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0003 BROOKSHIRE ROAD
3��cY.eg � - _f — —_ \ Town of Barnstable S c ..;;.t wp A Yam- a ..,Fx . m.=+, .... .: �i s; v' ; ,:.;.•'k v..k.Sb` �` ,^-..�. ��", Building Post This Calcd So That rt is Y�s�ble,from the Street Approved Plans Must be Retainedzon iob and this Card Must be Ke`t •Ma 'Post dUntil§§Final Inspection Has Been Madet .°, E , �, a�a Where a Certificate of Occupancy�s Required,sbch Bu�fding all Not be Occupied until aFinal Inspeitron has been made Permit Permit No. B-20-48 : Applicant Name: BOLIVAR E IDROVO Approvals Date Issued: 01/08/2020 Current Use: Structure Permit Type: Building-Sheet Metal-Residential Expiration Date: 07/08/2020 Foundation: Location: 3 BROOKSHIRE ROAD,HYANNIS Map/Lot 328-030 Zoning District: SF Sheathing: Owner on Record: DaSilva,Marcos Samela � ' Contractor4Name' ..BOLIVAR E IDROVO Framing' 1 Address: 5 BROOKSHIRE ROAD r w Contractor`b6c se ,7623 2 r` `z " HYANNIS,MA 02601 Est Project Cost: $4,000.00 x . Chimney: Description: retrofit ductwork. Removing existing branches and relocating vents Permit Fee: $85.00 in bedrooms and living room.wrapping Iductwork and sealing joints o- Insulation: Fee Pald` to better air flow �p r ,� ° � . $85.00 1/8/2020 Final: Project Review Req: FACTORS SUCH AS SMOKE DETECTOR LOCATIQNS MUST BE '' Y k � CONSIDERED FOR PLACEMENT OF NEIIVUENTS"5 Plumbing/Gas , e %L Rough Plumbing: Building Official " Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized bythis permit is commenced within six months;after.issuance. All work authorized by this permit shall conform to the approved application and theapproved 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 tawsand.codes. This permit shall be displayed in a location clearly visible from access reet or road and shall be maintained open for public mspection for the entire duration of the Final Gas: st work until the completion of the same. ' r i t Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe Building andrFire Officials are:provided on thu'permit. Minimum of Five Call Inspections Required for All Construction Work.°' ,. <> Service: d Kr 1.'Foundation or Footing 2.Sheathing Inspection _ " Rough: a..�.� , 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. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Town of Barnstable Billldl g ' n FAAR Post This Gard So That ibis V�sib'le From the;Street=Approved°Plans Must be Retained on Job and this Card Must be kept Posted Until Finahlnspection H,as Been Made. ` `> ' . w ��� ° Permit tR Where a Certificate of,Occupancy is Requ�retl,such Bwlding shall Not be Occupied until a Finahlnspect�on has:been made Permit NO. B-20-48 Applicant Name: BOLIVAR E IDROVO Approvals Date Issued: 01/08/2020 Current Use: Structure Permit Type: Building-Sheet Metal-Residential Expiration Date: 07/08/2020 Foundation: Location: 5 BROOKSHIRE ROAD, HYANNIS Map/Lot: 328-032 Zoning District: SF Sheathing: Owner on Record: SHEA,ROBERT L& NANCY J Contractor Name .BOLIVAR E IDROVO Framing: 1 Address: 5 BROOKSHIRE ROAD r Con_tractor License: 7623 2 HYANNIS, MA 02601 ( i 'st. Project'ct Cost: $4,000.00 - Chimney: Description: retrofit ductwork. Removing existing branchesi.and relocating vents Permit,Fe: $85.00 in bedrooms and living room.wrapping(ductwork and selling joints _ ; fz, Insulation: Fee Paid: $85.00 to better air flow Final: -Date: 1/8/2020 Project Review Req: FACTORS SUCH AS SMOKE DETECTOR LOCATIONS MUST BE CONSIDERED FOR PLACEMENT OF NE�rVENTS." Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized--by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and theapproved 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. - : Final Gas: 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 work until the completion of the same. R Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and,Fire Officials are provided on thisp4rmit. Minimum of Five Call Inspections Required for All Construction Work: ° ` Service: K 1.Foundation or Footing - Rough: 2.Sheathing Inspection - 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). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT a _ Commonwealth of Massachusetts { Sheet Metal Permit Map_ UP ar __ Date: 0f- 3U1LD1Nr. 0P_P'Pe 't Estimated Job Cost: $ JAN O 7 2020Permit Fee: $ . Plans Submitted: YES NO c7- TO�v�v .jr `Plans ev e,ved: YES NO Business License# Applicant License# Business Infomnation: Property Owner/Job Location Information: N urot)oame: 16D ,04Y Name: Yfyws Da,. &Lg Street: �3 1 �i c � Street: S goo�a('S�I City/Town.: d/1 City/Town: �T��yid5 A94 r mm W Telephone: Telephone:_�S"-7-33 Photo I.D. required/Copy of Photo I.D. attached: YES e/ NO sfaff Initial unrestricted license J-2/.M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family--6Z Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Fire Dept.Approval Institutional_ Other Square Footage: under 10,000 sq. ft._Z over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: !/ HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents. Air Balancing . Provide detailed description of work to'be done: (lie 'k �° ` ombiv /�J K 'vr room.j G)i y aCvC.�U �� ���rw�s���y A(rAw�r�Xvu�lr�.�. J . 1�SUFtANCE COVERAGE: I have a current liabilifi[insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes No ❑ if you have checked)LO, indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity Q Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application walyes this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box�J, I hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of.the Massachusetts Building Code and'Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Erogjess Inspections Date Comments Final mspection Date CoCo�ents Type of License: By Master Tide ❑Master-Restricted d,_R Sm Cityrrown ❑Joumeyperson Signature of Licensee Permit# ❑Joumeyperson-Restricted License Number: 6.Z� Fee$ El Check at WM.mass.a /dpl Email: J Inspector Signature of Permit Approval �' a Camx�a�nverrs �t��et�s ' ,�e�ar6r��t�'� �cci - • 60-0 Wa>ais&-eet Bastwi ,MA 02111 • •rvEv�u�as�g�e�a Worlers, CumapensafiagIIISII�'. SeAEffi/1layit13 Mel*Cmbl'al 3Z5 ECb^n IIIl1j]EL5 � �51�1'� #I�foMath n f�Z VO��/I� l P� 2I�FID NmiC�$ . Are ru an e=Tjoyer?Oheckthe appropriafe bcw ' -Type,of praject{regrind}. I am a geu�l c�a�md=and I 1-0 Iauta eaiplflyzs 6. []New • emFrSo�{fu11 a=dfa:part-�ime�# have hied f5ce s�#r-coa��acs ' ha a Z.�I am saSe Fropsietar argar6aer- wed�f;ze af�hed shee€ �- El sidp anti have no emPls Giese su1�cactnLs �a g..Q bevsalosf employees aha�*acPss' 9. ❑SniS addifinu wadIIng F �e in any cry comp.in s+ # . jN�s 'gyp- Weam a tatpasafi aild its 14 0 Elecmual sepaizs Cr add nns WVL�M&l - �� cfficsrslzzMC=rdseaV26W 1LQPb�gmpaimora8iEtions 3-❑ Iamab o' aperMM o,��•,CMp_ 1?[]Boaf729 �11 myself �I(, imuca=exeq,me�-I I [� t l � Y2 1 CCMP-m ] 'Any aN€ i�c c�e�s�z alp fn ate s�t�abersrc�® apFrm � #�,meowa�sw�suit aris�daea`imc�ic=Y'a�t�epstz��ne saF��Tc xadtb�h�n�ide.eo��sis�mitsaemen-&-a mdiae�g socn.. viaL I am an ernpZoyar flintis praiNiag ivar ers'co rm iH=raurJ fcr in,}AMPLDwe. BOBIV is fiiepaEcy and jab sits` in„�orraatian, It��m��e CampaayY'Fame: Job. Address Cidgp: Attach a cagy crf zs or rs'co�peasa�napnTcrdeclaraf�page�(sho ving the p�Y>�ber and C3#-al ion 3a#e). Fatlnre sew e,,erage as reguiredunder Se�xt 25A of MM o.l ca a lid to EFie isoposit at of criminal peffilties of a fine up#o$�00:Oa andlor one-yearim en�d�as 1 as ci Z.penal�s m the fa�au of a STOP WORK{]BDERavci a of up to$2.50-00 a clay against&e Violld-M Be.Ngvised flxd a copy of this zbhmed miay be f ded•fa the Office of 11�vestega&m ofthe Dom..for fi==ce caveraP VeIiE _ I rJa hem by c ' T aud�al F���thdills ifarrm =Aran. tl a ivrs Ls has a stT cttrr�t IJatf,- _ p� Phone� � �-�( ?�v � - •_ t3 c ai arsa mr2}z. Va iirrt Write in Il s.,ea,to be sam}�rJete�by�tcrf¢�Fu or�a a: Pe fncease 9 Oiy (dr 1.Board oIlre a z� S-' Iovrn Cier 4.'F7ec ricer Isp�s S.P�bimg r . 6.Other 6 I 1 11 1 1 1 1 1 i 11 u_ n■�i7i .ter- wf:u 1« �•u1 I .+ul• ••�R u n ■- 1■ n■ ►a .■n■u«aLv u m ul is a maw ••��. 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INFIGOR Mill a .1 i �.t...tiro■• wv tie �� a•. •�■ ur Town of Barnstable Building Department'Services t RIRNiRARf.R : Brian Florence, CBO MAE& Ea 39- k`0� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us , Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sigh This Section - If Using ABuilder as Owner of the subject property hereby authorize 'o l ua y 01-0 U10 to act on my bebA. in all matters relative to work authorized by this budding permit application for- 3 b o ok4 . (Address of Job) **Pool fences and alarms are the:responsibility of the applicant Pools ate not to be filled or utilized