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0181 ARROWHEAD DRIVE
1 �� d� � � \ �- tj12,41 Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 r _ 3/10/17 Town of Barnstable Thomas Perry CBO 1 Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permit#B-17-366 3-11 TO: Building Inspector(s), , This affidavit is to certify that all work completed for-181 Arrowhead Drive,Hyannis has .een' inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a Parcel ®$ TOWIN OF RARINSTABLE Application # Health Division .; 12: o Date Issued Conservation Division Application Fee cc �j/� - Planning Dept. ., ,. Permit Fee y5 V y Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village 4 oAnn ii Owner rnrnje, u� �I Address 5 &In 6 Telephone a �� �� 9 .Permit Request (4.1 1 cek\yAo)P, - 0 -4 c FICAa k'I [\;T1 ion to rt Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION I (BUILDER OR HOMEOWNER) Name �'III`ti M l'i c���F Y�' e Jars c Telephone Number 0 3 9 Address Tilll�- O n p ,fb License# 1 C l 00-�- Home Improvement Contractor# � g b Email Worker's Compensation # W C A 5 S g o fob ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �,�f tYW 'h SIGNATURE DATE S FOR OFFICIAL USE ONLY `APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION:_ FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. a HOME OWNER WEATHEBMATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. 1 � ' '� " `v ' ere consent to and agree that weatherization work re may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: 4-1 4- The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic&basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. 1 give permission,to Housing Assistance Corporation to access the property with such N equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis.for no more than five(5)years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature) Home Owner email Date: r Agent:(signature) OAA Date: Weatherization Contractors: Y'L" Adam T Inc Cape Save All Cape Energy Frontier Energy Solutions Aftemative Weatherization Lohr Home Improvement Building Science Construction Tupper Construction Cape Cod Insulation `• •,....4, .�,.., �� Mgr Si'"���i #i• �t. ''�!*! .1��i�.r.(a.3v :�: �,'_I��-s� �s�;,��. � �•,f'� • ` ` ;- ,: .r, r• -1 ;The __ ` t Comrrivnweiilfh of Massachusetts,,r a'fl i' t «i?+•; tC'i3 l,i i trr 1 Deportment of Industrial Accidents Y t c t.r •a .. 1 Congress Street,Suite,400 r..a A -`•1 , . :. s: Boston;MA 02114-201.7 i�7,51 ':�z. <aC A'. a`c Jr tYt: . ri' r^ ., •r t� ct r �t a ',rear;e+ f l. llvq 'L 7)'I www massgov%dia °•,r. s t rnelr'- _ .p , _ - . @r's ._.. . ..._... �._... -N�'arkers'Com ensation.Insarance:Affidavit�Builders/ContractorslEleef.ikians/Rlumbers. " TO BE FILED WITH THE.PERMITTING AUTHORITY. ApnlicantInformation Please Print,Legibly ; } -: . . 1 Cape Save Inc V. • Name(Business/Otganrzatton/Indiyidual) I ! t•'Y 4, rr ,,•"x _ ? t_°•I. F v scar, .� a °r"fi. .. } I Address-7-D Huntington Avenue r r a� t South Yarmouth, MA.02664, rj ., �, 508-398-0398 r City/State/Zip. ;Phone# r ; Are you an employer?Check the appropriate box _ T, _ _ ype of e project(rquired x '_ I am a employer wrth 15 "x:employees(full and/or part-time)* fir_ t 4 p + s r 2. I am a sole propnetor`or partnership and'have nti employees.workrng,fo me m a' New�cOnstruChOn 8• i —) any capacity.[No Workers'comp.tnsurance required] ,}•'' ,•;!�,� `<<y ;y^ki'�.Ft ,�,ii:,hlt,.;t..l's? ....{,,': ,, c,;. �,w❑ -' 's , 8."Q Remodeling » , ` 9 r Demolitlonz,ijv •s,r. , r":k+; �.r .,";... .{, ."i,tt•,rt'r-:'" ` .wJ s, 6 3.a I am a homeowner:doing all,work myself.[No workers comp.insurance required.] a F ' '.'"' s,40,a Building addition = :' 4.❑I am a homeowner and will lie hiring'contractors to.conduct ill worts on my property. I will-"` ,+r ensure that all contractors either have workers'col ipensation:insurance:or are sole 11:❑Electtical repairs or additions ` ] t 't proprietors with no employees. 12.❑Plumbing repairs.or additions " r r p 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached These subontractors have 13 J�Roof repairs r n c employees.and have workers'comp.insurdnce. •T - i .. , 6.Q We are a.cotporation.and its officers have exercised their right of exemption per c 14.Q:Other lnSulatlon 152,§1(4),and we have'no employees..[No workers'comp.insurance required,] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation volicy 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 thoseentiries have ; employees. If the sub-contractors:have employees,they must provide:their workers'comp.policy number- Tom an employer that:is providing workers'compensation insurance for my employees. Below is the policy and job site 1 1nfOr)1tQflon. _ s._B .. -_... r 1 lnsurance Company Name:'- Star insurance Co. Policy r 4, #o.r.Se. .f=ins Lic:-# 'WC085540700 ,Expiration s"xt''�"�Date:_4�/9/ 031 71'4"`` JobCity/State/Zip: Site Address:181 Arrowhead Drive ,ra;,•"t,• City/State/Z p Hyannis + .H Attach a copy of the workers�compensatiion policy declaration page(showing the policy number and expration:date)., _ Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as.civil penalties in the form of a.STOP WORK ORDER and a.fine of up.to$250.00 a ..__ day.against.the.violator.A.copy of this statement may be forwarded to the Office of Investigations of the DIA•far insurance- coverage,verification. rz: t; 1 a rr`i�, .r ^ :. e. t , . fS: ...,... _. I do:hereby certfy undeth ans adenales ofper�uiythat the information Provided above is true and.correct { 1 Signature: Date: 2 8/17 Phone M 508-398-0398 t r Official use only Do not:write in thisarea,to be completed by city or town okcial { City or Towns r � > ' , = ""�a"A r°.1�zte' Permifticease Issuing Authority(cirele one). 4""`"zl'k i.Board of Health 2.Building Department 3.City/Town`Clerk 4.ElectricalLnspector 5 P.Lumbing.Inspector T , f 6.Other r�,.. .at airs :ra; •. I ` - r..►.s_C' sal ..�. ;x,.tt Contact Person: Phone#: 1 1, ._ ... .. .. :. .... . .. �C�® DATE(MMIDDNYYY) �� CERTIFICATE OF LIABILITY INSURANCE F10/2a/z0i6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer fights to the certificate holder In lieu of such endorsements. PRODUCER NAME: Colleen Crowley Risk Strategies Company PHONEE (781)986-4400 FAC No:(781)963-4420 15 Pacella Park Drive ADAILSS:ccrowley@risk-strategies.com Suite 240 INSURERS)AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURER A:Liberty Mutual Insurance Co INSURED INsuRERB Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc iNsuRERC:Ohio Casualty/Peerless Insurance 24074 7 D Huntington Ave INSURERD:Star Insurance Co INSURER E: South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL16101422377 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EF POLICY EX LIMITS LTR POLICY NUMBER MMIDD MMI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS MADE OCCUR DAMAGE TORSWE15- PREMISES Ea occurrence $ 100,000 BLS1757246490 10/16/2016 10/16/2017 MEDEXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑2� LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILfrY COMBINED SINGLE MMT-- Ea accident $ 1, 0,000 B ANY AUTO BODILY INJURY(Per person) $ AALLOWNED X SCHEDULED AVNX46796600 11/6/2016 11/6/2017 BODILY INJURY(Per accident) $ X HIRED AUTOS X AJJTOS NON-OWNED _ P 0 RTYDAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LIAB CLAIMS-MADE ,!') . �i e AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 US057246490 - 10/16/2016 10/16/2017 $ WORKERS COMPENSATION r Officers included for �( PER OH- AND EMPLOYERS'LIABILITY ) I y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N❑ NIA D (Mandatory In NH) ' WCOBS5407 4/9/2016 4/9/2017.