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0195 MAPLE STREET
Iq5 MAPLE S T'RCEET r O ,� 110. 152 1/3 ORA � oFtKME'�ti Town of Barnstable *Permit# Expires 6 months front issue date Regulatory Services Fee l0 + BAxMsrABLE, M"� $ Thomas F.Geiler,Director i639 .0 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230- EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY 1 o6 of Valid without Red X-Press Imprint Map/parcel Number Property Address / �]Residential Value of Work 05�'r Minimum fee of$35.00 for work under$6000.00 i Owner's Name&Address ��) k, d I'A7FC) / A o .Contractor's Nam LLB Telephone Number '7,� -L2 ! Home Improvement Contractor License#(if applicable) a /W/ LOs Construction Supervisor's License#(if applicable) L L 5�jWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor X-PRESS PERMIT ❑ I am the Homeowner I have Worker's Compensation Insurance OCT 24 202 Insurance Company Name 7_,�,1 / c } Workman's Comp.Policy# bz6 4 q!- C/q TQWN OF BARNSTABLE Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows :-' ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&)Fire Permits required. _a yl }Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc: ' t ***Note: Pro erty Owner must sign Property Owner Letter of Permission. opy o he H�pro ement Contractors License&Construction Supervisors License is `N1 qui i. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporaty Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 tf� ' ''t1 i �'fie 1°a.,vrrcan..rea�/c a�✓�aaaac%.,caelld Office of Consumer Affairs&Business Regulation License or registration valid f Dr individul use only OME IMPROV ENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs ai d Business Regulation Registration:-1+48688 Type: 10 Park Plaza-Suite 5170 Expiratrn;; jg2p13 Supplement Card Boston,MA 02116 LOWES HOMESrCNTIMC.. ROBERT ABBOTS.; :•`:;:' ?.:::.;: ::':.: 136 TURNPIKE RI)-SU Yt::4-60: ��- ---> — SOUTH BOROUGH,MA'017 2 Undersecretary Not vg6d without si Ynat e v • 1i i M�.,�i •+��y+pion.. L 5 J��1)�p■/v/� a ■}/dry f O / /� /�(� /�/y)}■�(� [ter 77j Conn tonivealth V�.Mass(i Y�liuselG7 .. E• F'} '4fi d ArMiL�wZ•z's{'y T't �?'�. Depiqwinmit o,f Industrad Accidents of re of Inve-strgations 6D11Washington Sheet Boston,MA 02111 sviviv.mass.gotfddia 3 Workers' Compensation Insurance Affidavit: Bx ilders/Conh—act€ vFlectdcianslPlumbi'rs Applicant Information Please Phut Leklbltit ? {� Name(Businessiorgau ntiowhdividual). L6�(iLI.S t6 tt.. Address: t ' CiCy.'Statt~J'Zig:. i �► � one�;: S � �� Are you an employer"Check the apprapt' a bag.. Type of project(required): 1.❑ I am a employer with 4�arc a general contractor and I * / have.hired the sub--ccmtrschars 6. ❑New cwnsfructsan employees(hill and/or part-time)_ 2.❑ I am sole proprietor or partner- ship listed on the attached sheep - ❑Bemodeltng ship:and have no employees These sub-contractors have 8. ❑Demob#ate '' working fume. ca ci employeersand.haveworloexs' g y Pa t'I 9. ❑Buttding�€dation r �a� [No workers'comp.insurance comp.insuratrce.l ' d] 5. ❑ We are.a cotporatiotr.and its 1fk.❑Electrical reltaffs or adciiNt is Y ,, 3.❑ I am a homeowner doing all work officers have exercised their 11-❑plumbing repairs or:as�dit.11= right of exemption per MGL t, myself o'workers' P .,.... my � cow• � ( }. 12.❑RoDf repat�rs insurance required..]1 c.152, 1 4 .and.we haze n® employees.(No workers' 13_❑Other. _ comp.insurance required.} r yY "Amy applicant that checks bon#1:rmist also Eal out the section below showing their' o3kers' �g cmmpeaasa3imnpolicyiafori$atitm. „ .Komeoemers Who submit this:af8da dt indizstine they are doing all woad sad then hire outside conttactors n�submit anew affidavit sndicatiatg snc6 r SCcatrsetors that check this boat must attached an additional sheet showing the nacre of the sib-contracrars zad:state whether or oat thoie-en fit f�t95 t• {P ' employees.Iftlse:swircuatr�tuss:hst-e employees,they Must provide their workers'comp.policy cumber. :. � �`R�.�, -•_�{ L � I ain an eanployer that is providatzg nwrken'coaTensadion insurances for aty PuWloyees. Bobai is!#re polacy aril jobI.M. information, Insurance.Company Name_ 14ee, /^ � Policy 4 or Self-ins.Lie.#:. vj/�'D I�f 3 [SD�� Expiration Bate: u ,lob Site Ad&vmL: ��' City/Stater Attach a'copy of the workers'com rrsation policy declaration page(showing the policy number and esp"tidi date).' `-- Failure to secure:coverage as required under Section 25A of 1s,'LGL c.. 152 can lead to the imposition of criaainal pei altres.of ° fine up to$1,500-00 and/or one-year im prisonmenL as well as cit it penalties in the form of a STOP WORK GIRDER and`a of up to$250.00 a.day against the triolator_ Be.advised that a copy of this statement rosy be forwarded to.the,Office of III[-estigationss of the for fi once coverage verification. I do lrerett3'ctgrti n t S a a he Ire in ormo ion pntjided abtme rs sad'cs�rrac.t tSr -t Bate. N Phone 9: � 2 Offleial use only. -Do not tsrite in this area,to,be completed.by cidy or fotrr6 of ciaL City or Town: PermitlLlcense 4 s y ' Issuing Authority(circle Acre): f 1.Board of Health Building Department. 3.CitylTown Clerk 4,Electrical Inspector33 Plumber I for'f ' 6.Other Contact Person: Phone 9- .4 s CERTIN ATE OF LIABILITY INSURANCE I�►TbIIA14r0IYYT1'!, Y � ' TICS CERTIFICAT9 IS 1881JED AS A MAYTE OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS t 'CERTIFICATE DOES NOT AFFIRIMATIVELY R NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13y THE POLICIES # V Ell:l,0Yi1.'s Tf9S CERTIFICATE OF INSURAN DOES NOT CONS'TIY'UTE A CONTRACT Bf="I'WEEN THE ISSUING INBIlR✓;R($), AUTHOWtED 1> t388ENTAIIIV E OR PRODUCER,AND TH 0ERTIRCATE HOLDE q. IMPpRTANTi If the eertlHratQ h er i8 8n A)DITIONAL(N6 RED,fho pot a as muut bo andorsa SUBROGATION IS WAPJED,qublerx to ' tho tOrIrIA And Gondlldon,of the policy,corialf poUolao may mquiro nn ondorumant A statamor*on this co Micato door,not confor Nyhta to the dor 111440.holder In lieu of such onderaWamV6. ice,`? 'Sr` pl;DCtlCigt Cdc -Insurancm Ammociatoo xn A ,a,r ` dbc 'Igor Stxet xnauraaaa Ag I�esl aallwa9.s 4a nat>rIIripQI9&�O.Odm �'27 97otex Stsoot �,lxs�ual:Iyetaa�Aexa,I�vavrrrAcrr c d ➢Q kefield, MA 01880 In :Txavreyerr► t^ Ri1tlRap y I au fh�cbrolla ArDtieaetie y Ttt alma, c xataikis and Dimogoula me �'�""'; K 1�iD D LLC alasuacao I xu �.eh .. f r 945 Main St INSUReItol ...�,. !? . Wilmington, ,MB. 01887 INOuaIJtPr :>_-'COVf:RAGES CERTmAtE NUMBER: R8VlS14N NUMBER' �'= f =THIS IS TO CE;Mr-Y YOM Trr:C O=UC S OF I RANGE uSTED UFL( N 14AVE BEEN ISSUND TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAY�: NOTWITHSTANDNG ANY REQUUq TERM OR CONDITION OF ANY CONTRACT OROYMER 00CLUDIT WITH RESPECY To WHICH Tma ' 'CERTIFICATE MAY 8E ISSUED OR MAY PERT THk INSURANCE AFFORDED BY TN6 POLICIES GESMOED HER IN IS SUBJECT TO ALL THE'TERMS. INSIt> 04 AND 0ONCMQNS OF SUCH POLI LIMITS SHam NAY HAVE BEEN RMICED BY PAID CIAINIS. ` rvP13bRPJ61A4ANC0 roft Plouoymumlml ItLIaGTs WIISAGIdRCILITY 16802AO37752 5/1A/12 B/19/19 DA N 1:4.,KRENGC 9 1 tlOD OD CaMMa:RCIALG04RA LIA IPAY DMwGe r0 ae or a 30 0,000 CLAIMS4AA06 OCCUR NED mm a am emmi 9 ii PrA§2NAL&ADVIWURY S OEI. RAL A00JtL'GA71', m r 2-0.00-000 ?'� GSN'LAOOASQA'fgLIMIYMI'LIL'l9VBR rRooucrs-cDr�ar v o 0 POLICY I� Lae S AUTOMMILELrA&WTY 9/27L/12 9/ti/13 mu 8 72879400004 -if, N3 3 _ ":. ANYAUYO 1 Or BODILY IN,IURY(rupammv z ALLOWrIEb x 3C1110ULGO BODILY INJURY AUT 300,000 WNEDNOI HIR6DAUT06 AUTO 000 A UM1r4fUALUIO OCOUA EAGNOCCURRENCE 5 _ - s= cmeovNA9 CLAIMS-MACE ACDRCCnTC r z Ko p MIoNt C MRKMMCOMPHNAAYIDN IWC004768349 Awo CmPL*VRM1 WA010Y i j we7ATU• O7t•I• , AW FIRCPMEMMARR•1ERflVCUTIVLT L,fACH ACCIMNt 00 0 0 _C� rnJdl�ExaL0509 N!4 UA+Inaa s�100 Ir U% N`0001. T b w R 900,000 131116eRPTION OF OPInAWNS I LOCATIONS 1Y9MGLE3 IAIe h ACORa UN,AddidarW Rmmdu 8ahadwa,Irmamiptoa bngUfvdl Lowe's CampanioJ Xnc. , Lowe's Home Canters LAc— and Lowe`as EIW Inc ara listed An additional iaauxed as xespects to "neraftl and auto litrbility, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP YH9 AOOVC 068CRIBED POLICIP;OG CANCL°LI.1?0 EREFORE THE EXPIRATION DATE THEREOF, NOTIC4 WILL BE OE.LIVERED IN SIQWO O Compsnims, Inc ACCOROANtCEWITHTHEPOLIGYPROVISIONS. Attn: lS Umurance 7Fo Box 1111 AU71+o=NGPMUMA71VII X. Wilklmsboro, NC 2865 Caxxcen COCCC (D1988.