before fence is installed and all final inspections are performed and accepted.. Sid tote of Owner Signature of Applicant 1 "� fCQS �A :� UD �J�Y rOJO Print Name Print Name Date Q7FORM&:owrraxPERMISSIoMooLS Rev:09/16/17 Town of Barnstable 4, J r - Building ]Department Services Brian Florence, CBO o Building Commissioner _ 200 Main Street, Hyannis,ILIA 02601 SAMMILIMKAEA ' www town.barnstable.ma.us r Office: 508-862-403 8 Fax: 508-790-6230 HOMEONVNM LICENSE EXEMIION Please Print DATE: JQB LOCATION: nnmber strttt. village "HOMEOWNER": name home phone s wodr phone# CQRRTNT.MAHJNG ADDRESS: . ertyhawn• state up code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFIlMON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- f anily dwelling,attached or detached structu es'accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Milding Official on a form.___ -„rceptabie to me B '3m- trial, he/she shill be responsible for all such wor's pe�or�ned und.�r the bu�ding_pe�rt. (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 Banast-able Building Department minimum inspection procedures andregniremeuts and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EMIPTION 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.L1-Licensing of.construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often . results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against-the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page . . this issue is a form currently used by several towns. You may care to amend and adopt such a formlcertification for use in your community. Q:\WPF=)FORMS\buHdmg pemiit fmns\MRESS.doc 08/16/17 �Q�MMONH/�pLTH OF M t AdH....... �. SHEETMETA:�WORKERS ::ISSUES TH �F°pLLO1Nl NG'LICENSE SEER UNRESTRICTED. s 3 I;IV I� 7 ROVip'fti�`�r r�x � a 8000EARSg APT:6s HY NIS,MA 02601234` 7823 N : t. 128, . ,. Town of Barnstable_ Building ' Post;°This Card So That�t,�s`Visible From„the Street-Appro-ved Plans,Must be Retained on Job andth�s Card Must be Kept iA•NSCABLE. �a � ;, ` �. .:` ;� • M Posted'Unti1 Final Inspection Has.Been Made x ,,' ` ., i63p ♦ .s„4 a :.r ,... 0 .< .,, .s,.<. ' ?r,. :a Perm s WhereaSCe,'rt�ficateof Occupancy is Required;suchBuLd�ng shall Not:be Occupied wntil�a Final Inspection has bxeen matle �t ;�� Permit No. B-19-838 Applicant Name: LEWIS,GEORGE A& MARIE V Approvals Date Issued: 03/15/2019 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 09/15/2019 Foundation: Location: 3 BROOKSHIRE ROAD,HYANNIS Map/Lot: 328-030 Zoning District: SF Sheathing: Owner on Record: EORGE A&MARIE V - ContractocYName Framing: 1 LEWIS,' 4 � Address: 3 BROOKSHIRE RD Contractor„License 2 HYANNIS, MA 02601 _ st�Prolect Cost: $0.00 y. Chimne Description: Remove Fireplace and add windows in same place.? Permit Fee: $ 100.00 Insulation: FeeiPaid'; $ 100.00 Project Review Req: 3/15/2019 Final g wl r, Plumbing/Gas F � � Rough Plumbing: Building Official :,r, Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authcrized�by this permit is commenced within six months after issuance. 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. " The Certificate of Occupancy will not be issued until all applicable signatu es by�the Building amend Fire Offi�als are provided onthisspermit. Electrical Minimum of Five Call Inspections Required for All Construction Work: r n Service: 1.Foundation or Footing h Y 2.Sheathing Inspection Rough,: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed .-. a . 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 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. "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 Fire Department �5- All Permit Cards are the property of the APPLICANT=ISSUED RECIPIENT - Final: c u OF'THE O Application Number..&....i..... .......... .. . ... ... .......... • SABNSPABLE. • MASS. Permit Fee.......................................Other Fee........................ Total Fee Paid ........... 1..................... ........ ...... TOWN OF BARNSTABLE Permit Approval by...........�.t... ................On.....3 ... BUILDING PERMIT 630 ......Parcel.....Map................ .. ..................... APPLICATION Section 1 — Owner's Information and Project Location Project Address_ o oA D Village -( Owners Name_ z22 o.,5 o Owners Legal Address City z!