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0119 CEDAR STREET
,a i� �` c�� ,. �' RIME Safety Insurance AUTO•HOME •BUSINESS P.O. Box 55098 Boston MA 02205 617-951-0600 August 17, 2017 Building Commissioner or Inspector of Buildings w.> Fire Department or Arson Squad " Board of Health or Board of Selectman City Hall HYANNIS, MA 02601 Z �- U) Insured: G_ERALD ELOVITZ and ARTHUR BENCE Property Address: 119 CEDAR ST, HYANNIS MA y_ Policy Number: BMA0023446 Claim Number: BOS00077202 Date of Loss: 8/16/2017 Notice of Loss Under M.G.L. c. 139,§3B This communication shall serve as written notice pursuant to M.G.L. c. 139, § 3B that[Safety Insurance Company] ("Safety") has received a claim involving loss, damage or destruction to a r building or other structure at,the above-referenced address which may either: (1) meet or exceed $1,000; or(2) cause the condition or the building or other structure to render M.G.L. c. 143, §.6 applicable. In accordance with M.G.L. c. 139, § 3B, if the city or town intends to initiate proceedings designed to perfect a lien under Section 313; M.G.L. c. 143, § 9 or M.G.L. c. 111, § 127B, please notify Safety of the same by certified mail. Kindly forward such notice to my attention, at the address indicated above, and include with such notice a reference to the above-described insured, property address, policy number and claim number. If you have any questions regarding this notice, please feel free to contact me directly at 617-951-0600, extension 5015. Sincerely, Dan Lourinia Claim Examiner - -. .� .. .G'�_ _. _ - _ _ __. .. _- '- - __ - � - - -_ - - _r.� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �Cd Application # o),o Health Division Date Issued Conservation Division Application F / 0 a Planning Dept. ' Permit FeeNv 06 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis O(Als- Project Street Address Village Owner CCP v d z 1 1 f Address Telephone J ^670 3G 4/ —T ?? � r Permit Request 5 t �r Ga — e(,<- 7'�,r r `moo coeyc- '44 a leis /'mac roc, rG l �c� 4qc le qu e 1 st.f or: existing4proposed 2nd floor: existing7ed proposed Total new Zoning District 2z� Flood Plain //►► Groundwater Overlay Project Valuation ---Construction Type ("Or Lot Size oe Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) .tile gr C e d � Age of Existing Structure Historic House: ❑Yes ,rNo On Old King's Highway: ❑Yes Artqo Basement Type: JArFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing el new Half: existing f new Number of Bedrooms: 0 existing _new Total Room Count (not including baths): existing � new�_First Floor Room Count Heat Type and Fuel: Chas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes n No Fireplaces: Existing G 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 A(Ye ❑ No If yes, site plan review# Current Use C ' Q T/c C. Proposed Use J-6 APPLICANT INFORMATION _ (BUILDER OR HOMEOWNER) Zr d!?il s'4 '� q, Name L Telephone Number �� Address 4 1*' License # Home Improvement Contractor# e-**Oe?7�� Email CJKe4 So'"� V S �•*fWorker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE sl 4 f l w: FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED i - i' MAP/PARCEL NO. ADDRESS VILLAGE y OWNER DATE OF INSPECTION: FOUNDATION t FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 271011 / 41511 go S■ 11 911 / /17 1V4� \ i N S - - f O 1 N N O O 7' 8" 2' 6' N O co 1 1 2 11" 41111 gg O \ 8' 111 E � 1011 is' 1o�� \PO I J O �1 O a � _ N 7 711 1 —� 1— - 51611 . . . . . . � . 27 O" z z~ � . §11 ! ! ( ) , ( { � 1& 10" / \ ( ^ ~ ) ) . . _ M � ( � & O" j . & 1" = . : I. , ! _ . �_ | ( 0| &4! 2 11" 4 1" g o . > : : � ) ® 8 ill / & O" 18 1 � - o � ( ^ 71711 ~ ! x 51611 ^ 271011 13' 1" 13' 11 61 411 / / 21 1011 51 611 61 511 / \ w = o ca ` \ n'- 11' 611 14' 5" ` cn ' / ' N \ 21 7" 2' 6' 91311 cn / J O 00 w w - N O � � O 5 0 0' 5 � 4' 11' o U' I N 4' 1" O 0 N 81811 \ _ 1 1 w^ 4+ c J N V1 = O 41011 w cn c'_ 2- 11" cn 10 4" 0, w J N (p O pp M A 1 co O N 1 O N W O V V W w O 31911 \ 16' 11" 11 411 4' 7" l Massachusetts Department of Environmental Protection Bureau of Waste Prevention•Air Quality u 100220780 BWP AQ 06 Notification Prior to Construction or Demolition Asbestos Project Number# A.Applicability A Construction or Demolition operation of an industrial,commercial,or institutional building,or residential building with 20 or more units is regulated by the Department of Environmental Protection(MassDEP),Bureau of Waste Prevention,Air Quality Division,under Regulations 310 CMR 7.09.Notification of Construction or Demolition operations is required under 310 CMR 7.09(2)ten(10)working days prior to any work being performed.The following information is required pursuant to 310 CMR 7.09.Is this a fee exempt notification(city, town,district,municipal housing authority,state facility,owneroccupied residential property of four units or less)? Is this a fee exempt notification(city,town,district,municipal housing authority,state facility,owner-occupied residential property of four units or less)? r Yes r No Type of Notification: r Revision of an Existing Formj Cancellation of Project Instructions: 1.Blanket Permit Project Approval,if applicable: Approval ID# 1.All sections of this 2.Non-Traditional Asbestos Abatement Work Practice Approval,if applicable: form must be completed in order to Approval ID# comply with the Department of B. General Project Description Environmental 1.Facility Information: Protection notification NONE 19 CEDAR STREET requirements of 310 CMR 7.09. Name of facility Street Address HYANNIS MA 026010000 0000000000 2.Submit Original CityfTown State Zip Code Telephone Form To: Commonwealth of GERALD ELOVITZ OWNER Massachusetts Facility Contact Person Contact Person Title P.O.Box 4062 5082647702 GPELOVITZ@MAC.COM Boston,MA 02211 Facility Contact Person Telephone Facility Contact Person Email Facility Size: 1600 2 Square Feet Number of Floors Was the facility built prior to 1980? F Yes ❑No Describe the current or prior use of the facility: MEDICAL OFFICE Is the facility a residential facility? r Yes F No If yes,how many units? 