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0009 DALE AVENUE
Town of Barnstable *Permit Espires_6_months.from.issue date_ X-P,RE,$.$ PERMIT Regulatory Services Fee Thomas F.Geiler,Director SEP 2 3 2008 Building Division TOW,N OF BA RNSTA6,LE Tom Perry,CBO, Building Commissione r 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Rex: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number G 6 03 l Property Address ❑Residential Value of Work ( �� / Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address (Q Contractor's Namerjj�:&,VjTelephone Number���� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) �orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [],`I have Worker's Compensation Insurance Insurance Company Name •� �� Workmen's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacernent Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliaflee with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop Owner mu operty Owner Letter of Permission. ome Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 Department of Industrial Accidents Office.of Investigations 600 Washington Street , a` Boston;MA 02111 www:mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information Please Print Legibly 'dame (Business/Organization/Individual):. Jkt ch r"r W (hf IP C ' LLrr address: '�C� >a (Z� _-ity/State/Zip: C1 (I t S d W Phone#: -' 7y. 4q1 re you an employer? Check the-appropriate box:. Type of project(required): q- ram 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 I am a sole proprietor or parer- listed on the attached sheet t ❑ Remodeling ship and have no employees These sub-contractors have 8.' ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their ME] Electrical repairs or additions required.J • ❑ 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. [No workers' -3.❑ Other comp.insurance required.] iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' 'z )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an an employer that is providing workers'compensation insurance for my employees. Below'is the policy and job site 4rmation. t� � *: urance;Company Name: ,ey e Q ,icy#or Self-ins.Lic. #: �6�"! .L �Q Expiration Date: / U l � 7 Site Address.: City/State/Zip: 4/z--VT w- :ach a copy of the workers' compensation policy declaration page(showing the policy nu ber and expiration date). lure to secure coverage.as.required.under Section 25A ofMGL.c. 152 can lead to the imposition ofcriminalpenOties'of a 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 ip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o IL estigations of the DIA for insurance coverage verification: 9,hereby eerti er the ai a ' s of perjury that the'information provided above is true and correct mature: Date: one#: Official use only. Do not write an this area,to be completed by city or town official City or Town: Permit/License# - Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town.Cler k 4.Electrical Inspector 5.Plumbing Inspector . . 6.Other Contact Person: Phone#: Board of Building Regul 1 ions and Standards One Ashburton Place -Room 1301 Boston: Massachusetts 02108 : Home Improvement,-Ontractor Registration Registration: 110609 Type: Private Corporation ': } Expiration:n: 11/3/2008 Tr#=124739* E J JAXTIMER;:BUILDER, INC: � ERNES JAXTIMER - -- - ) -- 4.8 ROSARY ,r -- RY LN` - �„-�-�-� d>.', a - Jh„'�E✓ - _ . ..... -- 1 HYANNIS, MA 02601 . .�, � ,��; - - � , r �w 6. Update Address and return card. Mark reason for change. ;,Address Renewal GmploymenY, Lost G1rd .DPS-CA1 a ;50M-05/06-PC8490 - - - _ - � ���,ad•.����Q � ii II p.Boa d o.f Bmidm`g Ke ulatwns;and:$tandar`j g. ds .i era{ ;# 9 ' s Construction Su a P p n✓isor License . a�F ,' Luse CS a { sIR ) � P 3251 i fE'xrat�o 1/14/2010 Tr# 13629 rij ERNI r kr 3)� ' is PST J,JAXTIMER 2 i 48 ROSARY IS MA w HYANN 02601 Commissioner 'I - 'f r �` }. "s c v SEP-22-2008 11:43 FROM: T0:15087754909 P.1/1 U71 G1/tUUD UU.JU _ DUO/ f J4 7U7 - CJ.JHA 11PIGR - rMur- al D1 . • ..Tow�t ��:Ba�nstable :. : . - Ztegalator� e3.-v3ices• . 4 3UMTiloII789 F.'Gegat Or Tom Dmim AWftg Cv=mbidoner 200 MAin SUWL.Hya=.%MA 026M ice 508-862-4038 . 508-1%odm Property Oi*ner Must. Complete and Si en This Section . , l'f.�leixtg A►Bulider.• . , - , . • as Owner-of the i*ect pzopart hemby au&ozize to ad an my lnh , irl all.matters zelattve to vvaz�authoxixed by this p Pik applic�.t'soa foc ,, , Q94tS ' - (A,d& as of Job) Sj&natute.©f Owner . Prat Name . . Qey�iWl1 . f+ f - Client#:2093 2JAXTIMEREJ ,A - Dr. CERTIFICATE OF LIABILITY INSURANCE DATE( M/ Duerr) 08 PFROUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION . Dowling& CXeil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency —ALTER_THE_ _ __ _ _ _ __ _ 9731yanoucgfiRd., PO Box 1990 H yannis, MA D2601 INSURERS AFFORDING COVERAGE NAIC# INSU ED wsURERA: Acadia Insurance EJ. Jaxtimer Builder, Inc. INSURER B: Enest J. &Marie T.Jaxtimer INSURER C: 48 Rosary Lane INSURER D: Hyannis, MA 02601 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIR EVENT,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' POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MM/DD/YY A GENERAL LIABILITY CPA010264814 01/01/08 01/01/09 EACH OCCURRENCE $1 00Q 000 X C04MERCIAL GENERAL LIABILITY - DAMAGE TO RRE SIE,ENTED - $250 000 CLAIMS MADE F xJ OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE $Z 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS, BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY EA ACCIDENT $ t ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLALIABILITY CUA010264914 01/01/08 01/01/09 EACH OCCURRENCE s2,000,000 X OCCUR CLAIMS MADE AGGREGATE s2,0001600 $ DEDUCTIBLE $ HX RETENTION $0 $ A WORKERS COMPENSATION AND WCA020455011 01/01/08- 01/01/09 WCSTATU- OTH- EMPLOYERS'LIABILITY c ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIM T $500;000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. '- 7> E.J. and Marie Jaxtimer are included under the workers compensation policy. _ CERTIFICATE HOLDER CANCELLATION . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town Of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ 0 DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE m ACORD 25(2001/08) 1 of 2 #51277 LSt 0 ACORD CORPORATION 1988 Town of Barnstable *Permit# Expires 6 months from issue. Regulatory Services Fee 6 Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5087790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X Press Imprint Map/parcel Number Property,Address_ ( l� S ��� ❑Residential Value bf.Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Gil i�i C�u�[GUTA i Telephone Number �)�•I Home Improvement Contractor License#(if applicable) I D 10 U Construction Supervisor's License#(if applicable) .�Orkman's Compensation Insurance X-P S PERMIT . Check one: ❑ I am a sole proprietor J U R 6 2008 ❑ I am the Homeowner [ij-1 have.Worker's Compensation Insurance TOWN,OF BARNSTABL.E Insurance Company Name C WorlM='s Comp.Policy.# Copy of Insurance Compliance Certificate.must.be on file. Permit Request(check box) �Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Q'Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) l��(S(A6I *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop Owner must sign Property Owner Letter of Permission. of the Home Improvement Contractors License is requ dd . 9— (�( 08Z SIGNATURE: ,8Y SNdVO _0 NAO-1', Q:Fonw:expmtrg Revise061306 I The Commonwealth of Massachusetts Department of Industrial Accidents 10 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information }• Please Print Le 'bl Name(Business/Organizationandividual):' `v l C Address: Y Knattsl City/State/Zip: Phone.#: (, 1 Are yo an employer? Check the appropriate box: Type of project(required): 1. I am a employer with -50- �4. I am a general contractor and I 6. ❑New construction . employees(full and/or part-time).* have hived 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.t 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 11.❑Plumbing repairs or additions myself:[No workers' comp. - right of exemption per MGL 12.[;1`Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp,bmirance 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$rey 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-contmct=have employees,they must prvvi&their worker:'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: / Q Policy#or Self-ins.Lie.#: JV Expiration Date: / Job Site Address: City/State/Zip: V� r 7 Attach a copy of the workers'compensation policy declaration page(showing the policy nd6der and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statzmerit maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi sand penalties of perjury that the information provided above ' /andd orrect Signature: Date: Phone# Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City%Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other IT Contact Person: Phone#: t: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees: Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is�defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant tliereto shall'not;b4ause'of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that""every.state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage.required." Additionally,MGL chapter 152, §25C(7)states'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." .- • . Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbe(s) along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LIP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required,Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. sign•e. Also be sure to si and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to'fill in the permit/license number which will be used as a reference numbed In addition,an applicant that must submit multiple permiVlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should'write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone-and fax number. The Ummonwealt i of Massachusetts Depaitment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 W. #617-727-4900 ext 406 4r 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia Date: 2120/2008 Time: 4:04 PM To: N 9,15087754909 Page: 002 Client#-2093 2JAXTIMEREJ - ACORM. CERTIFICATE OF LIABILITY INSURANCE 0/2008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyanough Rd., PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED iNSSURERA: Acadia Insurance E.J.Jaxtimer Builder, Inc. iwmm B: Fireman's Companies Ernest J.&Marie T.Jaxtimer INSURER a 48 Rosary Lane INSURER D: Hyannis,MA 02601 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 CLANS. rAGENERAL CY TYPE OF INSURANCE POLICYNUS pADM �ATE I HIVE PDATEE NFAM ATION UWrS LL46U TY CPA010264914 01/01/08 01101109 EACH OCCURRENCE. $1 000 000 X COMMERCIAL GENE LIABILITY DAMAGE TO RENTED $250 000 CLAIMS MADE FXIOCCUR MED EXP Wy one person) $5 000 FREMISES PERSONAL&ADVINJURY $1000000 GENERAL AGGREGATE $2 000 000 GEW AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2.000.000 POLICY � LOC B AUTOMOBILE LIABILITY MAA010395014 01/01/08 01/01109 COMBINED SINGLE LIMIT ANY AUTO (Eaacadem) $1,000,000 ALL OWNED AUTOS BODILY INJURY X WMEDULED AUTOS (Pet pe—) $ X HIREDAUTOS v BODILY MURY $ X NONN43wNEO AUTOS (Per acddent) PROPERTY)AMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN' EA ACC $ AUTO ONLY: AGG $ A EXCESSAAYRSRELLA LIABILITY CUA010264914 01/01/08 01/01109 EACH OCCURRENCE s2,000.000 X OCCUR ❑CLAIMS MADE AGGREGATE s2,000,000 $ HX DEDUCTIBLERETENTION $O $ A WOR!<JRSCOAU+EsATIONAND WCA020455011 01/01/08 01/01/09 wcsTATU OFR TH- ENIPL DYERS'LIABILITY E.L EACH ACCIDENT $5OO OOO ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? NO EL DISEASE-EA EMPLOYEE $500 000 desaftundar I fAL PROVISIONSMwv E.L.DISEASE-POLICY LIMIT $500000 OTHER i DESCRIPTIQN OF OPERATiOTLS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDS)BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holder Is named additional insured for general liability. E.J.and Marie Jaxtimer are included under the workers compensation policy. Operations performed by the named insured subject to policy cond'Ttions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF.THE ISSUSM INSURER YIe L ENDEAVOR TO MAR in DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLM NAME)TO THE LEFT,BUT FAILURE TO DO 50 SHALL Hyannis,MA 02601 MPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUnIORl�D�NTA C. ACORD 25(2001108)1 of 2 #S50995/M50595 LS1 0 ACORD CORPORATION 1988 &mwwwwea" 0 Board of Building Regula/iois and Standards " One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Reistration•4 • 110609 Type: Private Corporation Expiration: 11/3/2008, Tr# 124739 E J JAXTIMER, BUILDER, NC. ERNEST JAXTIMER 48 ROSARY LN -_----- ------ HYANNIS, .MA 02601 _ Update Address and'return card. Mark reason for change. -; Address ; Renewal Employment Lost Card DPS"CA1 t3 50M•05/08•PC8490 - 10007 977/lfLO7l6!/6CLGUL'O�i.///LROO�CJLUdP lei ; Boa�d of Butlding;Regulations and:.Staridards I :Construction Sup@rvlsor Liceris@ {( ;! f LiF$�115`e� C$ 3251 i 1, ii�x�iratlan 1I1.%2010 Tit 13629 }' ERNE I�ST J JAXTINIER �� 48 ROSARY LANES ,- HYANNIS ,MA 02601 Coinrnissloner oF� Town'of Barnstable Regulatory Services BATWSTABiA ` Thomas F:Geller.,Director nsess. 9�pTEn H►t•�°,��. Building Division .Tom Perry, Building Commissioner. f' 200 Maim Street; Hyannis,MA 02601 ° ffice:. 508-862-4038 Fax: 508-790-6230' Property owner Must Complete and Sign This Section' If Using Builder I, as Owner of the subject pxoperty hereby authorize - J c!Q.1Er ��'1e to act'on i ay-behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signa of Owner . Date Print ame a . Q :FORMS:oWN"ERPERMISSIOII r 5 Town of Barnstable I :VN `Jf BAIT INSTAOLE ,*THE Tp� ti Regulatory Services 2007 JUN 25 AM 11: 30 b� 0� Thomas F.Geiler,Director + BARNSTABLB. + i619. � Building Division 4 aT fp MAC° Tom Perry,Building Commissioner DIVISION 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PERAUT# W ` l FEE: $ SHED REGISTRATION 120 square feet or less Location of shed(address) Village n/i4 i o dre.� 10 QC , _ I u A A n b 1pofT 1 `� )e S S OG/kF h orl 3 Co Pro erty owner's name Telephone number 1 o x la 1-912) CP 63 Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature required) PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. TI3IS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg n al r.�mnni ' S' I oFtNE r Town of Barnstable o� Department of Health,Safety,and Environmental Services * BARN STABLF, r MASS.00- Conservation Division Argo A 200 Main Street,Hyannis MA 02601 Office: 508-862-4093 Robert W.Gatewood FAX: 508-778-2412 Conservation Administrator MINOR ACTIVITY REGISTRATION UU4IV 5 Pvv IV C gs li0C-1 7 3 (0 Pr6perty Owner Telephone number �J y� r-- 9 Mailing address 266 6)3 Project location Map/Parcel# Project description The following minor activities will be reviewed,under Art.27,by Conservation staff instead of the Conservation Commission,as long as they are constructed at least 60' from a wetland resource area or top of a coastal bank. * Pathways 4' in width * Fencing that does not create a barrier to wildlife movement,6"above grade * Conversion of lawns to decks,sheds,or patios that are accessory to single family homes,as long as: -house existed prior to August 7,1996 -alteration within the buffer zone is less then 250 sq. feet. -sedimentation and erosion controls are used during construction * Stonewalls(this does not in lude stonewalls for retaining wall purposes,grading and/or fill) 7 Signatur l5ate Reviewed by Date _GIS Plan Attached(fee charged for plan) Q/WPFiles/Form/MinorAct T'J r .1 �'1 Ez 1..'T� . - , �. - .. :' T4 'C 7 'ap + 5 ,Fl y.. l (' t �zrx� -. Z „t_�i�a - ,-nzo c , 'E C c.c.s:s X t /�. --- t � 1""' ( V . U o�._ ol 0 t; . : t ::.. r - .li f. :I _ - 'l t. ..1 . .. 1. ..t . . .::• - - - . i " � �. �' 3 . .t. - . . ,. ''' t — �/ , : . , f�� /; r � ", .-+'" . I. N �: , I:, , ,,�; i, ;,�,1'! ". - ,- , � , 7�77 1:: , I �I I.,I; �: i i " � � ''. � t-�__ . . i��� ��� - L�� 7 . . _ , r APR-13-2006 14:02 FROM: TO:15027906230 P.1/2 -YJ4/l l/LUDO 1L•lO JUO'+L UL fU:J MI•ILf�1 VhU'1 IWIl I j Ij Towa� of B�, rustabie 3 Regc lator3� Services s Tea as F.Q6T,Oireetor e ° Bu ding iwision Tom Pe , Bladmu . commissioner 200 Main treat. H}"V ;MA 02601 Office: 508-8624038 Fax: 508.790-6230 Property Cr Must Cornpletc and Si n This Section If Using� i� ' . n� odder as Owner of'the subject p:opexi~y �►-� i `-- bemby authorize 40C. r. = � Lt,1/ to Act oa my behalf, in all matters relative to work authorize by thisl€,uildi>3gpexsnit application for: ('dares of joby L ,h lVatutr of Ow = Date i. Ptint Name i' i. i i i APR-13-2006 14:02 FROM; TO:1502790623`0 P.2/2 U4/11/14ut9b 1G:lb 0GG4zvz( 0 IAMCKIUAIN fG141 FH%XL ui I ! Gi I LII American Tent A Table, ed 381 Old Falmouth Road, Jnh 41 P.O. BOX 1348 !' Marstatts All N MA 026 8 800-542-4335 508-120-2 1S FAX 508-420.2705i i I PAX 0 YER SHEET I' TO. Dana.Delorey FAX., 781-749-9167 FROM .Ian syhwsler is RE. Rest Buddies pe It rev if ferne>ata DATE: Aprlt 13,2006 �itd) PAGES: 2 (includ scover COMMENTS: Hi Dance, on I again We acre in the proedw of obtaining the requ&td perndb for the ten&for the ev4ni this ar: Asyov know, ?'Vie Town of Barnstable requires that the owner of the Oroperly'7" 9 Ode Avenue,Hyannis poll sign the attached form The teats will is set up !t Friday,May 190 2006 bgattning at appmrimately.12:00 Noon ani wHf be oak ken,down an Sunday,May 21,2006 at approx0 mvely 12:CIO Noon. C uld you') I ease sign the form aced fax k back to us at your earliest convey kneel Pee ise let know f you have any questions or concern& TVeetnks! � I: i i. ! I ! t ' 1` I 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION k Map Parcel 031 Permit# C2406 01 cl� Health Division Date Issued (O Conservation Division Application Fee ��o Tax Collector Permit Fee TreasurerD1S(O h6t7% Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner I, Address Telephone Permit Request 0 D �s � o� -c 4 a - O -� s - f-\-- D Square feet: 1 st floo : xisting proposed 2nd floor: existing proposed Total new Zoning District .Flood Plain Groundwater Overlay Project Valuation 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: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) r 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# Current Use Proposed Use t BUILDER INFORMATION . Name �'I �G�lYU `d` pr /�Z _ Telephone Number &"�� '�� Address PO License# t7/Lt& h, 4 Home Improvement Contractor# Worker's Compensation#�✓LQC01 �or�-O�� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY r PERMIT NO. DATE ISSUED " MAP/PARCEL NO. i - i . ADDRESS VILLAGE OWNER g DATE OF INSPECTION: FOUNDATION - 1 FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 1 FRUIIJ �1 tfJ�7b J,�.lb h� d�a"?705 FAX .NO. Aug. 05 2005 07:43AM Pi AMERTr4,1 TENT PAGE 02 p i TOwn of Ratable Regulatory Services a F.Ceaw,1hrector SuBding DivW00 Hyanfib,MA 02601 O�iae: 50�-8�i2-�D39 - Fax: 509-790-6230 Property Owner aust Complete and Sign This Seedo n If Using A Builder '-----�—� - ,as Ovuez of the subjectptopety laezcby�ut]_Ctze Fi�f � '�; to art on-nzy..b*lhalf, i an nlarters relative to work Autbmrszed.b}+thaw bualcing pe=it application for (Addles of job) x Owner Date Prim Naz ae jTRANSMISSION VERIFICATION REPORT TIME 04/11/2006 13:05 1 � DATE,TIME 04/11 13:03 FAX NO./NAME 14014614647 DURATION 00:02:01 PAGE(S) 03 RESULT OK MODE STANDARD ECM 6' '` F �S3 y: t `cry- .:,fig �. ay'Q.:h �;r h 71r•.r3aiv'< & - -§ n'f ...___.. .�`a�'z��� �'4,�z". RE C �." f '�' i �zy4�i6.�r=d�3Fa�" vA .. Certif irate of iflame Is REGISTERED ISSUED BY: Date treated or i ��.r� ,� al�ucaTtoN g2,TEC TENTS 8r EVENTS manutacwred k x t CONCERN NO. 490 ALASKA AVENUE My TORRANCE,CA 90M t CAL COMB F419.04 3 f0 32l3-5060 "? This is to certify that the materials described below hereof have been flame retardant treated(or are inher- ently nonflammable} . ^: AMERICAN TENT S'TABLE- - nanREss 381 OLD:FALMOU_T.H.ROAD,_S.T.E 4? t ' crry MARSTONS MILLS STATE' li1A.,.02848 ` Certification is hereby made that. (check "a"or "b") (a) The articles described below this certificate have been treated with a flame retardant chemical approvedx r and registered by the State Fire Marshal and that the applicationof said chemical was done in confor- mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. y r Name of chemical used.................._...._.................Chem.Reg.No....................:... 1 Meathod of application......._......................................................_..._.......................... ��F} �N (b) The articles described below hereof are made from a flame-resistant fabric or material registered and approved be the State Fire Marshal for such use;Fabric has been tested and passes NFPA701-96. �Y - coated Fabric Trade name of flame-resistant fabric or material used.. Reg.No.......................WILfi The Flame Retardant Process Used .......L M ...... Be Removed by Washing (will orwiU not), OAR David Bradley Chuck..Miller....- Presktont .. . � Nre or$A,� 4ca�rfw or P>r od'uy"c.�l'ito.n-^�S'`�}uAy&Yp�Ue.rintengd,ent Tma MEMO mg �x , 1t III"WI NE 1111 �&�d'h". "_'.i �C�ps4a+y�;�ii'.,�?y.$h�r y�a2-. �.e;�i��t ��!�h`t�2p3.�y''%• .s« CUSTOMER1ORDER-NO.- - € 134793 e Rl34713 ITEMS MANUFACTURED, 2- 10 X 10 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA WHITE, 2-10 X 10 STANDARD FRAME CANOPY MIDDLES:-CLASP ULTRA WHITE, 2- 15 X 15 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA WHRE, 3-20 X 20 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA WHITE, 3-20 X 10 STANDARD FRAME CANOPY MIDDLES-CLASP ULTRA WHITE, 2 30 X 30 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA !WHITE, 3-30 X 10 STANDARD FRAME CANOPY MIDDLES-CLASP ULTRA WHITE. l � � I %S r �erfifi t 4- of JUnw 3ANislance c�ta t� REGI'STEPED 'SSUPO BY Date treated or APPI.200N Academv Tent & Canvas manu ac red 9 Q CONCEIRN I . 5035 Gifford Ave. 03108/2000 �grep O Los Angeles, CA 90058 I (323) 277-8388 This is to certify that the materials described below hereof have been flame retardant treated(or are inherently nonflammable). FOR AMERICAN TENT&TABLE ADDRESS 381 OLD FALMOUNTH ROAD CITY MARSTONS MILLS STATE MA 0269 I Certification is hereby made that. (Check"A"'or "b„) El(a) The articles described below this certificate have been treated with a flame-retardant chemical approved and registared by the State Fire Marshal and that the application t f said chemical I I was done in conformance with the laves of the State of California and the Rules and Regula- tions of the State Fire Marshal. - Name of chemical used............................................................. Chem.Reg. No. ........................ Methodof application.............................................. ............ ....................,...._............................ @I I1 X (b) The articles described below hereof are made from a flare®resistant fabric or material regis- tered and approved by the State Fire Marshal for such use;Fabric has been tested and passes lFPA7131-9 . VINYL F19.01 Trade name of flame-resistant fabric or material used ..................................a Reg,No. ............ The Flare Retardant Process Used ... .... t...Be Removed by Wash n (Wi11 or V:{itt rtoi? David Bradley By Tom Shapiro - President � larne of Applicator or Production Superintendent rile THIS FABRIC WAS USED IN THE MANUFACTURING OF THE FOLLOWING. 2EA 30%30 UM 213C TOP ONLY 1 EA 20X30 U/ 1 RC TOP ONLY 3EA 30 10 U//W MID ONLY 3EA 20X10 UM MILD ONLY 2EA 20 20 UiVV 2PC TOR ONLY 4EA 10y10 U/W MID ONLY CONTROL NO. r CUSTOMER ORDER NO. ay �( 39896. CUSTOMER INVOICE NO. YARDS OR QUANTITY COLOR STYLE DATE PROCESSED ** ALL MATERIALS ARE CERTIFIED BY THE CALIFORNIA STATE FIRE' MARSHAL AND MEET THE REQUIERMENTS OF;NFPA 701 AND UL 214*** G%STER +4: rs¢�`R�.,qro RES4�"1`Fr�iA ISSUED BY Date treated or F APPLICA-110IN Academy Tent& Canvas manufactured m 9 2 CONCERN No. Academy Gifford Ave. 05/3112002 Las Angeles,CA 90058 (323) 277-8368 This is to certify that the materials described below hereof have been flame retardant treated(or are Inherently nonflammable). FOR .tlMERICAN TENT&TABLE ADDRESS 381 OLD i~ALM®UTH ROAD CITY MARS TONS DILLS STATE MA 02695 I Certtfrcation is hereby made that:(Check"a"or"b") (a) The articles described below this certificate-have been treated witch a flame-retardani chemical approved and registered by the State Fire Marshal and that the application of said chemical was done In conformance with the laws of the State of California and the Rules and Regula- tions of the State Fire Marshal. Sl Larne of chemical used.........................................................__ Chem.Reg_N€h......................... ! Method of application................._................................................................................................. X(b) The articles described below hereof are made from a flame-resistant fabric or material regis- tered and approved by the State Fire Marshal for such use;Fabric has been tested and passes NFPA701-96. VINYL F 9.(11 Trade name of flame-resistant fabric or material used ................ Reg.l o. The Flame Retardant Pl^QCeSS used ...Wi.l Not...Be Re moved by Washing jwill or will not) David Bradley By Tom Shapiro - President Name of Applicator or Production Superintendent Title t` o THIS FABRIC WAS USED IN THE MANUFACTURING OF THE FOLLOWING 2EA 3OX30 URIV 2PC CANOPY TOp ONLY 3EA 3OX10 WIN MIDDLE CANOPY TOP 2EA 201220 U/W 2PC CANOPY TOP ONLY CONTROL NI _e 3EA 2OX4044M MIDDLE CANOPY TOP ONLY 51988 2EA t 5X16 Ufa€2PC CANOPY TOP ONLY CUSTOMER ORDER NO. _ aGmft 53�Utt�2PC CANOPY TOPS ONLY CUSTOMER INVOICE NO_ �956 YARDS OR QUANTITY COLOR STYLE DATE PROCESSED ALL MATERIALS ARE CERTIFIED BY THE CALIFORNIA STATE FIRE MARSHALL AND MEET THE REQUIREMENTS OF THE NFPA 701 AND 1.11_214:"� 4 N xs r r ( VOLVO BEST BUDDIES CHALLENGE HYANNISPORT WEST BEACH CLUB FINISH AREA BAD WEATHER TENT 1 REFRESHMENTIGIFTT NT BAGGAGE TENT I f A B 2UX2[F TENTS TENTS , w R 'ma m"s lw I I I I � soo'o'sosao�oecoeso'+e'o � t :*eso°Dp°r°oateo°ds:°Ae gA°o-<+•o-°+°0°6 M1✓ + a�] o:x;r...FA >.��M1. a •o.e _x+ �.,s`��). .. «�_''. ���O Oqe°A09 p°egppi 4+0•i°+°e°ede°O� e09eeeeepeeeee•+eLe. .r���.,,•.. .�._..sir ._�,5�',r£ `Sr..%.,'mot ►0A0°OpeAOAA°A+0+0°°OO+PAO°0°O+OeO°O°0A.=�- a e°+L .. i 'e'O�Ob OeOOdelOeAepOPA� i seeaoeeeeeeeoeeeeoe+ �. iseeeeooe0000seemeeo asooeseeeeooeoeeeoso+ oeeeeaoo•.•eoe e9eoo • - °e�AiOtl®"v°p�0 A'So 69e�A�AbOtlA°p 1'O'A°I 06900ee900eAee660a0e , ' eta°i@e°s!s�i�+0m�e°•°o40*+°o°+°d°o@+�+� MASSAGE TENT CHANGING TENTS CHANGING TENTS A B o°000000°.egage+o�oo°O®e°Aae°e°eep°osA� eseoeesppeeeeseeooea i � iAeoe°edoeoe�oo0°eo°o°o°e°o°oeogop+oA°+a 1 t � ao...e.e..eso�...°o i i 1 o eaee�ro'o'ee`o'oc+**+� od 2(1)WTENTS 20XVTENTS eeopsooeeeee+ epaeotl oaeeeeoeseeoesoeoee eoe•eesoeeomeemeosetl ` 00000e�Ao_ee000�!eoee feAis.1�.IPf��9 a�r i�vn•6 •.. O/oeoe em•r:.oe _ --_ _.—_--- 0000000000000000®OOgO00q®OOOtl•000®gOq,/Agf • us�Oe°a+a�an��osee<n°wwsa DUMPSTER PORTABI_E TOILETS RACKS FOR 30 BIKES FINISH LINE F AMBULANCe"00- ' i SERVICE VEHICLES DALE AVE t ANNOUNCER&PHOTO FINISH 85 MILE ROUTE " CROWD CONTROL PANELS NO PARKING ON CAUSEWAY TO SQUAW ISLAN I i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# ' ;'-' 01 8"'R STA,BL.E- Health Division Date Issued Conservation Division ?1=15 APR 29 PM j: 12 Application Fee . Tax Collector Permit Fee ,60 Treasurer _Ui1SiQl Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village T G Address Owner .S�► �a Telephone dPermit Request �� k 4s a ce Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family 0 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 O , Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name T �� Telephone Numbera _ - n" T _6 [ALL ss � � License# � �/ Home Improvement Contractor# Worker's Compensation# i Gx g 6 d� _ ONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ATURE DATE FOR OFFICIAL USE ONLY w i PERMIT NO. F DATE ISSUED MAP/PARCEL NO. ADDRESS - VILLAGE _ OWNER DATE OF INSPECTION: f FOUNDATION FRAME + INSULATION ' y FIREPLACE ELECTRICAL: ROUGH FINAL . PLUMBING: ROUGH FINAL GAS: ROUGH FINAL . } FINAL BUILDING r r �' •'f t DATE CLOSED OUT ASSOCIATION PLAN NO. 04/25/2005 14:33 5084202705 AMERICAN TEN- PAGE 02 Town of Barnstable Regu latory Services Thomas F.Geffer,Director Building D!vWon Toro P'aara-p, -8ni0dhtg ConmAuloner 200 Main Street, H'yanois.,MA 02601 Office: 508-8624038 Fax: 508-790-6.2-30 PrOPerty Owner Must Complete and. Sig This Section If Using A BuiJder as ownex of the aubjeGt pxapertyCW��� �'1`- ' 4creby authoziae jQ11f -� to act on mar behalf, all matters zela&e to wozk authorized by this bi i dmg pemit application for. n (Adc reRs of`jo ,mature of Owuer Date i_'.cint Name The Commonwealth of Adassachusett s _ Department of lnrhrstr•ial Accieleni s Office of Invesligations 600 Washington,S'tr eet Boston Mays. 02111 Workers'Compensation Insurance Affidavit Itc�ntr:� rot afiottSo•' .i l Y r 1i ivf {:F yr! .y> n f t, T F g ♦�y(�{y{ 9yn'iy p(( V 7 Name: Location: City Fkpo / /�' OR ygf/Z�4 phone -701 C. lam a homeowner performing;all work myself. G I am a sole proprietqr and have no one working in ^• ss � L I am an employer providing workers'compensation for my employees working on this job. Company Name:_ AMAFJC l A) f CA9 T 1�9,6�'-4F_ Address:i---h_,_ City: e%A STT A,1� J1IL L �, }YA ez� phone Insurance Co, A:oYF 3 X . policy j,? {►__ Qt� t f /�o j J L R fl. t ;.. "S -lM 7 UT •V {� 3 �.tY�:£, i _ :,E •:•.•. a, .. lr- .ai e.....yr t.- _+.n..e 4 Y....x.a a e..x r.. ...,(+t t.t �t ,..t-..:, .....a:.1,ems. >,..rru - I am a l0,sole proprietor D general contractor rJ homeowner and have hired the contractors listed below who have the following workers' compensation.policies: Company Narne: Address: City: phone Insurance Co. policy ai i i --f! ..5 .•4 t ,3f..,.::.Ci ., J.,i., z.:,.?:... ,...::.'...P 1r{. .ll. .4s.! ) c, Company Flame: Address: City: phone Insurance Co. pal icy# Failure to secure coverage as required tinder Section 25A ofMGL 152 can lead to the imposition of criminal penalties of a fine up to$1 500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK.ORDER and a fine of$100.00 per day against me. I understand that a copy of this statement maybe forwarded to the Office of Investigations of the DiA for coverage verification. I rto hereAr certify under the pains a►rd penalties of perjury that the information provided above is true and correct. Signature Date Print nam 7 0 - ,L J Phone old 0 Offidal use only: Do not write in this area. To be completed by city or town official. City Or Town---- Permit License It C check,if immediate response is required Contact Person t?ept. Phone Client#: 18103 2AMERIGANTE ACORUM CERTIFICATE OF LIABILITY INSURANCE _F /Y DATE(MM/DDYYY) 04/26/05 PRODUCER } THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling 8r O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 West Main St. PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Associated Employers Insurance Compa American Tent and Table, Inc. INSURER B: P.O.Box 1348 INSURER C: Marstons Mills,MA 02648 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM DD/YY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RPREMISES 1E.ENTED eel $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ _• GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- El LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO _ (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ sJ SCHEDULED AUTOS (Per person); - r HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY .. EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ TWCYA WORKERS COMPENSATION AND WCC5004440012005 04/23/05 04/23/06 �(„ OR STATUS OTH- 1 -- LIMITS I I ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $100,000, ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1 OO,000' w If yes,describe under r a • - SPECIAL PROVISIONS below E.L"DISEASE'=POLICY LIMIT $500,000 OTHER r r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Best Buddies/West Beach Club 2 20'X20'tents;2 20'X40'tents 5/20/05 Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable-Bldg.Dept. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1Q_ DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL I Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 'Of'2 #38000_ _. . .._ LS1__ ,,, _ O ACORD CORPORATION 1988 api Cledffitw of G%STER REGISTERED ISSUED BY Date feasted or y APPUCATIO! Academy Tent & Canvas manufactured CONCERN No. 06/22/2001 5035 Gifford Ave. F419.01 Los Angeles,CA 90058 (323) 277-8368 This is to certify that the materials described below hereof have been flame retardant treated(or are inherently nonflammable). FOR AMERICAN TENT&TABLE ADDRESS 381 OLD FALMOUTH RD#41 CITY pMAR¢S�T0g1�1igSpsMIL/LS[yb made Q ¢ STgATE MA 02648 ha (a) The articles described below this certificate have been treated with a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done In conformance with the lags of the State of California and the Rules and Regula- tions of the State Fire Marshal. Name of chemical used.................................... . ..................... Chem.Reg.No......................... Methodof application......................................... . ............................... ........................ ... . . .. (b) The articles described below hereof are lade from a flame-resistant fabric or material regis- tered and approved by the State Fire Marshal for such use;Fabric has been tested and passes NFPA701-96. VINYL 419.01 Trade name of flame-resistant fabric or material used ................................... Reg.No............. The Flame Retardant Process Used .. Vir'ill.Noto...Be Removed by Washing (will or will not) David Bradley By Tory Shapiro- President Name of Applicator or Production superintendent Title t THIS FABRIC WAS USED IN THE MANUFACTURING OF THE FOLLOWING: 21EA 10X10 2PC X211 WHITE CANOPY TOP 3EA 20X10 MID X211 WHITE CANOPY TOP CONTJQ 213C X211 WHITE CANOPY TOP _.._X2R WHITE CANOPY TOP 46455 4EA 30X10 MID XZR WHITE CANt2PY TOP CUSTOMER ORDER NO. IEA,tOXS MID X2R WHITE CANOPY TOP CUSTOMER INVOICE NO. 45822 1EA 8X5 2PC GABLR MARQUEE WHITE TOP X2R WHITE CANOPY TOP YARDS OR QUANTITY COLOR STYLE DATE PROCESSED ALL MATERIALS ARE CERTIFIED BY THE CALIFORNIA STATE FIRE MARSIHALL AND MEET THE REQUIREMENTS OF THE NFPA 701 AND UL214 1,j3 C a - � � b.' Certift f r ' REWSTErtED ISSUED BY- Date treated or VA o* o APPUCATION AZTEC TENTS 8e EVENTS manufactured ^� �t CONCERN NO. tU 490 ALASKA AVENUE TQRRANCE,CA 90503 ( t 3 a ' CAL COA�B F-�19.04 ( )328-5060 f 0 This is to certify that the materials described below hereof have been flame retardant treated{or areinher- ently nonflammable} FOR AMERICAAC TENT&`TABLE _..