e only. Do not write in this area, to be completed by city'or town ojciaL City or Town: PermittlL,icense# lssuirzg Authority(circle one): I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town of Barnstable a " Regulator y'Services 9HAS& Thomas F.Geiler,Director 1639• RFD hAA'� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.to u.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 au un STD /2eSTb R, o to act on my behalf, in all matters relative to work authorized bythis building permit application for. ST- W aS-r 4-940u STD-Bye_ (Address of Job) (C7/5� Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION P�oFt�Teti - Town of Barnstable Regulatory Services Thomas F.Geiler,Director MASS. Building Division �Atfb MA'I A 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-occupied dwellings of six,units or less and to allow homeowners to engage an individual for hire who does not possess a"licehs6 provided that the owner acts as supervisor. DEFINPITON,OF HOMEOWNER Person(s)who owns a parcel of land on which'10sfi 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 Iuse 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) A• 'J, 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 I 91te -� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 140427 :.,...., =.: :.....::.:::............. Type: Corporation -= Expiration: 10/15/2013 Tr# 217009 MULTI-STATE RESTORATION, INC. P:E;....,, . ...: ROY RICCI P. O. Box 2210 ._..... MASPHEE, MA 02649 - - Update Address and return card.Mark reason for change. _ Address ❑ Renewal Employment Lost Card )PS-CA1 v 50M-W04-G101216 OfficeAAWEM License or registration valid for individul use only before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR p Registration: _.140427 Type: Office of Consumer Affairs and Business Regulation Expiration: 1 j11 013 Corporation -:10 Park Plaza-Suite 5170 Boston,MA 02116 STATE RESTORAT-10.;lIJC:CAPE COD ROY RICCI 21 PEQUOT RD. MASPHEE;MA 02649;,. ;= Undersecretary Not lid without signature i iviussachusetts- Department of Public Safety 4 Board of Building-, Re�Lulations and Standards Construction Supervisor License One- and Two-Family Dwellings License: cs 51784 RICHARD. D LAURIA 1. LEAH DR.. ROCKLANDi MA 02370 Expiration: 4/1/2013 Commissioner Tr#: 12672 + Client#:34309 MULTISTA ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1/25/2012 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 Sandy Benigno Starkweather&Shepley PHONE 401435-3600 FAA 401-431-9678 PO Box 549 AIc No Ext: aC,No E-MAIL stibenno Providence,RI 02901-0549 ADDRESS: s g @ arshep.com INSURER(S)AFFORDING COVERAGE NAIC# 401 435-3600 INSURER A:American Safety Insurance INSURED INSURER B:Beacon Mutual Ins Co 24017 Multi-State Restoration Cape Cod Division,Inc. INSURER C:Hartford Ins Group 19682 1135 Charles Street INSURER D: North Providence, RI 02904 INSURERE: 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 CONTRACTOR 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY ENV0307221201 1/01/2012 01/01/2013 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $SOOOO CLAIMS-MADE 51 OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 !i GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOC $ C AUTOMOBILE LIABILITY 02MCPHX6227 1/01/2012 01/01/201 COMBINED SINGLE LIMIT Ea accident $1,000,000 C X ANY AUTO 02UENHX6545(RI) 1/01/2012 01/0112013 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS X AUTOS NED PROPERTY DAMAGE $ Per accident X Drive Oth Car S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B AND EMPLOYERS' YERS'LIABILITY IONILIT 50845(RI) 12/01/2011 12/01/201 X WC sTATU- OTH- AND EMPLOYERS'LIABILITY C OFFICEWRIETOREXCLUDEDE?ECUTIVE N/A 02WECTK2360 7/16/2011 07/16/201 E.L.EACH ACCIDENT $500000 Mandatory i(f yes,describee under er E.L.DISEASE-EA EMPLOYEE $500 000 If DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 A Pollution ENV0307221201 1/01/2012 01/01/2013 $1,000,000 Each Occ. Liability $1,000,000 Aggregate $5,000 Ded. DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: 1721 RT 6A,West Barnstable,MA CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 367 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE �y ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S376404/M374383 SSB MULTI-STATE RESTORATION, INC. FIRE* FLOOD *WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT �J A ,herein referred to as "Customer" authorizes MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform apy and all nec s ary clean' and cops t cctio services, nn Cu to}ners'pro erty at: 1 -1 ��.,� J� ! A/ ti s lr lam- , , J Telephone: G and with respect to items that need to be cleaned at a_5emote location,to remove and ✓ v' clean such items as necessary. Customer authorizes / �'�?