Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0081 BLUEBERRY HILL ROAD
ACTIVE FEB 0 6 2020 OF"RIVSTA.QLE rlomel`Work� n Energy, Inc Insulation Affidavit HomeWorks Energy has installed insulation at the following address(that meets or exceeds Massachusetts building code and IIC requirements. Project Address: Permit Number: B-20-298 Julie Lytle 81 Blueberry Hill Road l3arnstabt+='Massachusetts 02601 r+yA,,;N=s Location Material Addt'I Thickness Final Assembly R-value Attic Floor Green Fiber Cellulose 7' Sincerely, Scott Veggeberg HomeWorks Energy Inc. CSL#103832 HERS Certification#3081658 HomeWorks Energy 101 Station Landing,Suite 110 Medford,MA 02155 wxpermitting@homeworksenergy.com Town of Barnstable Building Post This Card So That it is_Uisible'From the Street Approved Plans Must be,,Retainei!on Jo"nd this;Card Must beXepX 1. auwse Posted Until_,Final Inspection,Has Beern Made b 9. . _ Permit Where a Certificate of Occupancy is Re uired�such Buldin shall Not�be Occu ied until a Final Ins ection hastbeen rnade Permit No. B-20-298 Applicant Name: HOME WORKS ENERGY INC. Approvals r Date Issued: 01/30/2020 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 07/30/2020 Foundation` Location: 81 BLUEBERRY HILL ROAD, HYANNIS Map/Lot: 249-076 Zoning District: RB Sheathing: Owner on Record: LYTLE,JULIE A& BOLSTAD,CAROL '' Contractor Name:` HOME WORKS ENERGY INC. Framing' 1 Address: 81 BLUEBERRY HILL ROAD Contractor License:; 191138 2 HYANNIS, MA 02601 � ��' .'� Est_ Proj'ct Cost: $3,866.00 Chimney: Description: Weatherazation Permit Fee: $85.00 ,., Insulation: Fee Paid{€ $85.00 Project Review Req: Date. 1/30/2020 Final: Plumbing/Gas Rough Plumbing: -�- e ,Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afterissuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,public inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on thisp rmit. Minimum of Five Call Inspections Required for All Construction Work: +� Service: 1.Foundation or Footing 2.Sheathing Inspection Rough. 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: � 9 Application number . TOWN OF BARNSTABLE Fee ................................`............................................. Building Inspectors Initials.. ............................ I o i `°T Date Issued: ,.... .1 !.......................................... iSION Map/Parcel..........:.`.3......0. (p................. TOWN OF BA STABLE �— EXPEDITED PERMIT APPLICATION: SCANNED ROOF/SIDING/VVINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION JAN I .�,v Address of Project: 0 NUMBER STRBtT VILLAGE Owner's Name: , 01 I L L 4 LUL Phone Number 61 ToGQ g 4 Email Address:+) l`1 E(.Q— ()ZI LA 0 COMCQS. 11.E Cell Phone Number Project cost$ -3j US 3 (4 Check one Residential V Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize S E Air A c A W rt to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding ❑ Windows(no header change)# Oz Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to Gf G 11 b a-✓r!J S 4 A a nll CONTRACTOR'S INFORMATION ATION Contractor's name 5 C 0 I f �J R(�Z Home Improvement Contractors Registration(if applicable)# I S I l `3 f( (attach copy) Construction Supervisor's License# OMB Z .y s (attach copy) Email of Contractor/Io,},dnflaAl.4 &M VQ,J p .(.o1M Phone number APPLICATION.NUMBER }...........................................................\ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event x -� Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No ,if yes, a gas permit is required. If food is being served at.your event please obtain a health Department approval between the-hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date- - 28-2 02 0 All permit applications are subject to a building official's approval prior to issuance. SCANNED_.: JAN3U1010 `o PLAN VIEW Name: - );�- L,, rp Site ID: 3 �ln / Finished Sq. Ft: /6z>o 4 Phone: Year-of House: K&O Electric Acct#: Address: Z/ l.rt.r r.; �&11" #of Floors:_ I Gas Acct#: t fn44�W, Boa unlit#: #Occupants: )-- Housing Type? 14e-' %h DUCTWORK INSPECTION Ducts Insulated?D Duct Linear Ft. AS Duct Square Ft. p:,G� J Duct Air Sealing Hours +. wj VI& 1 Duct Insulation " Duct Insulation Removal BASEMENT INSPECTION Existing Spec'ing In/Sq.Ft, Bsmt Wall AG Q` Crawl Ceiling Crawl Rim Joist Bsmt RJ w/Sill Bsmt R1 NO Sill arrier sgft. Bsmt Door ' Y wer Door? WALLS&GARAGE Drill Location? Lt' ati Siding Ceil.Height Existing Spec'ing S .Ft. Framing Exterior Wall 1 x & Balloon/Platform Exterior Wall 2 x x Balloon/Platform Overhang x x Garage Wall x x Balloon/Platform t Garage Ceiling x x Insulation Removal` Sot. Sweeps:; , WX Stripping: WORK SPEC'D BUT NOT CONTRACTED AD BLOCKS PRESENT ANDATORY) r c Basement/Crawls ace Other. I<&T Y oisture Y ombustion Sft ewall Overhan /Gars e Asbestos Y/N old>100sq.ft Y N O Detector Missing Y N twork Exterior Walls Vermiculite Y N Structl Concerns I Y N ther: Notes for Lead Vendor/Work Not Contracted:. Gr ,r P f J� KW SLOPE AND GABLE END 61ind Spec? KW WALL ANDSKW FLOOR Blinds Spec? [t " +tJh ? T c hy? c;; n.,� SQ T7. FR NUING £Y.I`TI G cper•Inl Ste.c AG lr<G ExISTING SPEC'UNG . SLOPE x x WALL X X GABLE X x FLOOR. v x TRANS X X ACCESS X ATTIC. TRANS X X SLOPE X x ATTIC X X EXISTING VENTING? • SLOPE EXISTING PIPES? Y/N EXISTING VENTING? M1 ::�V Vett3n; .vent 6F Temp Access KW Vencin; vcn- F RF moss: Uanrang Shcath�ng Arcess temp Access 13 b' O 06 a� �lav,n�dc t 6n tj V o In;a;latvd Wall :.k Rp[r Cyhi ,a.Nos Hf i vent,F iq 1] Ca m lCh f 4a,{nR ._. ?"Roof I [tipv' qw Yanole.,AH+ letup nur-s tT 1 Pali Down POST eaten ; w,,Mash noon.,, S Roo.Ven ,Sh4 —• Vol. %. ,0058 ATTIC 1 Blind$ ec? r._I % o. x P X X ATTIC 2 Blind Spec? f j. �t5 t Iz s myt� - Existing Spec'ing Sq ft Existing Spec'ing Sq ft loored 1 F nfl Of d buss Cross eatting lOfeCI FlooreC! dot D •„work Cath Sloe Cath Slo a ose No Walls Walls ' as Access Access : Venting Propavents Vent BF Br dose Damminn Venhng p.e4Ven,s Vent BF BF Nose Damming o oa c tJt HF Box t � TempAc s:_ : !� to Sneathing Access $' S+. _ r.. _ R.L.Covers:fa N _ ',11F .o.l chn�i (Needed Existing Venting? ,,,t ,nt;n,,,t � g EXISttn VE!Iltl ? NFAVen[ing) Roof Type: 1 HomeWorks To whom it may concern, Scott Veggeberg is a current employee of Homeworks Energy Inc.and operates under our insurance policy. Policy numbers that Scott is covered by are as follows: Commercial General Liability:_793006065002 Automobile Liability: 6244378 Umbrella Liability: 7930060660002 Workers Compensation and Employers' Liability:ECC-600-4001017-2020A All HomeWorks Energy permits are pulled under his CSL license. The insurance provider is AIM Mutual Insurance Company. If you have any questions or concerns please contact Director of Weatherization Adam David Glenn at 774-365-2446 or adam.glenn@homeworksenergy.com. Thank You, Adam David Glenn - Director of Weatherization HomeWorks Energy. r j The Commonwealth of Massachusetts Department of Industrial Accidents kzz� 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/Individual): HomeWorkS Energy Address: 101 Station Landing Ste 110 City/State/Zip: Medford MA 02155 Phone#: (781)305-3319 x5007 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 200 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 capacity. employees and have workers' y p n'• 9. ❑ Building addition [No workers' comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.❑■ Other Weatherization 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: NH Employers Insurance Company Policy#or Self-ins.Lie.#:4001017 Expiration Date:1/1/2021 , Job Site Address: L Sw e—�"v 1 City/State/Zip: G V} 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 pai penal 'es of perjury that the information provided above is true and correct. Signature: Date: Phone#:(781)305-3319 x5007 / wxpermitting@homeworksenergy.com 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#: Construction Supervisor Re:Address R lv e,rr.