=10ACORD CORPORATION, All NOW re3mod. A PAID M 9CMA4nIAC.t 'p,.w AP non www w—41",•rrr.rl.LrrJrrrl.w rA A/�I1A� 10MAN 1247. � 7M. 00 LA d S918S 11e4sUI-Z£ << S8�ZMESZ sajeS jel.OJal1111100 £O:ZZ £Z-OL-EL02 2012-10-24 19:26 Commercial Sales 2534607485 >> P 2/ Oboe of Coosw=Alias and B Regulation 10 Park Pl—-Snipe 517 'Bosun,M chusetts 021 6 Home 7mrovement cGnr Rc firm KATS KIS8 ExShUdd=: errors To x�staa DIMOPOULOS LLC JAMS KATSu cs lee 945 M ALIN ST y'rl'c•ra ��i VVILM NGTON,MA 01887 CCA 1 O ¢Orosrn Q ❑a!'w11 ❑R-Pwy— ❑Last c.,d or Wi aFd ftr{ediwWcdP IQa tSatT C4MYWAC7oR ccpin.tioa lit found nnrr fte wOo ( 49 T ofoar aadltoataroa)1<q�[offoa baton: LLC 1S Park n=.SateSD KATvs A DIMO r BesOaa,MA Qblld JAMM)CATSIMMS �a �- UO MAN ST VIUMMWON.MAo1 rl NIuela:tluxR.K-Depnrtmon nP�uAllc Safn,• 7 Bo>acYl of 8u41Qla�Rcfimlutl nN uad StatlJurdK I Canstntdlon SuperVI LiCense Ua n w.. es UStYd JiAWS S KAT611 tii 'A s DAU AROVALF RD AWOYM MA C"8 0 ►anon: 717=0 caKanUaMro�r TM 176W ���-5-rcej(41xr All are CONTRACT# 0102976 EXTERIOR SOLUTIONS INSTALLED SALES ROOFING/SIDING CONTRACT INSTALLED SALES SPECIALIST NUMBER CUSTOMER STORE NO.� ,STREET ADDRESS , _ �/'�� STREET ADDRESS CITY STATE ZIP F- !!CI__W. 1t IP A Y`�STATE O G W Z� TELEPHONE t !l �� TELEPHO3,. CF3 ^ w 7 30 3 DATE LOWE'S CONTRACTOR LICENSE NUMBER CASH CARD LCC • CHARGE - -/1. This is only a quote for the merchandise and services printed below. This becomes an agreement upon payment. Upon payment,the entire agreement,including the specifically completed pages of this document,the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this"Contract." PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. i INSTALLATION STREET ADDRESS ' tCITY STATE ZIP Roofing/Siding Color: Style: 44414ttc'C vyo C1��NS `r14`—rti4 Accessories: 12 1 5 I "Show drawing where shingles or siding will be installed. i NOTE: If rotted wood is discovered during installation additional charges will apply.You will be given a quote and a change order must be completed and signed by the customer for any additional charges. Customer must initial. Any work or material not specified is not included in this contract. Any changes or additions will be at an additional charge for the material and labor. NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamphlet Renovate Right. By signing this Contract, Customer acknowledges Contract Total having received a copy of this pamphlet before work began informing Customer * I/' of the potential risk of the lead hazard exposure from renovation activity to be applicable tax included performed in Customer's dwelling unit. WAIVER OF LIEN and ONE YEAR WARRANTY(TO BE SIGNED BY INSTALLER) I,the undersigned Installer/Independent Contractor,having been employed by the Customer who signed the Certificate of Completion below do hereby certify that the work for this project will be or has been completed in a workmanlike manner and to the Customer's satisfaction.In consideration of the receipt of one dollar and other good and valuable consideration,and to the extent permitted by applicable law,I hereby waive and relinquish all liens and all rights and claims of liens which I,the undersigned,now have or may hereafter have for labor or materials ifurnished,and further certify that all work performed and materials furnished,if any,by any other party or parties upon the order of the undersigned,have been fully paid for.Further,I the undersigned,agree to cause the prompt release of any mechanic's lien(s)which may be filed against the Customer's premises by any subcontractor,laborer,mechanic or material supplier claiming the right to file such a lien through work related to the Customer's Contract with Lowe's.In addition to any warranties provided by law or specified elsewhere,including the Customer's Contract with Lowe's,the undersigned,further warrants that all work furnished for this project shall be free from defects either in material or workmanship.If any defects in material or workmanship shall be discovered in the work furnished or material used during the course of the work or within one year from the date of the Certificate of Completion,the undersigned agrees to replace or correct such defective work or material,free from all expense to Lowe's and the Customer in a manner satisfactory to the Customer. I further represent that I have given Customer the option of retaining some or all of the surplus materials or having some or all of such surplus materials removed from the Customer's premises. � .. If applicable to the performance of the work required for this project,I,the undersigned Installer/Independent Contractor,do hereby certify that I have complied with all requirements of the _ Lead Renovation,Repair,and Painting Program Rule("LRRPP Rule"),40 C.F.R.sec.745.80 et seq.,or any applicable state laws or program regulating lead-based paint safe work practices, including compliance with all information distribution,notice requirements and work practice standards in performing the work required for this project.I certify that I have provided the Customer with all documentation required to be supplied under the LRRPP Rule or state program,shall retain all records required by law,and have attached to this document copies of all of the records required to be retained by the LRRPP Rule or applicable state program. Signed and delivered this day of (seal) l Installer Print Name CERTIFICATE OF COMPLETION 1.I,the Customer,certify that the Installers/Independent Contractors or their sub-contractors,have furnished all Goods and/or services,that installation,repairs and alterations or improvemnets ("the installation services")have been completed as set forth in my/our contract with Lowe's,and that I have been offered the opportunity to request that Lowe's allow me to retain some or all of any unused,receipted surplus materials rather than have such surplus materials remain the property of Lowe's. 2.Buyer's initials(Buyer INITIAL ONE only) ' There were no such surplus materials. I accepted all surplus materials I wanted. I declined to receive any surplus materials. { Date: Owner's Signature Owner's Printed Name ©2064 by Lowe's.®Lowe's and the gable design #90793(Rev. 12/10) INSTALLER COPY are registered trademarks of LF Corporation. ✓dy," os^^sus P�`�s Old King's Highway Regional Historic District Commit f497 115 In the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, in 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 ❑ Alteration Indicate ty pe of building: [+]11-fouse ❑ Garage ❑ Commercial ❑ Other 2 Exterior Painting: Z 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 MM 25, 199-7 ADDRESS OF PROPOSED WORK 1q5 MAPLE ST.) W., BAKI, 5TA15LE ASSESSORS MAP NO. 1 3Z OWNER WiLLIAM MEA209 F DONNA MURPyy ASSESSORS LOT NO. 06 HOME ADDRESS 125 MA PIS Sr Ap nlsrAR( � TEL N0. FOR- 36Z- 3013 FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). ATtACH90 AGENT OR CONTRACTOR 5EAN SP-,OCk 5a8- 563- 53 98 . TEL N0. ADDRESS 20 C-UVEKEIELD WAY EA►L.MOU• ! . MA OZ556 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). A ONE 5rORy ) MA'Mg bEDRoaM A-0PlTj6n! (INCLUDES N&W 8,j- R00M) THAT MEASURES I4' x Zfo: TD PrLLt Sh r1f'I5 NEW MAA1 A0 E14HT X l%ovR. EXrtN,510N Wlu- be ADPf9 OFF+TNg VITCNEI`� . A6 PAI�r ar- Tj+rs PR.a7u.T' rHE EFrd-rIRE Ijou6C WILL, ft RE-FINFED. AND IZE-5/IJ 1 SF-E ArrAOEP SPEC s� ` igned `1 Space below line for Committee use. wner•Contractor nt U � et id-�y r �--M�- a. Lea ertif'��te is hereby Date —©6zJ'7h1a1' 2 3 1997O U�GUI , ,lV l O VL4 LD KING'S HIGHWAY � Approved . ❑ IMPORTANT: f Certificate is approved, approval is subject to the 10 day appeal period provided in the Act. Disapproved ❑ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION:. Map ( •3 Parcel �� ,.'Application # � �30 Health Division Date Issued eaD Conservation Division Application Fee Planning Dept: :`Permit Fee* :: Date Definitive.Plan Approved by Planning Board Historic OKH Preservation / Hyannis Project Street Address 5 P LE Village GCS . (3(.CN.R.iy.S7P)YJL—( Owner �0 C Vy Z f/-} O�—( Address F Telephone S� 3 30 r Permit Request •-�h0/��Iutk6/�n ' —'AiC `' -6 C oo�f Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new 1�� Zoning District Flood Plain Groundwater Overlay -7rProject Valuatio Construction Type Lot Size Grandfathered: 2(Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure 2 Historic House: W1 Yes ❑ No On Old King's Highway: Yes ❑ No Basement Type: ❑ Full 2170rawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq. ) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing w —a Total Room Count (not including baths): existing new First Floor Rogm#Count Heat Type and Fuel: &Gas ;❑ Oil ❑ Electric ❑Other s _n 01 Central Air: ❑Yes XtNo Fireplaces: Existing New Existing wood coal stove pLll Yet' &No Ln Detached garage: Xexisting ❑ new size—Pool: ❑ existing ❑ new size _ Barn:3.existing gxnewV ize_ Attached garage: ❑ existing 0 new size _Shed: ❑ existing ❑ new size _ Other: o m Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION i (BUILDER OR HOMEOWNER) V C cU (. c t)"TC'—vt 't 1 f �r1 & Name CU� o � � Telephone Number 1/ ddress SD`a- �Z T Zr�j License # �q �- k CO qyy Home Improvement Contractor# Worker's Compensation # C 1 9 _i.e l Z ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO -3'SCC - IGNATURE DATEI/ ^ �� FOR OFFICIAL USE ONLY l APPLICATION# x UDATE ISSUED MAP/PARCEL NO.' ADDRESS VILLAGE k OWNER DATE OF INSPECTION: FOUNDATION -FRAME INSULATION Y _.,.FIREPLACE ' ELECTRICAL: ROUGH FINAL _ -PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. R r .,. 