�,�} State ? /� Zip Owners Cell#_ 5-oO— �3 -I q 5'�41 E-mail 4I$9C_S Section 2 —Use of Structure Use.Group ❑ Commercial Structure over 35,' cubic feet, 9 ❑ Commercial Structure under 35,00 cubic eft- a ❑ Single/Two Family Dwellingir� Section 3 — Type of Permit New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment © Sprinkler System ❑ Addition ❑ Retaining wall ❑ . Solar ❑ Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 - Work Description 1 ©e�' tl E Last undated: 11/15/2018 r Application Number................................................... Section 5—Detail c_ ost o��toposed Construction 0,00 Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing . Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed . Side Yard Required Proposed - Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated. 11/15/2018 " The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPReant Information Please Print Legibly Name(Business/Organization/individual): /)A . :5- Address: 3. 0,9 City/State/Zip: t� sLiL/ o/ Phone#' E .D O Are you an employer?dheck the appro ratebox: Type of project(required): 1.❑ I am a employer with- 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 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 S. ❑Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'comp.irmir nce comp.insTMance.$ ed.] 5. We are a corporation and its 10.❑Eleclrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers right of exemption per MGL comp. p p 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ' $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DU for insurance coverage verification. I do hereby certify under the pains and pen of perjury that the information provided above is true correct sign Date: Phone#: Ojj`iclal use only. Do not write in this area,to be completed by city or town ojjiciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health_2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. " Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152;§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of s hceise or permit to operate a business or to construct tinliin�=the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public.work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of in mmee coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number.listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant~ Please be sure to fill in the penmit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The CommomWealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street BostM MA 02111 - Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Application Number............................................ Section 9- Construction Supervisor Name Telephone Number p Address City State Zip License Number License Type Expiration Date C Contractors Email Cell # 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.Attach a copy of your license. I Signature Date I Section 10-Home Improvement Contractor 4 I Name Telephone Number Address City State Zip E t Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors 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.Attach a copy of your H.I.C... Signature Date I Section 11 —Home Owners License Exemption Home Owners Name: ,�/� Z Telephone Number j®. 3 - S'Y Cell or Work Number SOm - 3�- -� 5 11 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 arnstable. Signature e DateZ1 APPLICANT SIGNATURE -c Signature Date Z XSZ l 7 Print Name d/�/1 Cvs Telephone Number 5;�) E mail permit�to: Last updated- 11/15/2018 Section 12 —Department Sign-Offs j Health Department Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ 1 Conservation ❑ i For commercial work,please take your plans directly to the fire department for approval Section 13— Owner's Authorization I, , as Owner of the subject property hereby " authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name �I Last updated: 11/15/2018 . tt Town of Barnstable$] Building-, Post This Gard So That rt is;V�s�ble';From; he Street,-Approved Plans Must be Retained on Job and thisCardMust be,Kept M Posted�Until Final Ins ect�on HaswBeenNlade r 163A° , sue ps. +: g .. . ., l Not bne Occu red until'a Final Ins ec_t..