� (or)application# Dame Scott Veggeberg Telephone Number 508-273-7593 Address 101 Station Landing City Medford state MA Zip 02155 License Number 103832 License Type Expiration Date 10/13/19 Contractors Email N/A Cell.# 508-273-7593 l understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. 1 understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable,Attach a copy of your license. Signature Date i HOMEENE-01 LLARIVIERE ACOQQ� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1E(MMID IYY 19 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S)„AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lisa Lariviere NAME: Foster Sullivan Insurance Group,LLC PHONE FAX 163 Main Street (A/C,No,Ext):(978)686-2266 301 (A/C,No):(978)686-6410 North Andover,MA 01845 E-MA'L ',certificates@fostersullivangroup.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Homeland Insurance Company NY 34452 INSURED INSURER B:SafetyIndemnity Insurance Company 33618 Homeworks Energy Inc. INSURERC NH Employers Insurance Company 13083 Homeworks IIC LLC 101 Station Landing Suite 110 INSURER D: Medford,MA 02155 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE!POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 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 INSR TYPE OF INSURANCE ADDINSDL SUep POLICY NUMBER POLICY EFF POLICY EXP(MML LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR 7930060650002 4/1/2019 411/2020 DAMAGETORENTED 500�OQQ PREMISES Ea occurrence $ MEDEXP(Any oneperson) $ 10,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY pRefELOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Ee eBINEDSINGLE LIMIT ccide ) $ 1,000,000 ANY AUTO 62"378 4/1/2019 4/1/2020 E30DILYINJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILYBODILY INJURY Per accident $ X ALT OS ONLY X A�0 ONLY PeoaccitlentDAMAGE $ $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X1 EXCESS L'AB CLAIMS-MADE 7930060660002 4/112019 411/2020 AGGREGATE $ 2,000,000 DED I X I RETENTION$ 0 $ C WORKERS COMPENSATION X PERTLITE OTH- AND EMPLOYERS'LIABILITY Y ECC-600-4001017-2020A 1/2020 1/1/2021 ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE � N/A 1/ E.L.EACH ACCIDENT $ FFICER/M�MBER EXCLUDED? andatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If as,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence Only i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Homeworks Energy Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9Y ACCORDANCE WITH THE POLICY PROVISIONS. 101Station Landing Ste 110 Medford,MA 02155 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r .//i� rr�Cifr��rt�1�t�-fir��f�y i� . ���r:•i�rr/%trr�/% . Office of Consumer Affairs and Business Regulation 1ff00 Washington Street-Suite 710 , Boston,Massachusetts 02118 Home Improvement Contractor Registration Type G'orpDt0tI0P. Registrtton: 181138 - WJM.EwORKSEN4ERGY,INC. cxpr tix 03 Cl'tr2o2; "lot STATION LANDING STE 1,t} - - LEDFORD.NIA 02155 Update Adam.and Ratura Card.. - f x p... C w(�lrw � t:f?ice •� oirr nt ttmsutneratfntrs a Eml—x ReaulEton Registration v3?i6 tor individual ma ardy NOME RABROl(EIAEIiT CONTRACTOR TYPE:Cosa-•eren hetnre the axRirotion dato,if round rfiurn to- istret�p r tion . a tice or consumar AP(e,.rs and eusiruas RoguWon - tEtt3.3 031(41202-- taaD'Nash(r o street.Suite710 OME W42 RKO ENFRGY.14C Baton,M 021t - 101 STAT10ff I.TWrylWj%TE 111) - - o valid without signattire t>1Cl3fORt1.r,7A-=35fd .Untimsetx0ay - - rt� Commonwealth oL M tssachuse[ts. Construction SupeoviIsor Specialty s`vJ� Division of Prolescionat LicenSure Soard of Building Regulations and Standards Restricted to: #rt CSSC-IC-Insulation Contractor ConstructiorPSOP�l'+A"r 5poctafty CSSL-103832 +* E• E�spires:10#13#2021 It SCOTT VEGGEBERG 8 COVINGTON ST#1 BOSTON MA_02127 t Failure to possess a cut rfition of the Massachusetts �. State Building Code is r'. ur revocation of this license. Commissioner For inforrnatarst about this license Call(617)727.3200 or visit www.mass_govldpi i e 4 Insulation/Air Sealing Permit Authorization r Specialist: Adam Hoyng Company: HomeWorks Energy Email: Adam.Hoyng@homeworksenergy.com Address: 101 Station Landing Cell: 5088139054 HomeWorks Medford,Ma 02155 _ Phone: 781-305-3319 Customer: Julie-holi64�, Address: 81 Blueberry Hill Rd Email: jlytle02l4@comcast.net Barnstable MA 02601 Site ID: 3941091 Phone: 617-669-8411 I,the owner of the property identified above hereby authorize HomeWorks Energy Inc.,or their Partner to act on my behalf in obtaining any building permit that maybe required to perform insulation and/or Weatherization work on my property and all matters related to the work authorized by said permit if one is obtained. Any related permit application cost will come at no additional charge provided that the agreed Weatherization work is completed. Customer C Signature:._.___ Date: 12/2/2019 Julie k Page i of 2 `{flomeWo mass save Energy, Inc PARTNER 101 Station Landing Ste 110.Medford MA 0219S (781)305-3319 ext.120 Customer Name:Julie Lytle Email:ilytle02l4@comcast.net Phone:617-669-8411 Premise Address:81 Blueberry Hill Rd.Barnstable,MA 02601 Mailing Address:81 Blueberry Hill Rd,Barnstable,MA 02601 Project ID:3942810 Date:Dec.2,2019 Job Description Measure Descrtptton Location .' :Quanfity Urt►t; TotaiCost Custo7rlerEpsi =: ATTIC FLAT-5"OPEN R-19 CELLULOSE 1436 SF $1,809.36 $452.34 AIR SEALING 13 hr $1,040.00 $0,00 ATTIC DAMMING-R-38 FIBERGLASS 60 SF $147.60 $36.90 VENT BATH FAN THRU ROOF 2 each $237.50 $59.37 WEATHERSTRIP DOOR&ADD SWEEP 3 each $240.00 $0.00 VENTILATION CHUTES 112 each $390.88 $97.72 Project Total $3,865.34 Weatherization incentive ($1,939.01) Air sealing incentive ($1,280.00) Total Contractor Price and Payment Schedule HomeWorks Energy,Inc.agrees to perform the above described work,furnishing the material and labor specified for the listed total price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature: Date: Customer Phone: Specialist Signature: Date: LIMM mutt oFcot: The Prig and incentives in this contract are subject to change in accordance with the sponsoring utility MassSave Home Services Program offers. Proposals can be sent to:inbox@HomeWorksfnergy.com Page 2 of 2 rks mass save Energy, Inc PARTNER 101 Station Landing Ste 110,Medford,MA 02155 (781)3t2S-3319 ext.120 Customer Name:Julie Lytle Email:ilytle0214@comcast.net Phone:617-669-8411 Premise Address:81 Blueberry Hill Rd,Barnstable,MA 02601 Mailing Address:81 Blueberry Hill Rd.Barnstable,MA 02601 Project 10:3942810 Date:Dec.2,2019 Total Program Incentive -$3,219.01 Customer Total $646.33 Total Contractor Price and Payment Schedule HomeWorks Energy,Inc.agrees to perform the above described work,furnishing the material and labor specified for the listed total price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature• Date: 14Z i Customer Ph e: Specialist Signature: 1A, Date: um TIME OFFER: The prices and incentives in this contr ar subject to cha On cordance with the sponsoring utility MassSave Home Services Program offers. Proposals can sen o:tnbox@HomeWorksEnergy.com i I i Town of Barnstable Building . Post..This Card So That�ttsUisible*From the Street Approved Plans Must be,Retamed on Job and his Card Must be Kept ,, M" Posted UntilF,mal Inspection HasBeen Made ' Wfiere a Certificate of Occupancys Required;such Bwldmg shall Not be Occupied;until a Final Inspection has been made Permit Permit No. B-18-1074 Applicant Name: SOUTHERN NEW ENGLAND WINDOWS LLC. Approvals Date Issued: 04/13/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 10/13/2018 Foundation: Location: 81 BLUEBERRY HILL ROAD,HYANNIS Map/Lot: 249-076 Zoning District: RB Sheathing: Owner on Record: LYTLE,JULIE A&BOLSTAD,CAROL Contractor Name: :-.SOUTHERN NEW ENGLAND Framing: 1 a � WINDOWS LLC. Address:. 