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/Plumberg pplicant Information Please Print Legibly Name (Business/Organizadon/Individual): C C a' Address' City/State/Zip: CO 1 o t Me Phone.#: �J �[ 2a YO Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with A 3 4. 0 I am a general contractor and 1 6. ❑New construction employees(full and/or part.tim.e).* have hired the sub-contractors 2.0 I am a sole proprietor or -' listed on the'attached sheet. T. K•Remodeling ship and have no employees These sub-contractors have g, '[demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'•comp.•insurance comp. insurance.$ required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 33 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions a myself. [No workers' comp. right of exemption per MGL 12,[]Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant.that checks box NI 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must providb their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: / Policy#or Self-ins. Lic.#: Expiration Date: � ` /o r Job Site Address: ' 1 S �1 City/State/Zip: U)• 1 ` 'I''/Lp Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure io secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to$250.00 day against the violator. Be advised that a copy of this statement may be forwarded to the'Office of Investigations- a MA for insurance covers e verification. do here b u er the pains-and penalties ofperjury that the information provided above is tr a and co reel. �1 attue: Date: '© Z Z � — Phone#:0 ��9 Official use only. Do not write in this area, to be completed by city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health '2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: Information a*nd I 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 tiustee 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 oir 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." m the commonwealth nor any of its political subdivisions shall Additionally,MGL chapter 152, §25C(7) states`Neither . enter into any contract for.the performance of public work until acceptable evidence of compliance vzth the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if ec nessary,supply sub-con6actor(s)name(s),-address(es)and.phone number(s) along with their certificates)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 rm be returned to the city or town that the application for the peit 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' lease call the Department at the number listed below. Self-insured companies should enter their compensation policy,p 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 Sile Address" the applicant should write"all locations in (city or policy information(if necessary)and under"Job 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 obti n;ng a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to bum Ieaves 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 MassachuseOs }department of Industrial Accidents Office of Inyestigat QnS— 600 Washington Street Boston, MA 02111 Tel. #617-727-49.0.0 ext 406 or 1-877-MAS.SAFE Fax # 617-72777749 Revised 11-22-06 www.mass.gov/dia DATE(MMIDD/YYYY) ACORDM ,CERTIFICATE OF LIABILITY INSURANCE 0411512009 PRODOCER (800)782-0251 FAX (781)261-2099 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern 'Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 77 Accord Park Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Unit BI Norwell, MA 02061 INSURERS AFFORDING COVERAGE NAIC# INSURED Capewide Enterprises LLC INSURERA: Hanover Insurance Co. 22292- PO Box 763 INSURER B: ACE USA Centervi77e, MA 02632 INSURERC: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rA 7DD'LTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MM1DDfYY1 GENERAL LIABILITY LBN5336555 0413012009 0413012010 EACH OCCURRENCE $ 1,000,00C. COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,004 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 11 000,00 GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,001 POLICY PRO LOC JECT AUTOMOBILE LIABILITY. TBD AUTO 0412012009 0412012010 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 11000,006 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELA LIABILITY UHN5336545 0412012009 0412012010 EACH OCCURRENCE $ 2,000,O0 OCCUR CLAIMS MADE AGGREGATE $ A 2,000,000 $ 2,'000,00 DEDUCTIBLE $ X RETENTION $ 10,00 $ WORKERS COMPENSATION AND C45761472 04/14/2009 04/14/2010 `n STATU- OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 5001 00 B ANY PROPRIETOR/PARTNER/EXECUTIVE . OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 5001 00 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 5001 00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of �ir4�s�t�aba<e T'7n D7V7S.7,On• BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY LUO.M 7n..St. OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Ronald C7eaves/KCl ACORD 26(2001/08) ©ACORD CORPORATION 1988 a i 0'0-3:5�UO.U=c:f ep.cl'osedspace 1•A'-Nl,.asoniy oply. 1s.G-1.2:Family~Ho.mes r 3 Flailuce to pdss,ess a,c.'pr,'e'dihon of;the t Massachusetts}State Buddin Code is,•cause�for•�rev�cationof,thrs�licens.e. i� q 6: • 1 �auo�sstwwo.J. c� �£SOlydCN 1! ' � 060}I:a •.#!1 '600ZILZ'G'l �T�> ,..u, [< ' esueai�aosiiuedng uoi;an�3suo�� ` SPagP_�BtS P P su pgejq.a��u�p�tnff)o pusoII �`. ,per ��e.�oo7romo�zuieall� o�./�aaca%: . S •\ B.oardofRWldtngrRegulafions-and Standards ,; MOMR+IIGIl7R©VEMENT GON fFi4CTOR I ldgist ;; 14,3358 — — 81.201-0 Tr# 2,72627 _ ems_—_ iability.Corpor c i r9 N y License or tagistRation valid for individul use only before the expusation date. If found return to: Boa-d:of:Building�Regulations andStandards One Ashburton Place Rm 13a1 Boston,Ma..02-1108 r =•alid,w"th'put• ig`nature a+I Town of Barnstable .� o� Regulatory Services Thomas F.Geiler,Director ' Building Division. Building Commdssiouer Tomperry, -( 200 Main.Street, 13Y +MA 42601 www.town barustable.ma.u3 Fax: 508 790-6230 Office; 508-862-4038 Property owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property � 6'to act on n p ybehalf; hereby authorize fitters relative to work authorized bytes bmlding permit application for, in au ' address of J b} Dat e of er . . i • Printl'�ame • • - Town.of Barnstable sf Old King's'Highway Historic District Committee 200 Main Street, Hyannis, Massachusetts 02601 Pb�Eoa�,� (508) 862-4787 Fax (508) 862-4784 APPLICATION, CERTIFICATE OF APPROPRIATENESS FOR DEMOLITION OR RELOCATION OF A BUILDING OR STRUCTURE (including partial demolitions of buildings,structures; outbuildings,stonewalls,etc.) Application is hereby made,with four(4)complete sets,for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973,for proposed work as described below and on plans,drawings,or photographs accompanying this application: o ---Aco .7 Date: Address of Proposed work: Assessors �Map and lot# 1 t�o O. House#l9� Street�yl,� 5'%'' Village:�r�. iQ(/P j� G 0 Demolition of ❑house ❑part of house XGarage Z barn ❑stable ❑commercial ❑stone v%ll ❑othe Description of Proposed Work: JCL ram ,(�yi � ��/� z �^� C EA Please complete the following information: a AQ-k u ; ILI Square footage of footprint of building(s)to be demolished: Building 1: / 1 f 2: Square footage of total floor area of building(s)to be demolished: Buildin'g�,1: 2: Owner(please print): 1d. /(.J 6' r v7ld - Q Owner's mailing address: �9 j/y� �f —' ls�s•� `J ZU,44 Signature of Owner : e: All applications must be gn by the owner,or evidence of authority to act for the owner submitted Agent/Contractor(pl print): Tel#: Address: Signature of Contractor/Agent: If application is for removal to a different location,state where: i Note: A separate Certificate of Appropriateness is required for a relocation of a building or structure within the Barnstable Old Kings Highway Historic District Chec list Application for Certificate of Appropriateness for Demolition)or Removal,4 copies Site plan,4 copies, O Photographs of all elevations of building(s),outbuilding(s)or stone walls being demolished. J I Fee according to schedule. List of abutters,see staff 10 For Committee Use Only This Certificate is hereby Approve"enied ' ate: EC ( V 22 Committee Members Signatures: MAR 0 2009 Con U all, if any TOWN OF BARNSTABLE ISTORIC PRESERVATIO 1 i Q:IGMD-Groups l0ld Kings High waylOKHNewAppIOKHDemolition 0Zdoc i OF tHE Tp� f i Barnstable Old Kings.Highway Historic District Committee- O,„ i s ,stAB ; 200 Main Street, Hyannis, MA 02601;TEL: 508-862-4787 Fax 508-862-4784 y MASS P 1639. ,EO s APPLICATION; CERTIFICATE OF APPROPRIATENESS Application is hereby made, with four(4)complete sets, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470,Acts and Resolves of Massachusetts, 1973,for proposed work as described below and on.plans,drawings,or photographs accompanying this application for: Clieck all categories that apply; o 1. Building construction: El New El Addition Alteration 2. Type of Building: El House Garage barn ; °"hed El Commercial ❑Father - 3: Exterior Painting, roof ❑ new roof ❑ color/material change, of trim, siding, window,T ,cd'oor co 4. Sign : ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sig , m 5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaininor !.1 ❑ tennis courWN❑ Other 6. Pool ❑ swimming ❑ Other man-made pool Type or Print Legibly: Date: Address of proposed work: House# Street: Villaged).