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Home My WebLink About0230 MAPLE STREET e v'1' 1 UPC 12534 No.2�153LOR HASTINGS.MN �:. Y �-j� ,I\ V ��I �I _ f��;� 1'� �.,I1i 1 �Y ° qz I C)oto .4 �oFrFtr'0'�ti Town of Barnstable *Permit# Erpires 6 m rth jr ssue Regulatory ,services Twee N tb 9d � PAIS Thomas F. Geiler, Director ,I UN 2, 2.• Building Division f (�U1�� O� Tom Perry, CBO, Building CommissionerSARN 5LE 200 Main Street, Hyannis, MA 02601 ' www.town.barnstable,ma.us "Office: 5 08-862-403 8 EXPRESS PERMIT APPLICATION Fax: 508-790-6230 - RESIDENTIAL ONLY Not Valirl tviiliarrr Red X-Press Intprini Map/parcel Nurnber.1 2 /Residential tyAddress 3 0 , G S Veal AG114 p CA. ?Value of Work 7 V Minimum fee of$35.00 for work under$6000.00 Owner's Nam e c@ Address Contractor's Narne !�/Y►e O/� Telep hone Number - Home Impro.vement Contractor License#(if applicable) Co ruction Supervisor's License#(if applicable) 9 9 — workman's Compensation Insurance Check one: ❑ I;the a sole proprietor Homeowner I have Worker's Compensation Insurance Insurance Company Name l�etc � (/ y� Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. 'ermit Request(check box) ❑ Re-roof(h urricane nailed) (stripping old shingles) All construction debris will be taken to ❑Re-roo 'hurricane nailed) (not stripping. Going over existing layers of roof) ❑ -side #of doors Replacement Windows/doors/sliders. U-Value G> Q (maximum .35)#of window *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 & Construction Supervisors License is required, NATURE: _ '-- PFILESIFORMSIbuilding permit forrnslEXPRESS.doc The Commonwealth of Massachusetts ` Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/1 ividual): 670 SSoc Address: 32 City/5 to/Zip: (i(, Phone#: Zfi//— ,��^ CA26 A;/,(am on an employer?Check the appropriate box: Type of project(required): 1. a employer with 9`0 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑N construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check.this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: ACON U44/ Policy#or Self-ins.Lic.#: 0 s Expiration Date: "/CzJob Site Address: City/State/Zip: •r, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiratin date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official i City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Ww V law ovo Type ETT y�ly�IESe P !Y.21...L! 2�!�'f f _ / r MOONA DATE 10/05 1 Ro CERTIFICATE OF LIABILITY INSURANCE OP w SR. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NA1C INSURED Moon Associates Inc. INSURER A: Rational Gunge luvrance Co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURER9: Beacon Mutual DBA Gutter He Roofing INsuRERc DBA Moon Works 1137 Park East Drive INSURER Woonsocket RI 02895 II.'SURER E: COVERAGES THE POLICIE$OF INSURMCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWnHS`ANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO YVHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERV>S,EXCLUSIONS MID CONDITIONS OF SUCH. POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POUC LTR NSR TYPE OF INSURANCE POLICY NUMBER. DATE(MMIDD/YYYY) DATE(MM(DDIYYYY) I.941TS . GENERAL LIABILITY EACH OCCURRENCE $ 10 0 0 0 0 0 A X COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREMISES Eaoccurence) $500000 CLAIMS MADE X]OCCUR MW EXP(Any one person) 6. 10000 PERSONAL.&ADV INJURY $ 10 0 0 0 0 0 F1 GENERAL AGGREGATE $2 0 0 0 0 0 0 GET,f-AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2 0 O O 0 O 0 POLICY PRO- LOC � AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY ALTO BIS26619 09/16/10 09/16/11 (Es accident) $ 1000000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ F I ANY AUTO OTHER THAN EA ACC $ AUTO Ott Y: AGG S EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X I OCCUR CLAIMSMADE CUS26619 09/16/10 09/16/11 AGGREGATE $ $ DEDUCTIBLE $ . X RETENTION $10 0 0 0 $ 0 WORKERS COMPENSATION X I TORY LIMITS ER _ AND EMPLOYERS'LIABILITY YIN B ANYPROP RIRIETOR � CUTIVE 28586 10/01/10 10/01/11 E.L.EACH ACCIDENT $500000 (Mandatory In NH) E.L.DISEPSE-EA EMPLOYEE $500000 If yes,describe urger E.L.DISEASE-POLICY LIMIT $50 0 0 0 0 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO MOONASS DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRRTEt NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR' REPRESENTATIVES. AUTOO REPRESENTATIVE t ACORD 25(2009101). O 1988-2009 ACORD CORPORATION- AR rights reserved. The ACORD name and logo are registered marks of ACORD 1137 Park East Drift 'j '✓` J R.I.Reg. )7h9r30a391Moon A%—'rs Inc • Woonsocket,Rhode island 02895 Conn.HIC-0562775(Moon Assoc'utes im l lens)Name: e�.l O Mass.HI a 119535(Moon A••.-•:es Inc.l Pur�dsaser(s)Name: /BSI` � Pox�ass ��+[ d ��tt Installation Address: M sr )escr 15&+4'ST4go.Le. m.Tr 6ZY MaltingAddress:s,P6• 6DI &; Ho rne Phone:Ps�L Cell Photo:: E-mall: SPV K CIAS S 2 S 6 Q Ci.C*Ca•T4 VT Year Home Suitt:1 ? . 6 Customer Inrdak- L--- Taxes Paid in Town of 7 �i(/ O►C B/�QitJ��d G I/We,the above purchasers)("Purchaser(s)")and the r'e"oowlllner(s)of Me property located at the above installation address,hereby jointly and severally agree to contract with Moon Associates,Inc.("Moonworks")to furnish,deliver,and install of all materials as described in this agreement("Agreement"),the attached Spec Sheet(s)and diagram(s)which are incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all loos at the end of the installation. Order ' Order Number: Order Number: j Project Type: n f✓`J S / Project Type: Project Type: I !Agreement Amount $ 0 Agreement Amount $ Agreement Amount $ 1 Less Depositt Less Deposit$ $ Less Deposit$ $ 4 Balance Due On Completion Sj S V Balance Due On Completion $ Balance Due On Completion S I I ,r..M-mum 33%or Agreement Amount dur upon executon. Minimum 33%of Agreement Amount me upon execution. 40nimum 33%ol Agreemem Amount due upon execution. i Indicate Payment Method For eatar" Indicate Payment 1YMtttod far Batme indicate Payrnem Method for aauma ` Due at Time of Installation; Due at Time of Installation: Due at Time of Insmllatlon: OW6e Est.Start Date: Est Co letton Date: Est.Start Date: Est.Completion pate: Est.Start Date: Est.Completion Date: 6-3 wlc 6—� �c � DEPOSIT/PAYMENT OPTIONS(Subject tofund verification and/orcredit approval) I.Check,Cashier's Check or Money Order Ck R 3.Financing (Made payable to Moonworks) Acct n Approval Code 2.Credit Card*(circle) ^,Visa MasterCard Di cover Act b Approval Code cop 1�f) Q I��151 7 S�S ? Wwe agree to allow Moonworks to charge the referenced credH card for the deposit amount \.J ACct / Exp Dat urlty Code�J oWkued.aktance to be ct—sed to credit card upon completion cd isnumation A meta steam. it is agreed by and between Me parties that this Agreement constitutes the entire understanding between the partles,and there are no I understandings changing or modifyhhg any of the terms of this Agreement Purchasers)hereby acknowledges that Purchaser(s)1)has read the front reverse of this Agreement and has received a completed,signed,and dated copy of this Agreement.Including the two acmmpartyIng Not%el Cancellation forms,on the date first written above and 2)was orally Informed of his/her rISM to cancel this transaction.DO NOT SIGN THIS CONTRACT If THERE ARE ANY BLANK SPACES. Purchaser Purchaser Moonworks /51knature Signature r' Signature ,ca toojc rs C,nc1ARo k:2o&AASS i t Name Print Name Print Name YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELOW FOR AN EXPLANATION OF THIS RIGHT. NOTI E%CANCELLATION NgXUQF CA CEON Date of Transaction 4me Date of Transaction You may cancel this transaction,without any penalty or obligation, You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel,any within three business days from the above date. if you cancel, any property traded In,any payments made by you under the Contract or property traded In,any payments made by you under the Contract or Sale,and any negotiable instrument executed by you will be returned Sale,and any negotiable Instrument executed by you will be returned within 10 days following receipt by the Seller of your cancellation within 10 days following receipt by the Seller of your cancellation notice,and any security interest arising out of the transaction will be notice,and any security Interest arising out of the transaction will be canceled.If you cancel,you must make available to the Seller at your canceled.N you cancel,you must make available to the Seller at your residence,in substantially as good condition as when received,any residence, In