�-� Insurance Company,hereiin J t; ::a-d J b referred to as "Insurance Company",to directly and solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services. Customer agrees to pay Customers'deductible in the amount of$ /2 00.0 that applies to this claim. If the loss is not covered by insurance,Customer a s t pay e total amount to MULTI-STATE upon receipt of the invoice. 1� Signature o owifer It is my understanding that the services to be performed by MULTI-STATE will be limited to those,which are authorized by my Insurance Company. /4 e-t Insurance Company Name / Zic umber Customer agrees that MULTI-STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional remarks: A1547�K—J Dc, -2 e yr7V e- I have read this777;� omp etely pnderstand and agree to same. Signature � Date a � uS Printed Name P.O. BOX 2210•MASHPEE, MA 02649 .866-921-9111 •FAX 774-238-4422 I i i op LA c� i c MH X �'' zi CA k � x O D P� ro � 4TT- M�re�- � rl W S e �jlYSehe►s.r un) 4ed TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 1 �1 Map Parcel t�� ' '.Application # Health Division 1 ``'Date Issued Z- Conservation Division :.Application Fee ;60 Planning Dept. :PerrNt Fee Date Definitive Plan Approved by Planning Board �,l Historic - OKH Preservation/Hyannisin rI v Project Street Address Village Owner J s r Address ��dd JI Telephone G," / .-,gam 1,, ,,n .,, • _T: _- Permit Request n noun l��l �YIX� S n9 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size j Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family; : Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: P Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq. .1 -� -flNumber of Baths: Full: existing 2— new 0 Half: existing new RPmber of Bedrooms: existing 0 new w 0:) Taal Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other �,� ca Central Air: ❑Yes No Fireplaces: Existing New Existing wood/c I stove;❑I%s ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: 0 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑U Yes �No If Iyes, site Iplan review# l ,, Current Use / rtl-iJ fe lwl ��L�YI� Proposed Use 5i o�,I� fin i k4_ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �"y� � C � Telephone Number J b YJ Address i r' License # rS 0� M,6 OZ&� I5 ��Home Improvement Contractor# Worker's Compensation # VU� U I -11 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PR JECT WILL BE TAKE TO � . SIGNATUR DATE 3 f t : z j FOR OFFICIAL USE ONLY -Y ' -APPLICATION# DATE ISSUED MAP'/PARCEL,NO:. .ADDRESS VILLAGE OWNER. DATE OF INSPECTION: ,��FFOUNDATION� I .. FRAME { == INSULATION,' ` 6t '.vw r>z7 z� z FIREPLACE ELECTRICAL: ROUGH FINAL 3 ; PLUMBING: ROUGH FINAL f C�,A&I-i .�ROUGH <. FINAL -� �tiF;INALrtBUILDING�.L�.;RE_,r ?;:::.� 61U dd l.� �a- t sDATE.CLOSED..OUTd .,. } ASSOCIATION PLAN NO: _ C ' The Commonwealth of Massachusetts --= Department oflndustrialAccidents i; Office of Investigations { r4r�4i 't 600 Washington Street Boston, MA 02111 vim,; ` ! www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly � IName (Business/Organization/Individual): v Address: �(A b gr ,, Stu_ic, City/State/Zip:a-KNI I I-e - MA 0 2 OJC Phone #: JDO -T 0 UA-' Are you an employer? Check the appropriate box: Type of project(required): I.K I am a employer with � 4. ❑ I am a general contractor and I 6. ❑New construction employees (frill and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy inror nation. 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 emploier that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /�� �� ( t� '(�� r/l C !,, �1 Insurance Company Name: n an t(,I�1 �/�.