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0012 CAMROSE COURT
�C��J� ����f �- - - - - Town of Barnstable «ate•a * � :, `' .` •ttt�'r3 .:;q t ;;' a .. �:;-i. r\"' Building Post�This.GardSo:That.�tas=Uis.�ble From':the Streets Anr roved.PlansMust be Retained on Job and this Card Must be Ke't anitxtrCw[�, �� �Y-�sk�� �;.. :�-� �`�E" ".��`�, rFr �� -s' a ' ��"�'�"'-� ;--�� � w:��t� z� ^A C 'h � p 8 arPPosted Until Final`Inspection�Has'Been Made o a :^i :I . . t: �+ .� �aa, ': c ^.. h e�. k x �::!'�"°'\,��zx•\ :s.. '.` �, .; a�.,.a,'�, ° W,here a Certificate of Occu anc : s Re wired such Bu ldin shall Not=be'Oecu red antil a Final Inspectwn has been made Permit Permit No. B-18-57 Applicant Name: David Nordberg Approvals Date Issued: 01/30/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 07/30/2018 Foundation: Residential Map/Lot. 273-110-003 Zoning District: RC-1 Sheathing: Location: 12 CAMROSE COURT, HYANNIS h Contractor'Narne: . DAVID O NORDBERG Framing: 1 Owner on Record: RENDULIC, FRANCIS J&BERTHA M TRS �` Contractor.-`License CS-090682 2 Address: 12 CAMROSE COURT Est Protect Cost: $ 10,490.00 Chimney: HYANNIS, MA 02601 .,Permit Fee: i $ 103.50 weep living room and=.kitchen.., Insulation: Description: Create opening in wallbet g ; $ 103.50 r .s _ Final: l Project Review Req: at 1/30/2018 Plumbing/Gas Y •� Rough Plumbing: Q 41, Building Official final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorzed by this permit is commenced within sic months after Issuance. All work authorized by this permit shall conform to the approved application and theapproved construction documents',for Rough Gas:which,this permit has been granted. g All construction,alterations and changes of use of any building and st ructures'shall be in compliance with the local zoning bylaws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street of road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ( � l - Electrical The Certificate of Occupancy will not be issued until all applicable signaturesby the Buildirigand Fire Officials are provided on this;;permit. x Service: Minimum of Five Call Inspections Required for All Construction Work: " t 1.Foundation or Footing Rough: ,.. 2.Sheathing Inspection w . ,,. ., ••�• 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 6 j-Lire c i�u S EST' FF �*TM[>, TOWN OF BARNSTABLE Permit No. .3565a,.... ` I BUILDING DEPARTMENT 128. ©0) bn/q� TOWN OFFICE BUILDING Cash ...,.,..,, +u HYANNIS.MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to Bayberry Place Realty Trust Address Lot #22, 12 Camrose Court Hyannis, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, .AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. . 19 g.......... �..... Bui1'Alg Inspector i .tip. '.. �. t• + MW It u,{ y r ourt f � C is �}� ��'hhl W, 1 �i•iniw•u.« .1 d ,�f ri 1 � t rti`tr4�r;�i �'�i E�� '' • � • • • B 1�L6i41taF•4"Ne a s3 :Ll t ik�ri t / s 1), j J\ �� �(:t' �- • • • 1 0 t • 1 K'v i J-f �r }4 t. 4�iy"4 " Y 1 ;:P z r 1 • ' • e e :a,', '�� • `�' 'rrT J Yj 111YtY YLA yy, .{. +I` f r F ti h� l,� 4$T. <tr t 1 .f.. e • {t ppG,E t"� .. 93 .k tlV t f ( illhS' f 4' • Uild x 1 J� f� �'g�• ,r .iiu f t TOWN OF .,4 y'.QNIa'.:u yW�, "�}^�C+. 1 ,-f� F ry�Y��.�.+,. -s�M�•••% •- " itT YSJ h; �G.f tii �1a?�i4 t 11 S y2Y i ING BUILU • •• OFFICE 'Idt i t 4tp5v'Y (. ,ATE ' 1r ptT j..s1 UP o MA `�� ��'rrILLV��`I YM1N �•- ' , •r � t�3�P�-Y�4fJ4 y S 1�. i (�i! 1 t 1;G • • tt F tt O 5 r r ¢� I4 l / r 1 } � �.vaS �� Assessor's office(1st Fbor):number Assessor's map and lot Conservation Board of Health(3rd or): SAUITUL Sewage Permit number. � rua Engineering Department(3rd floor): --V�r ��/ �e,.�.e3q.