substantially as good condition as when received, any goods delivered to you under this Contract or Sale;or you may,If you goods delivered to you under this Contract or Sale;or you may,it you wish,comply with the instructions of the Seller regarding the return wish,comply with the instructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk.If you do make shipment of the goods at the Sellers expense and risk.N you do make the goods available to the Seller and the Seller does not pick them up the goods available to the Seller and the Seller does not pick them up within 20 days of the date of your Notice of Cancellation,You may within 20 days of the date of your Notice of Canceliatom you may retain or dispose of the goods without any further obligation.If you retain or dispose of the goods without any further obligation. if you fail to make the goods available to the Seller,or if you agree to return fall to make the goods available to the Seller,or If you agree to return the goods to the Seller and fail to do so,then you remain liable for the goods to the Seller and fall to do so,then you remain liable for performance of all obligations under the Contract. To cancel this performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and dated copy of this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice ce sqnd a telegram to cancellation notice or any other written noti ,or send a telegram to MOONWORKS, 1137 Park East Drive, Rhode {stand Moonworks, 1137 Park East Dfire, a Rhode Island 02895,NOT LATER THAN MIDNIGHT OF (Date). 02895,NOT LATER THAN MIDNIGHT OF (Date). I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date Consumer's Signature Date REP'•:WER r APr 'WE T Town of Barnstable ert P • �. ,y Expires 6 mo sfronr issue dot' Regulatory Services Fee y BARNSTABLE, i v� 6 9 -Thomas F. Geiler,Director �rFD MPt A G Building Division Tom Perry,CBO, Building Commissioner 200 Main Street Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number C) Pro erty Address l/t/ � r�sT,A L Q 2-0C O Pro Value of Work (� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address (4r � PQAS4 Ir?6 Contractor's Name Am e� , �/`od/1� Telephone Number ��/—l_` yo Home Improvement Contractor License#(if applicable) Zo ructi on Supervisor's License#(if applicable))rkman's Compensation Insurance Check one: ❑ I a sole proprietor ❑ mt e;Homeowner -PRESSPERMIT I have Worker's Compensation Insurance Insurance Com an Name �e4 (��}' 1 J U N 2 3 2010 p y G�J Workman's Comp.Policy# g TOWN OF BARNSTABLE Copy of Insurance Compliahce Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re side #of doors Replacement—Windows/do s/sl•ders.U-Value �� maximum.44)#of windows_31 A • M *Where required: Issuance of this permit 1oes not exempt comp lance w!i 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&Construction Supervisors License is required. SIGNATURE: �Zz-- 7_1 r3 The Commonwealth of Massachusetts Department of Industrial Accidents 'Office of Investigations �s 600 Washington Street Boston, MA 02111 4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly / S Name (Business/Organization/Individual): l� 50 e,1q, �G Address: 11 57 PGxl(- go-5 I? r/V e— City/State/Zip: ®a 9f5lPhone#: 1(0( ' (o 7/— 6 7 Are you an employer? Check the appropriate box: Type of project(required): 1.91 I am a employer with 0 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ N construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.. 7. Remodeling p P ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition comp. insurance.1 [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ct Cat) (> c—��1u5 co , Policy#or Self-ins.Lic.#: U lO Expiration Date: Job Site Address: �qLe City/State/Zip: /U 4 Aw. 0-?a$ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature• �`/�- -- ��z--` Date: �_3 Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling.house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permt/license applications in any given year, need only submit-,one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia U ROM M Q i 1 �WOW - ' _ W� „ '' E gg VV-0Ql ;;QCKETf F3ad secre#aty Of . t+4 idto wwa F v IA WON �VV � s hioi ? 46 i BiaCUM WWW WOW I • ' z LACK 111-I1.►H I C V1- LIAbILI I T 11VJUKHIVI.0 OF OON JV A-1 05/07/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC� INSURED Moon Associates Inc. INSURER A: national Grange Insurance co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURERS: Beacon mutual insurance Co. DBA Gutter Helmet Roofing INSURER c: DBA Moon Works 1137 Park East Drive INSURERD: Woonsocket RI 02895 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 MAYBE ISSUED OR MKf 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. POLICY'EFFECLTR NSRd TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDA YYl) DATE(POLICYMht@DJYY51� LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A X CONMERCIAL GENERAL LIABILITY MPS26619 09/16/09 09/16/10 PREMISES(Eeoccurenca) $500000 CLAIMS MADE X❑OCCUR MED EXP{Any one person} $ 1 Q 0 Q 0 PERSONAL&ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $2000000 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO s2000000 POLICY PRO J LOC ECT AUTOMOBILE LIABILITY A X ANYA.UTO BIS26619 09/16/09 09/16/10 COMBINED(E asaccidccident)SINGLELIb1IT $ 1000000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per Bcoidant) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $1000000 A X OCCUR FICLAIMSMADE CUS26619 09/16/09 09/16/10 AGGREGATE $ $ DEDUCTIBLE $ X RETENTION $10 0 0 0 $ WORKERS COMPENSATION X TWc LIMITS , ER AND EMPLOYERS'LIABILITY B ANY PROMEMBEREXCPLUDRED? CUTIVE ❑ 28586 10/01/09 10/01/10 E.L.EACH ACCIDENT $500000 OFFICE(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $50 0000 It yes,describe under SPECIAL PROVISIONS below E L DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION RENEWAL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILrTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Renewal By Anderson REPRESENTATIVES. 1137 Park East Drive AUTHORI DREPRESENTATIVE Woonsocket RI 02895 ACORD 25(2009/01) O 1988-2009 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD Cusher mr.S 140-4 PO KIRASS Year Built: I7 / l� Renewal T 1 430 A- L� �. Customer ID#: 11137 Park Fast Dive of RI,CI,8c Cape Cod address: Renderse l Sales 4reement N Woonsocket,RI 02895 byACity,State,Zip:iJe`.1'C fib s7t'`�Ll le >Itl _, Order Number: J WINDOW MISPLACEMENTnAtdvaerCatpury Phone-Home: license#RI-30839 RI- 12259 MA- f�j Phonc-Woole��.CStb/CS2b I -_ Page:_of!Dare: 119535 CT-562725 Email: UNITS T°p �`� a x d f /.yf .�/ a GRILLES JG ; $tr _ 6 b� C �, QD ' � � � � 3� N log 0 it E ROM ~ N� $Fplaf1 r B w 6 N WK N x 1 S 5 Z z 6 u iA to!{ l 3 x3 1 sT �- Z ti W141 X3 x3 �- 0 OH wH x3 113 1 1 ST HyIL 49L m 11 LZ 140K z3 x3 1 st" P tal NI o!tha show win4wr ru)doors m be s,r tho wW m ovw umd in d a r v rams The IV(iteell cot Credits or Expenses. Sub Total race•1) nt Meth d roPo o:pt yt (Swalning,Wnp,Rqt Pepalr,Promotin,etc ?q) pm".4 wal«Hoer.'-lid!m sn u mbjeet m ctapturee br both Gut by Mdetfcn Mmyler u Sub Total Wht►p.h �?/3//�� °'" /L Dtscriptbn!Nora f Price S � Qtedr !_ Sri TOW W row e4r/ D br men Srk.ft. 'e sgnuum Credit Card Customer ACce n YOU audrorixml m e re wind;r>„d drat.rcquimJ to mmldem d. Miss Credits or Expetuei Wtgb� �K N15S .greetMN for which Ac uiuln' m pry Ibt amoutu.nRJ in drir agreement aml according m tht terrrn brtenf. See Reverse Side for Tetras and Conditions of Sale.You,the buyey may cancel Total Finweling this transaction at day time poor to midnight of the third business day after the date off this txansactioa.Tlesse T abed notice of cancellation for an Saks Tax explan�aetttd OI,this tight. oMixellarcour Credla or Flume°n ndabmrdatriatarmlutadKd Acuprcd.7 ?' d 4 (warty a.e.tool to mLc.acdlr/apnra column n rigF,d Work PCtlldt cost �.` (D�fe tLti aft as alwyl Q.,ocnIr AMN.