�on:,;h`as beenmade y < Permit itWhe w Building shal Permit.No. B-19-563 Applicant Name: LEWIS,GEORGE A&MARIE V Approvals Date Issued: 02/21/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 08/21/2019 Foundation: Location: 3 BROOKSHIRE ROAD,HYANNIS Map/Lot 328-030 Zoning District: SF Sheathing: Owner on Record: LEWIS,GEORGE A& MARIE V Contractor Name �, Framing: 1 .. , Address: 3 BROOKSHIRE RD Contractor L ense� r 2 NA' HYANNIS, MA 02601 Est-Project Cost: $2,200.00 Chimney: VA'Permit Fee: $35.00 Description: roofing and replacement windows Insulation: Project Review Req: Fee Paid $35.00 Date. 2/21/2019 Final: E , t Plumbing/Gas .. Rough Plumbing: Building Official 3 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 stru,ures`shall be in compliance with the local zoning by laws n codes. This permit shall be displayed in a location clearly visible from access street or road�and shall be maintained open for public mspectiah for the entire duration of the Final Gas: work until the completion of the same. z § y Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Bulicling and Fire Officials are provid ed on�thi permit. Service: Minimum of Five Call Inspections Required for All Construction Work:i 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 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. -"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Fire Department Building plans are to be available on site C� All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: 5 Application number......................................:......... A. 2)) 1k ,� � Fee . ............................................................. WIA NAM �. 1 '�" Building Inspectors Initials....................................... �. Date Issued............��,. ......................... Map/Parcel...... ..:.a.. ....................................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 3 ZZ /1 6�v_ Al .l NUMBER STREET VIL AGE Owner's Name: llv�a Co S 5i 1-C/l Phone Number Email Address: yrCe9S ���j, ` Cell Phone Number Project cost$ . 2-0 0 •d 0 Check one Residential Commercial F- OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK E] Siding �D Windows (no header change) Insulation/Weatherization 0 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 l,'Mov'Th A.,m P yelt&> CONTRACTOR'S INFORMATION Contractor's name 'Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. 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 X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event 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 tV c) Cell or Work number ` c 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 2 /�z APPLICANT'S SIGNATURE s Signature Date All permit applications are subject to a building official's approval prior to issuance. Bk 31815 Pg114 #4991 02-01-2019 @ 11 : 31a QUITCLAIM DEED I, VIVIAN J. BUSSIERE, Personal Representative of the Estate of George A. Lewis, pursuant to an Order of Informal Probate of Will and/or Appoint of Personal Representative issued by the Barnstable County Probate and Family Court on December 4, 2018, Docket No. BA18P1792EA, of 6 Danielle Drive, South Dennis, MA 02660, For consideration paid and in full consideration of less than ONE HUNDRED EIGHTY- FIVE THOUSAND AND 001100 ($185,000.00) DOLLARS, Grant to MARCOS DaSILVA and SAMELA DaSILVA, husband and wife,,as tenants by the entirety, both of 65 Camden Circle, Mashpee, MA 02649 WITH QUITCLAIM COVENANTS o the land, with the buildings thereon, situated in Barnstable (Hyannis), Barnstable o County, Massachusetts, bounded and described as follows: Northerly by Brookshire Road, eighty (80) feet; Vl Westerly by Lot 4, as shown on hereinafter mentioned plan, one hundred (100)feet; x Southerly by land of the Barnstable American Legion Home, Inc., eighty (80)feet; 0 and Easterly by Lot 2, as shown on said plan, one hundred (100)feet. :B o Containing 8000 square feet of land. 2 to Being shown as LOT 3 on plan entitled "Subdivision of Land - Hyannis - Barnstable, Mass., as Surveyed for Ralph Johnson, Scale 1 inch = 40 feet, May 1948, Whitney & Bassett - Architects & Engineers, Hyannis, Mass.", which said plan is duly recorded in .