�Wk&30ffsessors Map Lot# � Description �of�Proposed Work: Give particulars of work to be done: a&64-4 Ao,-M L-C,.�f' CG��G�.�X v aq Agent or Contra or(print): 10 Telephone#: Address: Contractor/Agent'signature: NOTE All applications must be signed by the current owner Owner(print): Telephone#: Owners mailing ad ress. Owner's signature: For committee use on . T ertificate is her APPROVED/DENTED (� E fC E E Date Members signature O L' �j I ► t MAK 0 2009 OWN OF BARNSTABLE 1 S�a�\a� HISTORIC PRESERVATION An Mop f approv + 1 of Qy� ee I I 1 O:IGMD-Groups101d Kings HighwaylOW New ApplOKH Cerl Approprhwt ness 07.doc ti Noble B I u C42-6 J I Town of Barnstable Old King's Highway Regional historic Distrigt %1*11Ae�0 CERTIFICATE OF APPROPRIATENESS SPEC SHEE Scab�e �O�Cm�SN'eev�ay Please submit 4 copies � pld COVR �tt Foundation Type: (Max. 18"exposed)(material-brick/cement, other) Siding Type material: Color._,�/,j/./.(� Chimney Material: A J% I Color: Roof Material: (make&style) Color: Trim material %/�� Color: Roof Pitch: (7/12 minimum) Window: (make/model) material color Size(s): ;tT, Door style and make: material Color: 1 Garage Door, Style&14,,k/ SizeaU4_Material Colori", G�Gzaa".) Shutter Type/Material: : 1 Color: _ ?-Gutter Type/Material: � ��/l_ ! Color: i Decks: material /`���� Size Color: Skylight, type/make/model/: /V material 1 Color: Size: Sign size: Type/Materials: Color: �i Fence Type(max 6' ) Style , /T material: I Color: Retaining wall: Material: 4 Lighting, freestanding on building i illuminating sign Please provide samples of paint colors and manufacturers brochure of style of windows o y age,,,dpo , fences, lamp posts etc .� ADDITIONAL INFORMATION: Signed: (plan preparer) ti print name tel.-no. Location of application. . , Street.no. Street Village r Q:I GMD-Groups101d Kings High wnylOKH New AppIOKH Cert Appropriateness 07.doc i TOWN OF BARNSTABLE BUILDING PERMIT.APPLICATION.. 17 Map Parcel Applicatioh # �� Sp Health Division 2 o o 1 2 3'8 - ' Date Issued Conservation*Division ' ' Application Fee dl��b Planning Dept. - Permit Fee .c-70 Date Definitive Plan:Approved by Planning Board Historic - OKH Preservation/ Hyannis _ r ' Project Street.Address Village Owner Address: k) Telephone Permit Request dvmo XQQ(ox S� �� c� 01�b . u)kin Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation a�1bDo Ob Construction TypelB Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family)2( Two Family ❑ Multi-Family (# units) Age of Existing Structure >1_11)y1 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes j<No Basement Type: �4 Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (scft� Number of Baths: Full: existing new Half: existing Number of Bedrooms: existing _new . x Total Room Count (not including baths): existing ' new First Floor Roo Couffl) x>:' CD Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:Xexisting ❑ new size—Pool: ❑ existing ❑ new size _ Barn:Vexisting ❑ new size_ Attached garage: ❑ existing 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes *0 If yes, site plan review # Current Use �����l�C\Q1� Proposed Use NL APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ��y�bC • T �Sl�(.�\� �\�� Telephone Number Address License# u� gobgq $►�\ wN\ Home Improvement Contractor# Worker's Compensation # W L M 'C'6'Al LL CO TRU ON PEBRIS RESULTI G FROM THIS PROJECT WILL BETAKEN TO -11W. Ok Y\p"(Uw1G`�; SIGNATUR _ DATE z _ FOR OFFICIAL USE ONLY APPLICATION# - DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER I i DATE OF INSPECTION: FOUNDATION { FRAME BFiC cow c xr_ - INSULATION 7 b i o olp FIREPLACE ELECTRICAL: ROUGH FINAL - PLUMBING: . ROUGH FINAL GAS: ROUGH FINAL `FINAL BUILDING DATE CLOSED OUT i - ASSOCIATION*PLAN NO. 1 .T 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/P.lumbers A licant Information n�. Please Print Le 'bI Name(Business/Org-mization/Individual): 4k3U� NrU i D� IS Address: i r Av City/State/Zip: Phone.#: ��✓ � �`�'���� � 'b;)1�`�✓ � Are you an employer? Check the appropriate box: Type of project(required): L%I am a employer with t 4. Ej I am a general contractor and I ti 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 in any capacity. employees and have workers' 9 "Building addition [No workers' comi.•insurance comp.insurance.t required] 5. F1 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right 6f exemption per MGL 12.[]Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑Other comp.insurance required] *Any applicant that cl=lm box#1 must also fill out the section below showing their workers'conTrnsetion policy information. t Homeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must subrnit anew affidavit indicating such. =Contractors that check this box must attached ao additional sheet showing the name of the sub-contraetors and state wbether or not those cntitics have employes. If the sub-contractanr have employees,they must providb their work=,comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site • information. �\ \ �� Insurance Company Name: ±tp - r.L G 1( Il3 U t= Policy#or Self-ins.Lic.#: UU 1.���'v`� `� Expiration Date: Job Site Address: �"\/�'] �- 4 ��`��(`lX� / City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to socure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 5ne 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 statzmerit may be forwarded to the Office of Investiizations of the MA for insurance coverage verification. I do hereby certi n the pa' d penalties of perjury that the information provided above it true and correct Date: rl- Phone Official use only. Do not write in this area, tb be completed by city or town offcciat 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 rContact 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.ongaged 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, §1.25C(7)states`Neither the commonwealth nor any of its'pohtical'sUbdivisions shall enter into any contract for•the performance of public work until acceptable evidence of compliance with the insurance, requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es) and phone numbers) 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 notregi ired 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 Towpi 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 permittlicense 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 fo any business or commercial venture (i.e. a dog license or permit to btim 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 6.00 Wasl ngton Street Boston, MA 02111 Tel. # 617-727-490.0 ext 4.06 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia r ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE- AND TWO AMILY DETACHED w\RESIDENTIAL'CONSTRUC I N (780 CMR 61.00) Applicant Name: '1�.1J1� C��L 10� 1 �VLJ Site Address: WS print ` Town: Applicant Phone: Applicant Signature: Date of Application: g NEW CONSTRUCTION:' choose ONE of the following two options) 780 CMR.TABLE 6107.1 -PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE- AND TWO-FAMILY BUILDINGS MAXIMUM' MINIMUM Ceiling or Slab .Option 1: Fenestration exposed Wall Floor Basement perimeter U-factor floors R-Value R-Value Wall R-Value AFUE I�SPF SI�1R R-Value R-Value and Depth National Appliance Energy .35 R-3.S R-19 R-19 R-10 R-10, Conservation Act(NAECA)of 4 ft. 1987 as amended,minimums or greater as applicable Note: This form is not required if you choose either of the two versions of REScheck as.listed below. ❑ Option 2: �. REScheck Version 4.1.2 or later variant software analysis must-be completed (780 CMR 6107.3.2 REScheck—Web which can be accessed cit.http://www.energycodes.gov/rescheold ,'A:DDITIOlNS 012�.A:LTERATTON•S:TO"`EXTSTING..BUILDINGS:::OVER5.'YtA.RS OLD* *Buildings under 5 years old must.use option#4 or#2 in New Construction section above. Complete the following formula to determine the % of glazing: (a) ro s4Vall & Ceiling Area equals Formula: (100 x b- a) SF _ v(� 100 x � =��� i�— Q pr�0% ofglazln9 (b) Glazing area equals. `�� SF b a If lazing is'<.401/o use'.the chart below. .-. If.glazin is>-:40:% proceed to "SUNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS T MINIMUM Ceiling and �r,�all Flooi Basement Wall Slab Perimeter Exposed floors R-Value R-Valuel 'n Value R-value R-Value and Depth .39 R-37 a R-13 R-19 R-10 R-10, 4 feet a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling. area(i.e. not corn ressed over exterior walls, and includingan access o enin s).- ❑ SUNROOM—An addition or alteration to an existing building/dwelling unit where the total glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition, Note: Owner to B11 out Consumerl"nformation Form found in Appendix 120.P Date* 6/12/2008 Timee 10ti6 AN 701 V,1DU0 JAAWV9 - Client#-47015 AVIACON ACORD. CERTIFICATE OF LIABILITY INSURANCE 06121200E PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC 8 Motion INSLwatA.. Aspen Specialty Insurance Company Aviator Construction,LLC INSURER B: American International Co P.O.Box 3 INsuRERc: E.Harwich,MA 02645 INSURER D: INSURER E: COVERAGES THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING x ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W nH 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 POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TYPE OF INSURANCE POLIO/NIMIEER TE TUELT-EffAlliffn PDA EMDIM ILYNI S A GENER&LNBI I Y GL00110403 06101108 0610U09 EACH CURRENTEDCE $1,000 000 DAMAGE TOX COMMERCIAL GENERAL LIABILITY S5D 000 CLAMS LADE a OCCUR WO ExP ony am v0wn $,000 X BVPDDed:1,500 _ PERSONALaAwINJURY $1000000 GENERAL AGGREGATE s2 000000 GENT.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $, 000 000 POLICY gam- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ CEO eoeaeny ANYAUTO ALL OWNED AUTOS BODILY INJURY $ l�tom) SCHEDULED AUTOS HIREDAUTOS BODILY INJURY $ (Perecad.0 NDN•OWWO AUTOS PROPERTY DAMAGE $ " I) GARAGEtUBLnY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC S AUTO ONLY: AGG $ O(CESSAMIARELLALIA88RY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE s RETENTION s $ B w0wam compENsATONAn WC2359S13 06110108 06110W X IT Y W11 CSTATu• % EMPLOYERS'LIABIITY E.L.EACH ACCIDENT $500,000 ANY PROPRIETORIPARTNERIEWCUTNE OFFICERMEMIBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500 000 Itye9,d ;0.16totdd SPECIAL PR0IASIONS UeWv E.L DISEASE-POLICY LIMIT OTHER 0ESCRrT=OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVNSKM Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%PWAnoN Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MUAL In DAYS WRIT-TEN 200 Main Street NOTICE TOTNE SATE NOUN R NAM TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 MPM NO OBUGATH)N OR LI OLM OF ANY•KLND UPON TIE NCR nS AGENTS OR R�iSEMTATRES- AUTIgItfaED REPSIESEIrATKIE ACORD 25(2001108)1 of 2 #S361941M35079 KW m ACORD CORPORATION 1988 i oFr Town of Barnstable ° Regulatory Services � Thomas F.Geiler,Director p 6,316 - Building Division Tom Perry, Building Commissionee 200 Main Street, -Hyannis;MA 02601 www.town.barnstable.ma.us { Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using'A Builder I �D`�N 1YXO�l as Owner of ro the sub eect ` l . property herebyauthorize �lU` \\V 9 to act on my behalf in all matters.relative to-work authorized by this building permit application for: Va6 %ACCA Uj. "At N� (Address of Job) 1 , Yignae o wner ate Print Name If Property Owner is applying for permit please complete the Homeowners License . Exemption Form on the reverse side. Town of Barnstable y��pF Tp�yo,. Regulatory Services • Thomas F.Getleir,Director KAM • sAartsrwe� • . Building Division Tom Perry,Building Commissioner 200 Main Street', Hyannis,MA 02601 YrwwJown.bar.mdabl e.ma:us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LACAIION: 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 license,provided that the owner acts as supervisor. DEFINMON OF HOMEOVOWER Person(s)who owns a parcel of land on-which he/she resides of intends td reside,on which there is,or is intended to- be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 100.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. Tlie 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. 1 Signature of Homeowner Approval of Building Official Note: -Three-family dweHings 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 perfomong work for which a building permit is regirired shall be exempt from the provisions of this section(Section 1 o9.1.1-Licensing of construction Supervisor):provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor." . Many homeowners who Use this exemption sit unaware that they.are;assuming thcresporrsrb�lities;of a supervisor(see.Appendix.Q. Rules&Regulations for Cleansing construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner him unlicensed persons- In this rye,our Board cazmot proceed against-the uelice used poison as it would with a)icdlied Supervisor. The homeowner acting as Supervisor is ultimately respbnsrble. j To ensum that the homeowner is fully aware of his/her respormlAities,many communities require,as part of the permit application, that the homeowner certify that Wshe understands the respmmbifitics 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 fom✓certif cation for use in your cormnuniry. ./1e &OV1114anwea< o�9.11&46aalmme& Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:,.,146765 E P#0000 '5f12J2m Tr# 128858 `Typist. Ltd:Liability Corpor AVIATOR CONSTRUCTION -ANTHONY SCHIAUI'. ' 1550.ORLEAN RD. �p .(..•+C1�-.� E.HARWICH,MA 02645 Administrator 072- Bo lm ui iog egdl"a ioTis an an arils Construction Supervisor License License: CS 90074 F'i5r, Expiration 2/11/2010 Tr# 15422 rResfrijfison:-.db',> ANTHONY E SCFi��bl= 1550 QRLEANS ROAD;'"`` HARWICH,MA 02645° Commissioner I License or registration valid for individul use only before the expiration date. 1f found return to. Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,Ma.02109 Not, lad without signature i. T 'd 88SZ-ZEb-80S F;UO1 4Obt80 80 TT unC I /� LmAa) 1"-i x b1 -1, 03 LVvkvl� k1. SP.Col�G(Oby �-Qtbw [,I,AlWD Sko e RR�r` �"\z ec,—,,v �pf1HETp�y Barnstable Old Kings Highway Historic District Committee O i RU,,,S.ABLF- ; 200 Main Street, Hyannis, MA 02601;TEL: 508-862-4787 Fax 508-862-4784 y MASS, a �p 1639.q�0� rEa MA'S APPLICATION, CERTIFICATE OF APPROPRIATENESS . Application is hereby made, with four(4)complete sets, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470,Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings,or photographs accompanying this application for: Check all categories that apply; 1. Building construction: ❑ New ❑ Addition Alteration 9 2. Type of Building: House 1� Garage/barn ❑ Shed ❑ Commercial ❑ Other s 3. Exterior Painting roof ❑ new roof color/material change, of trim, siding, window, dory 4. Si n : ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign Co 5. Stricture: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaining wall ❑ tennis court '® Other rT1 6. Pool ❑ swimming ❑ Other man-made pool Type or Print Legibly: Date: ZL Address of proposed work: House#/9j 104PG45 577 Street: . Village ?W p -a/Go6 ,,Assessors Ma Lot# Description of Proposed Work: Give particulars of work to be done: G� Agent or Contractor(print): &2Y Telephone:#: Address:�00 S,02G J Z111�40ICfl 11n?9i7ii Contractor/Agent' signature: r- ,� NOTE All applications mus be signed by the current owner Owner(print): �Dy� Cj�}�'(/9'> C•/ Telephone#:j_b Owners mailing addre s: 40 Owner's signature: 7—� For committee use only. This Certificate is her APPROVFt(DENIED Date L��D Sr' Members i natures v 1 Owr' King's Highway TU v 41 ABLE ny co ditio appr val: �. 0 Hl-1`�;1C PRESERVATION Q:IGMD-GroupslOid Kings HighwaylOKH New AppIOKH Cert Appropriateness 07.doc 1 Noble Blue C42-6 IFY 0 7. 2008N OF BARNSTABLEAIC PRESERVATIONTonstable Old King's Highway Regional Historic District Committee CERTIFICATE OF APPROPRIATENESS SPEC SHEET Please submit 4 copies Foundation Type: (Max. 18"exposed) (material -brick/cement, other) Siding Type material: 5L� LCJ Color: Chimney Material: Color: Roof Material: (make & style) Color: Trim material Color: Roof Pitch: (7/12 minimum) Window: (make/model) material color Size(s): Door style and make: material Color: Garage Door, Style Size Material Color Shutter Type/Material: Color: Gutter Type/Material: Color: Decks: material Size Color: Skylight, type/make/model/: material Color:55_go00(JQ Size: ,( 5 d eb Sign size: Type/Materials: Color: Fence Type(max 6' ) Style material: Color: Retaining wall: Material: Lighting, freestanding on building illuminating sign Please provide samples of paint colors and manufacturers brochure of style of windows OY`ddoor, fences, lamp posts etc ADDITIONAL INFORMATION: ��Qa D e. of Ba �9hw Signed: (plan preparer) print name tel. no. Location of application: Street no. Street Village Q:IGMD-Groiips101d Kings HighwnylOKHNew AppIOKHCerl Approprinleness 07.doc 2 °F� r Town of Barnstable *Permit#4dV Fo 3��'•�, '4 Expires 6 monthsfrom issue date R-egulatory Services Fee BARNSTABLE, : Thomas F.Ge.iler,Director 9 MASS, 9, 16s9• ,� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us .Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION = RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address \ `A L`LA— 6tlA-kuw_ L I\e'A [ Residential Value of Work $1 ic�_Cb C��V Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �;`1 �kcl�l Contractor's Name L�`_C C'.ku,l o Ut Telephone Number Yorkman"s mprovement Contractor License#(if applicable) Compensation Insurance Check one: Va a sole proprietor the Homeowner ve Worker' Compensa 'on Insurance `/ Insurance CompanyName �� � i t caC3 (� �{j 11 FtF; �`ll�l 1 S PERPAIT Workman's Comp. Policy# LJL11_ L) � I I I N 13 2008 Copy of Insurance Compliance Certificate must be on file. TOWN OF BARNSTABLE Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ R -roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. i SIGNATUR Q:\WPFILESTORMS\building permit forms\EXPRESS.doc Revise020108 4 4`b 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 Apiplicant Information / Please Print Legibly Name(Easiness/OrgM1izationlIndividual): CQ( N U (L ,6-) 1 � l � Address: ,O , _.OIL L b IA,,, City/State/Zip: �K l3J Phone.#: �v�� Are u an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1. I am a employer with 6. ❑New constrmtion . employees(full and/or part-time).* have hired the stib-contactors 2.El I am a"sole proprietor or partner- listed on the attached sheet 7. ❑R�deling ship and have m employees These sub-c°ntractors have 8. ❑Demolition woding for me in employees and have workers' �Y��• insr�rance,t .I. ❑Br'ilrj�additiOII [No workers comp.-assurance imp' required.] 5. We an a corporation and its 10.❑Electrical repairs or additions 3.❑ I am.a homeowner doing all work officers have exercised their 1 LEI Phm3bing repairs or additions myself[No workers' comp. right 6f exemption per MGL 12.0 hoof repairs t e. 152, §1(4),and we have no insurance required] employees. [No workers' 13.❑Other comp•insurance requited.] •Any applicant that checks box#1 mast also fill out the section below showing they workers'eon pcmmAon policy infm mtimL t HoTwownes who submat this of davit indicating Icy are.doing aA work and then hire outside wntraetm-s unist submit anew afGdavit Mcating such. =Contractors that check this box nnut atiaehed as additim d sheet showing the name of the sub-cantraetam and state whether or not Srose entities have er,ployeeL If the subtoutnwtors have employees,they must prvvidt their wmk=l comp.policy mmnber. I am an employer that is prT g workers'compensation insurance for my employees Below is the policy and job site information. Insuiance Company Name: rr nn ii p� Policy#or Self-ins.Lic.#: W . �] cin Expiration Date: Job Site Address: l ��V , ,* 1,U, 6-M"\,Q,U 1 City/Stattaip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of erimirial penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statzmerit may be forwarded to the Office of Investi lions of the 1DIAjb&invzran=coverage verification. I do hereby c ndd pains-an en of perjury that the information provided above is true and correct Si e: �7 (�� -�2,, Date• _ Phony Of Wal use only. Do not write in this area,to be completed by city or town o.07claL 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 M 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]rouse having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,it necessary,supply sub-contractors)namc(s),address(es)and phone number(s)_along with their certificates)of inetrra m. Limited Liability Companies'(LLC) or Limited Liability Partnerships(LIP)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. B;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 Towti 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 sine to fill in the permit/license number which will be used as a reference number. In addition, an applicant that nu st submit multiple permit/license applications in any given year,need only submit on;affidavit indicating current policy information(if necessary)and under"Job Site Address"1he 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 fidure permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related io any business or commercial venture (ie. a dog license or permit to btim leaves ctc.)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 Depailm=fs address,telephone and fax number. i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Str-eet Boston,MA 02111 W. #617-727-4900 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia Date, 6/12/2008 Timer 10119 AM Tot ------ - ---- (I* Client/{:47015 AVIACON ACORD. CERTIFICATE OF LIABILITY INSURANCE �;2"'�"" P CB THIS CERTIFICATE M ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,NA 02660-1601 INSURERS AFFORDING COVERAGE NAIC RSSIIR» i4LAIpmA: Aspen Speclafty Insurance Company Aviator Construction,LLC INSURER e: American International Co P.O.Box 3 INSURERC: E.Harwich,MA 02945 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUFDTOTHE INSURED NAMED ABOVE FOR THE POUCY 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 HEREINIS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICYINSR TR TYPE OF INSURANCE POLICY NUMLIM OATS o t9 WUQ LIMITS A GENERAL L1ABalrY GLOOI10403 06101" 06101109 EACH OCCURRENCE _ $1000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENGED $m m CLAIMS MADE FX OCCUR MED Erie one p waon $1 OOO X 1311130Ded'1.300 PERSONAL aPDVINJURY $1000 00 GENERALAGGREGATE S2 000000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1 000 000 POLICY PRO- Lee AUTOMOBILE llAIll" COL»OSNGiE LIMIT $ ANY AUTO (Ea oodOe,d) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per P-00 HIREOAUTOS BODILY IWURY $ NON OWNED AUTOS (Pet-dden9 PRCWERT'DA AGE $ (PeraccU-9 GARAGE LIABILITY AUTO ONLY.EA ACCIDENT $ ANY AUTO OTKERIHM EAACC S AUTO ONLY: AGO $ EXCESSARABRELLALJABAITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE s RETENTION $ $ B WORKERS t ATIDN AND WC2359513 06110A8 06/10/09 X WCSTATu• OT1i- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT SSOO 0W ANY PROPRIETORWARTNERIENECUTIVE OFFICER IMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $500 0W If yyes,desatbe under SPECIAL PR'01/ISIC#6 belay I I E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATMIS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT J SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATETNEREOF,THE ISSUING UMIRER WILL ENDEAVOR TOMAL 40 DAYSWRTTTEN 200 Main Street NOTRETOTHE CER'TMATE HOU)ER NAO®TO THE LEFT,BUr FALURE TO DO sO SHALL Hyannis,MA 02601 U1FM NO O NX-ATIDM OR LMOUrY OF ANY MM UPON THE UEURL3;RS AG WM OR REPRES®RAMMM AUTHORIM REPILE.SENTATLYE ACORD 25(2001108)1 of 2 ttS361941M35019 KW 0 ACORD CORPORATION 1988 41 ,,� `�,<ee ioamrmza�zurea�t o�/�aaaccclurbella '�'<, _ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:.1.46765 pica fon: 5/12/2009 Tr# 128858 Type: tstcf Uability Corpor AVIATOR CONSTRIJOTtONUC. ANTHONY SCHIAVI 1550 ORLEAN RD. E.HARWICH,MA 02645 AdWhistrator Isoaoui mg egu a[io7s a1n ar s Construction Supervisor License License: CS 90074 Expiration: 1/2010 Tr# 15422 estric a ANTHONY E SCHiAW' 1550 ORLEANS HARWICR,MA 02645• - Commissioner sg; • License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rum 1301 Boston,Ma.02108 Not `'lid without signature I •F pc1KE rqy, Town of Barnstable Regulatory Services • HARNSTABLH. MASS. �, Thomas F. Geiler, Director $A .sp i6 �� . jFn 39 Building Division - Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the'subject property hereby authorize_ �l�'CU�L)�Nky)lV A to act on my behalf, in all matters relative to work authorized by this building permit application for: Vucq Uj . "A& (Address of Job) r Nd ignature c caner ate ti k I Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. •ram , 'Town of Barnstable �pF SHE Tp�� Regulatory Services • Thomas F. Geiler,Director BARNSTABLE. MASS. Building Division jE01�� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508=790-6230 HO)\IEEOWNER 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 license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on'which he/she resides or intends to reside, on which there is, or is intended to- be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with'said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner perfomung work for which a building permit is required shall be exempt from the provisions of this section(Section I o9.I.I-Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to dosuch work,that such Homeowner shall act as supervisor." i 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 fu1ly 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. ngineering Dept.