�`�d' House number o rev Definitive Plan Approved by.Planning Board 19 APPLICATIONS PROCESSED 8:30-9.30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR /� r A • APPLICATION FOR PERMIT TO CLAr 4/ TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: �`— The undersigned hereby applies for a permit according to the following information: Location )Z a Proposed Use �✓4 , Zoning Districts' Fire District Name of Owner �I/J�/Yy /�i¢C� /�/ j �rAddress z. 6.0 9 Name of Builder ;7 c� Address !� Name of Architect �. / AddressIy�Lf3- Number of Rooms_ Foundation r Exterior Roofing .0� 4- Floors. p L T ®vim Interior /ri/ ✓ri�yL�/ Heating ,,+�i✓ s' L Plumbing C*;L�L Fireplace s L/G�/ G+ �Ot�dy[ Approximate Cost O�ll Area 2�7 Diagram of Lot and Building with Dimensions ' `O Fee_ ! ' OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. . Name Construction Supervisor's License 0 C D _ BAYBERRY PLACE REALTY TRUST -'No 35659 Permit For 1 z Story x - Single Family Dwelling Location Lot #22 , 12 Camrose Court Hyannis Ba berr Place Realty.' Trust Owner '� Y Y Y•' x. -{ '•Frame .t Type of Construction- Plot! _ Lot ..�^7 ! ?J a —., * .0 - i� ± ' I , •! _ � 4 Permit Granted 1 February 16 ,- 1 g.' 93 r' i Date of.lnspection 191. Date Completed � 3 w 19 tj !' rt r 7 i { t . I Spy I 1 v op 00 At2 z. h 4) - 1 IS, ' 2,00 I , CERTI FI ED PLOT PLAN LOCATION & '. . .'A&J ..(Al.� 60W SCALE . .�.��-.'30�... DATE '�M of PLAN REFERENCE o`er EDWARD S S.�pWn/ p y.. ..lohn . . KrC., i(` Z9 "'o. 261 C)d o ` I CERTIFY THAT THE � �^!� SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF B/32N.STi9C�GE", WHEN CONSTRUCTED. DATE . . .. .. . REGISTERED LAND. SURVEY R LOCATION B�rLvST.9l�'Gc�' /ai�/ !�vis� DATEf��?`!:!//993 PLAN REFERENCE .<}s -S ?w•v a,v ILL.!?,e of j it o� EDtlj�(., "'-LLEY Z9 L L. rF o�'"E ro�� Town of Barnstable, Massachusetts Department of Planning and Development "►& Office of The Planning Board 9� 1639. �0 ArEO MA'S a 367 Main Street,Hyannis, Massachusetts 02601 (508)775-1120 ext. 190 June 20, 1989 Aune Cahoon, Town Clerk Town of Barnstable Town I•la I 1 367 Main Street Hyannis, MA 02601 Re: DEFINITIVE SUBDIVISION 4701 - SPECIAL PERMIT MODIFICATION Open Space Subdivision #701 ; "Bayberry Place" ; Subdivision Plan of Land in (Centerville) Barnstable, Mass . Prepared For Bmiyber•ry PIuce Realty Trust, Jacques N. Morin, Trustee; Plan dated 12/20/86; Low K Weller Engineers; Assessor's Map 273 , Parcel 86, 90, 91 , 8 110-4. At a duly posted meeting of the Barnstable Planning Board held June 19, 1989, it was voted to APPROVE the request to MODIFY the SPECIAL PERMIT, pursuant to Section 3- 1 .h of the Zoning Bylaw of the Town of Barnstable, to allow the reduction in sideyard setbacks from fifteen ( 15) to eight (8) feet for all lots, with the EXCEPTION of lots 1 , 3 , 11 , and 12, in subdivision #701 , "Bayberry Place" . Respectfully, m ' fl3 Jos p E. Bartell , Chairman N nstable Planning Board D JEB:vk rn �I + TOWN OF BARNSTABLE, MASSACHUSETTS BUILDING PE:R8V1,�1' A=2 ,r7i-11U-•-UO3 1If�171({ r DATE �. '_:{J U.%i Y'. . 'i JE 73 K+ r: I I„ , ,,. 19 PERMIT NO. W'' s1" APPLICANT PlarJL "jk,d !ic.(r1 ADDRESS C`c�nto 1/.1. 1ei A�t�.a 1-•'., :: IN0.) , (STREET) .: (CONTR S LICENSE.I { ) - PERMIT TO IiUa.I Ca L)W l?I} 11Cs - .cy_) STORY `��_,II J �"''11a J_1`,' D[J(i: lip..g NUMBER OF 1 A'� DWELLING UNITS y lll,l,� (TYPE OF IMPROVEMENT) NO. (PROPOSED USE)it y I ' 1 Lot V,2 12 f�Qf7 -(v);;i. l.�')lll: �,� .ii•,'cr!1,'.11.•"a ZONING' ( s AT (LOCATION) - 1 " •I (No.) (STREET) - DISTR ICT BETWEEN $•1 14 AND r (CROSS STREET) y� (CROSS.,STREET) SUBDIVISION LOT LOT BLOCK SIZE a y BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCT;I TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION y 'll lewe �3 /7 2 f (TYPEI. REMARKS: Jacques morin 300 13earses Way, Hyannis: AREA OR G379 i't. i S VOLUME ESTIMATED COST $ PERMIT. (CUBIC/SQUARE FEET) . 