-l Sigtuaa Special Orda Noto Total Amotrtt of AgrMmfm Mlo Deor Swann oaa V.Aecepnd i �0e "aom Due R—med by Amk—Mmager kgmrtm Deposit Raquked 23 %Waftywmia. Dewnma wadpa Rerkw brAndesnr atancala drtl 9arLtion Hasa roanae treat Haar tobdmrwpalrYq Balance Due on Complstlos 00 Lp errtfrmar dontat eo dwamrv�xe veear aa�as Re..rr%+wry uruetAAma b•nee0ea x na Lalyded at of dWwr t�90 N Is�ramerl rirbg lmrsRatlon r,a wa mama In eat mrkss rwattgr mnlm re otsromer urkfl and oarge you fiz aurepeYrWmCmr+PP 116ce included labor.material.inualbuon, >�&M arc Lwow. oaRroae noted. At the edd ON Wa mrMunbn RNb.NW rt+taved ud we aft<LYn yaw new wLrdaws and WWM.Mrta W M'Andusen Yelbw-Lwafadon Plnk-MMMamer removal.and disporal of psvduw replaced CWJ-W Gatomet Curtner de hugawn arse Initials: laitlats: Ydtlale copc� i ` , �tHE tpk i' wn of Bariistable *Permit Expires 6 months fit issue V7 Regulatory Services Fee r r + BARNSTABLE. v� ' MASS Thomas F. Geiler,Director 039. �0 ArfO MAC a Building Division D Tom Perry,CBO, Building Commissioner ova 200 Main Street,Hyannis,MA 02601 1V_ www.town.barnstab le.ma.tis Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number rResidential Address O S BQ /� A �'Value of Work V D — Minimum fee of$2 0 for work under$6000.00 Owner's Name&Address S Contractor's Name lT gy-n"e-_ l Anoelv Telephone Number 7 U lc:> Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) YY V O ❑Workman's Compensation Insurance -PRESS PERM17 Check one: ❑ I a sole proprietor S F P — ZOOy ' El Kam the Homeowner I have Worker's Compensation Insurance 'TOWN OF BARNSTABL Insurance Company Name G.-e6cc/N U Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re- ' e o Replacement Windows/doors/sliders.U-Value G , 3� (maximum .44) i *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. SIGNATURE: QAWPFILESTORNIMbuilding permit forms\EXPRESS.doc Revised 100608 r The Commonwealth of Massachusetts Department oflndustrialAccidents �i Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organizati Individual): m eS 11)0Qt1V Address: , wk F City/State/Zip: (Ndc�/�. (� Phone#: �0/ — �— (r�{OO� Are ou an employer?Chec �hJ appropriate box: Type of project(required): 1. I am a employer with ��/ 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. ❑Ne onstruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance. # 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work. officers have exercised their 1 LF1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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-coritractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for 7 employees. Below is the policy and job site information. n� Insurance Company Name: �}(� Policy#or Self-ins.Lic.#: Expiration Date: Q O, Job Site Address: d-30 City/State/Zip: 5 II✓Av� Attach a.copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator:.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenaldes ofperjury that the information provided above is trueayn correct Si nature: sv, Date: / V Phone#: 40��(9/( ` Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License#. Issuing Authority(circle one): 1.Board of Health 2.Building Department 3:City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: L Lkem or rag-bovflonnrialar#u lumonly :;.; e�ei.Coitsamer.Affairs,&. sin teguls�on Wore the eig s<i 'fsn d retm to* H ME IMPROVEMENT,CQNTRACT4R t3�ss rs}i + o Leo irtt ag(etl'841011;, 19535 boo boa QZf .EXptra Tr# 285438 MOON =5 :Y Hot Vdid tootdt Lure 1137 PlARK.EAS b.I r. F ==:air, p }.. ��,'.w� Undersecretary t ? f:e•a:schsp�itt� De1wr'tm"I of'.Puhliv "401 . oard +of Qulhlipy� Rc�„ts.luti�+u•and htuiularilk t�str��d� ��,�� Con*dtructljoio SUP-ecvis®r 4oc,vitty Ltionse IA- Matenry,.mly § '3z lu 11 ROAD POSI $A CUnWM edWou at the is cso f or womt;ou of t E:osratm- 1=2 Rotor W. '13.masa. r0 i•�flTilit�7�tlt•t' rm- Ono - 1 f From eYdE$m RoWnsm MuMw hmeam ft Fit ftr .blm t 7jW rOSIB6 A w CERTIFICATE OF UABJUTY INSURANCE mmd TMM CMtUWATa DM NOTAMIM OR 9 *ld var �, 9.0, son 1 ALTO TM0O11��''t� ,O3A1. t�V� pp3,,pp t 02 y}8-00011yy ' Y'7 S,�a'1��-i/�,V {d 4ihl„SiUd�JV,F'M✓�Qr ��`f�,+P�.Tr�YT1yy10-O y1i7V.\VdR�VYYii'� f197Waou, Qa moon !gtS s Wit@ nsoaa I Ao. . 607 a irr n*m. wWwTouapsmw P � b%,fpmm Tom Lgm ra �.a m W826019 QOJ1�/00 00t18joS a 0CLAW WM 0AttOf1 pQ .��rBeR�i't S� paElD0 - T& '0 2000000 T/l R 1Lt 0 f -gQ�P.Ci+9�s $2000000 a 100O000 A X�� 9 $ 4� O9116100, tag/9.�/09 � s an - Xt a s . �00A$,Y,f94 6 HA= ! emmoccumem 31000000 cs dm Ct=266 9 00/16/08 09E✓16/09 A 8 11000p• 8 vtts�3t� .mead :Lo/o 10/01/09 LUAW A=�ZUW I S00000 of MMAO-M&OLOM 8600000 ia ` S,Wseafis.PotsCtt Lut 690 000 aam=*m Howm ATEQI� . � !aF#�AAkFPI08' fi�B P � � � or admial'straVA'm 3Mvltol Hi)l tom' rrv►�r, a s RX 02009 �. mow✓ Act x� i y ze. �• 'm c ti I _\ fbor Plan C e_Q'�'1..• 2 ID Number �., •`.. � Jig ; gpy3, j awTit e a `•°�7 x�a ! I Aa WNaM to t,rdm r"� �;.�lg Knc �I � I 1 mtbeneawtl/96' g a , Adw1Helghtlebd,es t Ii F5;-r�� e ( j �eothentarestvls• �3 SMA MAW � °c� � g I i Rae�ii ll''> V Sash Bubo CalxEzteria Iv F, _ 1 c�, 4 iIts jis g j s�°n cr�e.or>a^ n i ! Qt IOL ' \+fn 1}y�..,y�.1,t ` e " , Urine Retam cl o� 1 � owaraau.r eseeu �O CAU L•M mGrille pwrde Q I j n a s sysj I of Iftw Writ n g i \ stm , R Of fife:tttGx 01 Lltes YFde 1 if 1) !I st - ZI r7•e t J i „_._ ttA 14lid 41 y ` a o v V' � � rF �. ��• I j y CarirgMethod w a a "(,1 Xter spedal Order W N qN�Y i �oF t�ram, Town of Barnstable �.*Permit# ��r�c F.tpires 6 mont&fropr qtsue date * Regulatory Services Fee �- riaxrtsraatt, Thomas F. Geiler,Director Mass. 1639. .�� Building Division PTF p�,t a 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 l Not Valid without Red X-Press Imprint Map/parcel Number Przesidential Address3C1 Mq,df� - Value of Work 406? "� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address S�On I fiw� ra � Contractor's Name s/ i e,1/ 2e-4 1�>vb7—PhN&1c, S(4y( e e hone Number s()rc�' Hororkman' provement Contractor License#(if appli?able) (f 1.) �4 3 Compensation Insurance Ch k one: -PRESS PERMIT I a sole proprietor the Homeowner JUN -1. 8 Z009 14 -have Worker's Compensation Insurance S �� ✓�'/1 /1/C TOWN f3ARIVSTASI Insurance Company Name_ � t;, ,/�f t', f Workman's Comp. Policy# 00o Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re ide Replacement Windows/doors/sliders.U-Value a S (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. SIGNATURE: �� Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name (Business/Organization/Individual): ' ,& �/ U'7titk: / 'S Address: numb &eA�L) . Gc�c' City/State/Zip: _' tY�j_ - 3 -'3 3 L Phone#: ? �� Are you an employer?Check the appropriate b Type of project(required): 1. I am a employer with 4. • I am a general contractor and I 6. VNemoconstruction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. deling ship and have no employees These sub-contractors have g•'❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other . comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ZZ�ew qm'sk& Policy#or Self-ins.Lic.#: J<J t� �O l Expiration Date: `3 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and co rect. Si natu Date: _ Phone#: � Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other l Contact Person: Phone#: I I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLdbly Naive(Business/Organization/Individual): Address: oVA1 bk, City/State/Zip: W one.#: Are you an ployer?Check the appropriate box: Type of project(required): 1.❑ I am employer with 4. ❑ I am a general contractor and I 6. ❑New onstruction e} oyees(full and/or part-time).* have hired the sub-contractors ..2.LI`'Yam a sole proprietor or partner-' listed on the attached sheet 7. . emodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers'.comp.-insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: P Policy#or Self-ins.Lic.M P (7 Expiration Date: 7" Job Site Address: �-�� City/State/Zip: l�l 0 U'��.r$ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the'Office of Investi ations of the JDIA for ins ce coverage verification. I do hereby certify nde e p sand p nal 'es of p jury that the information provided above is true and corr t. Signafore: Date: 0 Phone#: Official use only. Do not write in this area,to be completed by city or town official. .City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more .. ofthe-foregomg-engag m ajom--en r`pnseei-and. m u3mg=tfie legal-represen�ati�e of- dec�ased�empkryer,-or e- -__`:.: -- 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 or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)name(s),address(es)and.phone number(s)along with their certificate(s)of insurance. Limited Liability 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 UP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials .Please be sure that the affidavit is complete'and printed legibly..The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be' used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TO. #617-727-4900 ext-406 or 1-877-MASSAFE Fax#617-7274M Revised 1 i-22-06 www.mass_gov/dia Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety. Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License# 153140 Restriction Company Nu-vision Installations S, Name Stephen Restaino Address 32 Oval Drive City,State,Zip West Yarmouth,MA,02673 Expiration Date 10/31/2010 Status Current No complaints found for this Licensee. ruck To Search y License: CS SL , 99560 �ky�r`,I " Restricted to:- WS3 ^ STEP HEN :`RESTAINO. 32 OVAL DRIVE WEST YARMOUTH, MA 02673 expiration: 1 /22/2012 tJ117U.11� 11>ll('t �5 �%��o� Try: 99560 V5r0� / ------ --------- License or registration valid for indiyidul use only before the expiration date. If found return to: Board of Building Regulations and Standards _ Board of Building Regulations and-Standards I ' HOME IMPROVEMENT CONTRACTOR One Ashburton Place Rm 1301 - Registr p�; i Boston,Ma.02108 - 126893 Expiration 73/2010 _ T,' =Supplement Card �t The Home DepoWAtNom^ ce 6ARREN DEMERS a i ---- ---� .- ---- Q3200 COBB GALLERIA`PKVVY# [[ 1Vot valid Without signature ,,�y 20 1E HTLANTA,GA 30339 Administrator • 'S .T.sK.a-'(Y�iw:ic-..�.-.:�.+.�t�uivbr'33iL...•s:S:-:L'-.vait�i�-?�''.�,'�'}n•sM--�:TI.s3� . • f 04-29-2009 14:5T FROM-THD AT HOME SERVICES n• v +508 756 8823 T-4T5 P.001/004 F-520 a/ HOME 1MYI1(0 V EM_EN 1•t.V 1N 1 mA1.1 PLEASE READ THIS Branch Name; Boston Date: �/�/ Sold,Furnished and Installed by: THD At-Home Services,Inc. Branch Number: d/b/a The Home Depot Al-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 ❑North 33 �4outh 31 Toll Free(800)657-5182; Fax(508)756-8823 V / Federal TD#75.2698460;ME Lie#C 02439;RI Cont.Lie#16427 l! l CT Lie#565522;MA Home Improvcmcnt Coatractor Reg.#12689'3 L Installation Address: ��r„� 0aZYhi� City- S t 4'`� Zlp Purc aser(s): Work Phone: Home Phone: Cell Phone: Home Address: (If different from Installation Address) City State E-mail Address(to receive project conun ur"cations and Home Depot updates): zip ❑I DO NOT wish to receive any marketing emails from The Home Deot Project Information: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc. ("The dome Depot")agrees to furnish,deliver and arrange for the installation("Installation 1)of all materials described on the below and on the referenced Spec Shect(s), all of which arc incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"); Jon#: ttn:<rnd Reference) Products: Sec Shcet s # Roofing g (�• Pro'cct.4mount 3G ,;� g ❑Sidin indows Insulation lv p/l b ❑Gutters/Covcrs ❑)~, Doors ❑ G�/ $ A - Roofing ❑Siding Windows ❑Irtswarion O ❑Gutters/Covers ❑Entry Doors ❑ /1 '1 n $ �oi� ❑Roofing Siding ❑Windows Insulation V a( []Gutters/Covers ❑Entry Doors❑___ $ ❑Roofing Siding ❑Windows ❑insulation ❑Gurtcrs/Covers []Entry Doors ❑ $ tHinimum 25%Deposit of Contract Amount due upon execution of this contract tVlaiue Purchasers may nut deposit utore thnn one-third of the Contract Amomu. Total Contract Amount $------------- i Customer agrees that, immediately upon completion of the work for each Product,'Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Products(s)included herein,at is discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the bone,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Con ct. Payment Summary. The Payment Summary #_ o�L'4a Contract amount and payments required for the deposits and final la includedoc ( as part ab this Contract seta forth the total P payment,;by Product(as applicable). NOTICEYou are entitled to a completely fdled-in copy of the Cntracta t the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The I•Iome Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. TIM HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that'this Agreement is the entire agreement between.Customer and the rittklo Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writin si 1 by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement Accepted b �J t I ( _ 7), u fitted by: �" 1{fit 16 J 'r ram"'Gtt' _ X a 9 Customer's Signature Date I_n Sales 'ousultant's Signaay c DDaattee/r/ X f / `• L 1 b Telephone No. ��Y� Customer's Siguature Date 4 1— CANCELLATION: CUSTONIER MAY CANCEL THIS Sales Consultant License No. AGREEMENT WITHOUT PENALTY OR OBLIGATION (as applicabtc) BY DELIVERING WRITTEN NOTICE TO TILE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSLNESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACIIED HERETO CONTAINS A FORM TO USE 1F ONE IS -3 'FUZ L$ RCVD _ SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE, NOTICE:ADDITIONAL TERNS AND CONDITIONS ARE STATED ON Tlifi rtEVCRSG SIDE AND,ARE PART OF THIS CONTRACT a-05-08 C-SC White-13ranrh Files you ,,._n.. . __- -,-. .. - I / 07 �y[' WINDOW SPECIFICATION SHEET - Spec.She t#: 0 1 5 3 Sheet: of Customer: l + u" 3obAt•. !� C.onsullant: t}ato: v l� New Window Existing Window o Measurements Grids Product Options LaOptibor From alufsld.,I�nto Right s� t w Color Rough Opening or bars 9afba Bays,So&%Csmnts, Location t PH,use L.R or S v = GIs,Hardwr,Screens, Misc Items 0 0 o .o - c o u o Mull Code r=rdoonu.•s•=•ascaerr II \ � c n a` L u C _ u C y or'%•-opanuna No to Vlraps Styte Series r o o `o 0 0 o f Room Fraor. Style Cade '(YIN) Code Code — Vadlh H°tght N d H t LrI wo I I a m a I I N I CO m (D 4 u1 I f` O 3 rr° + 6 I to I I W ' SPECIAL CONSIDERATIONS: oc� Wrap color r ' w InterlorCasingType -- g I = Bay or Bow window; I.— Seatboard Material:(vinyl only-Birch or Oak) o Bay Projection Ang'c(30°or 45°) Bay Ranker Type(DH,SH or Csmnt) Top of window to soffit(Inches) aL __ If Tied to soffit,color of soffit material I have reviewed and agree with all the Job specifications above and the' - Construct Roof(Yes or No)' i Special Terms and Conditions on the back of the yellow{Customer}copy. Garden Window v ard Material :{vinyl only-While Pionite, Birch or Birch or Oak { i Wall ThfcknFSS,(Inches) Customer Slgnatvro rn .. � o I c Addttlonal Shelf{Yos or No) N i I t I.rtara 19 no i;—mnh .thalrre+:_Yir Jrs.vtll�, tche stlrg mbx. o - SFp•'.V-WA'f-l1 eB 'Afila-Thall—Poepot Yelts Cwtc— PUIY.-Spire.'C]n Stu-d THD-ICS i IHE, ti Town of Barnstable *Permit.4 96Qgl� Expires 6 months from issue.date Regulatory Services Fee .� .s. 0 • + BARNSTABLE, v� 63q. Thomas F. Geiler, Director \ Al fD MAy A fJ Building Division Gy • Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us 01'f ice: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number I✓�� D�1`� ZZesia Address �.->0 Qok Si it/ ejel17a1:S70ential Value of Work r L)o Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address l f 4�//`� l%f I C�� r 6s) Contractor's Name T ,47 n . �et4l C ejell +/1N elephone Number ,�Of/4�� I Ionic Improvement Contractor License#.(if applicable) / 7 -6 Construction Supervisor's License# (if applicable) ❑Work/eoon pensation Insurancegam® ®g��g, - RESS PE�9MIT sole proprietor ❑ I am the Homeowner JUN — 4 Z009 ❑ I have Worker's Compensation Insurance ' TOWN OF BARNSTABLE Insurance Company Name 5g le M .-DVS G� Workman's Comp. Policy# I P OOW 4 7C; Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re- e Replacement Windows/doors/sliders. U-Value 0- S,-j (maximum .44) •Where required: Issuance of this permit does not exempt compliance with other town department regulations,is e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: �.'WI'1 11.I.S\Pt7RM5\building permit forms\EXPRESS.doc Revised 100608 _-._.,,Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License r 153140 Restriction -Irt'company Nu-vision Installations Name Stephen Restaino Address 32 Oval Drive City,State,Zip West Yarmouth,MA,02673 Expiration Date 10/31/2010 Status Current No complains found for this Licensee. f r F3ack To Search a Bo al:(t of Buildiw, Re-til ttions and Stanclat ds u:.lnstrac-don `upervic-or Specialty License License: CS SL 99560 Restricted to: WS l STEPHEN RESTAINO 32 OVAL DRIVE WEST YARMOUTH., MA 02673 = Expiration: 1/22/2012 ( nlulis.iI'llcI- Try: 99560 n,/LI V'Slc�l 7n5 APR-17-2009 12:22 HOME DEPOT,HYANNIS P;001 HONE IMPROVEMENT CONTRACT PLEASE READ THIS Branch Name: Boston t� .. Sold,Furnished land Installed by: Date: / / :d. T14D At-Hoine Services,Inc. d/b/a•Th6,Home DepoYA't-Hm oe Services Branch Number: 345A Greenwood Street;Unit 2,,Worcester,N 4A 0 t607 []North 33 • onth 31 Toll Free(800):657-5182;Fax,-(508)756-8823 Federal ID#75-2698460;NO Lie#C.02439.R;Cont Lie#16427 l�A CTT,ic#565522;MA Home Improvement Contractor Reg.E 126893 Installation Address: . 3 IZrp Purr 'Work Phone: Home Phon'c- tell Phone: Home Address; ' (If different from-ins tallation Address) -. City, ! State • Zip E-muil Addiew(to receive project coirnmunication.