^ E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Evidence of Insurance / Insulation-Specialists; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Barnstable County ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact - � • 460 Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02061 Michael Christian/CLC �� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) all if Office of Consumer Affairs and Business Regulatlon` 10 Park Plaza Sine 5170 Boston,'Massachusetts 0211 b Home Improvement Contr'' Reglstrat>ori Registration 1;71380 �-z Type Corporation 170, � Expiration: 3/14/2018 Tr# a19391 CAPE SAVE INC. r 4 WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH; MA 02664' `Update Address and return card.Mark reason for change. . Address Renewal t L d nip to went os .Car SCA 1 gib: 2OM-05/11 �� - .. ❑ C' ❑� y _ ❑ - �l7C�671L777477Lf76CLllll Q����CL:i3CLCJ7 t/:iC a� Office-of Consemer Affairs,&Business Regulation License or registration valid for mdividul use only _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found`return fo Registration r'1713g0 Type: Office of Consumer Affairsand$usiness.Regulation 10 Park Plaza-Suite S170 Expiration 3/14/2018 Corporatiod Boston,lViA 02116 CAPE SAVE INC. ; WILLIAM McCLUSKEY 7-0 HUNTINGTOi9 SOUTH YARmou.TH,mkb[2 64 Undersecretary NotvAlid.wNtsignature . Massachusetts-'Department of`Public SafetV Construction Supervisor Specialty Restricted to: board of Building Regulations and Standards CSSLAC-Insulation Contractor . 1 • n.._.___• r_ .... l.tlllll l li1i11111 JLI/C).Y 1�111 JIIGI id_ILY" 1 license: ML 102716 f n WII.LIIAM JMC 4-tU 37 NAUSET ROAD � � 7 West Yarmouth 1NA , Failure to possess a current edition of the Massachusetts J,,(,;,;.lJ. •:�i ia. Expiration Failure Building Code is cause for revocation of this license. Commissioner 06128/20.17 DIPS Licensing information visit:WWW.MASS.GOV/DPS Town of BarnstableRES S*Per, # ' 1s�3 F-Vim 6 manm is rs e Regulatory Services MAY 2 2F2 a,�varner g. KAM Richard V.Scali,Interim Director TOWN OF BARNS SABLE Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY er Not Valid without Red X-Press Imp'7nt MaO/parcel Number OZ 7 Property Address kt Anp�[,Residential Value of Work$S Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address w� Contractor's Name S O u�PfN Q l j vte) ENN/ oX1 Telephone Number �b�—?�-�` �goo Home Improvement Contractor License#(if applicable) c�/17�`f� Email: Construction Supervisor's License#(if applicable) 0 /�7 70 7 XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner AI have Worker's Compensations Insurance n Insurance Company Name A%0^ nA) Q QII�UJ Workman's Comp.Policy# wC 1 a-- !,3O &- S 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) . ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders..U-Value • 3a (maximum.35)#of win ws #of door . Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le.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. t • SIGNATURE• TAKEVIN MBuilding ChaagesTXPRESS PEWITT)PRESS.doc Revised 061313 Renee �!t3 isisc sl,Y�.g b' , `'C Allim1m Rr�44��€d iltm, 7,p F!41 idle=� a+ �i d�.ce-os Neas':���ea��i�u@e�e�,lLd d;►"drl'a. I Alm AmdarsimdCUSTOMWINDOW AND bbOR ert Sudat�ee�,.Kf�,� -��anctl 2Z - MqT Lift t.5 W-gr(Cl 4A&irt&4C'r $cm:jrtjtV-C�o7ee' :9ac AP, tea P tea ! �_._ _ -'f•"�-�• 1r4b w c�gi E'�c' Y I�,n c � .�3hrnt iiz F'taxdsL�Ii�Ia>�xura � a�t(3, �YitinCg;�l t5�m itssr�u3ed .nanrc� 1 '�1�" mur9 t�17Ia6t ral i,�tl+�IwY L�F�n+Lio;{Lut4��(' Fil1:i5�$std� mu �im�trr�fixi�`u Ili tPrips'61adl mm -04 '. 11[ -ifi r.eci hl mA nn tW 1aik 19wc1 sl )i ,ilk i (atIJa_clikvl �IkQQ il:%a+*r°1ta"tils} 17 stora aeoet} H31 tt� • Taul a4,ngun Fs irrixOd�uftftEpi @tEai,�a�4s� ktiet3CAff vj*"t Rem" iavd 4�3 �. mii+rim it Sari aI'ju _ Or4m OflioftioD'rnd<C a�aaa� 1 )vy,swwm, s Este teri L law '0 8 i` 4 Job m#A tin Bal�ggq eIS, of wic era,be ngda ea%&. i cdmpt rlyn Of.1 ,�d.�,ao f a dt[ d �u c ® etee5�na1 aldedaQl>�lso d�g1[1_ie5t, ` �enB - y e w cg ¢6 cif ��s1�u�im—tixog 1etweefi di ke N.klhd�t. hE>nE �ec5�. eh , Eegdzarl� o�ympAu spy of chi cans at chip.. msmr +Ec�s� Its. j&ji 1 p ridW �e�y a�Erc3��+# tez of t irs•.rcra 'v ;andl e� +r+edl a'co�� ti3a Inc➢dd:- -60��th s;�l sectzx e�►i,Ilz,al c1s6� �t at le 'lY� sc o eell�ri�,�,On dui e:ttasl r rd 4R� d dfdaa,ryd� �f to ear, a eOcan�PilEhi� erae ca _fi Ti MN THf&C�1+1 TUAC'IP.W.TH s ., 3� RAWKSPALCES, ��acFt �a�Fcem�es 4? 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" ''` Expiration Commissioner 09/08/`2016 CJf!�' ((%CUli`1.172C✓/'1/,U�'CG/�3"l 4�u!'�CtriJflC�ILC;If���,i a-} Office of Consumer Atlairs and Business Regulation 10 Park Plaza Suite 5170 Boston,Massachusetts 02116' Home Improvement Contractor Registration Registration: 173246 Type: LLC Expiration: gn9i2o16 Tr6 2W352 SOUTHERN NEW ENGLAND WINDOWS LL MATTHEW ESLER 26 ALBION RD LINCOLN.R102865 I Iprlate Address and return card.utart reason for cEange_ scar o mu nrru Address []:Resmai [ Employment ❑Lort Card �e.TLerumvnu�n/.Af c�f{�u:ra�ri.;e(� i�0■tree ofCoasamsr Affain&Desi—RgaL6on License or registration valid for individul Use only ME IMPROVEMENT CONTRACTOR before the expiration dale If found return in: gistration: 173245 Type: Office of Consumer ARairs and Business Regulation piration:--9.42016- LLC 10 Park Plam-Suite 5170 ._ . .. Dosto'VIA 02116 SOUTHERN NON ENCLAND WINDOWS LLC: RENEWAL BYANCERSON MATT11EW ESLER ` 20 ALMON RD UNCO-N.RI 02865 Undone: mq _ Not v lid sritbout signature i ',: ERTIFICATE OF LIMILITY INSURANCE, WN CERMCAM IS IMED AS A NATTM OF WFORRTIO➢V OXY AND CONFERS NO RWHN UPON THE CERYWATE HOLUM 7W CENTUgCATE IM WT.AFFIRMAYMY an PIEOAT9l'ELY AMM EXTBID OR A01ER THE COVERAGE AFFORDED By THE POLICIES BELOW THIS CINt'B FICATS OF MWRANCE DOES NOT CONSflTM A COmiR=®EBfEN THE mum mmwm Ald mommu, REP99NNTATWEORI AM in CEItTMATZn - .II =rA -L�. Iotda -psnk�IT#9P t YPob s 1t slDrsed. Yr �. s gB cmuftaft holder In llen oto � PRADBt?8iMilia a£lien MmmW Zae- C/a 26 Cnat=r Blvd PHOW E-O. Bma 305M - 76 :Yaab"UQ. = 372305231 DB8 arawi99�n-cam of ffi 35926 munwSmxthmcm Mw Ragland Wiadasa LLC'. EL'63F$. .S AS019 fll9/a a"1enal by An6wown 36 AIM Rana - umampayffmomt mumcanm ammany mum _ U t,. unca n. sm 02e65 09SURER D: 4 POURERE: f• COVERAGES CERTIFICATE NumBwtgm2s1a0REVEMMUNUMb Tm ffi-M OAS'7MTTHE�fii'i ces OF MdRAME i.3S�BELOW 1AVE BEEN 1SSUM TO THE HORM ARl9M.ABOVE FM V6PWgf PUM WDICAM. NOT'MT)WAMNG ANY JU=AF JW'T.T ?QR a"' MR=OF ANY ww-=RkCT OR OTHM f MHMW VM Cr To MR"mis CST;:KAY-BE'fiSLiEt3-QR MAY PWrAK IM 90JRUM AFFORDED 3f T+fE,PM=W t .e WJBEcr.m ALL Tm 751w DOWSWM AN€ C00MONS OF SUCHPOUtjES.L19I13$SHOWN MAYHAVEBEF3d Rr iiC i SY PAil7 CAlNP3 i T7P8OF09SMAHM POLICY !m arm mpva - E• S tK CQ�pERCCIAI.G8�3l.11ABBJfY � - ® iQOf E $ 2.9"'"D amommslOc. PR6dLLSES $ 100.000 ! - 8e3?ERP(Ney 9i 20.000 s anas<ss. �0alla/aol$�De/aDlaD16"pay $ I,oao,ODa am AEHdT�-EEE#iPaTl f PSZ GSERALA A7E S 3.000:O8D x I.LlC... 1 �.C.OkfpA�►A� $ 3:00D,8D0 Oi7tF3t ¢ AUT02MO ELWBWTY CTM VNGLELIW pi 1,000.000 $ AWAUYUALL BD�LY9t�111RY(Ptrrpersort} $ 0 AUTOS S 2029659 09/20/2019 0B/So/2015 BWjLyWjRy(FVr8cdjw4 S AO .KSSAL'fOS mAum $ s IIixitR . FACIi4C $ .. 