1 A49 OWNER �a b?:ry Piaci 1 ez' ,.ti ' ,, Ti U:.;L. i JUU 13` a"'iY:al3 j CI" TI ADDRESS .'u.,`12ii i BUILDING DEPT. l" � BY r 11 THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER-TEMPORARILY PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE A PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINI FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS DOES NOT RELEASE THE APPLICANT FROM THE CONDITIO OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL FOR pPROVED-PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATION'S. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL FINALMEMB INSPECTION TI TO LATHE FINAL INSPECTION HAS BEEN MADE, 3. FINAL INSPECTION BEFORE OCCUPANCY. . POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS !'! ELECTRICAL INSPECTION APPROVALS i ,IA, � 1 L r 2 ___.. s) 2 C I/AvL�s 61AIc z i r / 3 HEATING INSPECTION APPR ALS ENGINEERING DEPARTMENT,. + 11 s �2 r cl c v li (II`t BOARD OF HEALTH ( I pS - a [OTHER SITE PLAN REVIEW APPROVAL 1r �t o I i WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT-W!LL BECOME NULL AND VOID IF CONSTRUCTION TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS DATE THE INSPECTIONS INDICATED ON.THIS CARD.CAW, OF s CONSTRUCTION. ARRANGED FOR BY TELEPHONE OR WRITTI I '.r PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION r. i s s' 1 BUILDING PrEtMIT NO. �S Dz -�/ /0 , i99 ASSESSORS PARCEL NO. -)-7 3 - 1 CONTINUATION OF ROAD BOND The undersigned owner/contractor hereby agree to maintain their road bond in 'force un _1 the following work- items are completed to the satisfaction of t:.e E:ginee=i:.; Section of the Department of Public worms: loam and seed shoulders as soon as weather pe omits: of er (e_vplain) lti3-13a c,- 0 ii L L (0 E./CC.;T?LACTpR). _ (print name ) t GI:Y cam.-' -Al:'"-- RI "T=ON n, - TOWN OF BARNSTABLE, MASSACHUSETTS BUILDING PERMIT. A�-27�-110-0.03- : � DATE February lb, t9 .93 PERMIT NO. �® tJ���� APPLICANT Mark Wenzel ADDRESS Centerville, Mass. #00 1 . (NO.) (STREET) (CONTR'S LICENSEI PERMIT TO Build Dwelling 7 ) STORY Singlq Family Dwelling NUMBER OF UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) DWELL - _ AT (LOCATION) Lot #22I I 12 Cemrose Court Hyannis DZONING ISTRICT RC-1 (NO.) (STREET) . BETWEEN. AND - (CROSS STREET) (CROSS ,STREET)LOT SUBDIVISION LOT ff BLOCK SIZE r BUILDIKG IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION A TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) Sewer #3727 REMARKS: Jacques Lorin ($12$. 00) 300 'Bearses Way, Hyannis AREA OR (1 - VOLUME 2379 sq. ft. ESTIMATED COST $ FEE MIT i (CUBIC/SQUARE FEET) i OWNER Bayberry Place Realty Trust earses b aY, ycian?s BUILDING DEPT. ADDRESS BY / y THIS PERMIT CONVEYS NO RIGHT TO OCCUPY�ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. - MINIMUM OF THREE CALL -APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FIN-AL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MINAL INSPECTION TI TO LATH FINAL INSPECTION HAS BEEN MADE. 3. FINAL JNSPECTION BEFORE OCCUPANCY. �. -- - ----. ----- - POST THIS CARD SO IT IS VISIBLE -TRONI-STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2ICA -- — ---- -- _ Z--3 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT Q s_ ti BOARD OF HEALTH OTHER SITE PLAN REVIEW APPROVAL PERMIT 'r/!LL BECOME NULL AND VOID IF CONSTRUCTION WORK SHALL NOT PROCEED UNTIL THE INSPEC- INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN STX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. I PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION. Joseph -D. DaLuz Telephoner 790-6227 Building Commissioner" TOWN OF BARNSTABLE 80ILDING DEPARTMENT TOWN OFFICE. BUILDING HYANNIS , MASS . 