•c and•Home Depot updates): 0 I DO NOT wish`to receive any marketing Mails-from Tbe'Home Depot i Pro•ect Information; i7ndersigned("Customer"),the owners of the prop—6rty located.at,the above.installation adilrelts•agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to f imish,-deliver and arrange for the installation(°;Instaliatlon-D of all materials Aescribed•on:the below and onAhe'referenced:Spec'.Sheet(s),all.of-which are-incorporated,into.this IContract by,this reference,"along with any applicable,State Supplement and Payment Summary attached hereto and any Change Ordl=(collectively, Coatr'acY'):. �p J " `'G � Job'#: Products-. . .S ee Shoe s #: Pro ext Amount �f GG Rooting Siding indows Insulation �.c7to•.0.��.b.. - OGuttcrs/Course []Laotry Doom Roofing Siding Windows Insulation 1 �Guttcrs/Coven.C]Entry Dooms.� m d $ Roo Siding •:Vftdews :insulation . :'Cutters%-Covets �L'ntryDooisQ' $' i Roofing Ljzslcinjg'u WindowsLJ Insulation ' 0GudmJCovers QEntry.Doors $ FMMinimum 2S%Deposit of Contract Amount due upon execution of this contract," , alnp Purchases mn not Total Contiact.Amount'.: .$ _ y deposit more than one•thlyd of the ContractAmouat ' Customer agrees.tl a't*immediately upon completion of the work for each.Produci,Customer•will'exeaue a Completion Certificate (one for each Product.as defined by an individual,Spec Shect)'and.pay any-balance due. As applicable,each C' 11mer under this Contract agrees to be jointly and severally obligated.and liable hereunder. The Home Depot reserves the right to issue a Change Qrder or.temrinate•this Contract or any individual Products(s)included herein,at i+discrction;.if The HomeDcpot•or.its•authorized service provider determines that it cannot.perform.its obligations due:to a structuralproblem.with.the.home,environmental bazards such as mold!:asbestos•or'lead:paint,other.safety.concems,pricing.en'orti or because work required to eomplete•the.job was.not•includcd in the Co'ntvict. Payment �ummar The Payment Summary # included-as*.part of this Contract, sets tforth the.total Contract amountand:payments required forthe deposits and final-payments by Product(as applicable): NOTICE TO CUSTOMER You are entitled to'a completely filled-in copy of the Contract•at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined.by individual Spec Shects)'before work on that Product is complete. _ ,... . bathe event-of termiAationW this-Contract,-Customer agrces-to"payThe Home"Depot the costs of materials,-la1bor,expenses and services•provided'by The Home Depot or Authorized Service.Provider through the date of termination,pllus any other amounts set forth in:this Agreement or wowed under applicable law.. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM. THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LU IITINC THE ROME'DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Aceentanee and Authorization: Customer agrees and understands that this Agreement is the entire agreement bctw1=Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,tither ors]or written,.rclating to said Products and Installation.This Agreement cannot be assigned of,amended except by a writing signed by Customer and The Home DepoL Customer acknowledges and agrees that Customer ha-read,understands,voluntzdly accepts the terms of and has received a copy of this Agreement Accepted b : Su I tied by: Al It Customer's Signahtre• Date nn Sales onsultant'ss Sign, ✓I /D/ate�i�j CrJ—I Telephone No. `yi 7j Customer's Signature Date ��- Sales Consultant License No. CANCELLAJION: CUSTOMER .MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERINC.WRITTEN NOTICE TO THE'HOME DEPOT BY NIIDNIGHT ON THE THM BUSINESS' DAY AFTER SIGNING THIS AGREEMENT. THE STATE ' SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE' is SPECIFICALLY PRESCRIBED BY. LAW IN CUSTOMER'S STATE. NOTICP:'ADDITIONAL TERMS'ANDCONDMONS ARE STATED ON 17M REVERSE SIDE AND ARE PART OF THrs CONTRACT WINDO SPECIFICATION SH ET - Spec.Sheet#: �§0873 �/��]/f;! (J tt(( Sheet: of< Customer:. : v"n l J bp: 4L Consultartl: Date: New Window ExI$ting Window. Measurements Grids Labor Irnge tAcauoa: . Product options FromouttIde, N . - ... OpttO rl,S Lets 6o R+gM r, 00 Location Color Rough opening _ k of bars' i of bane Csm As,tg F?• CO a m GIs,Hardwr,Screens, 111011se ltem,s vseL RorS o $`, g o. o `d S o Muil Code S." .", radoaa�na N W wraps' style Series N C 7R*�� Ffoor Code /Nl Code Code WA-h }kipM U Z c� n' j so s j _ s u N 64 0 3 t9 c7 o " - z s U) 77- 10 � W-p color SPECtat.CONSMERAnoxs• Jnbeeor Casing7ypa Bay or Bow window; ti Ssatboard Material>O nyt cnry-Birch or Oak) Bay ProJectionAngte(30°or40); Bay Flanker Type(DH,SH qr Camnt) Top of wlndori to sWd`ages) -f H Tied to soffit color of soffit material I have reviewed and agree with arl the Job specifications above and the Constn,cl Roof(Yes of NO)S Special Terms and QpMireon on r1,R t,a.k m Lf-••_,r_..iciWi-____ - �a-,..n r..uscvmerl y. . _Garden Winrinu._"_-- ----------- -- ,v Seatboard Material :(vinyl only-while Plonita,Birch w P r Oak) / ' p O Wall Thickness,(faches) N . Guslomer Signature - Additional Shell(Yes or No) 1.Thee is ro g�a�r.[ee tt,:i ro�shl•KJes call ma'ah esistiv�cdcr. Sr'Gh�Vlt'S::•L9 'Ails-7!p W.me Cc;c! YeS7r-O.sb-a .➢1-k-Szhs CpsaTdY THp-'Ic2 i ' �\ Board of Building Regulations and Standards License or registration valid for individul use only — —- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:, One Ashburton Place Run1301 Expiration: g/3/2013/2010 Boston,Ma.02108 ;Type: Supplement Card The Home Depot At-Home Service DARREN DEMERS 3200 COBB GALLERIA P,KWY#20 �� ATLANTA,GA 30339 Administrator Not valid without signature i The Commonwealth of Massachusetts rh Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le 'bl Name(Business/Organization/Individual): �fe PiV" A� Address: 0 VA- QYq City/State/Zip: . Ip /�//y� Phone.#: �� /��^ �O � � Are you an employer?'Check the appropriate box: Type of proj&ct(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction loyees(full and/or part-time).* have hired the sub-contractors ..2: a sole prpprietor or partner-' listed on the attached sheet 7. . emodeling ship and have no employees These sub-contractors have 8.-❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• # 9. ❑Building addition [No workers'-comp.-insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance 1eguired]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other . comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have�mploy=,they must providt 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 CompanyNa'me: 3 CO Policy#or Self-ins.Lic.#: I o o®O `Y'7bJ Expiration Date: Job Site Address: /e /1T city/State/zip: W` /e L/!L � � 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 finer tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a•STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy-of this statement may be forwarded to the•Office of Investigations of the DIA for insurance coverage verification. I do hereby ce • 'u der t pains• nd enalties of perjury that the information provided above is true and rest Si a Date: G ��7 _ Phone# Official use only. Do not write in this area,tb be completed by city or town offuiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health '2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Insttuctions 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 fore om -engaged m a om -i rise a�includ a le re resen�a'h�s-6f- b aced. i e._---.-.- g g g g• I rP !1 g PP receiver or tivstee of an individual,partnership,association or other legal entity,employing employees.'However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for the performance of public work until acceptable evidence of compliance with the inpance requirements of this chapter have been presented to the contracting authority." Applicants Please 01 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)name(s),address(es)andphone number(s) along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may y 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 time law or if you are required to obtain a workers' compensation policy,please call the Department at the nun}ber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly..The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in'the permit/license number which will be'used as a reference number. In addition,an applicant that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all-locations in - (city or town)".