2.Facility Owner: GERALD ELOVlTZ 1860 SANTUIT-NEWTOWN ROAD Facility Owner Name Address COTUrr MA 026350000 5084200032 City/Town State Zip Code Telephone GERALD ELOVrTZ 1860 SANTUIT-NEWTOWN ROAD On-Site Manager/Owner Representative Address Cotuit MA 02635 5084200032 City/Town State Zip Code Telephone Revised:03/17/2014 Page 1 of 3 �t Massachusetts Department of Environmental Protection Bureau of Waste Prevention•Air Quality � 100220780 {9 BWP AQ 06 Notification Prior to Construction or Demolition Asbestos Project Number# B.General Project Description(continued) 3.General Contractor: GERALD ELOVITZ 1860 SANTUIT-NEWTOWN ROAD Name Address COTUIT MA 026350000 5084200032 City/Town State Zip Code Telephone GERALD ELOVrrZ 5084200032 General Contractor's On-site Manager/Foreman Telephone General C. General Construction or Demolition Description Statement:If asbestos is found 1.Construction or demolition contractor: during a Construction or Demolition PETERJOHNSON 7 PENELOPE LANE operation,all Contractor Name Address responsible parties must comply with 310 COTUrf MA 026350000 5082373309 CMR 7.00,7.09,7.15, City/Town State Zip Code Telephone and Chapter 21 E of the General Laws of PETERJOHNSON the Commonwealth. Construction and Demolition On-site Manager Telephone This would include, but would not bw 2,Licensed Contractor Supervisor: limited to,filing an asbestos removal PETERJOHNSON CS-062830 notification with the Department and/or a Supervisor Name License Number notice of release/threat of 3.Is the entire facility to be demolished? r Yes F No release of a hazardous 4.Describe the area(s)to be demolished: substance to the Department,if NONE applicable. MassDEP Use Only 5.If this a construction project,describe the building(s)or addition(s)to be constructed: Date Received ADDING 10'PARTITION&DOOR TO DIVIDE A ROOM 6.If this is a demolition or renovation project,were the structure(s)surveyed for the presence of Asbestos-Containing Material(ACM)? C Yes F No 7.Was asbestos containing material(ACM)found? r-Yes F No If a survey was conducted,who conducted the survey? Name Department of Labor Standards Certification Number Revised:03/17/2014 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Waste Prevention•Air Quality � � 100220780 BWP AQ 06 Notification Prior to Construction or Demolition Asbestos Project Number# C.General Construction or Demolition Description(continued) The Asbestos Abatement Notification Number for this address is: This project 1✓ Construction Demolition is: 5/30/2015 8/30/2015 Project Start Date(MM/DD/YYYY) Project End Date(MM/DD/YYYY) 8.For demolition and construction projects,indicate dust suppression techniques to be used Seeding j Wetting r Covering rj- Paving r- Shrouding (j Other-Specify: 9.For Emergency Demolition Operations,who is the MassDEP official who evaluated the emergency? Name of MassDEP Official Title Date of Authorization(MM/DD/YYYY) MassDEP Waiver Number A Certification "I certify that I have personally GERALD ELOVITZ examined the foregoing and am Print Name familiar with the information GERALD ELOVITZ contained in this document and Authorized Signature all attachments and that,based OWNER on my inquiry of those individuals immediately Position/Title responsible for obtaining the OWNER information,I believe that the Representing information is true,accurate,and 5/19/2015 complete. I am aware that there Date(MM/DD/YYYY) are significant penalties for submitting false information, including possible fines and P.E.# imprisonment.The undersigned hereby states,under the penalties of pedury,that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised:03/17/2014 Page 3 of 3 I MassDEP Home I Contact I Privacy Policy MassDEP's Online Filing System Username:GPELOVITZ My eDEP Eortnss* My Profle00 Help I Notifications Nickname:XXX Receipt Forms signature Payment Receipt Summary/Receipt d print receipt i Exit Your submission is complete. Thank you for using DEP's online reporting system. You can select"My eDEP"to see a list of your transactions. DEP Transaction ID: 742928 Date and Time Submitted: 5/19/2015 9:00:03 AM Other Email : DEP Transaction ID: 742928 Date and Time Submitted: 5/19/2015 9:00:03 AM Other Email : Form Name: AQ 06 - Construction/Demolition Notification Form Name: AQ 06 -Construction/Demolition Notification Payment Information DEP code: 107937 Date: 5/19/2015 8:59:24 AM Amount ($): 100 Payment Detail: ELOVITZ GERALD --AccountType --AccountNumber ****9645 Confirmation Number: My eDEP MassDEP Home I Contact Privacy Policy MassDEP's Online Filing System ver.12.14.3.00 2015 MassDEP f _ C62mmwed&of-M sstFduseft HA 021H x�vw rr�ga�dr$ T�rrs'CcfaxpInsc� [.# ra P;f-�3ersfttrarrslL�cEricianslPlunziers Infarmat c�a Please Pifil Nan= -le )y 4 0 d-N � �c r r . 1. . awsfat&� !7r Pbom you asmmplayer?Cb &ffieappmpriatmbu= Fype of °l _ I_❑ I am a employer wig 4. ❑ I as confracfrir and I Netts 2-PC (fnit mWarpart ime *' havehiredtba (ors. 2-,��"(��am a sole proprietor orpaduer- Iisfez on the shed shs 7- ❑Brmodeling ship and have no cmpfo�s These vub-oontact=have g- ❑ Q- woddng forme is any capaca y =3playees,and have molkas' WO Worms`Camp.«naxxnAg comp.msura ❑Buih�mg adddion 1 S_❑ e are a omporafimmd ifs lfi?C1 nccfricai n paw or additions 3.❑ I am a homemnner doing aU vork officers have a m=med thew I Lo Plumbing rapass or additions.• Myself[No wodmr'gip_ ugh.afcm=pfianper MGI. L�$Doti,pairs snsuraacerequiit IF. r-157,§I(4} and wePrmno comp_immratim-rapire&I ��pmpsnc��tc�t��l,�stalmffiovct�s�bdos�s>�8�ir��oomprp�s�- wba=bmftf3 :ITAIWifi tneya�i3 �H saaL�eaItirga�de�o csm�isnbarrta»�ic darn sacTL -rem�cma�F a�eck f�is 6axuaFsr�he��a:��diuoazT s�Qer chtrmmgthea�e of�e�dx-ao �masm�ached ornut these e�r� ��• �€� a��-�e�r�,���sae ri�-,�a•��P�r�� I am an BacpIoyev duct ispravi&g mrlrers'cong asdi art tnrrmmm or nzy a gWoygsa MTn_tr it MaPAT and flab rites rnmr„m Compmym=e: Porsc�t fr self=iQs Ii� ` Rq)Zmti=Dat,-: IoTi Sibm AA&emciiy�stafe = Attac a°°PT`o-f fhei 4sorlo=rs'mmpm=tiou poHep declaration page(snug the:poficy nmaber JMd,CXpfi7Riiou dM(n). Failure to secare coverage as mTirexlun&r Sec(ihm 25A o€MM r-M can lmd to the imposes ofclimi�Ial geallEm of a fine up to$UDD OD andlor os—peari as wet(as card gemdfics is fhe foffi of it STOP WORK ORDMand a fins ofmp l o'250_00 a day against the violator_ Be:advised that a copy of this statement nzybe fmwarded la the Off of Twediya-.,t,e of the DTA for;., „ coverage 9 DAL I dies hereby call rp UJUIer at a,�per�up i#etffrer it arma€ra�aprm clalzav and carrect _ 4;anAtrx I wP G�s Phom S'o at 3> 3 3Q Et,�"af use rrzt£y: �r[¢t tptzfa inn fJus area{ar 8s caxtgFef-ed by�^'att'tatter a,f�iera� , CRy or rows: pe,�r;Nf..r ease# �atharifg{circle aae� � L Beard of Health 2.BmTdng Ilegart cnt.3r CafpTuwa Qe rk Elec Meal Ea ct r S.P`.umbii�g Fmpeetor 6.Other C*Ei*Ct P'rrrsaa: Ptr #= 6 L a 271 011 41 511 gigs 111411 N -IA O 1 N N 1 CI? 71 811 s IN N Gl ! 21 1 _ 31 " 1 a N 1 O Wig J _ J j 31 011 co 2' 1111 41 111 j 1 O � pl 111 ;81 011 o (vim. 18' 1 ' C c _ O IJ 7' 711 ii 5 1 C o / Y I C� 271 011 5 Q' S I B N 18 10" V N N C? C? 1 11 8 0 , e N_ 81 1 II (n I � � N \ II 31 1 11 _ 2' 1111 A l 1 11 Q J 0' I o O 81 111 \J F / T A 81011 _ W 18, 151, N � j J 71 711 N y2. V 51 611 — �; 1 "/ ,..� L �b ti �lILL 19L H LO o co io 2 co N r O M r co N o] CO T - Q) O O r N M CO nt i0L uLL �Z LO M \JN M {� n0 IY co T N C - M r N Its r N T o - e L zo n0 i L L i� 0 7� n0 s O M _ (O N Qo M M _ O T � 4) X s6 �,9 �Z ��L �Z - qt N 119 ti L LA r 119 iLL cV M O L CO) 119 19 9 I5 �' ?y ,'L L ,E L I Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet.(991m3),of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: vrww.Mass.Gov/DPS u Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-062830 PETER E J01INS9N 7 PENELOPE LPL- COTUIT MA 024:35 914—JJ . Expiration Commissioner O8/29/2015' ` GJF/" tpo'n4naruaeala Office of Consumer Affairs&Business Regulation ' .License or registra4ion valid:for individul use only , OME IMPROVEMENT CONTRACTOR before tl;e expiration date. if found return to: egistration:. ;1b2785 Type: Office of.Consumer Affairs and Business Regulation Individual 10 Park Plaza-Suite 5170 Expiration: l2ry/?o15 Boston,MA 02116 PETER EDWARD,dANSON. Peter Johnson 7 PENELOPE LANE COTUIT,MA 02635 - Undersecretary Not valid without sig}ature r Assessor's map and lot'`number ........ .. _ � y . , Sewage:::Permit)nu mb e r .............................. ......... ...............- y�F7MET0� TOWN' OF BARNSTABLE Z BAWST '- RUILDI'N INSPECTOR O,o,i6.39• �0 r_ APPLICATION FOR PERMIT TO ....'..:�...... ... r . TYPE OF CONSTRUCTION ........................ 7.►V1. ..�.................................. o ' .............19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ................J....... ......... ...... ...............................:........................................................... ProposedUse ... .�.r�. ,t;[ ..... .1- F �!L... .......................................................................... Zoning District Fire District .....::. ... ............................ .... ..... .. .. .... Name of Owner ...L!!...... ........ .d.. .s..AY -..................Address .5 1' .. —.....9� .:............................. . J( 1 Name of Builder�.r .........)--n :<.......................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ....................................`.............................Foundation ......�..j.....................................:..............................: '�= ......, t l..'S............Rooftng :......... 7 d .. Exterior L . .......................................... Floors ..................� /�.Ll :.�.K..........................................interior ......... . . ' /'12'. . ......................... -..... f Heating ..................................................................................Plumbing, .............................................. Fireplace ..........Approximate Cost ... ":.... �. ............................... . .......... Definitive Plan Approved by Planning Board ________________________________19________. Area �1 ....(1. .... Diagram of Lot and Building with Dimensions / . � Fee .... ....................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH hereby agree-to conform to all the Rules 'and Regulations of the Town of Barnstable regarding the above construction. Name . ......... !rL......T....... ................. Johnson, William F. add bo i room & No .................18816 . Permit for ................... -laundryto to -dwelling ................................... ................................ Location t/1'AW.Ceda.r...Street. . ... ... ........ ........ . .... . ..... ..........................Hyannis...................................... Owner ..............William F.- Johnson .................................................... Type of Construction .........frame ................................. ...........................................................:....................... Plot ............ ................ Lot ............................ t Permit Granted .... ...No.v.embp—r..17........19 76 Date of Inspection . ....... ......19 Date Cmpleted o' - 19 PERMIT REFUSED,, ..........................:........................... ..... 19 'A .......................... ................................................. .......................................... .................................... ........................................................!.......... ............ lie ......................... .................................................. Approved ................................... .............. 19 ............................................................................... .................. ...................................... .................... TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 1 (0 S' Permit# Alw a Health Division ' l z -dam Date Issued a f Conservation Division Fee a o E•0 Tax Collector Treasurer ✓% G � i� ��—�T c/ p�P1E R Planning Dept. ¢�NE�O � BZ� Date Definitive Plan Approved by Planning Board ` wczioz; Historic-OKH Preservation/Hyannis Project Street Address � '� &_ACAC 6` Village Owner t3c Address Li Telephone _ 646 `l c5-?) i Permit Request 9Q�-R-L. zNNcw kL4 1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cos;4211 SUa Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#'units) Age of Existing Structure Historic House: ❑Yes No On Old King's Highway: Cl Yes Flo Basement Type: Cl Full ❑Crawl ❑Walkout ❑Other &5 Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial 4Yes ❑No f If yes, site plan review# Current Use nrZ S d�-17L� Proposed Use �- BUILDER INFORMATION Name b f:9)nQ Da-VI S Telephone Number 3 2- Address q'_ ���J't License# ?3a S Z7Z o Home Improvement Contractor# Worker's Compensation# 1"L/6/,3bha 351s' r/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO x047e4ouf'h VY 5r�/ SIGNATURE DATE r s _ FOR OFFICIAL USE ONLY M `t�RMIT NO. DATE ISSUED MAP/PARCEL NO. ' ADDRESS ' VILLAGE OWNER DATE OF INSPECTION: t FOUNDATION r FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ri PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. e. r 1 ' } ' 9 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel;: 'Application #2—0-21 1 Health`Division Date Issued Conservation Division ,Application Planning Dept. I P_ V2•or\\ *. ." Permit Fee Date Definitive Plan Approved by Planning Board IJN Historic - OKH ut� _ Preservation/ Hyannis N� Project Street Address f C e d oa A f eet Village HVQ tk I'd Owner l• L l� ( � 1,.r�OhJ Address y CkAkr k A, Y0,(M,8(A h_0Qe, Telephone Permit Request le,Uac 6 MOP Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation AV 6 D Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup�sorting documen ation. hit Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) ;k Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: UI.Yes O No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) w Number of Baths: Full: existing new r Half: existing news Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size--Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name G co r a e, Cd Telephone Number (N I- 0c, Address License # SG _JO(,t, k YU M u,—I-L h A Qd-6 6 q Home Improvement Contractor# Worker's Compensation # C 7 G 4 )010 f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE - DATE I �� V FOR OFFICIAL USE ONLY ` APPLICATION# 0 DATEISSUED MAP/PARCEL NO. 9 ADDRESS VILLAGE OWNER DATE OF INSPECTION: 47, :FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 5 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL :FINAL BUILDING: r; i DATE CLOSED OUT ASSOCIATION PLAN NO. 4 I 2'` The Commonwealth,of lMassacifusetts Department of Industrial Accidents r�, x Office of Investigations ; la 600 Washington street a ij Boston,,M4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers Applicant Information u Please Print LeEibly Name (Business/Organization/Individual):� Address: Y t c a City/State/Zip: a Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.NI am a employer with 4. ❑ I am a general contractor and I - 6.' New construction '- employees(full and/or part-time).* have hired the sub-contractors 0 , 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.❑ officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions, myself. [No workers' comp. right of exemption per MGL 12. �Roof repairs insurance required.]t c. l 52, §1(4),and we have no F 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 anew affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-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: . Policy#or Self-ins.Lie.#: Expiration Date:- Job Site Address:J I C e dcjr (if,Met City/State/Zip: VaA,O,ci C YA 62(Pd� 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 f 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. 3 , I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Q - U Official use only., Do not write in this area,to,be,completed by city or town official, City or Town: Permit/Liceose# Issuing Authority(circle one): n 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#. ATE /- '1 O6 CERTIFICATE OF LIABILITY INSURANCE - F03/04/D2011) _ 03/04/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed." If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER - CONTACT NAME: Mason & Mason Insurance Agency, Inc. AIc°NeExt: 791.447.5531 acNo;781.447.7230 458 South Ave. E-MAIL ADDRESS: Whitman, MA 02382 PRODUCER CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Travelers Ins. Company 00034 George Davis, Inc. INSURERB: National Grange Mutual 014788 33 North Main St. INSURER : ACE Property & Casualty South Yarmouth, MA 02664 INSURERU: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 10/11 BA 11/12 GL WC 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY GENERAL LIABILITY 1680790OM226IND11 01/12/2011 01/12/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 50,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $. 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY M9M2849 10/26/2010 10/26/2011 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1,000,000 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ B X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION C46414561 03/05/2011 03/05/2012 WC STATU- I OTH- _ AND EMPLOYERS'LIABILITY Y I N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,.Additional Remarks Schedule,if more space is required) - Dperations: residential' remodeling RE: OFFICE COPY CERTIFICATE HOLDER CANCELLATION FAX: 509.394.5460 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES:BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. George Davis AUTHORIZED REPRESENTATIVE 33 North Main Street South Yarmouth, MA 02664 David H. Mason ©1988-2009 ACORD CORPORATION. All rights reserved.. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r Massachusetts- Dep irtment of Public Safety Board of Building Re!Ilulations and Standards Construction Supervisor License License: CS 56130 GEORGE IF DAVIS 33,N MAIN ST r S YARMOUTH,-.MA 02664'* Expiration: 3/1/2013 '(`i,�nmissiuncr Tr#: .12051 v. ✓� � Office of Consumer Affairs&B si';i s Regulation HOME IMPROVEMENT CONTRACTOR r Registration. •'160164 • Type: ` Expiration 71212012 Private Corporatio n VGENGEDAVIS,!fiNC GEORGE DAVIS I 33 NORTH MAIN STREET.. g a SOUTH YARMOUTH MA 0266- Undersecretary { LipjAK or registration valid for individul use only ` before lie expiration..date. If found return to:. Office cf Consumer Affairs and Business Regulation: 1" IP Rarl.Plaza-Suite 5170 st CIA 02116 i Not valid hout signature ' ~ � f .J • - �..+� \jam. rt, _ i. • eY • 1 IKE •ABNSr BM 1 ,� Town of Barnstable A Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO ; Building Commissioner ` 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This. Section If Using A Builder as Owner of the subject property hereby authorize l �Mjr�e, t 11f )ZL'f to act on my behalf, in all matters relative to work authorized by this building permit application for:;^ 19 �'e d ar A, N va-K.P.(V (Address of Job) w ✓ w a N ignature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.outlook\DDV87AAZ\EXPRESS.doe Revised 072110 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma e p�.,�,:.r 1 � Parcel Application Health Division ` Date Issued C1 awl Q Conservation Division Application Fee Planning Dept. ; Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH _Preservation/ Hyannis Project Street Address Village ��yGt+-.r• Owner `Ds - t Address If CA,\- "A Telephone Sb -Li Permit Request e- A10 C .�� r`�-, ei�� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type qJ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# a Current Use - Proposed Use A co APPLICANT INFORMATION (BUILDER OR HOMEOWNER) CA a a Name - / S Telephone Number L) Address 3->> License # Ste- Home Improvement Contractor# Worker's Compensation # 'W C ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L,_ SIGNATURE DATE go/0 y e' z FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. " ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION - FRAME ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL-- PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION FLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of btvesdgadons 600 Washington Street. Boston,MA 02111 www mass.gor/dia *M' Worke>s' Compensation Insurance Affidavit: Builders/Conti•actois/Eler.tticians/Plumbers Applicant Information Please Print Le 'blv Name(Business/organization&dividual): to raL owts. Address- Man t+ City/State/Zip: 0 Phone#: L1•M732-1. Are Vit an employer?CheA th appropriate box: Type of project r �/ 4_ I am a general contractor and I 3`P p J ( ��� 1_ I am a employer with ❑ g 6. ❑New constriction employees(full and/or part-time)-* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions self. o workers'co right.of exemption per MGL myself � comp. 12_❑Roof repairs insurance required.]1 c. 152, §1(4),and we have no J ,WLCJ� employees. [No workers' 13_�Other (A)f (.0(J ' comp.insurance required.] 'Any applicant that checks box#1 most 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 mast 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 theit workers'comp.policy number. lam an employer titat is proidding workers'compensation insurance for my employees. Below is the policy and job site information. ��� � Insurance Company Name: Policy#or Self-ins.Lic.#: W L n 0 6 NN Expiration Date-_ Job Site Address: City/State/Zip: 9Q QZ2201 Attach a copy of the workers'compensation policy laration 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 S1,500.00 and/or one-year imprisonment,as well as 6xvil 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 c nnderhe in�and nalties o eju�,ylhat tit information prm ride d above is Nrre and correct Signature: n Date: Phone#: Official rue only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License It Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffowa Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: •FA RD CERTIFICATE OF LIABILITY INSURANCE 03iiiz9 PRODUCER (781)447-SS31 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4S8 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Whitman, MA 02382 Gwen Vosburgh INSURERS AFFORDING COVERAGE NAIC# INSURED George Davis, Inc. INSURER A: Travelers Ins. Company 00034 33 North Main St. INSURERB: National Grange Mutual 14788 South Yarmouth, MA 02664 INSURERC: Star Insurance 000204 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY I680790OM226IND09 01/12/2009 01/12/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ 50,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- F_j LOC JECT AUTOMOBILE LIABILITY M9M28491 10/26/2008 10/26/2009 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ F1 PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ e AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE. AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC0452478 03/OS/2009 03/OS/2010 WC STATU- OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ SOO,OO C ANY PROPRIETOR/PARTNEWEXECUTNE OFFICER/MEMBER EXCLUDED? OFFICER OF CORP IS E.L.DISEASE-EA EMPLOYEE $ 500,000 Ryes,describe under SPECIAL PROVISIONS below INCLUDED E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, George Davis Inc. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 33 North Main St. OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. South Yarmouth., MA 02664 AUTHORIZED REPRESENTATWE David H Mason ACORD 25(2001/08) ©ACORD CORPORATION 1988 PDF created with pdfFactory trial version www.pdffactory.com IHEri Town of Barnstable Regulatory Services . v g"RMAB& Thomas F Geiler,Director �. Fnyq. a� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.rna.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If USina A Builder as Owner of the subject property hereby authorize 60-C)n c `�ck�IS to act on my behalf, in all matters relative to work authorized by this building permit application for. 1�'fCZr,r,:5 (Address of Job) -Signature of Owner Oate O t d AU J(,@A) Print Name . If Property Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. QFO RMS:O WNERPERM ISSION Town of Barnstable Hof z�try o Regulatory Services RA STAB Thomas F. Geiler,Director HAS& 1639. 0. Building Division rED MAy Torn Perry, Building Commissioner 200.Maiu.Street, _Hyannis,MA 02601 www.town.barnstable.ma..us Office: 508-862-4038 Fax: 509-790-6230 HOTdEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number s trect vi l l age --"HOMEOWNER': name home phone# work,pbonc# CURRENT MAILING ADDRESS: city/town state rip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow hwzneowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which.be/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner, Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that_he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and . requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HON-EOWNER'S EXEMPTION .The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuring the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awarrness 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/hq rzsponsrbilitics,many communities require,as part of thc permit application, that the homeowner certify that he/she understands the resporuibilities of a Supervisor. On the last page of this issue is a,form currently used by I several towns. You may care t amend and adopt such a fomnlcertification for use in your community. l Q:forms:homeexempt • Massachusetts- Department of Public Sarctc Board of Building Regulations and Standat-ds Construction Supervisor License License: CS 56130 Restricted to: 00 ►, a ;`` GEORGE F DAVIS 33 N MAIN ST . S YARMOUTH, MA 02664 Expiration: 3/1/2011 ('ummissiunci Tr#: 12220 per' g7l;, ��nm � a�✓G �\ Board of Building Regulations and Standards lugHOME IMPROVEMENT CONTRACTOR Registration: 160164 Expiration! 7/2/2010 Tr# 270040 Type: Private Corporation GEORGE DAVIS, INC.. GEORGE DAVIS 33 NORTH MAIN STREET SOUTH YARMOUTH,MA 02664 Administrator d Y The Commonwealth of Massachusetts Department of Industrial.Accidents 600 Washington Street Boston,Mass 02111 Workers' Com ensation Insurance Affidavit / name: location: I-1 CAC''`' S� city A-4&��`�I ri phone# ❑ I am a homeowner performing all work myselir ❑ I am a sole etor and have no one working in any capacity 0-01 ASO- an employer din workers' compensation for my employees working on this job. :;::;:;;;; I am p.oyei p :: g:..::..:..; ......,::::;;:..:.:::.: :..; Dow �' t comaanv rains ' ss addre >>. -:.' a ham qtV• ......: ::ii:::: :::: '::? ::-.,.: - ::..;y.:; :;.::;:;y:i;•>r};:''y:is ,•-::is:::i::;s:::i i;:; ; insurance co.. :. ;;:;:.,;::.. 3.. ::.:.:...... ... .: pricy#•' � .� `"�+ S"'�- ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have thefollowing workers' compensation polices: g . ::::::... ....:..,:..:...: : .::.:::::.:::: :::.::::...: ::::::::: coinany raMe* addre b . phone#. x. ...::.:...:...>::;> ..................................................................... :::::.::::::::::::::::::::::::::.:::. :: ........................................................................................... ............. ............ ........ ............................. ..r....................::.......................... ...... :.. Insurance ;.......,.... .:...-. .. :...::...:.:..::.:is i:::::..�i:. - .......v-v:i}i:i:iii:j:iii:iY:::v, viiiii,*:,}::.F:^iiiiii:?'>: .. :.... :: .ii:ii:is^i:::i::•.:: .......: .:... .::...::..... '::'; )i4v:�T:'viii:: address. ,..:..:.;.;:<:..:; `ere ............................... :.:::.:..................... X. ................ ...... :}::.;}:::::.::::.:........... ........... dt� ........::..... Failure to secure coverage as required order Section 25A otMGL 152 can lead to the Imposition of uhninsl pendfla of a Ihne up to s1,S0o.0o and/or one yam,,imprisomnent as well as civII penalties in the torn of a STOP WORK ORDER and a Sae of 5100.00 a day against me. I understand that a Copy of this statement may be forwarded to the Office of Iavestlgatioai ofthe DIA for coverage veri8catlon 1 do hereby certify under the pairs and penalties of perjury that the information provided above is trw and eoffect Date / -775'S' Signature Print name �.� ✓' — Ic S Phone# �-� 3•Z official use only do not write in this area to be completed by city or town official city or town: penou lcense# pBufla�g Departrnmt QLicensing Board ❑check if Immediate response is required �Selectinen's Office ❑Health Department contact person: phone#: ��e!. (Jevued 9/95 PJA) Information and Instructions ~9 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. 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 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. 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 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 redmmed 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 Otflce of Invesugadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 GEORGE F DAVISr/ o/ (.f r 9 NEW VENTURE DR it7 dmimi �✓ S DENNIS, MA 02660 Anistrator •1\ l.��M �.,III INII/II/WI��� lr�//l1.fVl�/iM.� r4_ 04 NOME 1MP90VENENi CONTRACTOR t Registration , 107333 Tyne a -_- ', ' ExpiTatinn 07/31/00 GEORGE DAVIS BUILDERS CooToe F. Dads i 9 NEW VENTURE RD. ---nt��a,n,;tttnTctn So. Dennis NA 02660 i N O n v TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel. CA L - Application # UC Health Division Date Issuedb Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by'Planning Board p Historic- OKH _ Preservation/Hyannis Project Street.Address q C y 2f Village 0-,Yl &('y Owner C(X,�k. �T(�i t,J'()�2 Address C k{vC k (('f,. Yo rkou,&I.0 in Telephone 3b a'_Li 54gy Permit Request IA'11 �.��re.t-� t jL�Pa�S 4 t 5 �u 1 i^��� fRuus S J4-1-< 40 rA Square feet: 1 st floor: existingci!'--proposed = 2nd floor: existing{L2' proposed - — Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type I') P Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes A0o On Old King's Highway: ❑Yes �610 Basement Type: 4YFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) d Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing j new Number of Bedrooms: existing —new Total Room Count (not including baths): existing 6 new D First Floor Room Count Heat Type and Fuel: ❑ Gas AOil ❑ Electric ❑ Other Central Air: ❑Yes kNo Fireplaces: Existing 49 New d Existing wood/coal stove: ❑Yes tiLlNo Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑ _.Yes No If yes, site plan review # .Ms j =v -:1 Current Use �� y L �- Proposed Use 0�— ' b�-- � ;: APPLICANT INFORMATION d --A (BUILDER OR HOMEOWNER) * Name y�V�°11 ��-1 S Telephone Number '—U y 3 Address 33 tIa s V"N License # Home Improvement Contractor# / U Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 5 SIGNATURE DATE E 4 - C ti FOR OFFICIAL USE ONLY r. APPLICATION# DATE ISSUED MAP/PARCEL NO. s s` ADDRESS VILLAGE F OWNER t I DATE OF INSPECTION: _FOUNDATION FRAME INSULATION: + t.,•3 k FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: _ ROUGH L FINAL FINAL BUILDING!i— DATE CLOSED.OUT i "s ASSOCIATION PLAN NO. J ' - The Cotnrnonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 L •''' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Bewilders/Contractors/Electricians/Plumbers Applicant Information Please Pript Legibly Name (Business/Organization/Individual): edr� (-ytl r lk _ Address: 13,3 �nr a.� , tr City/State/Zip: A WALLL Phone 4: -A , Are you an employer?Check the appropriate box: ; .- I am'a general contractor and I' Type of project(required): 1.NI am a employer with 4 ��' ❑ g 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 �' t 9. ❑Building addition , [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its� 10.❑Electrical repairs or additions 1.3.El am a homeowner doing all work " officers have exercised their' 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all,work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-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: Policy#or Self-ins.Lie.#: (o �{ y,yj('p Expiration Date: Job Site Address: I I ! C. elax A. s City/State/Zip: Attach a copy of the workers' compensation.policy declaration page(showing the policy numbs nd expiration'date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK-ORDER and a fine of up to$250.00 a day against the violator. Be'advised that a copy"of this statement may'be forwarded.to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: - Date: VA Phone#: UST Official use only. Do not write in this area,to be completed by city or town official r 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#: ` ACOR® �" CERTIFICATE OF LIABILITY INSURANCE 03/04ATE /D2011) 03/04/2011 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 1NSURER(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 sights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mason & Mason Insurance Agency, Inc. PHC, E,�. 781.447.5531 No.781.447.7230 458 South Ave. E-MAIL ADDRESS: Whitman, MA 02382 PRODUCER CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED - INSURER A: Travelers Ins. 'Company 00034 George Davis, Inc. INSURERB: National Grange Mutual 014788 33 North Main St. INSURERC: ACE Property & Casualty South Yarmouth, MA 02664 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 10/11 BA 11/12 GL WC 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 ISSUBJECT 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 POLICY EXP LTR INSR WVD POLICY NUMBER MMIDD MM/DDIYYYY LIMITS GENERAL LIABILITY 16807900M226IND1 01/12/2011 01/12/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 CLAIMS-MADE rRI OCCUR MED EXP(Any one person) $ 50,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOG $ JECT AUTOMOBILE LABILITY M9M2849 10/26/2010 10/26/2011 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1,000,000 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ B X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION JOTH- AND EMPLOYERS'LIABILITY YIN - _C4641456 03/0512011 03/05/2012 ORY L MITS _I R C OANY FFICERIME BOER EXCLUDED ECUTIVE❑ N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 506,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Dperations: residential remodeling RE: OFFICE COPY ' CERTIFICATE HOLDER CANCELLATION FAX: 508.394.5460 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,' NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. George Davis AUTHORIZED REPRESENTATIVE 33 North Main Street So th Yarmouth, MA 02664 David H. Mason ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r il7assachusetts- Department of Public Safety Board of Buildin! Re!-ulations and Standards Construction Supervisor,License= • I License: CS 56130 GEORGE F DAVIS 33 N MAIN ST S YARMOUTH, MA 02664 ^_ Expiration: 3/1/2013 t ('unnnissiuncr Tr#:'12051 `' ✓fze Lr anvmooswea�z a�✓C�a�cxc�ucaelfa Office of Consumer Affairs&B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration: " 160164 Type: a. i Expiration: .71212012 Private Corporation - t GE RGE DAVIS,! a GEORGE DAVIS 33 NORTH MAIN STREET . SOUTH YARMOUTH;,IAX 02664 j Undersecretary Lioedse,or registration valid for individul use only \ ti befece the expiration date. If found return to: s O;l►ce cif Consumer Affairs and Business Regulation k 10 ark Plaza-Suite 5170 1 MA,02116 I Not valid hout signature a r Town of Barnstable 6« Regulatory Services $A R1.7R1 Rf.A f -Thomas F. Geller,Director Building Division Tom Perry,Building Conunissioner 200 Main 5tn=e Hyamais,MA 02501 www.town.b arnstab le.ma.us Office: 509-862-4038 Fax: 508-790-6230 Property 07niermust Complete and Sign This Section If Using A Builder I, Ul L LC C L \Lk/l ok , as Owner of the Subject.proPerty hereby-authorize e- to act on my behalf, in all rna rs relative to work authorized by this bUffding permit application for. Ilq C e ar Areet (Address Of Job) da"I of Droner D. Prmx Name If Property owner i.s applying for permit please complete.the Homeowners License Exemption Form on the reverse side. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map oZ Parcel I G Application # y0��� Health Division Date Issued Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address L Village NNl S Owner 0J w 1 k,%4vv; •I- ANNE 0 a�AN s oN Address L/ CdvAcii 5T Vttmou1`i4kyi _'l� Telephone Sow- 3 01 - !� 's-9 Permit Request �N -►ova �,,r�a o�` Wa'r�'YL._jAvvLc�t—� d- 5Tw_vct7umc //6 ui-i oN woa c! r4 - tN Square feet: 1 st floor: existing proposed _ 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay oh Project Valuation AQ00 Construction Type Lot Size 0, a�' Ac4-c Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family `� Two Family ❑ Multi-Family (# units) Age of Existing Structure J Historic House: ❑Yes ),No On Old King's Highway: ❑Yes A No Basement Type: A Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Y5- SQ 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 XOil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name i Ak L*V,/- l►_A LwV Telephone Number 5-0Fs _XO )`71 1 Address as P�yw_w" w License # -7 L/ 9 a � S Jc"7�rLAS Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO TOU*J 0 YAKAWQ \3� SA-C, PfK� SIGNATURE DATE o1' y /l FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: 6 i* FOUNDATION FRAME INSULATION lr FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f 4 The Commonwealth of Massachusettsl;'�~ Department of Industrial Accidents Off ce of Investigations r k. f ,r a 600'Washington Street Boston,MA 02111 ` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r Please Print Legiblv Name (Business/Organization/Individual):- -Whalen�Restorat`ion Services , r' Address: 22 American Way City/State/Zip: South Dennis, MA 02660,. =phone #: 508 760 1911 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 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. I -. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'. comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a coip&ation and its . required.] officers have exercised their l0,❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees.TNo.workers' 13. Other comp. insurance required.] *Any applicant that checks box#i 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. tContracton that check this box must attached an additional sheet showifig the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance CompanyNaihe: Arbella Protection Co. Policy#or Self-ins.Lic. #: 4091320408 Expiration Date: 4/1/11 Job Site Address: I I C/ CC�A SST' City/State/Zip: C/YAIVAJ S M 4 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 coverageverification. I do hereby certify under the pains and penalties of perjury th the information provided'above is true and correct Signature: Date:' Phone#• l Cl 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#: 'ate: 2/3/2011 Time: 9:43 AM To: William & Ann Johnson ® 9,1508-760.9995 Rogers & Gray Ins. Page: 001 Client#: 32193 WHALRES ACORD. CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDDIYYYY) 2/03/2011 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 NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:Ifthe 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 NAME: Ann Pell _ Rogers&Gray Ins.-So. Denn Is PHONEArc No,Ext:608 398-7980 Arc No). 434 Route 134 ADDRESS: P.O.Box 1601 rKUWUUhK CUSTOMER ID 0: South Dennis, MA 02660-1 601 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED - INSURERA:Arbella Protection Co - 17000 Whalen Restoration Services Inc INSURER B: 22 American Way INSURER C South Dennis, MA 02660 INSURER D INSURER E: INSURER I : 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE L POLICY NUMBER MM/DDNYY MMlDDIYYYY LIMITS A GENERAL LIABILITY 8500040398 - 10112010 04101/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY - DAMAGE PREMISES Ea occurrence $100,000 CLAIMS-MADE F x1 OCCUR MED EXP(Any one person) $5,000 - PERSONAL&ADV INJURY $1,000,000 _ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $2,000,000 POLICY 7PRO- LOC - $ JECTA AUTOMOBILE LIABILITY 74917400001 D912512010 09/25/2011 ccMBINED SINGLE LIMIT (Ea accident) 1,000,000 ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS ' - PROPERTY DAMAGE - $$- X HIRED AUTOS (Per accident) X NON-OWNED AUTOS - A UMBRELLA LIAB X OCCUR 4600021586 D410112010 04/01/2011 EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE $ X RETENTION $ 10000 $ A WORKERS COMPENSATION 9091320410 D4101t2010 04/01/2011 X WC STATU- I OTH- AND EMPLOYERS'LIABILITY - ANY PRO PRI ETD RIPARTNERIEXECUTIVEY YIN F _ E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? ❑N NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEF1$500,000 If yes,describe under - - DESCRIPTION OF OPERA7IONS below - E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Workers Comp Information Included Officers or Proprietors Project location:119 Cedar Street,Hyannis, MA CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN William &Ann Johnson ACCORDANCE WITH THE POLICY PROVISIONS. 4 Church Street Yarmouth Port,MA 02675 AUTHORIZED REPRESENTATIVE 0198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S63226IM614390 MEE t AL-- Nlassachusetts-.Del)IIrtnarnt fit'Public$ufeth •'� Board of Buit(lim� ltc±ruiaticins and Standard, Construction Supervisor License License: cS 74928 i . WILLIAM, WHALEN r:x" 122 POND STREET 'BREWSTER,'MA 02631 �-i`' Expiration: 8/10/2012 (',innriii„nei. Tr#: 70 ,,ccam� ,71W eamm"11-1m �` iQ ` License or registration valid for individul use only 4 -\ Office of Consumer Affairs&Business Regulatio.n before the expiration date: If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration:' 129244 10 Park Plaza-Suite 5170 Expiration: ' 7/30/2011 Trit 287004 Boston,MA 02116 Type: Private Corporation Whalen Restoration Services Inc. William Whalen 22 American Way ` South Dennis,MA 02660 Y Undersecretary e Not valid without signature 'a I�r� `I'o��vu of B.arnstahle ti� w regulatory Services s�xxsresr� l''- Thomas X+_ Geiler,Director a Baildfug Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 w`vw.toFvn.barnstable.ma.us Fax: S08-790- Office: 508-862-4038 M r Property Qwx erMust M Con-zplete and Sign This Section If Us ing A Builder as owner of the subject.propertY .�i2vae�—�t0 act on my behalf, hereby authorize f .31�P Ley,,j R�S�o �:u�`► S m all matters relative to work authorized by this building pernvt applicatioa for. ST (Address of Job) Date Signature of Cvner' Print Name ro e Owner is applying for permit please_complete the' If P.__VeKty Homeowners License Exemption Form on the reverse side. V- P pt sm -e sV u n w i 5F -ep 'a ty IL ri 40 36' ' v 10-51/4 5-101/2 19 -81/4 Existing ExIeting _ EZIsUng Existlng - - L j - - - - --- - - - - - - - - - - - �, = Overall Scope of Work- OE] a M Repair water damaged building, damage o. resulting from winter freeze-up. Administration o No Structural or Layout changes. w Exam 2 Bath Specifically - 1st. Floor Inspect Electrical, repair as required Inspect Plumbing, repair as required - 2669 .s� � . 2688 a NwThmugh Replace Insulation . . E Replace walls & ceilings Replace flooring Re-install/ Replace interior doors, moldings, etc. N ti Replace six windows - noted on plan ALL-. _� z� - M z� z�a r `V Install new bath fixtures.. Closet i ' Waiting Area IF co Exam 1 w co f &W _ UP t n New New - , E%Is6ng New - New - 13'=7 3/4" 20'-0 1/4" � 36' - ) - DESIGN-.BUILD•RENOVATE Existing 1st Floor - No Layout Changes t Dr. Nilliam Johnson 33 North Main Street 1/4" = 1'-0" 11 q Cedar Street South Yarmouth, MA 02664 5e tember 21 , 2011 (508) 394-0832 p , Hyannis, MA uAu,u.GeorgeDavisInc.com 36' '-1 1/2" 13'-10 1/4" 8'-3" t—9'-7 3/4" '-1 1/2 ' Overall Scope of or - r ,fRepair water damaged building, damage resulting from winter freeze-up. No Structural or Layout changes. ti E Bath Eve Eve f� Specifically - 2nd. Floor ® tip Inspect Electrical, repair as required Inspect Plumbing, repair required p 9, p as 0 Repair walls where damaged Install new carpeting Private Office 1 2688 "me'µ r.=; Re-install moldings, etc. where removed. � - �„ �u=.a" Renovate bath - no layout change. Private Office 2 ti bo oo N zsse ti N DN � g o a r Eve LO LO R: g§ x '010'li4"kt wrINNJ. - a© �� � a a 36' DESIGN,BUILD RENOVATE Existing 2nd Floor - No Layout Changes Dr. Nilliam Johnson 33 North Main Street 11 q Cedar Street south Yarmouth, MA 02664 5e tember 21 2O1 1 (508) 394-0832 p Hyannis, MA www.6eorgeDavislnc.com Overall Scope of Work - r- - - - - - _ - - - - - - - - - - - - - - - - - - - - - - � L- - - - -� Repair water damaged building, damage - ��� -o- resulting from winter freeze-up. - - - - - - - - - -- - - - - - - - - - -J L - - - - No Structural or Layout changes. L I I ( Specifically - Basement Insulate floor assembly above r , A�x I I �m I • k �; I . I I ,mI F# �x uP I = j - - T -'jj n _:. - - ARL ��,�1 _. . . m . w ��� _ , i ,� Existing Basement- No Layout Changes I/�„ _ I,-O„ - DESIGN BUILD RENOVATE I I Dr. NIlllam Johnson 33 North Main Street 1 1 q Cedar CJtreet South Yarmouth, MCI 02664 Se Member 21 2011 (508) 394-0832 p , Hyannis, MA uuw.GeorgeVavislnc.com N 20� 00 072 X 44 co* N � FZ- IV /DNA 0 z r