02661 DATE: �y /� /9913 T0: %The �C�'�' �3NC . ��r� ram, inspection at rAv/'OSG' 1 Co�rl /}���5 does not comply with MA Building* Code, No. 3�/C/f %D, , /� �f� • `�i 3 �fG 3 7• Please contact this office for reinspection. Than)y,you , Building Inspector AEM:km I �IKKE Town. of Barnstable *Permit# `00 0 Expires 6 month from issue date Regulatory--S-ervices Fee sw�wsznsz e, : Thomas F.Geiler,Director 1639. ,�� Building.Division rFD MPt Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,lvlA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid.without Red X--Press Imprint Map/parcel Number Property Address sidential Value of Work �C� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address +�� — t?p - 2-6 Contractor's Name T C_ 4 I � CAS S 1 LS Telephone Number s S w. 3 Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance . Check one: PR a� PERMIT ❑ I am a sole proprietor - ❑ I am the Homeowner -4j-1 have Worker's Compensation Insurance MAY - 1 2008 Insurance Company Name �� rFt n ,+,cr T olm OF BARNSTABLE Workman's Comp.Policy# L SS Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) - oof(stripping old shingles)-All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Propertx..Owner etterX Permission.____ A copy of the Home Improvement Contra tors�License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 r License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards p HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards One Ashburton Place Rm 1301 Reglstrefflorj- 158587 Boston,Ma.02108 E j iratiore;:,218/2010 Tr# 264153 _' ►plc Private Corporation T.L.HITCHCOCK501VIGE�S iAIC. TED HITCHCOCK' 105 FERNDOC RD Not with t signature HYANNIS,MA 02668 Administrator bons an an ar�s� g/MBETo"ui"fmg*Wegaula One Ashburton Place - Room 1301 Boston. Massachusetts 021.08 Home Improvement Contractor Registration Registration: 158587 Type: Private Corporation Expiration: 2/8/2010 Tri1264153 T.L. HITCHCOCK SERVICES INC. TED HITCHCOCK 105 FERNDOC RD " HYANNIS, MA 02668 Update Address and return card.Mark reason for change. ❑ Address [].Renewal Employment Lost Card )P$-GA1. •:a 50M-07/07-PC8490 The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.govfdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: r7 e Phone.#: Are you an employer? Check the appropriate box: Type of project(required): I am a employer with 7Z— 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 tY� 9. ❑Building addition . [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or-additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL re airs insurance required.] t c. 152,§1(4),and we have no v pairs employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such., xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name: �,� Policy#or Self-ins. Lic. #: �a`( O F Expiration Date:. ,0 C a tk 12 oS E ' Job Site Address: ( oZ C-4 t 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 da st iolator. Be.advised that a copy of this statement may be forwarded to the Office of Invesd ations o e DI for' surance coverage verification. I do hereb certify der a pains and penalties of perjury that the information provided above is true and correct. Si'natur Date: Phone#: `�d� F 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#: " a 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 ofa-dwelling-ho sue having not more than three apartments!and who iesid ds 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�l5 §25C(6)also states�thafevery.state or local licensing agency_shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in�the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall' ---. , enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)-name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to.carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 1 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 flFin the permit/license number which will be used as a ref ence riurn er.