�,l V� C tr� (► samrtu WmD" Policy#or Self-ins. Lic. #: W a \15�Lll�Is "(to Expiration Date: &!Z�/ Job Site Address: 1.9 Z1 City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of fine tap 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 staternent may be forwarded to the Office of Investigations olthe DIA for insurance coverage verification. I do hereby cert fy arnr e pains and p allies of perjury that the information provided above is true and correct. Si nature: Date: r Z Phone#: 7i(]� �Z000 Official use only. Do not write in this area, to be completed by cih,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#: 1 ® DATE(MM/DDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 07/06n011 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 NAME: Germani Insurance Agency PHONE FAX 908 Main Street c o 508 428-9194 ac No: 508 428-3068 E-MAIL ADDRESS: Osterville,MA 02655 PRODUOCER CU MER ID : INSURERS AFFORDING COVERAGE NAIC q INSURED INSURER A: SAFETY INS CO Scott Peacock Building&Remodelling, Inc. P.O.BOX 171 INSURER B Osterville,MA 02655 INSURER C: INSURER D: National Union Fire Ins.Comp. INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY W MMIDD/YY A GENERAL LIABILITY CP00001152 7/5/2011 7/5/2012 EACH OCCURRENCE $ 1,000,000 TO RENTED COMMERCIAL GENERAL LIABILITY DAMA PREMISES Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIREDAUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC 5815464 6/22/2011 6/22/2012 WC STATu- oTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Scott Peacock Building&Remodeling,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Fax#"508-428-7625 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r 1 ' Massachusetts- Department of Public Safet'N Board of Building Regulations and Standards Construction Supervisor License License: CS 94500 . JAMES S PEACOCK - PO BOX 171 OSTEVILLE, MA 02632 Expiration: 7/22/2012 ('uuunissioner Tr#: 29233 1 Office of Consumer Affairs& Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ Registration: •'1.51853 Type: Office of Consumer Affairs and Business Regulation Expiration: 7/7/2012 Private Corporation 10 Park Plaza-Suite 5170 ::•'' :, s: ::;`i Boston,MA 02116 SCOTT PEACOCK'BUILDING=&REMODELING INC JAMES PEACOCK,, -�� 1046 MAIN STREET`'SUI'TE:�7::'y,, Q o OSTERVILLE,MA 02655',. `,�: Undersecretary Not valid without signature 03/29/2012 16:22 7186360250 KRAUS PAGE 01/01 : .�. : Town of Barnstable .0 Regulatory Services Thomas F.Cieiler,Director j Building Division Thomas Perry,CBO Building Commissioner 200 Main Str=4 Hyannis,MA 02601 W W WAGW R14rnstableina,tts Office- 508-862.4038 Fax 508-790-6230 Plmperty Owner Must Complete and Sign This Section If Using A,Builder X ' �V` t�'"` r ,as Owner of the subject property act1on , r behalf, hereb authorize in au matters relative to vmrk authorized by this binding permit 4ppkation for. (Address of jobry J err /l lgnatuie of Owner aDate U o N i<KA tAS Wi/m R Print Name Q;1WYT11.FS�FOkMSlbuilding permit fotmsll•Ja`1'tL•SS.dnc Revisc020108 I 'd 929G Bev 80S 3U3d 1103S d20%EO 21 62 JeW o loll HIV 710 _ - LI Assessor's office (1st floor): �FTBETD Assessor's map and lot number oT / /96 00 700/ Board of Health (3rd floor): Q( Sewage Permit number •••••• i JARESTADLE. S ............................................. rasa Engineering Department (3rd floor): 9 e � 1639. 7�� .......... `00 House number .........................:.',.......;�.� DMA APPLICATIONS PROCESSED 8:30-9:30 A.M. and; 1:00-2:00 .P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR 0 - i1Jp APPLICATION FOR PERMIT TO .............................................................,,.qq...........................�.S o........................... TYPE OF CONSTRUCTION ..... ........F!�.✓I.r!'!.t................................................................. .. :. .................... ................19.8 . i TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .vS 6 Proposed Use �S d,6N Cl I .............................Fire District ....c1J�•,13! !2•! {/S. Zoning District ........................................... ................................................. Name of Owner ...... ..........!..�ddress ..1.7.. .l.....n.!.6 W. i3iFi2�v� . ..................:........................................ e, Name of Builder .,.••, ,�.!V!9YA y91 w. Yart,., K ,,.•[.y:, �9irar,,•.tin➢: Address ..........................................�..., Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..... ..........................Foundation Exterior .,Ck.D!9 ....s !0u�'� .S..