(3rd floor) Map _ /.3 0; Parcel ;D 6 Permit# 2—5 c)b g House# /�,$� 6 Date Issueed� Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30)9/ VZ2 Guth, Conservation Office(4th floor)(8:30-9:30/1:00-2:00) {� P� Pl F �IKE 19 SEPT . N MUST BE ` INSTAL NIPLIANCE TOWN OF:BARNSTABLE LE 5 ENVIRONMENTAL CODE AND Building Permit Application TOWN 111EGU L AT!""NS Project Street Address Village W V-S'C �AAA Owner VJ I L-Lt. ^ i1ll1F_AP0A?, � DCXd m A, AOUR,V'Address t cIS- Telephone Permit Request -k . 144 ac First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning.District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family 3 Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House p Yes YNo On Old King's Highway ❑Yes RNo Basement Type: ❑Full Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) /U41 Number of Baths: Full: Existing 001k_ New 0M IF- Half. Existing New No. of Bedrooms: Existing"'rW0 New 0"li- Total Room Count(not including baths): Existing i_-1 V l_ New 0MI& First Floor Room Count -Fo%YE Heat Type and Fuel: ❑Gas [}(Oil ❑Electric ❑Other Central Air ❑Yes dNo Fireplaces: Existing 0 F-(E New Existing wood/coal stove ❑Yes &F`No Garage: ❑Detached(size) 24 X 30 fA- t N Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) 8 k g ❑Other size Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes dNo If yes, site plan review# - Current Use et&IC*kjf- F.�,A(01 J::&St pCMTS Proposed Use d Builder Information Name V W C,"F-5. 6j)I P__0 tiJ Telephone Number Address 4S DCA J L.I 2-�+ License# Z (o rc-A VNn n c) +i-% 1z)n 6L4 g: Home Improvement Contractor# Worker's Compensation# Q�/ 7_(7 aj 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 SIGNATURE DATE BUILDING PERMIT DENIED FOR THE OWING REASON(S) c 1 �. FOR OFFICIAL USE ONLY PERMIT NO. a a o. DATE ISSUED MAP/PARCEL NO. c - ADDRESS VILLAGE OWNER k; DATE OF INSPECTION: r U FOUNDATION �J FRAME ��✓I J000 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL o PLUMBING: ROUGH FINAL GAS: ROUC; I FINAL FINAL BUILDING9�- 3 a ` DATE CLOSED OUT 64c ASSOCIATION PLAN NO::� Y� t . �„ �M• ,� Town of Barnstable - Planning Department Q : a : Old King's Highway Historic District Committee En MKS MEMORANDUM TO: Building Commissioner FROM: Gwendolyn Brown, OKH Secretary DATE : SUBJ: Modification to Prior Approved Plan A minor modification has been approved by the OKH Committee to a prior approved plan for the applicant (s) named below. The modification is briefly summarized and I have attached backup material for your records . Applicant (s) lDn,la ('1vI4 �ti i t Iran. �Qotp/or✓ Address of proposed Work Meeting Date Approved, by OKH Minor Modification { x y Chairman If you should have any questions, please do not hesitate to contact me at ext . 285 . MEMOBC Application to V +ENNI�E jj E Old King• mte�s Highway Regional Historic District Com in the Town of Barnstable for a CERTIFICATION OF EXEMPTION Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 of Chapter 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings,or photo- graphs accompanying this application. TYPE OR PRINT LEGIBLY DATE ADDRESS OF PROPOSED WORK I i2 S ASSESSORS MAP NO. �3a OWNER 'VQIIflQ tIm Me'6 r ASSESSORS LOT NO. Q QfL HOME ADDRESS r�aS IWIt 1 IL TEL. N0�.3•Dg '�«' AGENT OR CONTRACTOR I nl GEN T 5. G U ao til p-- ADDRESS 05' DAA/15 ROA-D , FA LM0U AA TEL. NO..509-540 — 96F0 This application is for exemption of proposed exterior construction on the ground that: ❑ (1) It will not be visible from any way or public place. r2' (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission. r (Check applicable box) PROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot,and, if an addition Is involved,show• ing location of existing building. j O R10'D A WDOVEt-1 ViSr-V Ni\I I"i R 30 act1_1067 i 0 T� Mt__*'W L1I BUILT 13e SL16RfLV M6AA M"LIF 1�E&V_ M 6 ASO RE1 M X ZZ ' VEUC ::�1Foand - ZZ�I SIGNED - Space below line for Committee use. wner-Contracto►"A t Rece by H.DiCt111 The Certificate is hereby Date �e JAN 3 01998 i wwd /n&fa4tj T By 70V1fN OF BAR�'S"if.BLE Date Approved ❑ The categories of work entitled to exemption are listed on Disapproved ❑ the back of this form. I q_� _ Milk 51"1Z�"'�r, ''� • �Prt�tJSfir'Y.�L� D�GiL e 510iJS �I � tJ X Z,Z -T'to J�A6k U(r-W of AVP(r(Onl > ar- 1 > � vlfi1'lZ�`2•c� 1/�%' -1� 1 lll���� Town of Barnstable ' W ' Old King's Highway Historic District Committee SPEC SHEET FOUNDATION POORER C000,RETE GP-AWL 5PACE /4' e-IzOsT WALL FRONt:VINYL CLAPftA-17-D COL6p : WH IT6 MATGif EXIST104) SIDING TYPE 51DE 4 15AGL.= .5H IOGLE`i COLOR ' N ATU2f4ti 6MATOM6 &XI'5flr 0 CHIMNEY TYPE tJ Pc COLOR IJ A ROOF MATERIAL A 5 P 1A A LT COLOR `3 LA L 1L K PITCH IIJ Zp AAKCkp� P I T64 0 MCI M Fbulic WINDOW woos VOUbLg WU_M f oy �� SIZE PLU`7 P-Af4e;O(MS _LsE AVW-HED) TRIM COLOR WM ITE DOORS 1%9 (A D DO 2 5 (5EE COLOR W N IT6 SHUTTERS Y I:5 COLOR H UNTE R G REE W GUTTERS WH4TT— ALUMINVAA DECK A GARAGE DOORS /J A COLOR N A SIGNS N A COLORS N A FENCE N A COLOR �J R NOTES: Fill out completely, including measurements and materials/colors to be used. Three copies of this form are required for submittal of an application, along with three copies each of the plot plan, landscape plan and elevation plans, when applicable. Plot plan need not be "Certified" except for new homes, but should show all structures on the lot to scale. SPECSHT m -rytPl x 1 Z p - Fl - A lGZ Cl CUE _ I ;1I........ Fo v o/cA �- .......__._..._ - ?04 f-T> A-t-- -1 7:Z z X 1 13F= l7 R©o-,kA -42F—A I ' I .__-�----- ►._ . -,.l I. . .I l--I:L__. ._�I_... . 1 I_._. L(------i( s��I... ...•.I:_.._-J_L...__....-I:L��L_ �.:.�:: _ ►,�L�. -.:11_-:_.1,�`". ` ~ o.�. _ i POST u /U pF Z VJ 4- -L o��! i i po i o u i Ole-� 1 . -._._. _. i �ON�1 � . V�ICs� f�R�NsT� ;vt PT, 'P,T, /c�/ '(3�,,oc, K. o v FEZ S Tz ► ?t''�D TDow/-( TO -2- GAp 5/4 G v Mtn �- xLl DIU&1 k4Gs z o C . 0u w orr 1 ki cA s AAA PLC I-r���=:�" V� SST' �A t��•lSt�'1?��..C, �'��' i o-Foss p /Gil Q.G. pT--- C—Y11— GIRT 3 � Zx $ 1®' OFf ADD• I - - _... .. . ._ 1 p - �oo-riR.lca y ' y ' sTs4�1Z uu�,r I 3E�-nw � P� 00 �otil c-Lrr-1 Pk� - t , ylrP•' ��^M Sit P�G�S i y V�`�w M►�pL`N►1� ' Old King's Highway Regional Historic District Committee / a ...�• 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 f Addition Q Alteration Indicate type of building: Q'House ❑ Garage ❑ Commercial ❑ Other 2, Exterior Painting: 9 3. Signs or Billboards: ❑ New sign ❑ Existing sign • ❑ Repainting existing sign 4. Structure: ❑J Fence ❑ Wall' ❑ Flagpole ❑ Other (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE MALq 2-3, M-7 ADDRESS OF PROPOSED WORK 195 MAPLE ST., W. BAIZMs5T'A5LE ASSESSORS MAP NO. 1 32 OWNER WILLIAM MEADOR F (7ON(JA MURPHY ASSESSORSLOTNO. 06 HOME ADDRESS 12 5 AAAPL.E 5r, IA . 86P d5ra) E TEL No. wog- 3OZ- 30 13 FULL NAMES AND ADDRESSES OF ABUTTING OWNERS.' Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). 5�� ATtACtf�D AGENT OR CONTRACTOR -5 AH BRACV— TEL NO. 5a$- 563- 5398 ADDRESS 70 CL-by6KAEL.D WAY EALMOVO4. MA OZ556 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). A ONe 5ToRy ) MA, TMR BEflRoOM A0PiTl6,,1 ('04CEUDES NEW eRr4-90661) T14AT MEMURZ5 14 ' $ Zb: TO t U6% 0415 New mkl, A F'14HT- x FavP. 6MIQ510N WiP, M ADM2 OFF'THE KITCNEI� . RS PAKT 6P Ti+rS PRIOUr, THE ENTIRE 116ZE WIU, ft KE-1;66FEp AND 6eF- ATTAOED 5PEG SHLEI In ,� �,Space below line for Committee use. U caner Contraaor nt PReceived by,H.,D._C ertifica s hereby Date Je Aw Q i By 9_ m TOWN OFp LJ IMPORTANT: If Certificate is approved a� pproval is subject to the 10 day appeal period provided in the Act. Disapproved Cj r Town of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION POURED CONCRETE GP-AWL SPACE /L4' F'IZOST VVALL- FR6N'`:V1 OIL CLAP 1Z76A1ZP COLo2 �H ITS (MATGIf ELi I;X ISTrnI(�� SIDING TYPE 51DE 4 giACV = SN �N�!