�lri addition,-an applicant that must submit multiple permit/license applications in any given year,need only submit one af1.fidavit indicating current policy information(,if nece`ssary),and under Job Site Address the applicant should write" all locations in �c�t (city or town)."A copyof 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, andTax number: The Commonwealth of Massachusetts, _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia `04/14/2008 .15:15 508-790-0249 GOLIItAAN & ASSOC. PAGE 02/02 DaTE 1 �1 ACORD CERTIFICATE OF LIABILITY INSURANCE l RANCE E►a�go PRoc=VR TH CERTIFICATE IS OWED ASS�4TTE R OF OWOfI;MATION . GOTIMP 6 ASSOCIATES INS[lRWCE ONLY AND CONMRS NO MOMS .Ii%M-ME CEMtCAT€ SERVICES INC. HOLDER.THIS CERTIFICATE DOE NOT AMEND,EXTEND OR FINANCIAL 933 II'AI�S SE RD VI. ALTER THE COVERAGE AEFORIDEIT EIY THE POLICIES BELOW. HTAMIS Ate, 02i01 tdAtC Phone:SO9-775-6010 Faz:S08-790-0249 INSURERS AFFORDMIS COVERAGE INSURED - eJSUAERn ESSEX INSVPJUTCE CID watt a. PIFemm ru stiRm:m co. T. L. HITCHCOCK CONSTRUCTION mNIAPE .SMTZ I!4St'tRmI4">7 CO, SERVICES INC 105 FBR2� G ST INsuRERO: -- t7]iliNDTI3 mR 026o1 .0 tNS+fRER E: COVERAGES — 'IITI ISTANDIPIG THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MSURE�NAMEO ABOVE FOR THE POLICY PERIOD Qdmcmio:HOT ANY REQUIREMENT.TERM OR CO1aUR1Ou OF ANY CONTRACT OR OTHER OOCLIMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE( :.1/E O OR NAAYPERTAEN,THE INSURANCE AFFORDED BY THE POkI M(IE$ MED HFAEIN 18 EWOJECITO ALL THE TEPAM EKCLVSMES AND COPE= US OF SUCH POLICIES_AGATE LRAus 51gwm RAAv NAVE OwN REDVL•ED BY Pxo Ce 4m, rL'fR NSR TYPE OP INSURANCEPOLICY NUMBER 77cmm _ LAMEACHI CCIRRENCE 81000000 GENERALLIABILITY X X cODAME�AL GENERAL LAA u" *3CP2332 �� » �50000 CLAIMEt m*F ®OCCUR UW E P(.++yore paean) .15000 PERS1.�BADV INJURY $1000000 •ILn6ATE a 2000000 (iENt AGGREGATE IiMRAPPLIES PER: PRADi,T:-CODDP pmm s 2000000 POLICY Fl,IECT LoC AU`TC WBLE UA8fl.E4Y CASE•[T�8 E ISdiT g » ANY AUTO PSC1'0008214230 12/20/07 12/20/08 ALL OWNED AUTOS BODI' INJURY s 250000 (Perpe ton- SCE$DULEO AUTOS ^ X IMDAUT08 wow mJURV, 3.500000 X NON-0NMEEDAUIOS — PROPt M VAMAOE s 250000 AUTOIiR.^-EAACCIDENf S GARAGE LIABILTPI ANY AUTO OTHEF TH/tN EA ACC = AUTO �dl•': ADO g EACH CaiRRENCE $ ESECEE66Nk98RELDa1LIA9tI.('M — OCCUR CLAIMS MADE AGGRi!!LIE RET $ 5 OEDUCTEeLE —' MENTION 6 VIORKMCOUNMATLf WNAM T['Y WITS ER C opLovo mm" a246868 03/28/08 03/28/09 F-L.EA AjeCCuww 5500000 Aw PR EL.DU RIVE-EAEMPL 8 S00000 OFF O"qI RIMENIRERt E.LDI!JAEE,POLICYLRAIT 2500000 9PE�tAL PROVISIONS blow v OTHER Dfig0E0PTWN�dp�ATtONS1L09ATe0 /VEIeCLFSfE�GW9E0k8A BY ENtDORSE3AENTISPECIALPROVISK S THE CSR7t PICM HOLDER IS LISTM AS ADDITIO'I+1AL IVSUMM ATIM ACCORDISS :0 THE• POLICY PROVISIONS CANCELLATION CERTIFICATE HOLDER SHOULD ANYOS THE ABOVE DE�BEO POD•CKS SE CAMMLLEDI)MR8 TEES EVOlAYMN CRRRENTtlticREOF:TNEISSUAN GINSURERVML NOSAVRTONutL 30 t4AYWWi11Y4L/7 MATE . NOTICE TO THE CERTMATE2 HOLDER NAME! YO THE LEFT.BUT FARtm TO DO 80 BNALL IMPOSE NOOMMUONORUARLITVOPAM KDIDUPON THE MMER,ITS AGENTS OR AUTHOR SENTATM J wf ®ACORD CORPORATM 1981T ACORD 25(2dl [08) oFy own of Barnstable. 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