81 BLUEBERRY HILL ROAD % �� 2 ..-- ---Contractor License: 173245 HYANNIS, MA 02601 .•, Chimney: Description: replacement windows(6) Doors(1) Uvalue.29 Est Prof t Cost: $ 14,961.00 * 'Per nit Fee: $76.30 Insulation: Project Review Req: { , x _ Fee Pald: $76.30 Final: &Z '� x s ri { Date 4/13/2018 Plumbing/Gas Rough Plumbing: �` � � � A ' 1116�- `R Final Plumbing: Building Official Rough Gas: This permit shall be deemed abandoned and invalid unless the work author¢edbythis permit is commenced within six monthsafteri`ssuance. All work authorized by this permit shall conform to the approved application and`the approved construction documents for whichUs permit has been granted. Final Gas: All construction,alterations and changes of use of any building and strures shall be in compliance with the locazoning bylaws an'd ctu codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open,for public inspection for the entire duration of the Electrical work until the completion of the same. Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are providedr.'on this permit. - Rough: Minimum of Five Call Inspections Required for All Construction Work..:,.. 1.Foundation or Footing Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department ,Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site ,kt_ All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ! JJ b aF Town of Barnstable Permit• f I -•�yt Expires 6 mortllrs front issue date Regulatory Services Fee RARNSTABLi? 9$ 1` .0�a Richard V.Scali,Director Building Division ®�Tom Perry,CBO,Building Commissioner p 200 Main Street,Hyannis,NIA 02601 ��� ,q�r ll wwxv.town.bamstable.ma.us � � ��° • Office: 508-862-4038 ' 08-790-6230 EXPRESS PEM IIT APPLICATION - RESIDENTLAI ONL i\t[ap/parcel Number -.2-Wp Q�(p Not Valid without Red X-Press Imprint 7 Property Address 61 9We_6erreA1'-d9C• l [Residential Value of Work$ Minimum fee of�$35.00 for work under$6000.00 Owner's Name&Address 7IUirt-L v e- 5 T� �13rUe�- y IJY4 Any SSA a.2,(o6 1 Contractor's Name r�Sp�7q Telephone Number N o( 2- Home Improvement Contractor License;"(if applicable) 73 s Email: Construction Supervisor's License#(if applicable) 7 0 7 [Korkman's Compensation Insurance Clieck one: ❑ I am a sole proprietor ' the Homeowner I have Worker's Compensation Insurance Insurance Company Name F-r e m e_ n& Ins B rar1 C �fz. Workman's Comp.Policy# W CA 3158 7 2 9 — 2 L Copy of Insurance Compliance Certificate must accompany each permit. 3 Permit Request(check box) ` ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Be-side [ placement Windows/doors/sliders.UJ-Value Z (maximum.32)#of windows #of doors: / ❑ 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,i.e.Historic.Conservation,etc- ***Note: Property weer must sign Property Owner Letter of Permission. _ A copy cKthe Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: — CL ::,Users\Decollik\A,pDa,.\Locai\i4licrosoft\Windows\Temporary Internet Files\ContenL0utlook\2P101 DHR\EXPRESS.doc Revised 040213 � 2 Rdba:�n�eWal Agreement Document and Payment Terms ersen Renewal B Andersen of Southern New England Y g Julie Lytle&Carol Bolstad M.M..E...T Legal Name:Southern New England Windows,LLC 81 Blueberry Hill Rd RI#36079,MA#173245,CT#0634555, Lead Firm#1237 Hyannis,MA 02601 10 Reservoir Rd I Smithfield,RI 02917 H:(617)669-8411 Phone:866-563-2235 1 Fax:401-633-6602 1 sales®renewalsne.com C:(617)650-6497 Buyer(s)Name: Julie Lytle & Carol Bolstad Contract Date: 03/26/18 Buyer(s)Street Address: 81 Blueberry Hill Rd, Hyannis, MA 02601 Primary Telephone Number: (617)669-8411 Secondary Telephone Number: (617)650-6497 Primary Email: jlytle02l4@Comcast.net Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $14,961 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $0 Balance Due: $14,961 Estimated Start-. Estimated Completion: Amount Financed: $14,961 7 to 9 weeks 7 to 9 weeks Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contraci at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 03/29/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER,SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:R,e-al By Andersen of Southern New England Buyer(s)_ Signature of Sales Person Signature Signature Jonathan Rayburn Julie Lytle Carol Bolstad Print Name of Sales Person Print Name Print Name UPDATED: 03/26/18 Page 2 / 11 t a Otfiie of Consumer Aff airs and Business Re��aiati®� 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Recristrati®n Reqistration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9/19/2018 BRIAN DENNISON 26 ALBION RD LINCOLN, RI 02865 Update Address and return card.Mark reason for change. Address - Renewal Employment Lost Card Office of Consumer Affairs&)Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: Office of Consumer Affairs and]Business Regulation _ Registration: 11-32g5 Type: 10 Park Plaza-Suite 5170 Expiration: 9/19/2018 Supplement Card Roston,MA 01-116 ;OUTHERN NEW ENGLAND WINDOWS L.L.C. 3ENEWAL BY ANDERSON 3RIAN DENNISON '6 ALBION RDA _INCOLN, RI 02865 (-Uadersecrerary Not valid without signature Scar. d of Bjlidii"iaa t'[egfUlatii.Ji':S crud .-Otanciards CS-095707 TI BRIAN D DENNISON 7 LAMBS POND CIRCLE COHARLTON NIA 01507 A: The Commonwealth of Massachusetts Department of Industrial_Accidents I Congress Street,Suite 100 . Boston,MA 02114-2017 _ www.mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl. Name (Business/Organizaiion/IndMdual): E e t z Address: 2& AL&cL) City/State/Zip: p Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1,KI am a employer with �O femployees(full and/or part-time).' 7..Q New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp..-insurance required.] ` g- Remodeling 3.F_�I am a homeowner doing all work myself.[No workers'comp.insurance required.]; 9• ❑Demolition 4.a I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions proprietors with no employees. 5.❑I am z general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.# 13.❑Roof repairs / 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.r%th er (,J i1'1rS/ W 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 policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors 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 sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my empI veer. Below is the policy and job site information Insurance Company Name: `Ire me n S 11is. do m Policy#or Self-ins.Lis 4h C�3`��7 2-9 — Z.0 Expiration Date-- Job Site Address: I V E)a r f 7 A Co. City/State/Zip: /jt' Attach a copy of the workers'compensation po'cy declaration page(showing the policy numb r and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation pthiishable 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$250.00 a' Office against the violator_A copy of this statement may be forwarded to the Oce of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under th ains and penalties of perjury that the information provided above is true and correct Si ature: Die: Phone#: dip Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of$ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector. 5.Plumbing Inspector._ 6.Other Contact Person: Phone#: ACC)REP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) % 12/29/2017 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 UONTACT CoBiz Insurance, Inc.