� Barnstable County Registry of Deeds in Plan Book 85, Page 344. Being the same premises conveyed to George A. Lewis and Marie V. Lewis by deed from Edward H. Rychlinski and Loretta P. Rychlinski dated May 16, 1952, and recorded o with Barnstable County Registry of Deeds, Book 811, Page 344. See Death Certificate a for Marie V. Lewis recorded herewith. See also Estate of George A. Lewis, Barnstable Probate Court Docket No. BA18P1792EA. Property Address: 3 Brookshire Road, Hyannis, MA 02601 MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 02-01-2019 @ 11:31am [Signature Page To Follow] Date: 02-01-2019 @ 11:31am Ctl#: 450 Doc#: 4991 Ctl#: 450 Doc#: 4991 Fee: $632.70 Cons: $185,000.00 Fee: $566.10 Cons: $185,000.00 1 f Bk 31815 Pg115 #4991 Executed as a sealed instrument this day of L 9VIge , 2019, VIVIAN J. S Personal Reoresentative of the Estate ofbeorge A. Lewis COMMONWEALTH OF MASSACHUSETTS Barnstable, ss On this day of Fl bvm✓ , 2019, before me, the undersigned notary public, personally appeared Vivian X. Bussiere, as Personal Representative of the Estate of George A. Lewis, proved to me through satisfactory evidence of identification, being (check one): ❑ or other state or federal governmental document bearing a photographic image, a oath or affirmation of a credible witness known to me who knows the above signatory, or awn personal knowledge of the identity of the signatory, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it volun ily for,its stated purpose. Notary Public: Robert F. Mills My commission expires: 3/11/2022 ��111H1111111�11// ,f/.,� N• - ��j � •�CHySEt.•• ��� 2 JOHN F. MEADE, REGISTER BARNSTABLE COUNTY REGISTRY OF DEEDS RECEIVED & RECORDED ELECTRONICALLY i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Business/Or anization/Individtial : Address: R ."C' City/State/Zip: ©,2(o o 1 Phone#: Are you an employer. Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑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 working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.: 9. ❑Building addition ��required.] 5. ❑ We are a corporation and'its 10.❑Electrical repairs or additions 3.C:d'1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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 andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a' fine up to$1,500.00 and/or one-year imprisonment,'as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of rjury that the information provided above is true and correct. Signature: G'�; 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written. An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that".every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of publicwork until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the,affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents, Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.##617-727-4900 ext 406 or 1-877-NlASSAFE . Fax##617-727-7749 Revised 4-24-07 www.mass.gov/dia , Town of Barnstable �t# Expires 6 months f m issue Regulatory Services Fee f i • IAMSMBLE, ' v MAC' Thomas F.Geiler,Director 1639 fp MA't 6 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number , Property Address y /"DD,� Ij Residential Value of Work �/9y _ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name %qA-1 Telephone Number LOA Q--36 A Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 061 ,7 7X-PRESS PERMIT Pv orkman's Compensation Insurance Check one: MAY 3 0 2012 ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance ,. TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# (. (OQcgkSr �4D Copy of Insurance Compliance Certificate must accompany each permit. 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) Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#.of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. cop of the Hom Improvement ontractors License&Construction Supervisors License is -- re dui SIGNATURE: � — C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intern iles\Content.Outlook\DDV87AAZ\EXPPESS.doc Revised 072110 Au thorization Form: r ' f - ` I � ��� V G e w /S , as owner of the subject property, hereby authorize Baker&Associates to act on my behalf, in all matters relative to work authorized by this building permit application for Address of property: 3 Brookshire Hyannis, MA Signature of owner: �.;yam _I/ �- - = U � W/ s Print Name: I — Date: i •I asSachuseIts Uepattirt, : . ' D.- �t�SJ/ Rivard of Buddiny Reguianr � t s In r_s. Cnn.tructirrn Superni.rrr ; .icense. CS-009714 Y' RICHARD P. GARN EAU JR 251 Woodside Rd:: 5 West Barnstable MA Q db& "`:"'„ :°" 04/04/2014 /�� r3 airs Business Re ulation r Aa . Office of Consume g N 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 162600 Type: Supplement Card Expiration: 3/26/2013 BAKER & ASSOCIATES INC. RICHARD GARNEAU 521 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 Update Address and return card. Hark reason for change. Address I Renewal I I Employment Lost Card SCA! L; 20M-05ri1 . - - I v� t- (.ievmC Or IT OIN Ira(i'.t! N;ilni i,a ;n:{r.