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that'a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a horse owner or citizen is obtaining a license or permit not related fo any business or comnmercial venture (i.e.a dog license or permit to bum 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 Massachusel s Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TO. # 617-727-4900 ext-406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 . www.mass.gov/dia. i The Commonwealth of Massachusetts 4 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ry� Please Print Legibly Name (Business/Organization/Individual): dJ u7t I .� Address: L) Gc>i' City/State/Zip: �LLY�-�. 2 A - 3 0 3 3 Phone #: Are you an employer?Check the appropriate box: Type of proje (required): 1.0 I am a employer with 4. ❑ I am a general contractor and I 6. ❑Ne 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. emodeling - - `These sub-contractors have ship and have no employees 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.El Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. - Insurance Company Name: 3�eU) ffaAO,5 S Co Policy#or Self-ins.Lic.#: 5 l� 6 �l Expiration Date: -3 ( 10 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u r the pains am allies of perjury that the information provided above is true ai correct. S i natur �—�— �� — °'"y Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6..Other Contact Person: Phone#: i �OFTME rQy, Town of Barnstable *Permit# Expires 6 months fran issue date ,,,R,,,grAB , : Regulatory Services Fee' D(/ M"9• Thomas F.Geiler,Director 9 i639. .`� � �A'EDM°�p Building Division S�� Tom Perry, Building Commissioner �p 200 Main Street, Hyannis,MA 02601 �. ApR 9 I r Office: 508-862-4038 O�l�l�Fe 200? � Fax: 508-790-6230 �9l�'/V Nr L__ 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Srge Not Valid without Red X-Press Imprint Map/parcel Number 13z Of-a 7 Property Address /VPG esidential Value of Work GO Owner's Name&Address 6 P1 �30 Awe 2 C �.�Contractor's Name /O /'//S�'j i/�//S��'/� Telephone Number 3 d2 —7> Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) d n ❑Workman's Compensation Insurance IpMma*sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Comp Workman's Comp. Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of ro of) , [�] Re-side �� lS �C �« ❑ Replacement Windows. U-Value (maximum.44) tom` ❑ Other(specify) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signa e P Q:Forms:expmtrg Revised 121901 QG`J s �3 yParcel Q U� Permit# - Date Issued vu "FM •_� ' Fee Engineering Dept.Ord floor) House# X 3- IKE ^� QPnt (1St flnnr/Crhn,.t w- - W11 - BARNSI'ABLE. • - MAR& EDMPIA TOWN OF BARNSTABLE Building Permit Application ' Pro cf St a Addre s oCc3� 4 Village Owner S� �`— ��a� Address { Telephone Permit Request ,--, — ' I First Floor square feet Second Floor square feet Estimated Project Cost $ 6_4 / -7,� Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure 620 Basement Type: Finished Historic House Az d Unfinished Old King's Highway S Number of Baths � No.of Bedrooms 3 Total Room Count(not including baths) First Floor Heat Type and Fuel Q t j Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other ` , '' Builder Information � Name (C; W I t\1 I KA 11.1 E-)1 Telephone Number `7 q O I Y-d -7 Address Gab es i PO: T_-) License# i L R-V 1 L Home Improvement Contractor# j d 4Q S 3 Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION D BRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE D BUILDING PERMIT DodED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERM N DATE SU D MAP/ AR EL NO. ADDR SS VILLAGE i OWN DATE F SPECTI N: FOU ATION f FRAME ' INSULATION ` FIREPLACE ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL GAS: , • ROUGH FINAL FINAL BUILDING `•? �� ' - _ , ' , DATE CLOSED OUT ASSOCIATION PLAN NO. , The Common 1l'ealth of Afassach usetts Department of Industrial Accidents ` 'y _ ! oxceoJloYesl/gaUogs 600 11 ashinl ton Street Boston,Muss. (12111 Workers' Compensation Insurance AlMdavit locitia city ��+z-Pn.ti P ^`f"�--� nhonc I am a homeowner performing all work myself. �a.m a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. comanny name' address: city* nhonc#: insure ce co nolicv# 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: company nime• m1dress• cetx• phone#* insurance co nolicv# ^f �. :.T: - �..CIs�:/-�,ti-r.•7!t�'? .'.�<• Rt ,f ."Ii;^w 7h!"�!�r•9�.. '.'.....iS c6mnanv name, add City: phone#• insurance co policy# _ -Atiach additi6ital'sheet if rie 777 :..fir,,' • "' Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or unc years'imprisonm as W 1123 civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statcm t m e forwarded to the Once of Investigations of the DIA for coverage verification I do hereby ce ri the p u pe/n�a/�ti jpeduty that the information provided above is t and correecc't Signature Print name Phone it official use only do not write in this area to be completed by city or town official city or town: permit/license# riBuilding Department C3Ucensing Board 17 check if immediate response is required OSeleetmen's Office �liealth Departmentcontact person• phone#;. nOther r � ...�� Irtvued 3.95 P1A) . : The Town of Barnstable SAIDWAMM MM Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosser Offi= 508 790-6227 Building Commissions F= 508 775-3344 For office use only Permit no Date AFFIDAVIT HOME aff ROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the-instruction,alterations,renovation,repair,modeM'=don,conversion, improvement..removal, demolition. or construction of an addition to any pm edsting owner Oecupt ed building containing at least one but not morn than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain c=ptions, along with other requirenents lst.Cost - Type of Woric: - , Address of Work: Z,3 Q ' O%Mer.Name: Date of Permit Application: `/ G -96 I hence certify that: Registration is not required for the following reason(s): Work secluded by law Job under S1,000 Building not owner-ooeupied Owner pulling own permit Notice is hereby given that: CONTRACTORS OWNERS PULLING OWN IMPROVEMENT WORK WITH DO NOT FOR APPLICABLEr HAVE CESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent o e ner. Registration No. Date Contra o e OR ' owner's name . Application to g � ,65 tfPPEG��l,,$)tM 'Y-NOtt PPPyr . Sa�PNs Cf.�E,�ftHPPE�S eP �.�t�d► Old Kings Highway Regional Historic District Committee in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, iri triplicate, for the issuance of a Certificate.of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building ❑ Addition Alteration Q (� Indicate type of building: �House ❑ Garage � 1 G R Q g Commercial Other 2. Exterior Painting: ❑ 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole 22,16ther_ P. r— ,Qoo t!` (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE / ADDRESS OF PROPOSED WORK �� /X£ W£si [/e�14�1'S(o>7f�Lf ASSESSORS MAP NO.. OWNER S,�R,� �FOwA1,P / o ��A�S$' ASSESSORS LOT NO. 0 HOME ADDRESS 93O/ //9/h '✓�Fs?'�i9R�/�l�lj�£ i9 �.ZG6S TEL. NOJG$ 34-2 f Z 4 < FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet/if necessary). 'z!'r/119�� Jlo 44-r? R�'�s�v�c F�ifrsS. Q 2 44 9 /VORAAS,W//�� s� �l'��2G�'�/�Rsy�/a��`ss � las�y9/�iPir�R>,�1 •9. AGENT OR CONTRACTOR Y/�'o �lG�ll�cGT"/I/fF £ /� �e% !! TEL. N0.r ��b ADDRESS 123 �2A'i Q �� 'N Y4 vlCC S sS © (0 3 Z 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). � � �6 0 d�Io IJ �� 5 f�lf�`' �s I / a ec 4 4No l- c Signed Owner-Contractor-Agent Space below line for Committee use. 1 .Received-bIy{ H-D C- ,,Date The C care is hereby Date J J � 'T �' 1996 J �Ti me � e 1 ff,Q,%aN OF JAMTSTABLE Approved ❑ IMPORTANT: If Certificate is'approved,approval is subject to the 10 day appeal period provided in the Act. i Disapproved ❑ ` l Town of Barnstable p 'l Old IGng's Highway Historic District Committee `j SPEC SHEET FOUNDATIO i SIDING TYPE COLOR CHIMNEY TYPE COLOR 1 ROOF MATERIAL('R 0 C Z 3 COLOR PITC WINDOW SIZE TRIM COLOR DOORS COLOR SHUTTERS GUTTERS DECK GARAGE DOORS COLOR 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", but should show all structures on the lot to scale. SPECSHT I t ~ Ie 4 m <— k r ' cn -77 I o r _ �-• C C o o 11 v b° ti a' Qa 0 v $ 10 C� W n / e J I • p s k i D06 n 'i t14,' �v : • 1 OD 0 �l , O•OO �4 v r a Ab 1 le IF O 1 1 _, Y jIIPkDVMENT.TttIgTRACTOR; E�pitatl0rt' 16108/'46' V#�tar.