-CO NAME: PHONE 1401 Lawrence St, Ste. 1200 •303-988-0446 ac No:303-988-0804 Denver CO 80202 EDnAaEs : COMaiI cobizinsurance.com INSURE 5 AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 Southern New England Windows, LLC. INSURER a:Firemens Insurance Company of WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Company of New York j 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1252851165 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF MNUDD EXP LIMITS LTR POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2018 1/12019 EACH OCCURRENCE $1.000.000 GILAIMS MADE a OCCUR PREMISES Ea occurrence $300,00D MED EXP(Any one person) $10,000 PERSONAL&AOV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X GENERAL AGGREGATE $2.000,Q00 POLICY JECT LOC - i PRODUCTS-COMP/OP AGG $2.000,000 OTHER $ A AUTOMOBILE LIABILITY N CPA3158728 1/12018 1/1I2019 COMBINED SINGLE LIM Ea NE IT accident $1 0D0 000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ A X UMBRELLA LJAB X OCCUR CPA315872B 1/12016 1/12019 EACH OCCURRENCE $10.000.00D EXCESS LIAR CLAIMS-MADE AGGREGATE $10.0DD.000 DIED I X RETENTIONS() $ B WORKERS COMPENSATION WCA3158729-20 1/12018 1/12019 X PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE 1 ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,0D0 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE $1.000,000 H yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1.000.000 C Po9ubon Lia%y 79M073340000 1/12018 1/12M9 Each Occurrence $1.000.000 Claims Made Policy A99regate $1.000.000 Retroaaive Date 06202013 Deductible $10.000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space Is required] CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Cominowealth of Massachusetts Sheet Metal Permit 7 Permit 4. l=�-6 c5 qQ Estimated .lob Cost $ Permit Plans Submitted: YES_ NO, E Plans Revicwcd: YES NO T3usiness I,iCCIISC!l Applicant License# Business Inform Property Owner/Job Location Information: Wmcu PORT Name: HEATING &COOLING Name: �t� 461.bower County Road Street: _ t� :nh Dn street: MA 02646 S city/Town-_ - City/Town 3 Telephone: ` t t , Tcichlion Photo LD.required/Copy of photo LD. attached; YES NO, 'tiff h]ilia] J-1/M=1-unrestricted licellsc T-2/M-2-restricted to dwellings 3-stories or loss and commercial up to 10,000 sq:fi./2-stories of less Residenthil; 1-2 family - Multi-family Condo/Townhouses C:ommefciai: Office Retail Industrial T ducatfoflix -17 t r Ittistitrrli()rT{ll Othor. , Square.l+ootMge: under 10,000 sq. ft...` - over 1050,00 sq. A. -- Number of Stories: L'i Sheet metal work to be completed: New Work: Renovation; 1IVAC Metal Watershed Rolofing Kitchen Exhaust System Metal Chimilty/'Vents Air Balancing I r ovide detailed description of work to be done: -01, - S _ INSURANCE COVERAGE, I have a current liability Insuranco policy or Its equivalent which meats the requirements of M.G.L. Ch.112 . Yes eNo❑ If you have checked Yes, Indicate the ype of coverage by chocking the appropriate box bo.Iow: A liability insurance policy ether type of indemnity ❑ Bond ❑ t OWNER'S INSURANCE WAIVER:I am aware that the Iicerlsao does not have the insuranco coverage requl red by Chaptor 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only _ Owner .❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box0,I hereby certify that all of tho detalls anti Information I havo submitted(or entered)regarding this application are true and accurate to tho Bost of my knowledge and that all shoot metal work and installations porformed under the permit issued for this application Will be in compliance witli all{pertinent provision of tho Massachusetts Puilding Codo and Chapter.t 9 Z of the General Laws. Duct Inspection°required prior to Insulation installation: YES NO. Pro ess Ills vections Date, comillentS , 1 Final inspection Date Collinlents Typo of License: uy.._ ❑ Master Title ❑Master-Restricted Cilyfrown, . . ❑.faurneyperson � „ Signature of Licensee i i'Qrfi11€ r' FlJourneyperson-RestncteCl LfC@T1Se NUil1ber: Fee$ Check at wwvr.mass.stovldgl Inspector Signature of Permit Approval The Commonwealth of Massachusetts ,Department of Industrial Accidents Office of Investigations GOO Washington Street Boston, MA 02111 t svwtU.tnass.gov/tliu Workers' Compensation* Insurance Affidavit; Builders/Conti•actors/Eleetricians/Plumbers Aplilicgnt Infairllnatlon Please Print Legibly Name(Businessorgtttiiv.atiort/itidivi(lual):ttAM 110 Address: Cit /State/Zip: . Phone#: Q01V � Are you sit employer?Check the appropriate box: , '50 4. I ani a general contractor and 1 Type of project(required}: �i. I airs a employer with employees(full and/or part-time).* have Hired the sub-contractors b. []New eolistnteNon 2.C] 1 am a sole proprietor or partner- listed on the attaclied sheet. 7. [] Reniodelitig ship and have no employees These sub-contractors have g, ❑ Dcrnolition working for nie in any capacity. employees and have workers' [No workers'comp.insurance sonar, insurance.t 9. Building-addition, required.] 5. Q We are a corporation and its 10.0 Electrical repairs or additions 3.[l I am.a homeowner doing all work officers have exercised their I LLJ Plumbing repairs or additions inyself. [No workers'comp. right ofexemption per M(?I. 12.0 Roof repairs. insurance required.]t c. 152,§1(4),and we have no employees. [No workers'. comp. insurance required,] •Any applicant that checks box III must also fill out the section bolow showing their workers'compensation policy information. t liomcc,wnecs who submit this affidavit indicating thoy arc doing all work and then hire outside contractors must submit a new affidavit indicating,such. 1(.'ontractors that check this box must attached as additiunal sheet showing the name of the sub-contractors and state whether or not those entities have employees- If the sutrecar,tnictors have cniploycos,they must provide their workers'conip.policy number: Iantt mi employer Jltor ispropldlttg workers'contpettsatli►n insurtitice for my employees, Below is the policy a►djob site it forination. ` f n �,, { /�j Insurance Company Name: ll, V e✓ t ► ` �'t-fl(V t<{�''� A ---- —` Policy#or Self-ins, l,ic. It:_06 I Expiration Utitc: ..-. 1..3--- Job Site Addruxs:S-1�7:,,�1 `��`�' City/State/Zip: Attach a copy of the workers'.co erietk on policy declaration page(showing the policy nwii ratio expiration date). Failure to secure coverage as required udder 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 ORDFR 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 ofperjuty that the it{formadott pri)vhled above is'true and correct. 1Jatc: / t - Official rise only. Do not write in this area, to be cotttpleted by city or itlwte offlclol City or'!•own Porrult/Liceitse# Issuing Authority(circle ope): 1,Board of Health I.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Ofher Contact Person Phone#; Client#:47452 HARWHEA DATE(MMIDDIYYYY) ACORDTM CERTIFICATE OF LIABILITY-INSURANCE 9/10/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER - CONTACTNAME: Margaret Young Rogers&Gray Ins.-So.Dennis PHONE FAx 877-816-2156 A/C No,Ext: (IC,No 434 Route 134 E-MAIL ADDRESS: South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# 508 398-7980 INSURER A:Selective Insurance Co.of S.C. INSURED - INSURER B:Selective Ins.CO.Of the.South Harwich Port Heating&Cooling,Inc. - INSURER C: - 461 Lower County Road Harwich Port,MA 02646 wsuRERD: INSURER E: - INSURER F: - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI015 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP /Y LIMITS LTR INSR WVD POLICY NUMBER MMIDDYYY MMIDD A GENERAL LIABILITY S1899080 9/01/2012 09/01/201 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(ERENTED occuE ence $100 000 CLAIMS-MADE OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY - $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $'3,000,000 POLICY PRO- LOC $ BINEDJECT B AUTOMOBILE LIABILITY A9092466 9/01/2012 09/01/201 (CEO a�.d.n SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ . X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident A X UMBRELLA LIAB OCCUR S1899080 9/01/2012 09/01/201 EACH OCCURRENCE $S OOO OOO EXCESS LIAB HCLAIMS-MADE - AGGREGATE - s5,000,000 DED I X RETENTION$O - - $ B WORKERS COMPENSATION WC7938097 9/01/201 Z 09I01I201 X WC STATU- OH- AND EMPLOYERS'LIABILITY t ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N E.L.EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? FNJ N I A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS I LOCATIONS?VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) c Certificate Holder is an additional insured with regard to General Liability for written contracts or ` agreemens. t Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE =1 b ©190-2010 ACORD CORPORATION.All rights reserved.. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S86800/M85687 TLH s � Work Order Harwich Port Heating & Cooling, Inc. September 12, 2012 461 Lower County Road Summary: HVAC CONTRACT Harwich Port, Ma. 02646 Reference'#: 6970-114 508-432-3959 Fax 508-432-6075 Tech: ROB W. www.HarwichPortHeatingandCooling.com Bill To: Job Name: Julie Lytle Julie Lytle 81 Blueberry Hill Road* 81 Blueberry Hill Road Hyannis, MA Hyannis, MA 617-669-8411 617-669-8411 Description of Work Re-Do All Flex Runs that are in Way of New Soffit Add 3-Supplies and 1-Return to the Basement Area off Existing Ductwork 1-Aprilaire#1750 Dehumidifier for the Home Dedicated Circuit Registers and Grilles l Condensate removal Make u Air Du ct System as per Requested b Town In psector Y p Y p All material is guaranteed to be as specified. All work to be.completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving_extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements contingent.upon delays beyond our control. Purchaser agrees to pay all costs of collection,including attorney's fees. Signature Date V,Hv���`ITS c 60446813 2�2 2 � v - . 0 �� Yrt `3 T# DENNIS,MA s b263611921 '` COMM.0 WEALTH OF MASSACHU ETTS • • •• • • BOARD;OF SHEET METALMOFKEfS ,.a W ANDREW," M LEVESQUEc. x HARIICtI . PORT "HTNG CL.:NG:.. 461 LOWER. 'COUNTY RD ' HAR:WLEH PD_RT MA 02&4:6;-1&3}:•. - - LICENSE NO. EXPIRATION DATE SERIAL NO. COMMgt-WEALTH OF MASSAkl�1S T METAL ' ORKERS $ phIDREW. M `LEVES:QUE - }1ARW�CH PORT HTNG 461 l (}.WER '000NTY RD A4AR JI -H :PORT MA_ 02646 r • 1 , Y Y a o ax of eg �tr�t Deb ot ,��jeet �etat e - T_ abM . tt4 t •t e>re uirenxe tg of � c u ett :er er�t f $ . ta y a tei ectto 237 t oug 251 E , y t!6 "here.p: granteb, a4 ebibe�ce a, o � trji� 9r►� 04 ,f1 2011 t l In TeotimotTp Wrje eof, 45 bele tllto afftxe�b tYje lutilie oUtrje.C.xectttibe director of tije o.R%b t �Q a tip: Cxetutilm �Divcctur Mate y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel I l� T Application #�`����' Health Division )nr? t !� 17 # 3 Date Issued � 3� Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Boadz Historic - OKH _ Preservation / Hyannis Project Street Address Village N J Slc�> o �, Owner JUu►zz � E L Lei Address 01 ` W L — Telephone ,D Permit Request1�1i9,�• \YJ M Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District iti b Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size 6 ?)5 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family V/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes &(No On Old King's Highway: ❑Yes I(No Basement Type: 5/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 3(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 31"No If yes, site plan review# Current Use ��� _ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 5 � � Telephone Number '" Address = - License # (0100D Home Improvement Contractor# tog Worker's Compensation # sy 1l �Aw 141 ALL CONSTRUCTION DE ESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE '11�'I _ _ I FOR OFFICIAL USE ONLY APPLICATION# 4_ 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. ' 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 LeLa bly Name(Business/Organization/Individual): Address: CU e , ' / , .� ' e City/State/Zip: y�1V4OlxV\1 - Phone#: Are ou an employer?Check the appropriate box: Type of project(required):` 1.[ I am a employer with 4. Q I am a general contractor and I * have hired the sub-contractors 6. '❑New construction employees(full and/or part-time). _ 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling shipand have no employees These sub-contractors have 8. D Demolition working for me in any capacity. employees and have workers' a com insurance:$ .9. ❑Building addition [No workers' comp.insurance P•. 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 I I.D Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs: insurance required.]t c.152, §1(4),and we have no employees. [No workers' 13.0 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 anew 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: ��W Policy#or Self-ins.Lic.#: W.1.�2A1p _ Expiration Dater Job Site Address: CJ l.L- IL��h0 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 the violator. Be advised that a copy of this statement may.be forwarded to the Office of Investiga ' ns of the DIA in ance coverage verification. I do hereby certi nd th p ins and penalties of perjury that the information provid d above is true and correct Si ature: I •I 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#: CERTIFICATE OF LIABIL1 INSURANCE DATE(MM/DDIYY) ACO 08/30/12 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 endorsemen s. PRODUCER COMPANIES AFFORDING COVERAGE PAYCHEX INSURANCE AGENCY,INC. COMP Am NorGUARO Insurance Company 150 SAWGRASS DRIVE A P y ROCHESTER,NY 14620 COMPANY 877-266-6850 B INSURED COMPANY SHEA CUSTOM CARPENTRY C PO BOX 503 SOUTH DENNIS,MA 02660 FDP-y COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. O TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS T DATE(MM/D YM DATE(MM/OD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE[=]DCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED EXP(Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKER'S COMPENSATION AND SHWC360232 08/28/12 08/28/13 X we srA- EMPLOYERS'LIABILITY oEREL EACH ACCIDENT $ 100,000.00 THE PROPRIETOR/ INCL PARTNERS/EXECUTNE EL DISEASE-POLICY LIMIT $ 500,000.00 OFFICERS ARE: E�]EXCL EL DISEASE-EA EMPLOYEE $ 100,000.00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) _CERT.IFICAIE:H.OLDER ~' 3- CANCELLATION : TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 200 MAIN STREET DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY HYANNIS,MA 02601 PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ ,� 3y w- -rx' f•R. 'Y -. y¢ h�;. 3,s, 3 �3"ass kg "''vz # #, a*r °dam,'Ye i`'� sr Y ..._A._. ._.__.,�.._... x ACORD r x f DATE(MM/DDIYY) ^@ n CERTIFICATEOF LiS�LiTY� INSURANCE �f�� ��04/24/12 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 endorsemer►L A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen a). PRODUCER COMPANIES AFFORDING COVERAGE PAYCHEX INSURANCE AGENCY,INC. COMPANYGUARD INSURANCE GROUP 150 SAWGRASS DRIVE ROCHESTER,NY 14620 COMPANY 877-266.6850 INSURED COMPANY SHEA CUSTOM CARPENTRY C PO BOX 503 SOUTH DENNIS,MA 02660 . COMPANY D s 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 8E 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. O TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MMIDDIM DATE(MMIDD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGG $ E=CI AIMS MADE OOCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED EXP(Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ .- ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ H --- WORR'S COMPENSATION AND X WC srATu oTH KE EMPLOYERS'LIABILITY SHWC246119 08/28/11 08/28/12 EL EACH ACGDENT $ 100,000.00 THE PROPRIETORI INCL EL DISEASE-POLICY LIMIT $ 500,000.00 PARTNERSIEXECLMVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 100,000.00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) x' sCANCELLATiONw. _f z �GERTIFICATE FtOLDERhia,�,.: ..� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION u?: DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE , .` cs,"f..''`.w 1own.ofBarnstable E w R to egvIa rY Services Thomas F.Geller,Director , Bwitding Division s Tom Perry,Buffdiag Commissioner 200 Main Street Hyannis,MA 0260I _. WwWAtown.barnstable.ma.us Office.. 508-862-4038 Fax: 508-790-6230 ` _ Property Owner Must Complete acid Sign This Section If Usi�_g A.Builder ,as Ownet of the subject property hereby authorize � . ! ti to act.onniybehalf in an matters relative.to work authorized by this building permit. . 4 r i (A-ddress of Job) Pool fences and alarms are the responsibility of the a licait. Pools pP .. are not,to be filled before fence is installed `d.- ools are not to.be utilized until all final inspections:are erfo e d accepted. x e o er . S.ignat=e.of Applicant Print Name Pint Name; Date Q:Fox�:oWNERP�sSI0NPooLs 5 --- -- __ __ __To--wn-of Barnstable tt;F 1bh,_ Regulatory Services Thomas F.Geffer,Director MASS "Building Division '°tFa suet� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Qffice: 508-862-403 8 Fax: 508-790-6230 HOMEOWI M LICENSE XxEheTIOIt' Piesse Print DATE: JOB LOCATION: number street village "HOM OWNFR": name home phone# . work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include to dwellings of six units or less and toallow homeowners to engage an individual for hire who does not possess a lic supervis ense,provided that the owner acts as or. DEFINMON 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 constr cts 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 re onsmble 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 requirements. and that he/she will comply with said procedures and Signature of Homeowner Approval of Building official Note: Three-family dwellings.containing 35,000 cubic feet or larger will be required to camp with the State Building Code Section 127.0 Construction Control HOMZOWNER'S EXI;MPTTON ; 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 en work,that such Homeowner shall act as supervisor.- gages a persons)for hire to do such Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems when the homeowner hires.unficensed persons. In this ease,our Board cannot proceed against the unlicensed person as it ,particularly 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 n, seveusl towns. You may care t amend and adopt such a f xin/certification for use in your community, by �'forms:homeexempt W- i 6s��semer Affairs.&`Sbs.ness Re�utu�� A ME IMPROVEMENT CONTRACTOR TYPe egjstration 24769 $! 012 ll Qrivate Corp , Xpiration ; 74 Shea Custom Carper ry r ii Edward Shea 34 Cf"rfford Rct x1 , pryrrf0uth MA 60' Undersecretary f b �UlfPlrraa; �llfl�t dltt� iti }{ � ar _ fiCorsS��#rc�r Su Pef!rsot LrcenSIL Ttcse5* 70177 d. EDWAJ�D E SHEAF _. ,34 CLiF.FORD RDA * PLYM©U H,.MA�02360 } _ cpiration: 5130I2013 I l <14r, al G:7 }p S I V -� co) /o I � • r (rf ._ a � � Ts id Z lll..�i� r G 1 r w O Fz n C 00 I Town of Barnstable Regulatory Services ` s S& Thomas F.Geiler,Director 1639. a Building Division ZIP - Building Ulshoeffer,Building Commissioner 367 Main Street, Hyannis,MA 02601 = Office: 508-862-4038 Fax: 508-790-6230 a ' STIP337 SHED REGISTRATION Q120 square feet or less A ,30 Location of shed(address) Village Ac,o6c"Im Property owner's name Telephone number Size of Shed Map/Parcel,# Signature Date Hyannis Main Street Waterfront Historic District? ' A o Old King's Highway Historic District Commission jurisdiction? AYa Conservation Commission(signature required) PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. , PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg r OFF -JP 16� CPS) LOT 1 S- S'To FZY LIN n= S. oof LU BERRY 1 t--� L.L ROAD ' ,ATION OF S T RUCTURE(s) BASES'ON UNFE..OF OCCUPATION ti ONZA.•A MORE t (J."TE LOGATIOlm ` l WpRVL�OUtRE AN iNSTFUMEN.T A -� tHN Scale: 'ESSIONAL LAND SURVEYOR, REBY CERTIFY THAT THE AMERICAN SURVEYING COMPANY MORTGAGE INSPECTION'AS PREPARED FOR N 1264 Main Street, Waltham, MA 02451 (781) 893-6477 .� ` Rl SST'Fu D��,h� tN "TIONWRHA NEW MORtGA GE NOT INTENDED OR REPR Mortgage Inspection Plan E- TO BE A LAND OR PROPERTY IRVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT . COUNTY REGISTRY OF DEEDS CAN BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK 1147 k PAGE RING FENCE. HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE:�j-� K- I� ,� YG.S 1 3UNES.THELANDAS:%V N APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSORS IS BASED ON CLIENT FUR- FECT WHEN CONSTRUCTED WITH RE- MAP II ARCEL O,______ INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS• L-V E Y t LL AK�� . i f t , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ' Permit# 2 Health Division Date Issued It 1 (0 Conservation Division /!g/® Fee `t Tax Collector ( �p SEPTIC SYSTEFA MU ST BE. Treasurer `' tall _ INSTALLED IN COMPLIA NCE Planning Dept. f WITH TITLE 5 °Date Definitive Plan Approved by Planning ENVIIRONMENTAL'COMAND Board TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address /L /C,L Village V �,, Owner 4,et4-c-im,4�" LIti k7ea ,Address �S �/I.��k�r� �; Telephone S!2Fe`:) 7�zI k Permit Request —ter„�., C�,/ ire �—�r.� /. ��a�tx✓ Square feet: 1st floor: existing proposed Zt/y 2nd floor: existing proposed _ Total new Z yy Valuation =�, ` fining District Flood Plain Groundwater Overlay Construction Type Lot Size CX�'C Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 6, Historic House: ❑Yes -A No On Old King's Highway: ❑Yes No Basement Type: ;'Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) � ' Basement Unfinished Area(sq.ft) hL Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing' new 9O First Floor Room Count �7 Heat Type and Fuel: ❑Gas 0 Oil ❑ Electric ❑Other Central Air: ❑Yes �dNo Fireplaces: Existing _ New Existing wood/coal stove: ❑Yes No Detached gara 'sting ❑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 >0 No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number Address License# 3 4,0 Home Improvement Contractor# Worker's Compensation# l Z(!2 �0 7 . ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / �� j' t FOR OFFICIAL USE ONLY PERMIT NO. ' P DATE ISSUED 1 ' MAP/PARCEL NO. :P P 42 ADDRESS fi VILLAGE r a OWNER ".: •, DATE OF INSPECTION: k FOUNDATION FRAMED - INSULATION. r FIREPLACE ELECTRICAL: ROUGH: == FINAL ' ` PLUMBING: ROUGH' FINAL { GAS: ROUGH '' " FINAL i FINAL BUILDING ¢ ` (p Am DATE CLOSED OUT tga ASSOCIATION PLAN NO. F F �1�. cis � .• 0/ LOT I .7 , (IN 15" 5,54-0 �.S F Tic J !6` Iq _ LCT 1 S 1 S'T0 R.Y ow�t_t>Jc _ tJo. 81 � t - `D5. 00 ' LO BERRY HILL RoAD i I�II• + LOCATION OF STRUCTURE(5) BASF.:.ON I I14ES OF orCU'ATiON 'A MORE l;;l:;UfiATF LOCATION fi WILL flFOUIP,E AN 1N1',1FR0,\AEN? SURVEY. Scale: [PROFESSIONAL NAL LAND FY THAT EYO E AMERICAN SURVEYING COMPANY HEREBY CERTIFY THAT THE OVE MORTGAGE INSPECTION 1264 Main Street, Waltham, MA 02451 (781) 893-6477 N WAS PREPARED FOR tJD1 N NNECTION WITHA NEW MOR GAGE n A • LEASEMENTS OT INTENDED OR REPRE- Mortgage inspection P'an O BE A LAND OR PROPERTYVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT COUNTY REGISTRY OF DEEDS ANNOT BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK IIL7k, PAGE- �.C #NG FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: PLC By— 10 i, G• SI LINES.THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSORS S BASED ON CLIENT FUR- FECTWHEN CONSTRUCTED WITH RE MAP# ARCEL# DAFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: l LL- TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPTASEMENTSANDRIGHTSOF FROM VIOLATION ENFORCEMENT AC BORROWER: �-� C .— 1 , Tln All lAlneo IJA e• n 1 TIT evil nU„ 5 a i2 - s, SCALE: -/®J� APPROVED BY: DRAWN BY DATE: C7 /�� REVISED DRAWING NUMB � W o s �. \x, s i0 Q Na TN .mot. 1 , _f f ' k v a c� 3 - J J V4 c r. x Cy N sv ° x ~ O AIi V`\� , N `l` c S C E i f f j t • 4 The Town of Barnstable Regulatory Services `b i639. ► Thomas F. Geller, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 F Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. vt od6 Type of Work: Estimated Cos Address of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law []Job Under$1,000 ❑Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE PROGRA IMPROVEMENT GUA WORK DO NOT�D��M�142A. ACCESS TO THE ARBITRATION SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. � �5A /17- Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav M CMR AQpp�di= Table M&LIb(continued) Prescriptive Packages for One and Two-Family Residential Buildings Heated with Fossil Fuels MAXIMUM MINIMUM Glazing Glazing Ceiling Wall I Floor I Basement Slab Heating/Cooiing Area'(%) lJ.valuez R-value' R-value' R value° Wall Perimeter Equipment EfLcienry' Page R value° R value' 5701 to 6500 Hating Degree Days' Q 12% 0.40 38 13 19 1 10 6 Normal R 12% 0.52 30 19 19 1 10 6 Normal S 12% 0.50 38 13 19 10 6 85 AFUE T 15% .0.36 38 13 . 25 N/A N/A Normal U 15% 0.46 38 19 19 10 6 Normal V 15% 0.44 38 13 25 N/A WA 85 AFUE W 15% 0.52 30 19 19 10 6 85 AFUE X 18% 0.32 38 13 25 N/A N/A Normal Y 18% 0.42 38 19 25 N/A N/A Nonnal Z 19% 0.42 38 13 19 10 6 90 AFUE AA 18% 0.50 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: P!1,4- 3 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: Q0� " 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q--AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-t980303a 780 CMR Appendix J Footnotes to Table J6.2.1b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall area,expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area. Z After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units:center-of-glass U-values cannot be used. ' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space.and the ventilated portion of the roof. 'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing, and interior drywall. For example,an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. 'The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meat the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned bi,,sements must be included with the other glazing. Basement doors must meet the door U-value requirement &scribed in Note b. The R-value requirements are for unhea ted slabs.Add an addition al R-2 for heated slabs. " If the building utilizes electric resistance heating use compliance approach 3,4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a NOTES: a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels._ R-value requirements are for insulation only and do not include structural components. b Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested Y and documented b the manufacturer in accordance with the NFRC test procedure or taken from the door U-value- in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c)If a ceiling,wall, floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 _ ___� The Commonwealth of Massachusetts = = Department of Industrial Accidents Office of/nsestioo lens _ 600 Washington Street Boston,Mass. 02111 Workers Com ensation Insurance Affidavit name: location city " hone# ❑ I am a ho oWmer performing all work myself. ❑ lam a sole r rietor and have no one worku in a�ca acity to er rovidin workers' compensation for my employees working on this job. emp I am an y p g comaanY name •tte� + t 1 tt 4t J, .� citw � � �-I����•� phone# '�::>: �:�> JCV insurance co. :: A I ❑ 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: .. .. .. ...::..:;. ...:...mP com an name: - address :..:.:. :::. ........... .. ; hone#� - - : ........... or cv Lim Faflure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to s1,500.0o and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Offlce of Investigations of the DIA for coverage verification I do hereby certify under the pains and Penalties of perjury that the information provided above is true and correct �+ Signature . Date ' 0/ Print name Phone# OR R official use only do not write in this area to be completed by city or town official city or town permit/license 0 ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen'•Office ❑Heaith Department contact person: phone#!; - ❑Other___ Omsed 9/95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. associatio co oration or other legal entity, or any two or more of An employer er is defined as an individual,partnership, n, corporation ed employer, or the receiver or s of a deceased foregoing engaged in a �oirrt enterprise, and including the legal representative the g g gag J trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. XXX Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is of Industrial Accidents. Should you have any questions regarding the"law"o-T if you being requested, not the Department are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions- please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Me of Invesugadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 i FEE VALUE WORKSHEET LIVING SPACE ' (2000 sq ft or greater) st}i�ar�eet x$115/sq foot— !r (less than 2000 sq ft)V °�G square feet x$96/sq.foot (affordable housing) square feet x$57/sq.foot= (40B or low income) GARAGE(UNFINISHED) square feet x$25/sq.foot= PORCH square feet x$20/sq.foot= DECK I square feet x$15/sq.foot= `� ALTERATIONS/RENOVATIONS OF EXISTING SPACE . . . . . . . cost=. . . . . . . . . . . . . . . Total Project Fee Value Office Use Only y VO Permit Fee v projcost GTE � ,�, , BOARD OF BUILDING REGULATIONS •:: License: CONSTRUCTION SUPERVISOR ' { Number. CS 056340 I 3, .. Birthdate:°102971954 Pares:1029/2002 Tr.no: 27244 Restricts WILLIAM L SCHULZE _ PO BOX 288 CENTERVILLE, MA 02632 Administrator -71,.e ea mo uueaM ql-#awa� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 11 Expiration: 02N 92003 Type: INDIVIDUAL SCHULZE BUILDING , WILLIAM SCHULZE PO BOX 288/65 CROCKERST CENTERVILLE,MA 02632 Administrator ` s 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map� Parcel G Permit# M Health Divisions—7 03 12_6L74V 1 01< Date Issued Conservation Division G Fee 77� Tax Collect '�'+'�+ °Y �1ZI V" N} �„ea �n �'hr►� NaQ Treasurer SEPTIC SYSTEM MUST RE ' INSTALLEDN COMPLIANCE Planning Dept. WE '} 8 Date Definitive Plan Approved by Planning Board ENVIRONMENTALCODE ANDTOWN REGu1,pT1ONS Historic-OKH Preservation/Hyannis a Project Street Address •Village r p Owner /.���pi a: ✓�;`� �1 :1 If I-zr Address 6 Telephone' 7 / `Permit Request t'/ , alA Square feet: 1st floor: existing M/2 proposed_ 2nd floor:existing proposed Total new 7 .r. �. Estimated Project Cost 4 � D Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size 1W ` '00® ?1 ArGrandfathered: Yes O 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 Kin s Highway: ❑Yes No 9 9 ' � g 9 y '� R t Basement Type: A Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.). t Basement Unfinished Area(sq.ft) / Number of Baths: Full: existing new Half:existing Z 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 XNo 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 �a No If yes,site plan review# ' Current Use /4P Proposed Use BUILDER INFORMATION Name �� �sra-1-, e'�C P� I Telephone Number �� �!' ' Address S i License# L�C� 67 4—� Home Improvement Contractor# /Z Z Worker's Compensation# C23 Z—% 1 Jy 2- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �' �T� DATE _ Z-0 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED 4 - r ' , - $ I.. • s MAP/PARCEL NO. ADDRESS r VILLAGE OWNER DATE OF INSPECTIOI�� FOUNDATION FRAME- r P t - • _ + {, ) INSULATION E ; FIREPLACE ELECTRICAL: ROUGH FINALI PLUMBING: ROUGH FINAL t GAS: ROUGH `+ �' FINAL " FINAL BUILDING _ 7Z 9 DATE CLOSED OUT ASSOCIATION TLAN NO.-!