5,060,90E MMMMC LL48 IAIlSSM OE 6 2029853 08/10/2014 0$/10/2015 AGNEWE g 5,000.000 , Rr�s3rrsont t3 At�EE1Pi LIA®Bi4Y via x AW F-LE CHACC99M S 1,Do0.O0D E71CW016r1 H pile► 0000066028 09121/Ral0 00/21/2075 0 Oda� 1 . � EL. -EA€I*r"'ia S �"'3.000.000 /83tk"036 t�Rz .�Tn. Auvidmt6Y. > tc+tatvsy LimiCa R.L. Diaeaee policy rat-$1,660,090 L Ddpeeo Bs- apur e- $2,000,000 �iiPd�T�NS/L$ChYF�tYl09C�(gI2SR0 tat,Ad Sd ,0�ba00m�a8pmmpt a . S ICATE HOLM CANt LtRTTON 8H*=AM0PTWA8OVE PQUMSBE B�DRE THE E1tPMMM &4M UNWJW, NW= Y90.t BB UUMMM IN I :TSIE@OL�v . AUTNOl0agD Rt�R£8ENTA7ivE ` 6a0tbssa sm LiC a6 atb3m Baca ,�, ' ea]a, RS 01B66.DOD0 099"18ACORDCO TMIL All ftft iaWvQ . ACEIl��S 9�69� The ACORD=Me and logo we re end masks Of ACO18t1 sB IDs66$9635 s?�v�a8ceeb$o S96i7 otIN, Town of Barnstable *Permit# C Expires 6 months from issue date Regulatory Services Fee + DAMSTABLE, MASS. Thomas F.Geller,Director s61p. �m QED N1Ar A <. Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY . ,Not Valid without Red X-Press Imprint Map/parcel Number Property Address, % -� residential Value of Work f 17OU o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address I V1 M f e, —R ' 2r �1'(�� Contractor's Name -!�044erN A f, tVin �S �i fQ� L`// A/0;telephoneNumber 110 �� V Home Improvement Contractor License#(if applicable) 7 3 7 '° °' Construction Supervisor's License#(if applicable) Pa �-•�+ v s I tl (workman's Compensation Insurance NOV ^ $' 2p13 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [have Worker's Compensation Insurance TOWN OF 0, RNRTAYNA Insurance Company Name 5 Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit Permit Re uest(check box) [� Re-roof(hurricane nailed)(stripping old shingles)AAll construe ion debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) • i ❑ Re-side #of doors replacement Windows/doors/sliders..U-Value 0 p 73 O (maximum.35)#of windows D— ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with reed S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. r ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: t C:\Users\deco)likWppData\Local\Microsoft\Windows\Temporary Internet Files\Conteht.Outlook\QRE6ZUB14\EXPRESS.doc Revised 053012 Via,. C "�., .:,u The Commonwealth of Massachusetts ° Department of Industrial Accidents ¢' Office of Investig,ations 600 Washington Street ' Boston,MA 02111 www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name(Business/Organization/Individual): 146 Address: alblotj 90-a ~ p• t��86S Phone#: City/State/Zip: Ll/l/CDfIN.� /� .� Are you an employer?Check the appropriate box: Type of project(required): 1.[1 I am a employer with o2 (7 4. I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling, ship and have no employees These sub-contractors have g, []Demolition workingfor me in an ca aci employees and have workers' Y P tY 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. 0 We are a corporation and its 10.0 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 i2. Roof rep 'rs insurance required.] t C. 152,§1(4);and we have no „ employees.[No workers' 13. Other ac=L 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Al-40AI Ul-a,�Je,eas✓ Policy#or Self-ins.Lic.#:A' 75 �O 3 S02 3 Expiration Date: d a Job Site Address: l O F _r Aety _Prl V4Z- 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification., I do hereby certi&under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: D Phone#: L-10 Official use only:'Do not write in this area,to be completed by city or town official " City or Town: m Permit/License# a lssuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town,Clerk 4. Electrical Inspector 5.Plumbing lnspector'µ 6. Other „R . y ; Contact Person: Phone#. a Southern 'New. England Wind t do , d:b a Renewal by Andersen' of $NE , _.� •, Massachusetts'-Department of Public Safety-. r" Board of,Building Regulations and`Standaids C(histruction Supen isor; License: CS-095707 BRIAN D DENMSON. 7 LAMBS POND EIRC�:E Charlton MA 01507 , • 'Expiration Commissioner ` _ -," 09/08/2014 IT • xr ��r Office of Consumer Affairs n Business egulataon 10 Park Plaia-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration F Registration: 173245 ?y r i -,r. Type:.Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL"' FwIraton: 911912014 , DENNISON BRIAN •1137 PARK EAST.DRIVE " . ' 4 WOONSOCKET,RI 02895 ` Update Address and return card.Mark reason for change_ '-ScA i o roucvn; °,° - 0 Address: Renewal 0 Employment 0 Lost Card p _ Rice ofCo s mar Again&Badness Beanlahon., License or registration valid for IndWldul use only - - OME IMPROVEMENT CONTRACTOR before We eapirotion data If found return to: - Ofrice of Consumer Affairs and Business Regulatmn e Regisms n: 173245 TYPa IOPark Plan-Suite5/70 Expiration:911W014 w ,,:n Suppisment.;:erd ' B ' ostoa,MA 02116 "SOUTHERN NEW ENGLAND WINDOWS LLC. 6 RENEWAL BY'ANDERSON t, _ DENNISDN BRIAN ' -1137 PARK EAST DRIVE �` . —2�— Y+�� ° •. WODNSOCKET.R102895 Und,—,.ury- _ - Not-lid without signature , , .. yr. c ,. .. 