�. Mi'I�ikiaees .la-W f it-1W..8202 s i I 1 i v �• �i4 Application to 0,- 19 9 5 168 rr' ePp,M'�O`MN4ti.P�`G� Old Kings Highway Regional Historic District Committee 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 type of building: ❑ House ❑ Garage ❑ Commercial ❑ Other 2. Exterior Painting: ❑ 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other @Ill :hS W AL le 'WAY- . (Please read other side for explanation and requirements). / 7 TYPE OR PRINT LEGIBLY DATE ADDRESS OF PROPOSED WORK �, 3 e M A► O L e s 4- 18X 416' ASSESSORS MAP NO. Wept *61G C9 ,1(,b? OWNER S,j�A A PO ieR A- IS ASSESSORS LOT NO. � � HOME ADDRESS .2 3 O lyl AR®1'e ST TEL. NO. FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). C.A-LeS + 1a� rRi� kgkilfw V21 ktLa 14 gaas &X h09hiA VA-L' LLi0S' tog r t WJkRh5�A8 Ale,(es T 7 a�,le s I . ��r�r►��b o � �b 8 AGENT OR CONTRACTOR .SAG O � eA'ti- Ar TEL. NO. ADDRESS JUG-NtI �A (r ��P 4'��lW-die *A 6 164 2 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 newsigns. (Attach additional sheet, if necessary). 0.6b gT �V C-4 0 V41EWr W 1. I< l) ,(I OTC �4�� X 86 1 0 D Signed Owner-Contractor-Agent t space below line for Committee use. Received by H.D.C. Date The CertEicahereby 4 �� ate Time � By - Approved ❑ IMPORTANT: If Certificate is approved,approval is subject to the 10 day appeal period provided in the Act. Disapproved ❑ f A BUT 1' i n r, owme2 , i Town of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION t C SID G TYPE COLOR CHIMNEY PE COLOR ROOF MATERIAL COLOR PITCH WINDOW SIZE TRIM COLOR DOORS COLOR SHUTTERS GUTTERS DECK GARAGE DOORS COLOR .\ 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", but should show all structures on the lot ' to scale. SPECSHT ' .�. 0. � � y i c-w••u) •, tea" I o� `o G07 00 100 046 1 ��;._•`� Boa>wtaaat..� �s � 1• G'O .N ' y v < e rcp29- M / 4L L o� a •16 it d • � Masi-�� _ • ANA WILL POSO • ^ � gyp M• ;, 4! ..04 At O ': ► alb 'o t9-7 p>t • Loo.c c 1t e y 0 y hTO Q o� oll 0 44 �O • fief .A% � -...� .�..-..s..�-....h-.�.R-ter-.-� �. �•4+.-..-s.s�--*nr`•ae-'7rar•--'--�+•..;.�..-..�.�f1 7 .. .. .- _ __ �te�=«:..,.:...,,�.� ..i._,. _.ti•;i}]-+�I1+, w_. �•'-.) t�- { iY'/r� a• .t; .!. .'i j '..'4 l 33 i A• • ��r f � ` 47 ' � � t :aC//!� -,/'�QY, !DD ' fps„ (.�*�"' S. r .• - r '�� -• It • - .,ice . � i ,, 'ryP. W� c . ' .c ,,; ` •��c�„,�,,,, s�' PLOT PL A N :''',:_ �`• L 0CA I /Qi V • ,77 • r s 440 JL �fiF PGA,N EA/CE: 94,,�iy Ax � - •• . '. � . � f .. �3'S!li�1ii'YE.O fdP...�'/ ��//rrff�� l..E'i�6/�Sr. .�. � -. , ' .J � ,� ��t�'ciF�,�,��. • : .. I /+fEQEBY CE.�Ti�7"N • . �� .,.;, _ ., '. •�r AT 7,WE WlLfkcD ; l_< ,~FOUAIDAr/ON GOC4T/QN ,dS l �� S ,SHOWN AA10� 's--CONFO,Q'M Ilji7x( (31 TAt_OR r `; Ts,IE 294//4D/Av6 57ETt%4C,rrgE�C/ipEM �{ H F O71 46 TOWN OF .: �►r=tS?�� 3_ LLL777 O Sly . ' Ciro MF IV/4c•Ow sr yi4 0.uMrAppo r H.4. As map-,and :lot number ....:.. .... ... Sewage Permit number .................� ' .....:........... ....' .....:..... *T"Er°�� TOWN OF BARNSTABLE I BJHHSTAnLE, i 9�O M6 9•go? INSPECTOR„ YPY a' . 7 !, �L 7 .. APPLICATION FOR PERMIT T0 ..........�.......:........................ .-.-.........................:...................................;......... • �, ; . 'TYPE OF CONSTRUCTION ........................:.........., ............�..............................................:..................... ...........,9� � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies foro permit according to the following information: Location ...... :.. �fT%........ :.......... .....`- /..`. /5.:.a ).y....................................... ......... ProposedUse ...................... .. ..; E' ......... 1..'.......` .............................................................................................. ZoningDistrict ............................. ........................Fire District .............................................................................. Nameof Owner .............�................:............ �..... .:...Address ........................:...... ,............................ !?'.�...... .�?. ...r'f/G..`.� Address .......Ci�.?i.A r v................,.Name of Builder .. .. /" �......................... i�..�l L V$Gf7 / Grs1 ( / J" � s Nameof Architect ...........................................o......................Address ............................................................:........................ Number of Rooms ..................................................................Foundation ......... . Exterior ..................57;�.&r!.A.5...............................Roofing Floors Interior ...�........................ ...................................................... Heating ......................Plumbing ......:...., � y 4.................... ... ...:.................................................. r✓ /7<--� . �Fireplace .................................•...:...........Approximate Cost :.......... �� ...................................... z Definitive Plan Approved by Planning Board -----------_______------------19_______. Area ........ G?'.Z..L6............ Diagram of Lot and Building with Dimensions Fee ' SUBJECT TO APPROVAL OF BOARD OF HEALTH F.3�_;, I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regard ng the above construction. s Name,................................� . .... .....:�'........ .. Phillips, Gilbert A=132-25 5 1' 18137 two story, o .......A....... .Permit.for .................................... single family dwelling ....................................... ..... ... Locatio,n 0maple Street -j......................................................... West Barnstable ............................................................................... Owner .........................Gilber.t Phil I%ps .. ............. Type of Construction ....................frame ...................... ......................................................... ................... Plot ............................. Lot Permit Granted ......JA, gy...12............19 76 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSE/ ................................................................ 19 ..... ... ................ . ....................... .... ..... ...... .. ......................... ...................................... .....4.. . .............................. ............................................................................... Approved .............................................. 19 ............................................................................... ............................................................................... V �I A 6 6. ExtST'iN6. �'v (A PL o 7 oL. A ti MILS L CCA T/ON: j�an/Z? SCALE _ 41240 D,4 T&.22.3/-.7S W/-A/V /2E F&Q--NC E : C e�-/tt/G Q _ G.;q l�;, i�/ . inl et I NE k'EBy C 44—.?T/FY 7A-1 A T._.T/-/E E:X�ST- �� /NG FOUNDA T'iON LOC4 T/ON /S G2�,04C *�.' .45 SNOWAI AAvD OR SE7-l3ACk-VE0U1['EMEN70 OF 7,'V46 70WV OF QEC�YL�.vD zIF O . C;L,o.,6z-.L s 7o yc o2 // �� — SEPTIC GY-57641 E7ttY3T BEmap and lot number ......r.......! �..(? ........ INSTALLED IN COMY""LIANCE WITH ARTI^LE II STATE y� 7 p/l. J..-A _ e—�SSANITARY COr� AMD. TOWN Sewafj.e,Permit number ................. .........1.l'.............. REG'.IL.AT!'L ,S. " °`?"ET°�� TOWN OF BARNSTABLE H9Sd9TADLb, i b 9 BUILDING INSPECTOR MAI a' APPLICATION.FOR PERMIT TO �'................/r1,•••••••,• , !!/......� G..0�. f.,.�....... . ��`�'.,f?�..�-..........................TYPE OF CONSTRUCTION ................ In /� ............................... �.V...6;.�2e.............19;111...._ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby ap lies for a permit according to the following information: Location ......../.:1../..xg. ... �.......5'/.......... -�...`:f.:'...:..... .�.�...arn........................................................................ ProposedUse ............."..:.�j1_.y.....A .........��?.�.! �......................................................................I......................... v ZoningDistrict ....................................... Fire District ................................................................................. .......... �` �'./' �� /�••'••1. - Address .....�5{�G ...�)'ll Name of Owner .... l.. ... ......... /.. .�..// �...... Name of Builder ra-�ulro. ..:1�.' Address .......If . .... ..Y.��' .................... Name of Architect !, : .... ��r.......�)44 0....Address .....C�..r.��f��.5.......................................... Number of Rooms ..................... .... ....................................Foundation .......... ............. ...........�- ' ................................ 11 1 ,J� Exterior ..................�!1...'../,�. .....