� ca t 1 Lauke � EABNBrA�E Department of Health Safety and Environmental Services Eo " Building Division 367 Main Street,Hyannis MA 02601 ffice: 508-862-4038 _ Ralph Crossen ax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. ' Type of Work: Estimated Cost. 2— Address of Work: Owner's Name: Date of Application: /4121 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME E"ROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav --- The Commonwealth of Massachusetts y n-. W. _— Department of Industrial Accidents . -- - . ... Olfrce of/n�estigations 600 Washington Street / Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit name: Z7 69'! ��- location: � Sl_lAt /a a 1G1-/ city hone# ❑ I am a hom owner performing all work myself. ❑ I am a sole proprietor and have no one workin in any ca acity %%%///%%%/%%%%%/%%���%%%%%%��%%%%%%/%%%/%%//%/%%%%%%%%%%%%%%/..;;;�;; I am an employer providing workers' compensation for my employees working on this job. company name: �CA)en L//L i?>/1 zz address: -9 C :o, . city: / /c>7'lo-/,?',J,f PL E phone#: / -Z1 t-q 4:e insurance co. G�/970,-Az-� oiicy# �? `® ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the folloning workers' compensation polices: tom any name: address: city phone#� insurance co. oiicv#.. 60 comnany name: address: city: phone . ,. insurance co. Failure to secure coverage as required under Section 15A of MGL 151 can lead to the imposition of criminal penalties of a Me up to 51.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tlne of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage vetincation. I do hereby certify under the pains an d aloes of perjury that the information provided above is true d come Signature �'� Date _ Print name Phone# - ------------- official do not write in this area to be completed by city or town ofnciai permit/license 0 ❑Building Department ❑Licensing Board ediate response is required ❑Selectmen's OMce ❑Health Department : phone 0; ❑Other .:., (cevma M5 PJA) Information and Instructions � f Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any coatr.;.. 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 receive:c: trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto"shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa: of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who_.has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither.the. . commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may he submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.' please do not hesitate to give us a call. %//%%%%%%/%%/%/%%%%�%i,,%//%%%%%//�/% �i�i�,%% The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Me of IOl18sugado ns _ 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 NOM�I RQVERENTOMTRACTOR 7` H , ,'------ —_ - •:'.ice. H V: BOARD OF BUILDING REGULATIONS s. CONSTRUCTION SUPERVISOR License: j Number. CS 056340 Birthdate: 10129/1954 6pi�:10/29/2002 Tr.no: 27244 Restricted To: 00 WILLIAM L SCHULZE- PO BOX 288 MA 02632 Administrator, CENTERVILLE, "'U �, BUILDING CO.rZj M UALITY a:PRIDE Residential Construction & Remodeling P.O. Box 288 •Centerville,MA 02632 Phone(508)771-8604•Fax (508)778-9141 .3 o Suz cr o ki Q V S Ar o p " v v \ Q o Q 1 t ------------- LOT 1 1 5,54-0 A-s F LOT Eck L.O`r"1 S Q0, 81 05 ' - (DS• oo ' S LUESERRY - H7 LL ROAD ROGATION OF STRUCTUAE EiASF.si!�N LI�yES�tF T10N l:ii't)l': •l,hi• Olr `t. li NtOHE 1:"WRATF LOCATION c ' WVL1 F1GC7!;IRF_AN iN!51"E IMEN7 r .. SURVEY'. Scale: '4 PROFESSIONAL LAND SURVEYOR )0 HEREBY CERTIFY THAT THE, AMERICAN SURVEYING COMPANY %BOVE MORTGAGE INSPECTION 1264 Main Street,Waltham, MA 02451 (781) 893-6477 ; N WAS PREPARED FO D)R A"TTZI dT'1=U 1JC'i IN (� ,ONNECTION WITH ANEW MOR GAGE Mortgage Inspection Plan 1ND IS NOT INTENDED OR REPRE- 3ENTED TO BE A LAND OR PROPERTY .INE SURVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT COUNTY REGISTRY OF DEEDS ;ET. IT CANNOT BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK 1�PAGE 1I rABLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: PI )G•. )S7, G• SI WILDING LINES.THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSORS iEREON IS BASED ON CLIENT FUR- FECT WHEN CONSTRUCTED WITH RE- MAP# --PARCEL#tz� 1 L`DA 4ISHED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: ;UBJECT TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPT •AKINGS,EASEMENTS AND RIGHTS OF FROM VIOLATION ENFORCEMENT AC- BORROWER: L!_ G TION UNDER SS.G.L.TITLE VII,CHAP. •.;}}}:??.:}}y;;;?:;.}};:ryy.}}};.}:•}:^}}x•.v:.vvnvv:nv:x.,..v:,:..vvxw:nxv:nvvv:vvn v..v..vvv:::.vxw:::.::,:..vvv,;•;};}::::;:•.;}yv,}};n;:.;}:xx:vwn.w:.,.:::.vxx.:.w.w.:v.,,,,.m:v.:i:xvw.w::.v: Y:<::>::>::> 153 :::::.::.............::::::. ...............::::..::. <{<'<«< DING .'.•'.x ���`�: �.,}� i,'2 :R:::�%�:':r:` `�^'�if;`.'.+::'Y ::2��' � :tit.:': t? ;.<{}�'Y �}.�:•`.�;%%•`.#%%::~?`•`.•`•'%':r%�%:?�Yr ?'l}i; <'<?rr<353�# 43? 81 HYANNIS B< U Y•'•HIL.••�. w.:::.:w:•::..v............i}:.h}r}r}}}r}}'s3:•}}v}xvv:q:•.}}::r:•}}:•}}:?^;•}}r:6rrr}}}}}}} ::`•.•�'.•:•.•:4i;^}•::..... tt`Y':{:+.M1i::yy::y'i,>.iM1':•.:��;:iv{{y{}::ij}j::}t::{C?:•.`v<i::ti"i;}i`i: ':'.i:':i::ii}��}+•::ii{:':'Yti'.:;{::rp:+S7;.ry>�} :::?:,.'..•.,..{;:.•••,`•••-•r :iyitii <t :?YLllij`tiiii!ihL ,t1�`v>ii:;{�itiif:`tiLi{`«Yi{Stiiti'.`�l�i2C:jLu<iiy{tiyM1+ti'y!�4�y:•,.•.�M1{`2+>y'i`;:i;::4;:;:`}�`�� ::::}:iiiiii{{vv{vvvviii:}>}:iiiii:�iiiiiiiii?iii ii��iii:•iiiiiii"�i::yi}:ti<�i?�: :. .:.....:•. .v:••v:•.vvw.:vnxx,•:::•.vv::•.:vvvvvvvvw:.v, ANONY 4 ... ...f.;:c.:'•;:?<r?s:::?:i}i?v.}x•:.};•.;.:2v:. 5:;�`:::;'t}', .,rtr:'t>i;:.. }}r:rc'?"t;"r:2`}':`2:` 2;2�•:<:`;`2Y•;��t`:': 2;,t.t;.;;:i:�:ittt`::::i'?k+?: U K YARD KKK <> .......:....... .WENT R.T OUT TO SITE---CONFIRMED THAT IT WAS A M ESS-THERE IS O RD.THAT�O SAY S S WE AN T C I KET.W C E WIL L O END T O S B HT O SEE IF THEY HAVE ANY VIOLATIONS. ' > . ............. ..i .......... ........:....:........................... ::::..::..:..:.::.:.:.,.:::::..............,::..:.:.:v::::........... .............................................:............... t V >{q - r ___. ... .. T- w • I Town of Barnstable Building Department ComplainOnquiry Report �fP i J Date: °--- Rec'd by: 1 Assessor's No.: 2'1 0244 1 Complaint Name: ID--L Location Address: Originator Name: Street: cl i Village: State: Zip: C Telephone /)✓ Complaint Description: tAN Inquiry _ Description: For Office Use Only Inspector's Action/Comments Date: Inspector. Follow-up Action Additional Info. Attached Copy Distribution: White-Depamzent File Yellow-Inspector Pink-Inspector(Return to Olrce 1 fanager) L x 'A3:r. .yam •a `s j/IT�YY. k �. ,.- y a- �� o �e Y /� >i'Y t ;. •� Q �► �'� �. � ``,y 4 t,,,�� � � �,� 7 V+y `` .�W O 4 . '','� C � G `c:�� y i ` �' i� w � __ 4 ---• ...- ter•! J �� -.11�,`�"��� ��`�e.��i�' �7 y .> t.' .� ,y� ;�. I +! O ' '��' a �. �;�i��, ;, .., ,�-, � � �v r •• � �. -:,� a 4 ^G � ! 1L '1 "1 p-1 y � `.7 �..� 'r� L y � s'� � ,� t . _rv�c P, NO =w a•` a �1 y V / r IA 7f. y y y � o- 10 L - yy Y y - �. V;Wwi- COX } e. a 'p. t '�•= y+ � .'*,r�/��`v<Sw°k�'���iad�y��� .E°"�'!ram' - O��„•{!T'�'Z. ^''l �N 7 iliW� Ste'�,�� �j-` Y. [ ..y�' 9 FTt �!�• �. .. -Rr t r,'' I biz L- rr� � y o--ttl5,w` y ^r �/ 40 T , �'! ^it 7 � J O I 7 I \/ °�' ,•��Ili �''°w � ';� � �� i���w � �� �?rt i ;.-.� r- O / .� � ��j ts�mod• ♦'F i tj MIR 'ZkAo- sir� ��' �"`"�!'* �r��r•� -.'y�,�� -«�"��. �i�+ I�i►�'. .:� t��i�S�I� ty i F %': r"7 . I > + Ti jel s y L '3' �\ v �7 �\ �� � •Y 1 .d 4 ' `:�f4 �� r,� �1 Y� � y� � p y `�' :.a . �- ti.� � r � -�o-i ,r -12 may., y L �� 1 w �p ' > �„� a-\.� \\\� � 4 i. y� 'Y t' r �� a 7 G:^;� Qr tidy ��� "> 0-1 ".7 .r+� � � . .� O a- �' 4 � ��'d� y � � �'� ,�: �- _ � y. N r•a s> z-i °�..t .'fit �.. �3.,�:.•• . +.E..-, cs. J�» 9 �� q » / � � % & ¥ ,2 w � ® i f+^.I \ a- y � y