4.r•. r it d Client#:30124` SOUTNEW' -. -A.CORD,M CERTIFICATF--OFLIABILITY INSURANCE DATE(MMIDD/YYYY) 8/0612013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR-NEGATIVELY_AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED-BY-T-HE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER - CONTACT Anita Little NAME: Willis of New Jersey,Inc. PHONE 856 914-4660 FAX C No): 856-914-1881 A/C No Ext: 1015 Briggs Road,PO Box 5005" E-MAIL anita.little willis.com{ ADDRESS:" PO Box 5005 { - INSURER(S)AFFORDING COVERAGE NAIC A Mount Laurel,NJ 08054 INSURER A' Selective Insurance Co.of the S 39926 INSURED INSURER B Argonaut Insurance Co. 19801 Southern New England Windows LLC Beacon Mutual Ins.Co. 24017 D/B/A Renewal INSURER C ewal by Andersen INSURER D': 26 Albion Road INSURER E I Lincoln,RI 02865 INSURER F.1- - COVERAGES CERTIFICATE NUMBER: j REVISION NUMBER:" " THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.: LTR TYPE OF I ADDLISUBR NSURANCE NSR WVD POLICY NUMBER MMNDY EFF MM/LDIDY EXP ? LIMITS A GENERAL LIABILITY S202945900 8110/2013 08/10/2014 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY :' - R MI RENTED a occurrence $1 OO OOO lk� E CLAIMS-MADE F_XI OCCUR �. MED EXP(Any one person) $1 O 000 PERSONAL BADVINJURY $1,000,000 GENERAL AGGREGATE . $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i PRODUCTS-COMP/OP AGG $3,000,000 1"- POLICY JEC LOC $ A AUTOMOBILE LIABILITY S202945900 8%1012013 08/10/201 (CEO accidentMBINED SINGLE LIMIT 1,000,000 _ X ANY AUTO _".. BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ] BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS I Peiaccident 1 $ A X UMBRELLA LIAB OCCUR _ S202945900 - 8/10/2013 08/10/2014 EACH OCCURRENCE $5 OOO 000 EXCESS LIHB CLAIMS-MADE - -- AGGREGATE $5 000 000 DED RETENTION$ 1 $ - C WORKERS COMPENSATION 0000068028-RI 8/21/2013 08/21/201 X'rwcsTATu- OTH- AND EMPLOYERS'LIABILITY B ANY PROPRIETOWARTNER/EXECUTIVE� AIC927818352394 8/21/201$ 08/21/201 E.L.+EACHACCIDENT $1 OOO OOO (Mandatory InNOFFICER/MEMBER EXCLUDED? N N A . E.L,-DISEASE-EA EMPLOYEE $1 000 000 (Mandatary in NH) If yes,describe under:w DESCRIPTION OF OPERATIONS below 1 E.L:?DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) i j CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southern NE.LLC THE EXPIRATION DATE "THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE-WITH THE POLICY PROVISIONS. Lincoln,RI 02865., • . .-..-. AUTHORIZFID REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. die r .,t ACORD 25(2010/05)i- 1 of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088 AXL, CLLSTOM WINDO AND DOOR REmi 1bM,NuG AAREFEMRINT 'sit _ ®. ...... . s.xn —i1.1•o•..a'f kalyopt" 61p°ri°y�!Il l w�ii"I:�I IYCI 4 �i-0.'t:n.tlt� rQM l 71T 11 I4 �I�ISIuf i 3 p rt SLi adlo1 3_ryi[rri Of&WthmvNinv F41;! -WL WirAdw,TJ tr r,nrl7=13OfrIru&rEel-Now Englol9tl'�"�'ivalcva�lp]ly'c.�Ct1a�t:£��I.^l°i'tL': -to'lSrn13ta��ij �-u-ICEy�,r.�+lesujLwdOnThCf_o-OWg1idtiter'�fiF�ra:�l .1reenleat,and c:ly du -i�itIr�cHl� �- C� H tfari 1 i_ �s TtaGfyllabAms ur tr , ', 6dil t5dSr�ti-: a c:.' ' Mathod -i ent 'LA a; Check j:Q.$,h orc—eG ' Ccsclit srr�' � el`c s��aes klr�tG —rnaxirnllln�i P3 af'cir} EIttnce st: 'Eau t of 1,ea f 3?Jy6rra1ecc rasa~tF rcee. CfetM tip Aeyna�em e&Yei*you 1C1,MQ t�je at�,a tie Wannm-ac 5ti^at t cf fob wnd the Salsicc on subsea-all , �alanc�e are sdhviaitcnl Can,-r—a s,y�tj�c�ur�ac oe rrMa:kk bycrack; : Cddbn,or but f3�' 'a` nr4dla r l:dk _ I + dk bank�es7Z;c+r cdh lht are uu Verbal unalersasndin . t t .ytgr�eMment�e�all WTI tern s nskis+e attfesi4a a Iaet4we+aa` t� -;,and,(hat' $ayTr(s agrees "undea'aa nd+s that $ any,of rh-e wermis of thus Aygrtensoat Rogeufa) aangwtl dlgoe that Bu tr( (11 has re..-cl tluib+ bgreemea ,nndc;erttsbritls lfte i,Erns~of thfe.Agrr�cment, anti,h 5_rem red:;a.COMPlct+edm skned.and did ,a*"of'this Aprenbe l,,!zAnding the two avtacw Nedeela arf C',anctil`seriv%an the date fish awerittra nlaq*and inform-04 of, cea riAt to asl,acalr this,d9rt"Ment-DO NOT SIGN T!HiS CONTRAUI")CT 7i'kl ME AMI MNY"I Rf.{IZ~r'11:,SIP11V^'ES,. (lhwd*lar axd'swes OREF),Nolke W,$v (1)Do ai..ot Ai 'this,atdrec'nQnt X MY of the f atidfaer chi amcd term rn shyextent a1r then,awaRWAD iaformatta®are:Left blank.(2)you Ares endd ed w*copy or'IMS A(pr+aarment at the curie you sign act.13).Voss moray?at any thnopay�ui1'thefirll,�fr4, bala► due vaAer dub ASneent*ot;and"yin to tilai'u�gyvu�Y�cal tltdt,o c cca y ax r IbQ[a;9Ti 44�azae and raara t ,�luar elr.(`>t�'ll'br,.ss±lficc',has:no Might,to r1 Wallo ll~y enter your or,corn.-4t any brea-t,.of&a peace'tar rep0*8• 99-Rds,PurdmSed.under hio Agraipiaww, (S)you lftfi,)t cancel thhis Agnemedt if it h8s nut peen migneAl A Cht nwda ova or a branch of t"of the seller,provided.Tau,na if"sel er at,Ms or her insi s office Or branch 1F�'OCtf awl b the C BF3 fr1CSACa ONCer Med. wh`IkAdLU {� @ {C�tti.1►1 ffikeC 6 AnrL1�11If1� �It ad Q third ca cns$$z dad site r t7 e�dayrr on 11eh IkYtr sigma tire:; Bement,exthu in S.Udd*;r and any hot dz�an wthi. . rcgpfiar,ena-1deliveariex nre not,Ana. . owsn� n ice of c-Batlen.£orm,%r'nn,c 191t6t eurof-buyerx rlgib�1: Tiuy t-ass 2d`[L_[ 4 Ta r uat dlon jaxx lal-s r�rr_ni;c d.Icy-.tlac l j:j1j&JhltMd C iimoraiaor%R ,;"lua,. y�ii4 Renewid bf n.Of them "16w E4A Bu:yer1I'm$ , .o _ i netts _ :ulmwr % A;rt �oy�Lelwtt'�L' � 04 p'sal l N."kaiw`.of G w-da�:a N-Poi3r ra Tp ICI +TitIY"' _ 1?ri MI i ;l sic YouJ TM, ,BVv Il(6"ja MAY Q;J�4,1�°'(�' I� THES,T,I CTION AT 1,l 'l1,`MI N . , OR, TO ?M�1l�F MIGGIEW OF THE `!`T��L� ]BUSINESS.$):+�lc, TEE DATA;OF'TEMS TB� ACTION.�ZsE'L'.H9 ATtACHE ]1tiQT�C�,�IF "���1 t AT ON FORMIS - - - - NOTICE OF CANCELLATION �h �'O7 ��CA'1�:CILLA r� I (Date atfTraanacticn I�i7 .�1 -*au m*yt cancel �, Date of Transirctiork ' You Mays COM"t this ermi nctian,wie4� t any Panifty' or obli'xat ttrar writhin this tran scttan.wic6eout einye petraltlr or obtlga6wi withi'�n. ehra I Mslna z dam a awe,P�RfE„If you a bttl,any t. thre IL�rc+Sittles frornt thie,abo"date`If you cancel,arm pbb'�m- - trasled rel{,a y nrsrnts Mmade l under the; Ii pr party tt" i�d n,' ' payments I made by grata tirades o C'ontraet or Sale,aeld W IltgddAWI it instrument ex*cutedi I Contra&or Sa;le,and � na��vfti le lI n#um. ent executed) by you will be returned,+a+ttllirr ta2ri Itttsiare ii t s,tollirw n� II jrftui vrlll be rwaturmd wfthlrr 6uslttc iCrlla riasg reeelpt by thai. Keller art your apt teJMsttiabn natir ,it anyr l receipt': by- clue 'SMelr�er of tour cancvtlatd4tn nook i lard,MY Isrtc re urfty intest arkingj; out of t tie transaction welt Ire, wacarity inte est, Wiling; out 'ef thte tirearsactian will tam canccictf,l6lrnrr cancel,yrou imUst rrl4*xw-&lI b6 tq thi m Seller � -ca nceled.If yrou c-ancel1 yrauI n?tUsjt n�aaae w4i'l lblt:toth.'a!Soler at rMr resldimce,Ica substaatftlyas Said t;aebd11:10A as WhM I' at yrt3ur aeid''ence,,in subatanidally gas good)co.vi iticin ail.wherh r. i,l dl.a gads srepl+�rsrddi to yrrror asides ilhis Cunt, x of i1 reaolved,;aeryr gtwd's ftlivemd to you winder tl44 6attiMtlracir or Sale-:Or,you r if ,vd-4,,comply With the l bsewt ins of I, 'Sate;or yrau M,a at y��wti�b}t,ccset�i�iyr with Etwe lastruationls of t h*:S*I lnr regalydinlg tho return shipment of the goods a tho "'Sailor r egaidinj the;a�r�Mrrb sitiprb ie,t art tMhe +aos at tM Sell{ee° a;icysr;it d rlatt,If yrou do,M' ake the s avallAk �� 'Seilli4r5b tx r>�ind rick.If you&-make rho glo�ds avall�lble to the Sel err'arbd dw Seller d'�s not ptclt t m rip b Rhin to the, Seller and the SelJOI daft 06t pl'tla.tMhern up wriM:hin twenty/da asf the d 8f tsrYe ltaittiar�y'yfau may Maine or I' t ebfhy� cl'eyt ilf tite sta#t of canpCIlation,yteu t>�X tetaGr 9f d srpose of the Said. 