� Ec14PQOARd:.,....Roofing 9S !fA�T-....Sh�/ivG-4Jf�S .. .............................................. 3�y.....T-t G- PLv woos Floors .................. ..............................................Interior ........�/� tJ .� .... .......� .. ................... Heating_ ........................ ................Plumbing * 0. OAT... ..fj✓. Fireplace y�S Approximate Cost ZS O O O .................................................. ............. .................!•y/ :.�,.......... . Definitive Plan Approved by Planning Board --------------------------------19________ . Area ....' Fee Diagram of Lot and Building with Dimensions ......:....� �� / `r�.. ... .. SUBJECT TO APPROVAL OF BOARD OF HEALTH 336.g8 IN � e ,• � 13 �1,7 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS Rr64 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..... . ..... i�...................... O00 Construction Supervisor's License �� KING, NASONF. & BARBARA L. A=196-7-1 4Q/ ,-7- No .,29265,,;: permit for ...Remodel & Add„To ...........S 74??g,1 ..FII1741y_DWe l l Ong.................... Location ....... ..7..21'..RouX ...6A.............:.............. ........................West..j3alms.t.at 1e...................... Owner .. aSoFt..F.....&...$ rbar ..L....Ki?g...... Type of Construction .....Fra.me........................... Plot ............................ Lot ................................ Permit Granted ......�'p..i1...28.................19 86 Date of Inspection ....................................19 Date Completed Ao) 7 Assessor's office'(1st floor): QoFTHE AA7- Assessor's map and lot number J.......J- 9.b.� � ©. 7n�1' { SEPTIC SYSTEF&MUST EE e�, o� Board of Health (3rd floor): ��' ! INSTALLED IN-COMPLIANC _t EAaaST1ELE,Sewage Permit number .:......... �?.�... .` `� t "SIT Engineering Department (3rd floor): I � .00�t6q.TITLE 5 1�IR®�I ' House number f..7�3J........................ 1. v2:�...�/I. I+17'AL CODE �6�} OYPYa` A ENVIRONMENTAL APPLICATIONS PROCESSED 8:30-9:30 A.M. and! 1:00.2:00 P.M.'only' TO.t"m TOWN. OF BARNSTABLE BUILDING ; INS-PECTOR r ' /6? zi /soon APPLICATION FOR PERMIT TO ' �R.M..9Pk4.../. Mq..../�Q�.C�..��.`�'�G'���� �.......... .. . �.............................. ( fl DYE N� •� po/C /3PG TYPE OF CONSTRUCTION .....W...00.J2......:F!A.M.K...........................�. �.....r�............Pf........... .... .................../A ....--------....19.��- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....1.. ....... ..1....... '............. S.l...........af...a1 .S.rd46� ............................................................ ProposedUse ...... ...................................................................................................................................... N � Zoning District ........................................................................Fire District .....IV.r...1,34.!24/�............................................. /U!9So�l..F t...1 .9.t .& !�/t......4....�15�!`.��dress ..���.I.....13.i..f�. ......w:..1 /t�vA.r..................... Name of Owner ..... .... Name of Builder '✓......I '�4m.V ..............Address A1..A.7..... .....K.0.. w.... •9R.hJ.r..f*?.fF Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms J..0............................................................Foundation .......................................................... Exterior ..C.f'?,D!9. ....S�F!.v�.�' 5. 1�.Cl P@09.............Roofing ....!4SA�1�9.�T....S�}/.NG--[.t5 p........... . 1c ....... . T..?� ��" p[.YKJO0,0 ...............................Interior l..Wtt -..... ..C.� Floors ��....... Heating Q.l.!--......:.......................................................:.........Plumbing �1?A...l!)."(}!.t�A..✓.................................................... Fireplace ../...!�z 5....................................................................Approximate Cost .. /,Z�O....0................/ 7 E Definitive Plan Approved by Planning Board _________________________ 9 Area Aa.........-� /7 S' Diagram of Lot and Building with Dimensions Fee .......:. ... ........✓../..��.. SUBJECT TO APPROVAL OF. BOARD OF HEALTH SCR I �v �� t s ►l�il S3 y v " 39 Ae 0 ry y d la I � OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS RT'6.4 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....: .D7. .. .. ..................... Construction Supervisor's License ...