_lr�i COLOR N ATVWA _ CMATOM5 &X1�✓71�1C�� CHIMNEY TYPE W A COLOR rIA ROOF MATERIAL A 5 P 1A A LT COLOR 'P LA(,V- K PITCH IIJ Zi, MWRyC P1 r&14 oV MarltJ (-hpo,�E WINDOW W00f) VDUBLE N QM_ �OVR t, SIZE �► PLUS T(�arl`��5 t!S�E �� TRIM COLOR WN ITE DOORS FRENCH DPQZL 5 bF-E COLOR W1411T6 SHUTTERS COLOR H UNTE R C,IEEE W GUTTERS. WNAIT- ALUMINUM DECK A GARAGE DOORS tJ A COLOR N A tt 0 SIGNS N A COLORS A N U FENCE NA COLOR (,J A NOTES: Fill out completely, including measurements and materials/colors to be used. Three copies of this form are required for submittal of an application, along with three copies each of the plot plan, landscape plan and elevation plans, when applicable. Plot plan need not be "Certified" except for new homes, but should show all structures on the lot to scale. SPECSHT `�fXElpy_o� The Town of Barnstable 1; BARNSTABU. ' Department of Health Safety and Environmental Services MASS. 8 039• �0 Building Division 367 Main Street,Hyannis, MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice e of Ins � Type Inspection P Location h (� ^ "L Permit Number Owner 4n- Builder V <- J YOU V� One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: . V Le-c -S--eLi t v_� " 0 e-cacbk- �'1 a-[— -1 y9r, --p (2 ��," -� v�,--2.�„y S SQL t � ►� �► � �c t-f- v L 0"e- Please call: 5081-790-6227 for're-inspection. Inspected by • 2' Date Z l - t V lbw - Z � ZX12 I t7C�, v S-tQ ZI !]Cq z POST . 1 3 . it x p I� „ M tL r2D- �..dM ! 4RA.DE2 10 -f->AFT�� s -z. >C `, . s T U ns u L(f»7�- V E,t lT G O,c_I r. T y p, / Z 2 x S 14 F.4 o F_`r- IA- to i-( s. /Z ��•�F T �001� 5vL-ATio/i,/ -F c.00 fz o CO I' 1. I �► F�.r T�� ! . __ O%d•..v\ I/L( - ?O V 12E l7 Golc.l G�- "�F �Fov �.I D4TLo�( - Tv stoo dye�l s'r l ll!G-j�t I , I I j � I � Cam- G��V !b'f p, G, N C W WIU.tan AAEA�10� r. � MUP-PaY .4 T� D c T � o ti.l r �-f � x 2 6 M A PLf STZ£�f �. j5AWSTABLF , MPr. 77 , T ---_._.......... ..._.._ . . :RD o f ............. .. . . . 5c;A1__a ' LFT oc, I�I LLI AM MEAPL G ©A D�D i -�- tit y X 2(. t 5 /,��p�.� �.r DD lTt a�.l ca,4t3 t--� �c ►.p U t�� Sln V l-IFvJ oV:- If tin Al- 1 FLOC)R— A. .00 .� PST N V--c>v.An - 'FLA-T GEIL-i ti lG-t - GATH F-DZ.AL - i � ' -DZ-SSS i,c.J C-4 A CID I �1 .I E VJ �Q_.p.M T-�O•M T Z' — Z XtZ P-t,h G F k4Xt4 — — POS' M lc.Z© cl- - - 3AT+4 8�l7 R©off �TL ,d T3A T�k r-:oOT rc f 141 I Fo v P+T i o��l I (z.Tile Cunt»ru1t1"Cllll/I of:llas.VaC1jusctls %':►! ---�t:_'�- Department of lullustrial.4ccidcnts Y office of/nvest/921/ons \�';"•:_r;=' 6(10 If'ashingtutr Street Afaxv. (12in Workers' Compensation Insurance Affidavit r1liPlic:int inforrnatinn: Plcnse PRf1VT'legily -�� -----r name Incation: cif%• nhnne 0 1 am a homeowner performing all work myself. [1 1 am a sole proprietor and have no one working in any capacity ' ._ _.P- ........- �'.1�..�.�_f'��l•tT�e-1,1rI/_7�`I.Ar��P�.IY�Yrr..Y...�.��w�.�....�+.�..�.�w�.�ww.s H�.�.".�_....---.... [I I am an employer providing workers' compensation for my employees working on this job. cmmmarn• name: address: it city: phone tt- insnr�ncc cn. Snlict it [] I am a sole proprietor. general contractor. or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: comnam name• ndtlrrcc: city! ,phone i�• incurnncr rn. nniic%-0 - .l- Vw.. -... _ �..t.... � _- _- -�r��,.:�.-'fit�T"T!��wy �Tr•::-_ ...�.� ..�...._... •- __..._._ cmmnanv nnmc• adclresc: rity- nhnne tt• incurnncr co nolicy!/ Attach additional sheet if necessary _- -J�" _ -~_ -� •� _ •' - F:tilurc to secure covcr:tec:ts required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties ol'a line up to 51500.00 andiur unc%cars' imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a dad•against me. 1 understand that n cope of this statement mac be torwardcd it,the Office of investigations of the D1A for coveragc verification. !tlo hereht•certify tutder the parrs and penalties ojperjun•that the information provided above is true and correct. Signature Datc Print name Phone>~ Wcial sc unl_%- do not write in this area to be cumpleted by city or town official w �� ciq•or town: permittlicense i# t T13uilding Department Licensing Huard rl check if immediate response is required [3seleetmen's OfGcc ►_ C]Ilcalth Department phone ft; I"1Utltcr contact person: .5: Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for tl employees. As quoted from the "la++' all c�jrrpl({ree is defined as every person in the service of another under an+• contract of hire,express or implied. oral or written. An c•mplorer is defii►cd as an indiN-Adual. partnership. association. corporation or other legal entity, or any two or me the forc�goin�g emga�ged in a joint enterprise. and including-the legal representatives of a deceased a nployer. or the rccciver or trustee of an individual . partnership. association or other legal entity, employing employees. However 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 !: or oil tite ;,grounds or building appurtenant thereto shall not because of such employment be deemed to be an empio., 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 common-wealth for an• applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionaliv. 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 been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc supplying company natnes. address and phone numbers 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 sliould 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 anv questions regarding the "law- or if you are require 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 the affidavit for you to fill out in tite event the Office of Investigations has to contact you regarding the applicant. P1 be sure to fill in the permit/license number which will be used as a reference number. The at may be returnee the Department by mail or FAX unless other arrangements have been made. The Office of Investi=atioils would like to thank you in advance for you cooperation and should you have any questic please do not hesitate to _give us a call. Z77- The Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents :.:::. Office of Investigations 600 NVashington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone i.i: (617) 727-4900 ext. 406, 409 or 375 WORKERS COMPEN A. 1- N AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCC1 Co.No Policy No. 10901 WC2-0120338 1. INSURED: VINCENT S.CUTRONA y Renewal of Policy No. on- NEW The Insured/Mailing address: P.O.BOX 3306 INSURANCE COMPANY ®Individual ❑Partnership WAQUOIT,MA 02536 ❑Corporation or Other workplaces not shown above: Insured's I.D.No(s). (if applicable) See WC 00 00 01 F.E.I.N.# 042956253 Risk ID# 2. POLICY PERIOD: The policy period is from 03/26/1997 to 03/26/1998 12:01 A.M.Standard Time, at the Insured's mailing address. 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 100000 each accident Bodily Injury by Disease$ 500000 policy limit Bodily Injury by Disease$ 100000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: D. This policy includes these endorsements and schedules: W0000000A,WCOOOool,WC000414,W000031IA,WC200301,WC200302, WHOM,WC200306,WC200601, 4. PREMIUM: The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and chage by audit. i Premum Basis Rate Per Code Estimated Annual Classifications NO Total Estimated $100 of Premium Annual Remuneration Remuneration See WC 00 00 01 If indicated below,interim adjustments of premium Premium for Increased Limits Part Two,if applicable $ shall be made-- Total Premium Subject to the Experience Modification $ Premium Modified to Reflect experience Mod.of $ ❑ Semiannually; ❑Quarterly; ❑ Monthly $ Total Estimated Standard Premium $ MA - DIA Assessment $17 Premium Discount,if applicable $ Expense Constant Charge $ Total Estimated Annual Premium $ Minimum Premium$ 500.001 Deposit Premium$ 51-31 Total -F ted Annual Premium $ 500.00 Name of Producer: ALMEIDA&CARLSON Servicing Office: MASBU Program Countersigned B 04/03/97 2517 HWY 35,MANASQUAN,N.J. 08736 Authoriz�Iepm�nwive Date THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AbD PLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY. 810001(Ed.7-93)(1) COPYRIGHT 1987, NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A J a r 1 t I '� ►+A' I, + .�1.� 1,/t1y/IVd7tt'f�%2A� `� { 4EPAR10T Oi'MIC SAFETY ,! r ;+ C4VT�RUGIIC�N SV�ERVISOR�I�RS�';'���ly► ""' «"� �i�'Izpirts, f ;�,8ift � e • .► nn�y t}) 1 114115l1945 ,'' Po `. 1, 1 '; �, V t} !• f N�,. � , E� ROME IMPROVEMENT.,COITUCTOR .• r'� .. ReQiatratf on•�113573�;` Type 1'IMOIVIOUA >� + �� r .:Expireticn' 06/29199;� '', , 1CU€ROttA°'-4 ADMIPASTRATOq �k „ f I iI x • 1 � 4 i J ' °F ZFtE T The Town of Barnstable • asaNsrreatie. • Department of Health Safety and Environmental Services 'OrEo " Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only 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: d /U n Est.Cos o "Vo Address of Work: /'qf— '/ ' C e GJ Owner's Name ail)/ 4 Date of Permit Application: 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 Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a`permit as th gent of the owner- 2 113S -13 D to Contractor a Registration No. OR Date Owner's Name ■■■■■■■■■■■■■■■■■■■■■ .�... 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