's widtoet*ay Nr¢Ino>F �oblfgatf�".if YOU i dispose of the goods withorre any further abligatiorL If you fail to make cite gorids.ab!alla6ie ta5 t #epee;or if ywa:fie' l: fai too:n nuke the goodsavailarbre to the Seller.mr if you agree to return the goods to the SOW sndl fall'to d'o.�then you i tam to re the goods to o the Seller and fei! -w&a,,.thorn you awrnaYin 'liable for performance of ail obligatiltlGtt ond`�C ft t re", in 'I le for performance of,a_lll obirgadons under the ContramTo cancel thfa transactl'on,rnall a ekli~- ai sG grind Cantram1b,rance'li this transacdon,Mr ail or delirelr a s;xrvvd and; dated', c9w of this cancellation notike or any Ahtir I lard daxp- ,rants of cih;la concol]s<tlan nades er :tKwr neit-ow ter° Town of BarnstablePennit: j LL _ Expires 6 months from issue dnfe Regulatory Services Fee —� * RAIMSzAsr i MASS. � 1639. � Thomas F.Geiler Director Ar �aim Building Division.. Tom Perry,CBO, Building Commissioner, 200,Main Street;Hyannis,MA 02601 www.town.barnstable.ma-us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION..`- RESIDENTIAL ONLY Not VaUd without Red X-Press Imprint: Map/parcel Number . � 6 � . Property Address, kv MA, A, Residential ..Value of Work s e D °Minimum fee of$35.00 for work, under$600'6.0 �3 Owner's Name&Address. t-- 1K r P t�((�p�u : - �:$ ( ry DW ke- r— Contractor's-Name bS-eAk' K f�j l 9 Telephone Number"Sb$- 71 S'6,L4 4.g Home Im rovement Contractor License#. if applicable, ; P ( ''. A.So S o g Construction Supervisor's License#(if applicable). (` SS[, "`O 5 I L(d IT ❑Vdorkman's Compensation Insurance Check one: sl I am a sole proprietor _NOV. — 7 2012" ❑ I am..the Homeowner. ❑ I have Worker's Compensation Insurance Insurance Company Name TOWN ®F SARNSTASLE • Workman's comp.Policy,# ' :Copy of Insurance Compliance Certificate must accompany each permit.':' Permit Re Vest(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping.:Going over C: -.existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders U Value (maximum.35)#:of Windows, ❑ Smoke/Carbon Monoxide:detectors 4 floor plans.marked with,red:Sand inspections required. Separate Electrical&Fire Permits required. *Where required. rssumce.ofthis permit does not exempt compliance with other town deparimerit 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: 41 .Q:IWPFILES\FORMS\building mrit forms\=RESS,doc s° Re 053012 t Revised 1 The Com7nanwealth of Massachmsetts artrnent o,f Industrial Accide Office of Investigations 600 Washington Street _._ Boston,AM 02111 nwn,mamgovldia. Workers' umpensation Insurance Affidavit Bu'dders/Con#ractursflElectricianslPlumbiers Applicmt Infarmatian Joe King Please Print Lmblv 36 Checkerberry Lane Name West y......euth AAA 0 72 r �pri.�TT�TTT70GlCi'I�viTTv�`Hr Addrm: Phone: 508-775-6448 CitytStatdZip_ Phone# Are you an employer?Check the appropriate boa: T of project r 4. I am a. contractor and i Type: p j (required) I_❑ I am a employer with. ❑ .. 6_ ❑New consirucEion employees(fail andlor part-time).* ha'a hired the sutr�lsactors 2.. am a sole proprit:tor or party- gisbed on the attached sheet. 7_ ❑Remodeling ship and have na employees These.smb-contractors have g. ❑Demolition w far me in any capacity. employees and have workers' Diking Y tY- 9. ❑But7ding addition [No wodmrs'cDrup.insurance comp,inen nano-0 - required_] 5. ❑ We am a corporation and its 10.❑Electrical repairs or additions 3.❑ Lam.a hameoimxx doing all:v k officers have exeidsed their 1 L ElPlumbing repairs or additions myself. [No workers°tx�mp- right of exemption per IyiGL 12.❑RD of repairs msu ante required,]T c..152, §1(4),and we have no employees. o workers'.. ; 13..❑Other . comp.MSMM MM mgUka] '1Yay appiic�t that cheer boa#1 amst also fill out the section below showing rhea wodiets'cam sa peatiau.policy infarmatiao_ Ho®eoarners who submit this afid-4t ia,&cating they are doing ail work and rhea hire outside cofactors noel submit anew afdawk indicating such_ tconttac m tLat cbKk this ba x meet attached as additional sheet showing the name of ire sdb-r�and:state whether Drum those entities have enviny s..If the sub-caat[Rctorshal —pioyees they mimpuvideth&worlcen'comp.poUrcynumber. I am an employer thatisprmifding workers'coegrensafioll.insurance far my employees. Before is thapoUcy amid job site. informadom Insurance Company Name: Policy#or Self-ins.Iic_#l: ExpuationDate- Job Site Address: CitylStatel7ip- Attach a copy of the workere compensation policy declaration page(shoring the policy number.and expiration date). Failure to secure coverage as required.under Section 25A of MGL Q 152 can lead to the imposition of criminal penalties of a fine up to$1,500-00 andlor'one-year imprisonmerd,as well as cavil 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 Ex-awded to the Office of Investigations of the DIA:f w immuim coverage verification.. I do hereby cgmi,under the prime and ponahiss gfpedutp that the informadon.prati&d above fs true and carrect si Date_ Phone#_ b ? S' to t?, use only. I)o�not write in this arena,to,be completed by city or torn offiribt City or Town.: PermitUcense If Lw ing Authority.(circle one): . . . 1.Board of Health 2.Building Department 3.City[rown Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: 6 + 2ARN3IAHLEI+ 9� ' ,� Town of Barnstable AIfD M1A'1� Regulatory Services Thomas.F. Geiler,Director Building-Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder - r I, as.Owner of the subject property hereby authorize �0 CL to act on nay behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) MAZY six a e of Owner Date Print Naive If Property Owner is applying for permit;please complete the Homeowners License Exemption.Form on the. reverse side. I QAWPFU EST0RMS\building permit forms\EXPRESS.doc Revised 051811 t IKE Town of Barnstable Regulatory Services HUMS'-4214 ' Thomas F. Geiler,Director 9�pTMASS a``� Building Division Fn nw'� Tom Perry,Building Commissioner 200 Main Street, Hyannis;MA 02601 www.town.b arnsta b l e.in a.u s Office: 508-862-4038 °1 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Pease Print DATE: , JOB LOCATION: c number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109._.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner I= Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code - Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION - The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as*supervisor." Kany homeowners who use this exemption are unaware.that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc -wised 051811 U1zearwr�roazcaeall o�C%vuraaac�iiQeZ f� Office of Consumer Affli�s&Business Regulation' License or registration valid for individul use only V�eoj ME IMPREMENT CONTRACTOR ibefore the expiration date. If found return to: i'stration: 150889 Type:' + Office of Consumer Affairs and Business Regulation x iration 5/5/2014 10 Park Plaza-Suite 5170 p � Individual JOSEPH E. KING i f Boston,MA 02116 x l JOSEPH KING. I 36 CHECKERBERRY WEST YARMOUTH,MA'02673 r Undersecretary Not.vah without sign ure i . Massachusetts Department of Public Safety Board of Built'` gul.at, . and Standards Construction Supe,ri isor Spe chilt3 License: CSSL-099166 ` JOSEPH E IOENd� . ' �� Fv 36 CHECKERBERRI'LA1 W.YARMO TH I02673 Commissioner Expiration 0 112 4/2 0 1 4, ` . IN 5 0, CAPE SAW 671 Weatheriiation 508-398-0398 December 14,2011 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits P Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#201100589, Status A, Parcel 270080 at 181 Arrowhead Drive, Hyannis, Permit type: RADD, and issued on 2/08/2011 has been inspected by a certified Building Performance Institute (BPI)Inspector. R-30 Cellulose insulation was added to the attic.Walls were dense packed with R-13 cellulose insulation. Basement sill was insulated with R-19 fiberglass batts. Basement perimeter was wrapped with R- 5 reinforced foil or vinyl faced fductwrap.All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey �pFTNE,ay, Town of Barnstable *Permit# `/ 7 Expires 6 months from issue date BARMASLE, : Regulatory Services Fee Thomas F:Geiler,Director Building Division X-PRESS PER Tom Perry, Building Commissioner IT 200 Main Street, Hyannis,MA 02601 NOV 2 1 2002 4- Office: 508-8624038 - - Fax: 508-790-6230 TOWN OF BARIYSTAB EXPRESS PERMIT APPLICATION - RESIDENTUL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 0® ?�O Pro rty Address 114 Residential " ya�4f' Work �� Owner's Name&Address Contractor's Name - Telephone NumberA0 �02- Home Improvement Contractor License#(if applicable) A0 0 V�^ Construction rvisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I amfheHomeowner ve Worker's Compensation Insurance .Insurance Company Name ��L�(���li/�( /lam Workman's Comp.Policy# l C�2 l0 d !z I Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to O OL U Ur 0 p,�j 4 ❑ . Re-roof(not stripping. Going over existing layers of r000 o ❑ Re-side ���� - placement Win od wrs. U-Value (maximum.44) ❑ Other(specify) C / — A, I *Where required: Issuance of this pem3it does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signa 4L Q:Forms:expmtrg Revised121901 �• 1..� fin/' '��\ TOWN OF BARNSTABLE ZONING BOARD OF APPEALS IC 1 SPECIAL PERMIT DECISION AND NOTICE ------------------------------------------------------------ APPLICATION : #1989-81 APPLICANT: EMMIE N . MURPHY ------------------------------------------------------------ At a regularly scheduled hearing of the Barnstable Zoning Board of Ap als , held on December 7 , 1989 , notice of which was duly pub ! shed in the Barnstable Patriot and notice of which was forwarded to all interested parties pursuant to Chapter 40A of the General Laws of Massachusetts , the applicant , Emmie N. Murphy , applied to the Board for a Special Permit pursuant to Section 3-1 . 1 (3 ) (D) of the Zoning Bylaw to allow for a . family apartment . The applicant ' s property is located atC817Arr`h ad _D-rive in Hyannis . It is shown on Assessors ' Map 270 as-.lot^--8-0 and is in the Residential B, one acre, zoning district . The applicant , Emmie N . Murphy , is seeking a Special Permit to allow the construction of a family apartment in -the basement of her residence. The apartment will be occupied by her son . FINDINGS °OF FACT: Based upon the information presented , the Zoning Board of Appeals made the following findings of fact : 1 . The applicant complies with the provisions of Section . 3- 1 . 1 (3 ) (D) ► and. 2 . The grant of the Special Permit would not be detrimental to the surrounding neighborhood nor would it be in derogation of the spirit and intent of the Zoning Bylaw. The vote on the findings of fact was as follows : AYES : BLISS , BOY , BURMAN , JANNSON , NIGHTINGALE NAYES : NONE DECISION : Based on the information presented and the findings of fact , at a meeting held on December 7 , 1989 , by a motion duly made and. seconded , the Zoning Board of Appeals voted to grant the Special Permit subject to the following conditions : 1 . The applicant must comply with all of the provisions of the Zoning Bylaw, in particular , Section 3-1 . 1 (3 ) (D) , Family Apartments . The violation of these provisions shall be grounds for revoking the Special Permit ; and 2 . The . family apartment shall be constructed pursuant to the plans submitted to the Zoning Board of Appeals . The vote was as follows : AYES : BLISS, BOY, BURMAN , JANSSON , NIGHTINGALE NAYES : NONE Any person aggrieved by this decision may appeal to the Barnstable Superior Court, as described in. Section 17 of Chapter 40A of the General Laws of the Commonwealth of Massachusetts by bringing:.an action within twenty days after the decision has been filed in the office of the Town Clerk. hazrman I, Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty (20) days have elapsed since the Board of Appeals rendered its decision in the above entitled petition and that no appeal of said decision.has been filed in the office of the Town Clerk. Signed and Sealed this day of 19 under the pains and penalties of perjury. Distribution: Property Owner Town Clerk Town Clerk Applicant Persons Interested Building Inspector Public Information Board of Appeals d A' sor's map and lot number ................. .. Q..p... ,` THE tp�f Sewage Permit number ... . •. a. -64 .:�i: SEPTIC SYSTEM 7 INSTALLED INN COM ' House number ABLE, WITH'TITLE 6 900 m 9. ENVIRONMENTAL COD TOWN OF BARN STABLE, T,`�` : BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....................... ..�...._...•...i..Lz.. r.y�........,.................................................. TYPE OF CONSTRUCTION .. ..................................... .' :.... w.........19..0...t! TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit a ording tot following information: Location .................�-A ........... /....1..Y.. '. `l!J' .......... ............... ...............:........:... Proposed Use .. `V't'.r....��` G............. .......c ' ,,�. .....:.. .. ... .. Fire District Zoning District' .......................1 ......... ............................ ................. ..... ................................................... LName of Owner )! ..... ..Address '....... :.... .. ........................................................... Name of Builder .......:.......................Address Nameof Architect ..................................................::..............Address ...........................................................................:........ Number of Rooms ... ..............qq -� 1... Foundation ..... 4 ................... ................ Exierior .......................Roofing FloorsInterior ........ .......... .. ......... . ... ... ........................................ Heating . Q'r .c ....Plumbin �—' ...... . Fireplace ..:............. ��V'\ -'."'".................................................Approximate Cost ........... ......................................... Definitive Plan Approved by Planning Board ________________________________19 . Area ......1.6."1.... .................... Diagram of Lot and Building with Dimensions Fee ............ 4.. ............ SUBJECT TO APPROVAL OF .BOARD OF'HEALTH / 1 x�� . o I hereby, agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name '' .... �..... '� ................... MURPHY, ARTHUR .................22522 Permit for ............. .......Single................................ g............. Location .........181...Arr.oVhPiakd...11rive........... Hyannis . .............................................................................. Owner . ..M.....Arthur rp)Ay................ ............ ........t...h.....:. 0 Type.of Construction FXaMP.........;................... ................................................................................ Plot ............................. Lot ................................ September 23 80 Permit Granted ............I....................... ...19 ,.Date of-inspection ..... . .... ...19 Kv Date Completed .........................Z"4.nq?'2 PERMIT REFUSED l ........ ......fi l.....................................—19 /T ..............I........................I.......... rs .. ......... ...................................................... C) 15- .............................................. .. cc ..................... 19 ApprWel ...................... M V .......................... ................... ................... .................... .............................................. .......... �Xw S A-- ssor's map and lot number ................ ..-..................... cFTHEro Sewage Permit number ....�a<�.,. ..:>i� +� .:t%,.::.�% Z 9JH3STADLE. i Housenumber ........................................................................ 90o SAM 'F0 mix 0'.9 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....................... -: al..�...Lo" .............................................................. TYPEOF CONSTRUCTION .................................................................................................................:................... r , V TO THE INSPECTOR OF BUILDINGS: e undersignedhereby j applies or a permit according�to the�following•-�'" informat ion: Location ........... .•... t . ..... �Y . .,, Proposed Use .......?^-e•' '?. ....� ..............Wf........ ..... 1................................................... Zoning District ...................... ....................................................Fire District ................A'.1. Name of Owner f .......`.L. / 1 . ..................Address ......... .............`r-^............................................... Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .................................................................Foundation ...................... ?....,:...... .�`�c` � , ...........:....... .................... Exterior . Roofing �................... ..................................................... ............. .... ......... ............ Floors ... :........... .................................................Interior .......... g ............ ...rd..... .�a>�.:t*..................Plumbin ^'.� ........................ ................................. . Heat* g 61 q Fireplace .....,^^......... ............................................Approximate Cost Definitive Plan Approved by Planning Board --------------------------------19-------- . Area ...... .. ................. Diagram of Lot and Building with Dimensions Fee \ o SUBJECT TO APPROVAL OF BOARD OF HEALTH � I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ► fl:�� '�.c.-� MURPHY, ARTHUR A=270-80 22522 ADDITION _ ................. Permit for ................................ Single Family Dwelling ............................................................................... 181 Arrowhead Drive Location ......................_......................................... Hyannis . ............................................................................... Owner „Arthur Murphy ............................................ Type of Construction Fr.e�..... ........ . ................................................ ............................. Plot ......................... at ................................ Permit Granted ...September 2 3, 19 80 Date of Inspection ....................................19 Date Completed......................................19 PERMIT REFUSED .......... .. ........... ........,.,:,... .. 19 ....... .. ..../. ' .................. .......................v........................ ; .................................................... ................. .... ............................................................................... Approved ................................................. 19 ............................................................................... ............................................................................... TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 21 Parcel Application # Health Division Date Issued z � M Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic -.OKH _Preservation / Hyannis Project Street Address I R6W D& Village Owner CMA ME im u a leow Address .444 to Telephone S)E- -4s- log �--, At t,o.S& : Permit Request 8cn(&�tj -Iti Ak&SS6A-Nin C�EAJEAA-(__ u i on Square feet: 1 st floor: existing u or proposed 2nd floor: existing proposed , Total new _. Zoning District Flood Plain Groundwater Overlay co Project Valuation S=�, Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure - 1poHistoric House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑.No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER)- Name L-ft SAV£ / I J 110 -4 M C C(A-S / Telephone Number Address 3c, t 43� �� License # �Z 2;e I C. (e(L�n eatWk OWbq Home Improvement Contractor# Z_ Worker's Compensation # u1C, r T ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 FOR OFFICIAL USE ONLY . ,r APPLICATION# DATE ISSUED 'f MAP/PARCEL NO. a { . ADDRESS VILLAGE OWNER` DATE OF INSPECTION: 'Is FOUNDATION FRAME r l INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. T Umce or-Invatigadons 600 Washington Street Boston,MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amilcant Information Please Print Legibly Name(Business/Organizatiodlndividual):_( , (t,l i��t -CAME. AVE Address: City/State/Zip: v d i,)�A Phone#: SC)S-- R - 0?)0k Are you an employer?Check the appropriate box: . 1 am a en TYtm utProject(required): 1.[�I 4 am a employer with ❑ general contractor and I employees(full and/or oars time).* have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑Remodeling 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.t 9•. ❑Building addition regw.Ted;) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL insurance required.) t c. 152,§1(4),and we have no 12.0 Roof repairs 3a.