�...Q..9 KING, NASON F. & BARBARA L. Remodel & Add To ........... No .29265..... Permit for .............................. . ..........SiU.1e..F.a.mi.ly...Dwe.1.lin.g..................... .... .... .. . .... ... ...... . ...... . 1721 Route 6A Location ....................................................... West Barnstable ............................................................................... Owner .. Nason F. & Barbara L. King ................................................................ Type of Construction .......Frame......................... ................................................................................ Plat .............. ............. Lot ................................ April 28, 86 Permit Granted ........................................19 Date-of Inspection 3:7,2...F-7..............19 Date Completed .......... ......... ....19 Cn l R•559.48 A•13517� :..�—N�59 JI E A•92.00 A•43.17 .. 81.46'� , , Res A•>•j-03CD WESt 9 4/p S/00RISS Bk.23RUST4g EEl rY E 3 L AG,JD 0zss8 N• /r e / N ` p 1.961 ACRES. r �� / 0yI INDIAN ANf? CUU,Ja Rp�Jt E \ MA511FIV. p 02641? SK.3129 /p a, •$ 9• W T•26 k c DON4L0 WfSr�RN Sq�fTDfRS o 29 N@/•18,30�w N 9 129JT BLf'At, ees z4/SS °z zee,D0 ................. Fk to . . o m� ' •, O A , AppfR®VE® W e a 3 ' _S 74* GM DN / 2 S63.14•IS"W 104.46 S79.10*00"W 124.03 SIO 4.60 ACRES t 0 ,���• a 0H ti W b W O 3 ? v r�, •rya "Its o ��pP CM tic, p y INDIAN SPIRITUAL AND C"JIJRAL JOHN PETERS O) OE CA ; _ 28 PN�%o 2'�� MASNPEE..MASS. 02649 SK.3129 PG.15..1 h t AREA OF LOTS• 310,136 SOFT* OR 7.12 ACRES'* oP AREA OF ROAD 26.SOOSO,FL*• OR 0.61 ACRES TOTAL AREA•336.936 50.FT k OR 7.73 ACRES t I 0 Application to 9pP�¢OfHhNS�f'P•NpN� Old King's Highway Regional Historic District-Committee. in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, id triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building ❑ Addition. IM Alteration Indicate type of building: ® House ® Garage ❑ Commercial ❑ Other 2. Exterior Painting: 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE 4/7/86 ADDRESS OF PROPOSED WORK 1721 rte 6 A, W: Barns tahl P ASSESSORS MAP NO. 196007001 OWNER Nason F. & Barbara L. King ASSESSORS LOT NO. 1 HOME ADDRESS 1721 Rte 6 A, West Barnstable, Ma 02668 TEL. NO. 362-5880 FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). xlMx John C. Dorris 1685 Rte 6 A, W. Barns.- Donald Rogers Main St. W: Barns.- Rita L. Swift Bow Lane, Barnstable- Frank A. Maki Oak St. , W. Barns.- Robert Churchill 1736 Rte 6 A, W. Barns.- Indian Spiritual & Cultural C/O John Peters Rte 28., Mashpee, MA AGENT OR CONTRACTOR Vaughan Renaud TEL. NO. 394-7475- ADDRESS 487 West Yarmouth Rd. W. Yarmouth, MA DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No. 8,other side), including materials to be used; if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). Enlarge basic structure as shown on accom— panied plans. 1) Incorporate present garage'as part of living area. 2) Enlarge founda-' tion by adding approximately 250 additional, square feet to first floor. 3) Add storage barn for personal use. 4) Add second floor master bed,-.bath, & loft. 5) Chan e all existing windows , doors, and siding,. including skylights on rear of house. ' 6� New roof on house and barn to be salt box style with 10 inch pitch. Signed t `P 0 er•Contractor-Agent S ow TA,for Com ' tee use. Re d by HH.DrC;= �! Date The Certificate is hereby Date Time By APR 1q 2 Approved IMPORTANT: If Certificate is approved,approval is subject to the 10 ay appeal period ^ � provided in the Act. Disapproved ❑ OLD KING ' S HIGHWAY REGIONAL HISTORIC DISTRICT BARNSTABLE HISTORIC DISTRICT COMMITTEE 367 MAIN STREET, NYANNIS , V,A 02601 FORM.: SPEC *SHEET FOUNDATION TYPE: Existing block, new poured SIDING TYPE : Cedar shingles CHIMNEY TYPE: Brick COLOR•Red ROOF MATERIAL: Asphalt COLOR:White PITCH: 10 inch WINDOWS: Colonial - style as marked on plans . SIZE: TRIM COLOR: White DOORS : Colonial style as marked on plans COLOR: Wh e SHUTTERS: none GUTTERS : Aluminum White DECK:.- none GARAGE DOORS : - One 9 by 7 , one 16 by 12 COLOR: White TWO COPIES OF THIS FORM IS REQUIRED. FILL OUT COMPLETELY REGARDING MATERIALS, MEASUREMENTS AND COLORS . LANDSCAPE PLANS-PIAT PLANS-ELEVATION PLANS. L� APPRO� "1 a i i2t e 6 OKHIR .