� ;. brforc the etlriraUon dale 11 hrsn>,i r r ?r�+; - N!i !Mi'ROVI-ML.NI t,t1NTPAf r0R tlfticc rtI Cnn�umrr �fian , :.n;i l4rr'.., :r,, ic, , 11) fart, Plaza �ut(r fr If, r� 1 u�irr lri i.Inr� r Client#:9742 2BAKERAS DATE(MMIDDIYYYI) ACORD. CERTIFICATE OF LIABILITY INSURANCE 04/1W2012 •� 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 C. VERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil A"CD"fi Ex1:508 775-1620 FAX N,: 5087781218 Insurance Agency E4WL ADDRESS: 973 lyannough Rd., PO BOX 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance Baker&Associates,lnc. INSURER C P O Box 923 INSURER D Centerville,MA 02632-0071 , INSURER E: - INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. LTRR TYPE OF INSURANCE INSR y VD POLICY NUMBER M�MILDIpY EFF MPMfDDY EXP LIMITS A GENERAL LIABILITY MPJ7223M 4/19/2012 04/19/201 EACH �OCCURRENCE $1 000,000 X COMMERCIAL GENERAL LIABILITY PREMISES EaEo"cTaiErrence $500 000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:. PRODUCTS-COMP/OP AGG $2,000,000 JECT POLICY PRO- LOC $ AUTOMOBILE LIABILITY E COMBINED IMIT Ea accidtSINGLE L $ BODILY INJURY(Per person) $ ANY AUTO ALL OWNED F7 SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED. • Per accident) $ HIRED AUTOS AUTOS „ $ 70FFICER/MEMBER RELLA LIAB OCCUR EACH OCCURRENCE $ ESS LIAB CLAIMS-MADE AGGREGATE $ $ RETENTION$ WC STATU- OTH- S COMPENSATION - - WCC5002454012012 /23/2012 04/23/201 X LOYERS'LIABILITY. YINE.L.EACH ACCIDENT $500 OOO PRIETOR/PARTNER/EXECUTIVE NIA A /MEMBER EXCLUDED? a E.L.DISEASE-EA EMPLOYEE $50O OOO ry In NH)cribe under E.L.DISEASE-POLICY LIMIT $500,000 TION OF OPERATIONS below DESCRIPTION OF OPERATIONS l LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. 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 - ---� `t.� ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD.name and logo are registered marks of ACORD LS1 #S949571M94956 ` f Hze Commonwealth of Massachusetts !Q Department of Industrial Accidents a Office of Investigations > d 600 Washington Street Boston,MA 02111 QM =� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual)- ��Q�A//J Q n Address: City/State/Zipa"k.'Al/e �� Phone.#: _ yam. -Are you an employer?Check the appropriate.bog: -- 1N I am a employer with. 4. [J 1 am a general contractor and`I Type of project(requiretij ---�— employees(full.and/or part-time).*; have hired the sub=contractors 6, ❑New constriction . 1.�j' I am a sole proprietor or partner' listed.on the.attached sheet. 7. Q Remodeling.: ..ship and have no employees, These sub-contractors Have working for me in any capacity. employees and have workers' g' Demolition [No workers'comp.insurance comp.insurance.1 9. ❑Building addition required] 5. 0 We are a corporation and its 10.[]Electrical repairs or additions 3.❑ I am a homeownez'domg all work otiicers have exercised their 11. Pl❑ umbmg repairs or additions myself. [No workers'`comp. right of exemption per MGL insurance required.]t ' : :152 §1(4) i2.Q Roof repairs c ,and we have no _ employees.[No workers' 13._Qther- s comp.insurance required.] a *Any applicant that checks box#L•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.mustsubmit anew affidavit indicating.such. tC:ontractors 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 suli contractors have emlloyees,they must provide their workers'comp.poficy number. ^' I am an employ'&'fhat is providing workers'compensation insurance for my employees. Below is the policy and job site information. Py I Insurance Company Name: Policy#or Self-ins.Lie.#: 11�� a�/5, a0�� E. ' T �iration Date: �. 3� • _ - Job Site Address: -- _ City/State/Zip: . Attach a copy of the workers' compensation policy declaration page(showing..the policy-number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded-to the Office of luvesti ations of the MA for insurance covers a verification. I do hereby nd t pains nd penalties of perj that the information provided above is true and correct =Si -nattue. 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): L Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing.Inspector - 6.Other Contact Person: Phone#: