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HomeMy WebLinkAbout0033 CHASE STREET C daub f Application number... . ... .. .�?. Fee................ .................. ...... ...... ........... 8AR�81ABL& '113 BuildingInspectors Initials........ .................. '" Dq g f1 66 ��tt f .....................�..... IK � T1.�]t!� C:�� bAHt11�@ABL� Date Issued..... . ....... Map/Parcel............®�....... (�.Q....1................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: YM / NUMBER / STREET VILLAGE Owner's Name: ��{�/ Hr � Phone Numberr�bg ,5108 W78 , 'TQ0 H Email Address: C t CST A C 0tdAd Cell Phone Number Project cost$ 3] 7:, tom— Check one Residential V"— Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize kx to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding Windows(no header change)# Insulation/Weatherization Doors (no header change)# Commercial Doors require an inspector's review D Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 1t: CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration (if applicable)# /2,4 3-13 (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor ' '� fWal Phone number �� p �/j' w ALL PROPERTIES THAT HAVE STRUCTUR OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent..have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3.30 pm4:30pm.Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date /ej - s•�D/� All permit applications are su ect t a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 UIF www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individual): IJ4 el Address: City/State/Zip: U . 011 :!�f 0 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.5ri 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.: i` required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. ' right of exemption per MGL Y �o workers comp. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no q ] Y emplo ees. o 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. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site . information.Insurance Company Name: �_r&m 1"S Cp Policy#or Self-ins.Lic.#: r��rH, -�p L� Slay Expiration Date: Job Site Address ?] (�!l[�� rDT• City/State/Zip: NN O2—W Attach a copy of the workers'compensation policy declaration page(showing the policy numb r and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certi under the pai s nd penalties of perjury that the information provided above is true and correct. Si nature: Date: /O Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: f f r» � r = � -_Y'a Y ''� -+ A , : ...i ..ems _ a �" * + , r- �' c ?,z �r p��­�.��I"-.,-..1.,,,,-r%.�rr 1.­.�',4-,�.,:.--..1�:�r w.----,I�,r,��.�1.-­.--.".--;-...�,,�--"-­...�--­..I I I1,I�':,�-"--�-.r�,I-.-�-.,�-�-�"'I.,',�,I-,..,,',.r,Ir-�.r.�,r�rI��.­_-!,!�-,r;�-_.�,.��I-,�.I�.I,",���",1--�1".,-"-r,.�.:r­',-�.,1-r�_,­�-I I:1,.-�,I.r�,-r,�..­r-��:I.,;'—�­_',.�t,,-r.r r,:"",,.�:-,"'-:-..,,�;�'.-r7'�'.:..-.�,:,:-.',­,-_�:1­'-�­r,,r �: 5= J ''..­I'�,�-..::,_,',,-.�.��',,,-'��-,-,.,!­�7A�;rr,A-'-,r,,"�r�r�,.­1I-,�r-,'`.1-r�1.—�,l r.,�­,:,.,,-,,5,',�2-:,`�I.r-',.-,,I-,::,'.-"�,�.".o,­.'..�,,...­"::,,.,�',ljl­'r,r�.�....,�.6,:".­.,1.r.',,��,�l,,, jr 1. Y a „ t t 5 % x� ° h a a s ' a t t : £ 9 ,K _ t PROPOSAL 790 s nCZ�^ {: ` W b r 0° aA MA L:c #069680 A �� O k a#.,o,� ? rn s �'x - , Mayfair Rc1 { 3 �. s �:. r k t s -, E"F«h .i South Denrrts MA 02660 H I C #124793 1 }� fil caper odwtridows com � -jr, a j (508).398 1511 • Dennis,:MA (866):398.;1511 • :Toll<Free = a=k' -- 5 ,11 - s PHONE Y t . DATE , TO 'Carl Burbank 5 - 8 08; 760 0007 W 8/26/201 33 Chase St JOB NAME/LOCATION =r Hyannis MA-_ 02.601 .` ! t w1nd6,4Aiving room y dersen caseiten Andersen casement sash /` office area ' -, E' { ak �. r x r JOB NUMBER ' i:� .x z_,r- ,.' y= e ;i a , - ,� + _.3 JOBO PH 7 E$ 5 F 000 5 8 7 130 H VVe hereby submit specifications and estimates.for.- 1 Remo one broken Andersen basement sash from office ,/ frontyposcFi area and-replace 'with' one new Andersen casement sash'in same location New sash will be ,haven.a white', terior' a - 'a white interior We will re use the'old,,Hardware * New Andersen `:casement sash � $ 291 95'. * Labor to install s * Total due - , $ 135 00 2. Remove:one .Andersen bbw VindOW i 1ivng.room .and replace ;with•one Andersen flat;three. , sash casement "window: New Andersen casement window ;will ,have =threes,ash 'with:'the:center' sash being stationary and the other two sash vent ing:' The ;new casement``window will have'. a white exterior with a white interior; scr,.eens, ";white:hardware and LWE 4 `instalated:;.glass': * New Andersen casement window: t 1 3 ,$ 1190'.79 * Labor to install Y * Total =due.. $, 1 " 0: . . g x $ 2,750 79 3. Take. old window, `sash, .and any debris�from.this job to the town aandfill 4 Insulate the; cavity of -new•,Andersen .window:_. 5 Make arrangement for deliye ry of new Andersen window and sash. 6. Supply town,of .Barnstable bolding permit at cost payable ;at end of 'job * This proposal doesnot inchide any other, work not;described. above * All Andersen products described a) ove will be prepaid by the home, owner. * Any changes to this proposal :must be done 'in` writng and 'accepted by 'both parties , ** If this proposal is satisfactory,:.­please sign the YELLOW copy and return with payment schedule,. ** Please make a check payable to Vasco Nunez carpentry .in the amount of"- $ 1,482.74 for>your zr new Andersen products described above and please include this. check with your signed proposal:-A1Tow:3-weeks`for`delivery,this is - ;factory, or er — -- — � PI'OpOSe hereby ,.furnish material and labor—complete In accordance with the above spec ifieations,'forthe s u. m of: Three Thousand One Hundred Seventy Seven and 74/100:Dollars dollar§:($ 3,17:774 ) Payment to be.made as follows: ... Labor: 50 $ Down payment to start .At time of start. . I , Labor:: 50% -r on Comp1etio at time,!,of completion.. $ 847rr 0 '.Total labor. . ' ' ' • • .$ 8:4. All-,material is guaranteed to be as specified All work to be completed in a professional manner according to standard'pracfices.Any'alteration or deviation from above specifications Authorized '' ' involving extra costs will be executed only upon written orders;and will:become.an extra: Signature 'c' ' I 2 ^ i charge over.and above the estimate.All agreements"contingent upon strikes,accidents or delays beyond our control.Ownerlo carry fire,tornado,and other necessary insurance.Our Note:;This proposal may be workers are fully covered by Worker's Compensation insurance. - . withdrawn;by w-if notaccepted_within, _ da s. 1 5 /acceptance,Of"Proposal—The above prices,specifications and con- f--- ' % 1 � " x 'r ;ice ditions are satisfactory and are hereby accepted.You are authorized to do the work as t - -,-"^- -�-;,4 ' specified.Payment will be made as outlined above. S1gna re rw---� - �" , � , ...__ - - I I i - Y Date of Accep�3n$< Signature PRODUCT 13128G USE WITH 771C ENVELOPE Deluxe Corporation 1-800-32M304 or www.deluxe.com/Shop - PRINTED IN U.SA. a Construction Supervisor 1&2 Family Commonwealth of MassachusettsDivision of Professional Licensure Board of Building Regulations and Standards Canstruciia,., uj!yervi & 2 Family CSFA-069680 E c.pir.es: 10/03/2020 1, VASCO E NUNEZ III aM 79 MAYFAIR ROAD SOUTH DENNIS MA 02660 1 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Commissioner Call(617)727-3200 or visit www.mass.gov/dpl `timajoasaapun 099a0 b'W'SINN34'S 11(Z3Nf1N'3 OOS`dA Registration valid for Individual use only f before the expiration date. If found return to: ,III III 2iNf1N"3 OOSVA Office of Consumer Affairs and Business Regulation I 1 6l02:40/80 £6LbZ I 10 Park Plaza-Suite 5170 ! w � 1 Boston,MA 02116 I of e l x3 fenpinlP ogea;si as f � � C"I f i uI:3dA1 I� a010t/81N001N3W3AOHdWi 3WOH uop [eln6ali sseulsne sileav aawnsuo0 jo eoino y I / Te �• Z�Jn�ur„ I 1 Not va id without ignature �• Client#:647900 2NUNEZVA ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 10/07/2018 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: Dowling&O'Neil Insurance Agy PHONE 508 775-1620 Fax A/C No Eft: A/C. /c No):5087781218 973 lyannough Road ADDRESS: MA P.O.Box INSURER(S)AFFORDING COVERAGE NAIC a Hyannis,MA 02601 INSURER A:NGMInsurenwCompany 14788 INSURED Vasco E.Nunez III DB/A INSURER B:Cimion Insumnee Company 40274 V.E.Nunez Carpentry INSURER C: 79 Mayfair Road INSURER D: South Dennis,MA 02660 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTgR TYPE OF INSURANCE NSRL WVD POLICY NUMBER UBRI MMO/LDIDNYYF POLICY M DIDNYYP LIMITS A GENERAL LIABILITY MP05117J 9/12/2018 09/1212019 EACHOCCURRENCE $2000000 X COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED PREMI$E3 Eaeccurrence $500 DOO CLAIMS-MADE ERI OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $2,000 000 GENERAL AGGREGATE s4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPA GG $4,000,000 POLICY X PRO- JECT X LOC $ B AUTOMOBILE LIABILITY BGXJKW 7/18/2018 07/18/201 EO aBBIINdEeD nt)SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $250,000 ALLOWNED SCHEDULED AUTOS Ix AUTOS BODILY INJURY(Per accident) $500,000 XNON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident $300,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY N ER ANY PROPRIETOR/PARTNER/EXECUTIVE -- E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S220204/M220203 RPSW1 oFIKE?I_ Town of Barnstable *Permit# -Regulatory Services Expires 6mwtthsfrwn issue date t R�RNS.`TAR7�F,, ! F M039.ASS. Thomas F. Geiler,Director ' E RMM Building Division I Tom Perry, CBO, Building Commissioner . N O V 3 2011 200 Main Street,Hyannis,MA 02601rOWN CIF BARNSTABi E www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Vafid without Red X-Press Imprint Map/parcel Number-36 Z 175 Property Address 1, C4,ASS `. residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor'.s Name � �... Telephone Number P 'CIO T�L- Soar ybN i7 Home Improvement Contractor License#(if applicable) �'� Construction Supervisor's License#(if applicable) EiWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name L/ �-2a-� ,�✓ jv_,� Workman's Comp, Policy# GJC 2 S I S 3 3 S 4s ® 4®2 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) [?"'Re roof(stripping old shingles) All construction debris will be taken to yAzftc�_," _� ❑ Re-roof(not stripping. Going over existing layers of roof}. ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License.& Construction Supervisors License is -required. SIGNATU WPFILES\FORMS\building permit forms\EXPRESS.dOC P,evised 070110 Town of Barnstable Regulatory Services MASS g Thomas F. Geiler,Director 1 639. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Rmer Must Complete and Sign This Section. f If Using; A Builder I, rkA34 CQ- --CAF-1 y as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit 3 3 �I�A� S► l-�I ��n i� Y�'•1 f�-- (Address of Job) 'k*Poo l fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. Signature of Owner Signature of Applicant GqR� 7(3v(ZIbP-nK. ; Print Name Print Name ILI Date Q:FORMS:OWNERPERMISSIONPOOLS , I ' THE r, Town of Barnstable Regulatory Services B"NSTABLE, : Thomas F. Geiler,Director y MA89. `bA i639. •0� Building Division lFp�.lA Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: ( I t JOB LOCATION: 3 number street village "HOMEOWNER": L 011 W_ -5b 8—7(O0-0007 name home phone# work phone# CURRENT MAILING ADDRESS: 3.3 C N A se s—( S ® J city/to s to zip code The current exemption for"homeowners" s extended to include o er-occu ied dwellings of six units or less and to allow homeowners to engage an individua for hire who does not ossess a license,provided that the owner acts as supervisor. DEF ITION OF HO OWNER Person(s)who owns a parcel of land on which h she resides. intends to reside,on which there is, or is intended to be, a one or two-family dwelling,attached or deta ed struc, es accessory to such use and/or farm structures. A person who constructs more than one home in a two ear eriod shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official o a rm acceptable to the Building Official,that he/she shall be res onsible for all such work Performed under the b ermit. (Section 109.1.1) The undersigned"homeowner"assumes responsib' ty for ompliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that /she understan the Town of Barnstable Building Department minimum inspection procedures and require ents and that he/sh will comply with said procedures and requir Nents. Signatuhlof Homeowner Approval of Building Official Note: Three-family dw lings containing 35,000 cubic feet or large will be required to comply with the State Building Code Section 1 .0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: " y homeowner performing work for which a building permit is equired shall be exempt from the provisions of this section(Section 109.1.1 L' ensing of construction Supervisors);provided that if the homeo er engages a person(s)for hire to do such work,that such Homeowner shall ct as supervisor." Many homeowners w o use this exemption are unaware that they are assuming the response ilities of a supervisor(see Appendix Q, Rules&Regulations for Licensi g Construction Supervisors,Section 2.15) This lack of awareness ofte results in serious problems,particularly when the homeowner hires unli ensed persons. In this case,our Board cannot proceed against the unlice sed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities requ e,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of his issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt The Commonwealth of massachuseus Department of Industrial Accidents Office of Invesdgadons 600 Washington Street Boston,MA 02111 www..mangov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricisnslPlumbers r ADMI-feant Information Please Print Le gibly Name(Business/Organizwoa/bwividual): \}=1 Address• City/State/Zip: -9 -Phone#: Are u an employer?Check the appropriate bo= 1.U I am a employer with L. 4• ❑ I am a general contractor and I Type of project(required): errupioyeea(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-contractars have IS. ❑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 10-0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑P myself.(No workers'comp. right of exemption per MGL mg repan rs or additions insurance required.]t c. 152,§1(4),and we have no 12.10 Roof repairs employees.[No workers' 13.❑Other comp.insurance required,] ;Any applicant that checks box#1 nwt aho tin out the section below showing tksir werba-� �DoI�I+infesrr�tien. Nomeownas who submit this aQtdsvit indig g dxy are doing all wort and then hire outside conhactars must submit a new a8idsvit inditxting such tContiactom that check this box must attached sn sdditionak sheet showing dw tuns of the sob e cons acto ttrfma tsubmk a r or not those entities have employees. If the sub-contractors have cngloytea,they must provide char workers'c(dw polity number. 1 are an employer tl iat is prvvldur8 tvorkdrs'courpensa*w lasuren"jor my informat7fo ensPloYees. Below 1J ilia polity+onl fob she,es. Insurance Company Name:; Policy#or Self-ins.Lie.#:_ ( `) `� 7 1 f �'�� Expiration Date:_ Job Site Address: ^ {� City/StatelZip:` R Z(o� J Attach a copy of the workers'compensatloo Policy declaration pale(s n the= policy number and explraden date). Failure to secure coverage as required under Section 25A of MGL c. 152 can read to the inVosition of criminal penalties o fine up to 51,500.00 and/or one-pear,imprisonment.as well as civil penalties in the form ofa STOP WORK ORDER and affine 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 Investi a 'oas of the D for instrauc c vein a verification 1 do hereby ce under the pours aged pe perf UIY AN the informadew provided above/s and c rrrct; / Da Phone C J uj use only. Do not wrlte in/it area,to ve cOmpteted by city or 1Own o11'Iciat City or Town: Pertnit/Llcense# Issuing Authority(circle onep I.Board of Health 1.Building Department 3.CitYlTown Clerk 4.Efectricai Inspector S.Plunibing Inspector 6,Other, _ Contact Persons Phone!#: f , -- Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston,,Massachusetts 02116 Home Improvement Contractor Registration Registration: 128957 Type: Individual Expiration: 6/14/2013 Tr# 213157 Oliver Kelly Oliver Kelly 8 Rhine Rd - Yarmouthport, MA 02675 "Update Address and return card.Mark reason for chat Address Renewal Employment Lost $CA 1 is 20M-05/11 e moarAffairs&Bus de s Regulation r�elf License or registration valid for individul use only Office of Consumer Affairs&Busidess Regularion g y ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - egistration: 128957 Type: Office of Consumer Affairs and Business Regulation xpiration: 6114/2013 Individual 10 Park Plaza-Suite 5170 ® Boston,MA 02116 Oliver Kelly Oliver Kelly 8 Rhine Rd. Yarmouthport,MA 02675 Undersecretary Not valid without signature }- :Massachusetts- Department of Puli"lic �afetl Board of Building Regulations and Standard License: CS SL 99167 Restricted to: RF,WS .., x �R. OLIVER KELLY . 8.RHINE ROAD YARMOUTHPORT, MA 02675 Expiration: 9/28/2013 ,mmiai ncr Tr=: 5185 I , " DATE(MMIDDIYYYYi . ,CERTIFICATE 4F LIABILITY INSURANCE TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS .ATE IS ISSUED AS A MATTER OF INFORMA DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 11VE OR PRODUCER,AND THE CERTIFICATE HOLDER. If the certificate holder is an ADDITIONAL INSURED,the policy(tes)must be endorsed. If SUBROGATION IS WAIVED,subject to conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the [or in lieu of such endorsements). LING &ONEIL INS AGCY INC. CONTACT NA E: OX 1990 PHONE SOB 775:16._ FAX JAIC,Not: S 778-421 4NIS, MA 02601 E INSURERS AFFORDING COVERAGE NAIC A INSURER A: LIBERTY MUTUAL GROUP ER KELLY INSURER a: KELLY ROOFING INSURERC: INE ROAD INSURER0: MOUTH PORT MA 02675 INSURER E INSURER F CERTIFICATE NUMBER: 10268278 REVISION NUMBER: RTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE.BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS J1AY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ,NO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUB POLICY EFF POLICY EXP LIMITS 'PE OF INSURANCE POLICY N BER MMl D/YYYY M D EACH OCCURRENCE S 31LITY DAMA%E T RENTED PREMISES Ea occurrence S '.CIAL GENERAL LIABILITY lMS-MADE �OCCUR MED EXP An one arson) 5 PERSONAL&ADV INJURY S GENERAL AGGREGATE Is PRODUCTS-COMPIOPAGG S GATE LIMIT APPLIES PER: S PRO- LOC LIABILITY JECT Ea eBcluNdeDISiN LE LIMIT S BODILY INJURY(Par person) S 0 BODILY INJURY(Per accident) S IED SCHEDULED AUTOS PROPERTY DAMAGE S NON-OWNED Per accdent UTOS AUTOS S S EACH OCCURRENCE S LA LIAR OCCUR LIAS CLAIMS-MADE AGGREGATE S S RETENTIONS S S DM 12B/2041 PENSATION WC2-31S-338804-020 12/2812010 12 WCSTATu TORY LIMITS gp - C ER 'ERV NiABIUTY Y i N E.L_EAC 4 ACCIDENT $ 0000 iT.OR/P.ARTNERIEXECI.MVEEa NIA __. —.---- ---_. ABER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S 100000 1 NH) e under E.L.DISEASE-POLICY LIMIT S 5 0 0000 N OF OPERATIONS below )PERATIONS 1 LOCATIONS VEHICLES(Attach ACORD 101,AddlUonal Remarks Schedule,if more apace is requlred) ensation Insurance:Part One of the policy applies only to the Workers'Compensation Laws of the State of MA. (S'COMPENSATION POLICY.DOES NOT PROVIDE COVERAGE FOR OLIVER KELLY MOLDER C NC L T O SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NHELDON ACCORDANCE WITH THE POLICY PROVISIONS. )RT ROAD MA 02601 AUTHORIZED REPRESENTATIVE Jeff Eldrid e 01988-2010 ACORD CORPORATION. All rights reserved. volo5) The ACORD name and logo are registered marks of ACORD 7cenoCLIENT LI T CODEt cedes55-- lAnne chandler dlisaued6ceitificstea0e p:4 page 1 of 1 �6e i6 1 �- > Assessor's map and .lot number ... SEPTIC SYSTOM ;rMT I a INSTALLED IN CCi'APLIANCE . ' ' ...'... ' ,9� STAT`Sewage Permit number r.. 1 ITIi AP .'%C I.TARY CODE-AND SOWN F7NEt0 TOWN OF, BARNSTA LE off y�.�� O•w '_.t ' +`.: . i+ BAHBSTABLE, "39a - -� BUILD IN � IN, SP:ECTOR p y0O 039. 63 `e0°j APR.LICATION FOR PERMIT TO............ . ... ..... ................................... ............................... TYPE OF CONSTRUCTION .......... ! .........:.......- ::.Y ?!7......W................. ...... ..... tz ...................41T ... .•..........19. ._ TO THE INSPECTOR OF BUILDINGS: z The undersigned hereby applies for a permit according to the following information: Location ................... .... .a ........ ....................... ...... '? L{... ................... ProposedUse .......... '..:..........6:_ .aR. zcwM�.............................................................................. Zoning District ...............�\. .........................................Fire District � .! / .� ......:......................................... Name of Owner !ar.,t ",E f.°!e. P. ....Address '13..Ch.t: . .Se!............................................ Name of Builder ,<`/.l &I.e.t./.Tr.... �.1/!!"!/..............Address .5 4:.lq. yv..:r :,.....+` G�/ . Nameof Architect X.40 r ..... ............................................Address ............................................................................,...,..,.. Numberof Rooms .... ........��' ')..............................Foundation ..G,. .:.. . .......................................................... Exterior (!(/...f.ad......3.ko.; . .....:............................Roofing .,/` "� .1....'........ ...................................... Floors ....................................................Interior / y. t` ..................... Heating / .� *.... `...,,g.......... .::.....................Plumbing d/ ......................................... .............. ... ........ .................... .... .... .. Fireplace .11, .5 ....................................................................Approximate Cost ... j OO.�..�..=.................... ..... . Definitive Plan Approved by Planning Board ________________________________19________. Area .d..�/......... ,..... Diagram of Lot and Building with Dimensions Fee 17... '. .................. .. SUBJECT TO APPROVAL OF BOARD OF HEALTH Cess ,�oaLs r�. FCC" SIP -- c1, _ v I hereby agree to-conform to all the Rules and Regulations of the T n of B nstable regar ' the Bove construction. Name .......... ........ .................................... John H. & Clara M. Eilor No .18043 -permit'for :.......Addition•......... 4 . , i ....................... Location 33.•abase.:S.t...Hyannas................ . .............. ...........................................:.... _ .......... JV -� Owner .M....Ei1or•............ Type of.Construction ...b'•rame............................ ...........................................................�r� . .- .................. Not .M3b.-B .L:.IZ9 Lot ..........h. ................. t ,� Permit Granted ...............NAY ..7.' .......1975 Date of,Inspection ............... .;... Date Co pleted .. � ��. ! 19 �^ - • PERMIT REFUSED J r ti A...... ..................................................... '19 ..f................................ ....... ..`.. ............................` .nn,.. ,- .. .... .. .................................... .. # •,{ f - - k �, `• Vic.� ; ` ....•,.,� - _ 4 � �' �t Approved .................................................. 19 •........................................................• ; .•. 4 • •.... .............................................. •......... ......••• •..•• • r ♦ C _ Assessor's map and lot number Sewage Permit number y�*THE TQ�y ' TOWN OF BARNSTABLE i iBARISTA➢LE, i "6 o w u BUILDING INSPECTOR ay a' , APPLICATION FOR PERMIT TO ......... ..C....../. ..:.J tl? .......................................................................... TYPEOF CONSTRUCTION -1- v^2, -..............:............................. ... ......................... ......................................................... Xj rr I .1�2�" TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location � C, Qin rn!...5........................................................ • Proposed Use .......... . ...''.:.................!-....`' "?............./1.. ... 'L................................................................................. ZoningDistrict .....................<...'r.............................................Fire District :.....:....................................................................... r Name of Owner..,/!,1i, • .+... ..l �............`.. ••r�r .r , Address ::'...:'�..r:..a'.r.::................f........................................... Name of Builder #•fi.i. M.., rr/,s, 'f.'................Address ............................. .. ..:....... ...................................... ........ r Name of Architect ..... .......::.. . Address t' Number of Rooms ..........R............. ....................................Foundation .. �.. ..: -................................................................ �fifr ,� �- Roofing ,l! 1 11t � Exterior ....... ............................................................................ :..........................................:..................................... /.. f �� r Interior t/ , r r ,, .«.. el Floors .. ..... ...................... ` t i Heating ...........Plumbing - s ..Fireplace / v s ......•••••.•.•••..•.•.......•Approximate Cost a L� { Definitive Plan Approved by Planning Board ------------------------- ?6 d -------19--------• Area ..........................._............. Diagram of Lot and Building with Dimensions Fee 1' J~ �. SUBJECT TO APPROVAL OF BOARD OFr HEALTH r IL � I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . ! ........................................�.....:..... T John H. & Clara M. Eilor No ...1804 ...- rMW'for dd. .1~]L913... ...... ............................................................................... Location .......33..Cb,aae..S.t......H.yannis.......... ............................................................................... t Owner „Zphn�.H...&..C]asa..M....Ei1ax............ Type of Construction ........Feats....................... ..........................................................:..................... Plot M..30..$....L,..189 Lot ................................ r - Permit Granted ..... „ . ......19 75 Date of Inspection ....................................19 ' Date Completed ........... 19 i ` 7PE .T'REFIUSED - ............................................. ................................. = .. / ........ <>.. ...... S� F ............ ... . .0 �. .... Approved ................7./............................. 19 ZRO ..............................................................� ... !S 77