❑ I am a homeowner acting as a employees.[No workers' 13:(�Other_;_��� general contractor(refer to#4) comp.insurance requited.) 'Any applicant that checks box#1 must also fill out the section below showing their wotkets-compenwdoj� olicy 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. tConowtora that check this box must attached an additional sheet showing the name of the sub-conom s a d state whether or not those entities have employees. If the sub-contractors have employees,they mast provide their workers'comp.policy number. I an an employer that is providing workers'compensation insurance for my informadom employees. Below is the policy and Job site Insurance Company Name: ( il`' A 0-1- t 5 Policy#or Self-ins. Lic.M i& "; Q[A -q 3 .-(") 51 Expiration Date-_ ' Job Site Address: 1AMOji ffaa _Z( City/State/Zip:oya I)Z&o 1 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$2,50.00 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 eem*under the and pe of perjury that the information provided above is true and correct r Z,15 1 Phone#; .5o '-�'� -~/`5'� S [6.Other use only. Do not write in this area,to be completed by city or town offletaL Town: Permit/LIcense# IssuingAuthority(circle one): I. of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector S. Plumbing Inspector Person: Phone#: r ' CERTIFICATE OF LIABILITY INSURANCE °A'�`/210'""- Su l /1/210 ; THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE. POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Shannon Sperrazza Risk Strategies Company PHONE (781)986-4400 I A/C No:(781)963-4420 15 Pacella Park Drive ADDRIESS:ssperrazza@risk-strategies.com Suite 240 PRODUCERCUST ID#00018476 Randolph MA 02368. INSURERS AFFORDING COVERAGE . NAIC# INSURED INSURERA:Seneca Specialty Insurance Co INSURER BAeating Group Ins Services Michael McCluskey, DBA: Cape Save INSURERC:Chartis Insurance 7 C Huntington Ave INSURER D: i INSURER E: i South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1011132675 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R POLICY EFF POLICY EXP R TYPE OF INSURANCE IIN R D, POLICY NUMBER MMIDDIYYYYI (MMIDUITT7TI LIMITS GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 X I COMMERCIAL GENERAL LIABILITY DAMAGE TOR'NTED i PREMISES Ea occurrence $$ 50,000 A CLAIMS-MADE C OCCUR SAG1002608 �0/16/2010 10/16/2011 MED FXP(Any one person) is 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE is 1,000,000 OGE 'L AGGREGATE LIMIT APPLIES PER: ( j PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PFc RO- LOC i $ AUTOMOBILE LIABILITY ( I COMBINED SINGLE LIMIT 6208200 11/6/2010 (11/6/2011 (Ea accident) _ I$ 1,000,000 ANY AUTO I BODILY INJURY(Per person) s ALL OWNED AUTOS I I f BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS I (Per accident) $ 1 X NON-OWNED AUTOS ! $ I $ X UMBRELLA LIAB ; OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAR CLAIMS-MADE I AGGREGATE $ 1,000,000 DEDUCTIBLE $ B RETENTION $ 023578601 �10/16/2010110/16/2011, $ WORKERS COMPENSATION WC STATU- OTH- C AND EMPLOYERS'LIABILITY chaei McCluskey I I X I R ANY PROPRIETOR/PARTNER/EXECUTIVE YIN is excluded from coverage' ( E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? a NIA (Mandatory in NH) 9930951 �10/21/2610 j10/21/2011(E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under II DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 fj 1, DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Issued as evidence of insurance. Contractors-Executive Supervisors or Executive Superintendents. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Ruth 460 West Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601-3698 Michael Christian/SMS �'" ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2oogo9) The ACORD name and logo are registered marks of ACORD oFs"fra,,� -Town of Barnstable Regulatory Services hues �+ Thomas F. Geiler,Director 1639.. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 - www.town.barnstable.ma.us r Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must . Complete and Sign This Section If Using.'A Builder L. 6V its' tkj , as Owner of the'subject property hereby authorize -CAe& M e to act on my behalf, in all matters relative to work authorized-by this building permit application for. 181 M&tN9466D (W �Y4 MNLS it,* OZ-601 (Address of Job) Signature of Owner t Date Alln A j r Print Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION ^ M Town of Barnstable - 0FTHE t, Regulatory Services i3Amsr,BL ; Thomas F. Geile'r,Director tins. 059. ..eg Building Division PrED tMt Tom Perry, Building Commissioner 200 Main.Street, Hyannis,MA.02601. www.town.barnstable.ma.us Office: 509-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street Village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner occupied dwellings of sixunits or less and to allow homeowners to engage an individual for hire who does not possess alicense,-provided that'the owner acts as supervisor. DEFIIt'MON OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or faun structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"•shall submit to the Building Official on.a form acceptable to the Building Official, that he/she shall be responsible for all such work performed.under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that,he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lark of awareness bftzn results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it Would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a.farm currently used by several towns. You may care t amend and adopt such a fomrlcertiftcation for use in your community. Q:forms:homccxcmpt Office of Consumer AM s and Business Regulation . .� a 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164432 Type: Supplement Card• CAPE SAVE Expiration: 10/6i2011 WILLIAM MUCCLUSLEY 8201 S. HOURD CT f CHAPEL HILL, NC 27516 Update Address and return card.Mark.reason for change. oPs-ca, to 50rr-04.:04-U101-216 r:J Address. —] Renewal J Employment F—i Lost Card :%die �%'aarattarzrr�erx�.Cl r��'„-ltcrzucc�eoa��" Office of Consumer Affairs&Business Regulation License or registration valid For individui use only t before the expiration date. If found return.to: ,r f'HOME IMPROVEMENT CONTRACTOR AN Office of Consumer Affairs and Business Regulation 5 Registrations>_1'64432 Type, e 10 Park Plaza-Suite 5170 Expiration -j ft!2011• Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM MUCCLUSLEY 7C HUNTING AVE. S.YARMOUTH,MA 02664 ` Undersecretary Not valid wit ou signature Nlass,achuwtts - Di:11artment of Public Safet. Board of Buildinf_ Rai-ulaetions and >t<uicl:trtts Construction Su"pervisor Specialty License License: CS SL 102776 ReMrictecl.to. IC ` r WILLIAM MC CLUSKY 37 NAUSET ROAD WEST YARMOUTH, MA 02673 Expiration: 6/28/2013 t.,rtrxtn i,iti'a Sri: 10277,6