�...............................Roofing ........./' ! -.. (,,. / ..:..sue?... . '*,1... ................................... Floors ..............�.:C!./... ...................................................Interior ........... !„G. rl.... ~`, '. .......I................ Heating ......./..........4 fry.../ ...........................................Plumbing ........... ................................... ............. en- Fireplace ...............</; q.......................................................Approximate Cost ........... z j,..�%0��.:....—.. Definitive Plan Approved by Planning Board -------------------_-----------19_______. Area �..rr.... p�. .. ............ Diagram of Lot and Building with Dimensions Fee 7��'............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 0 3�. Z � 4 l0U - rr I hereby agree to conform to all the Rules and Regulations of the To of able r gar ng the ab e construction. Name .. .. .... .. ... ...... Phillips, Gilbert i j 1 18137vrPermit for - two story, , �,......... ................................... - L t `. single family Hwelling 1 ....L ....9.Map le ..... . .Street ...... Locatio ...:........... � � •. - _� .. � � �� •� West Barnstablei A Gilbert Phillips , '� : Owner .............................................. Type of Construction .,•,,.,., frame_/ ` J ............................................................................ Plot ............. .. ......... Lot ..........'.................... Januar 12 76. r (Permit Granted '- Y _119 r Date of Inspection . 7 ��11 7r9. , .. � Date Completed .4A . ... ..7� !19 r '� L PERMIT"REFUSED ......... , ........ ..�19 t ✓ ,,-S' - r ......................................... ..... . ... V .................... .. � �' .y r .T IV) Approved ......................................... 19 ................................................. ................ .......................................................... -��............. t �.ff. sir �) 43"t a ' E,gTl NQ- +a . •e a,y t}' pry `a ✓,F'z T Af30✓L PO.dD --�- �'L O T' oL A N 141Lj- LOCAT/ON S CA L.6 -,! �'�Q Z .GA T& _/2 3/-7S PLAN 361, C- A yL ok'_ CC}t:y dCT 1,97 M•al��a4. pqr'f. I NE2EgY CEPT/FY 7;L1A T T.yE EXiST- r'� IN& FOUA/DA r,'ON L0C4 T/ON 45 CbPeE qS SHOWN �vl7 q __C7_ _COti/FOPM Wlrq ' ��; TA.YI.t_tr ,� THE SU/LD/NG SETl3AC.L�,�f�Jl��,eEMf�/T OF 7, : TOWN OF RA 64& C Co.-- 77 Assessor's maps and lot 'numb '. ... �is THE To Se-wage Permit number :................ �......... Z BAE99TADLE, i Z 3 q Mne6 HoGse number .................................................... .................... �O i639. \0� CFO YPY p,. TOWN OF BARNSTABLE BUILDING INSPECTOR Iq�.APPLICATION FOR PERMIT TO .......... .... ....... . ...................................................................................... TYPE OF CONSTRUCTION ........... eo 00.......`. !!1!1 4.............................................................................. ................� ../................ 19� 7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit �a�ccJording to the following information: Location ......2.3 D.......t:/..lA.ple.... ..t... `��a .. ..., 1 ................................................. ProposedUse .......hei..4G:aRx? ....�...?A.Ik................................................................................................................ Zoning District ............................... ..................Fire District .................. ............... ........ ......./...................//................................ Name of Owner .1.I. .. .:..V filC�IIS..........Address .. 3.a...rn.! '�l,~.. s .....��"r..!�!. ....... Name of Builder ......Address .....`'. :.QQs• ..4...G.T!J1.4? l..LlLa. ...... . Name of Architect ...S"...Y. ,/J..�.�.!..1G ........Address ......Woods..44.�....),4,s. .................... Number of Rooms ............! ...................................................Foundation .......Pig."III..Z,24......;rv',FfV..IC_a&............ Exterior ......1/ . '��C1�lA.1/ ...................................Roofing ................ . 'l.(. ...................................... Floors .......... ..Q 4.�C.......................................................Interior ............ t C.GC..................................... �^ A, Heating ............. ...`►` . ........ ...........6A......................Plumbing ..............cp.A ..................................................... Fireplace ..............Ir. .........................Approximate Cost ..........:d-. .Q..C? e.. . ............................... Definitive Plan Approved by Planning Board -----------_------_-----------19________. Area .........(0.0..................... 7z 5— Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..... .................................... i ConstructionSupery Supervisor's License ....Q.1':.4?....��....... � PHILLIPS, GILBERT A. No 26 44.... Permit for ..ADDITION .................................. .....Single:le,Family Dwelling .... ........................................................... Location ..230 Maple Street .............................................................. West Barnstable .............I.................................................................. Owner Gilbert A. Phillips .. .............................................................. Type of Construction. ..Frame........................................ ................................................................................ lot ............................ Lot ................................ Permit Granted ...September 71 19 84 Date of Inspection ......................................19 Date 'Completed ......... . 19 � 5 Assessor's map and lot number . .,� .. .. � �.. .. ... Bpi THE Sei (age Permit number ......................... ................ .1�!....... . EARBSTADLE.r a tH,ouse number .:....:.....:. b M a� TOWN OF BARNSTABLE BUILDING ANSPECTOR l'T"I cs . APPLICATION FOR PERMIT TO .....................................................................................................................:......:... TYPE OF CONSTRUCTION l P a ................:.P ...... ..............19. .. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..... .... .. .. ... .. - ..... ... ...,_ ................................................. ............... ProposedUse ......... .............-��?'.�........ ../.�...!�%lR................................................................................................................ Zoning District ...:....................................................................Fire District Name of Owner 11..�.CJ.QlI.N..... `S' /�.�(�!(. S .......Address ..� .alt!'.. ...... :..!�.(i�:IZ!4�....... Name of Builder :/ �A .. .s .:e ... ��. .� (.�r.<.. ......Address ..`t :.Q .'l> {!l, !<1lL!l . Name of Architect ...�?.. 5 .lX.�� ../4)..� ./� 1i .5........Address ...... .�� !,S...f c�: .! ....!//... -..5 . .................... �. .� L Number of Rooms ..............�.....:..............................................Foundation .......P .L4..f.►—?.4......1'.C�!ip? ob:f,............... Exterior :.....�. C�gr'X a.. -art�i.. Q. Roofing �.r G .tom .. v Z.., v .. g .........................' A _ . :,. .......................... ...... Floors ......... ( ..W.t.. ................... ..............................Interior ...........:. :. .Q✓` .�PLC.. ..................................... HeatingtU.� r< !.1..........! a ......................Plumbing ............./ !� �•. .................................................... Fireplace .............. 4..........................Approximate.Cost ..........�.-ac.l," ............................. Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area ........".. rr).................... Diagram of Lot and Building with Dimensions Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH i i y . t ,a OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS " I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..... .!. .....:( k "` Construction Supervisor's License ... .1( �...�(... PHILLIPS, GILBERT A. A=132-25 + No .A%4 Permit for ...ADDITION DV1e111415....................... Location ...230..k1aP-.e..S.txeet.......................... West Barnstable ...:............................................................................ Owner ...Qilb.eXt..A,...Pal I P.S..................... Frame Type of Construction .......................................... Plot ............................ Lot ................................. Permit Granted ......... .......19 84 Date of Inspection ...................:................19 Date Completed `'