__._..--ADDREss 381 OLD:FALM0UT.H.ROAD,.._STE 41 1 gg'g Crnr Af1ARSTONS MILLS sraTE MA •02948 x Certification is hereby made that: (check "a"or "b") (a) The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the State Fire Marshal and that the applicationof said chemical was done in confor- mance 4s with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. � r .. »...» . ». Name of chemical used .......�. ._.._........ ....Chem.Reg.No..» .»..».......... IMeathod of application.».».»..........................._.»........................»............................ �;v J (b) The articles described below hereof are made from a flame-resistant fabric or material registered and ', 4- * approved be the State Fire Marshal for such use;Fabric has been tested and passes NFPA701-96. Trade name of flame-resistant fabric or material used..CoaradFabric Reg.No. ..........._....... Q� % 1 The Flame Retardant Process Used .WI�:L NOT__ Be Removed by Washing " � v4 e (wiH or vAH nai){ i David Bradley Chuck Miller.-_P.resident u=�f Name of ApPEcalor or Production SupOnlendent Tine �€ � _ 3 � r Mr i yam'# DNS � '?� gti�� lvNz� c_m:, .d•%£�' ``� ,:*� :�s� .� .,:'�,•�a :�� �� °av S h �� t;s- �vstk ,�_.:gam.._ � e., I �.>��� �.. ��`t�M. t, .•.�-_ �.`�. CUSTOMER_ORDER-NO.- -.0934793 v R134713 ITEMS MANUFACTURED; 2-10 X 10 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA WHITE, 2-10 X 10 STANDARD FRAME CANOPY MIDDLES:-CLASP ULTRA WHITE, 2- 15 X 15 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA WHITE, 3-20 X 20 STANDARD FRAME CANOPY 2 PC. TOP ENDS-CLASP ULTRA WHITE, 3-20 X 10 STANDARD FRAME CANOPY MIDDLES-CLASP ULTRA WHITE, 2-30 X 30 STANDARD FRAME CANOPY 2 PC. TOP ENDS CLASP ULTRA WHITE, 3-30 X,10 STANDARD FRAME CANOPY MIDDLES-CLASP ULTRA WHITE. t WHITNEY P: WRIGHT 'CARPENTER 256 OCEAN AVE. HYANNIS,MA 02601 771-4912 Assessor's map and. lot number ...... ....................................`.. . , �► cow�E�:��1 -7 ®12 �h n C SYSTEM MUST of THE TO�,� Sewage Permit number R.. � 6m 1®J` 1 � 1C2tly IINELED 'NCOMP -'........................... ...... ..# (.� WITH TITLE 5 = 9T11DLE, • House number .................[........�ALL.......M.........:::....., AL COD °` � ENVIRONMENT Opp�63 9•a�00 A P P R O V E QW REGULATION MAy B ns ble Conservation s N. ®F B A R N S�A W L TO APPROVAL OF SUBJECT TION 1 ! �� ► BARNSTAB LE CONSERVATION i ned z Date COMMISSION g ILDIHG INSPECTOR APPLICATIy ON FFOOR=,PERMIT TO ....:...�C..�C��jp�%............................�............................................................ TYPEOF CONSTRUCTION ......... ........ ..................................... .... ................................ ,�. .........7 .36..... ...............19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby+applies for apermit according to the` ollowing inform i n: Location ....... �l.C�.M�?Y. .......96T, .�.:...........l.kl�1 �...............[........ ..................................... ProposedUse ......4:.1 P1.�F,.............:L o &:T.................................................................................................................. f .............................Fire District ..... `lt��� Zoning District ...... .1..t.. ...�:�: .................... n y..�...................... Name of Owner .....IrTYI ......:�U�i ...L .. 5�lddress ...... t`u: ......':!UFir........viC1N ... n Name of Builder .. .+�F �✓ .... ......�.M�rl.1..... ddress .......2a.......o(IF;A0.....(W L.....1 i-YAM!C•J. Ws$ Name of Architect ..ALaf-A-A....(-:- N.........................Address .....1'.D.......3.01.......J r�..`404x ►i..�.....1�:�5� Number of Rooms ........!. .................................................Foundation ....(�i.�( Glr�I.��..... f...t..1.L5....................... Exterior ......C- ..................Roofing , Floors ........0...........................................................................Interior ........ ............................................................. Heating ..........��` .:r............................................................Plumbing ............. �.. ��gg �' Fireplace ...8".� �i...............................................................Approximate. Cost ......�. (. 0....60.. . �J . ............. v , Definitive Plan;Approved by Planning Board ________________________________19________. Area f....................................... Diagram of Lot and Building with Dimensions Fee :Iprp . ... SUBJECT TO APPROVAL OF BOARD OF HEALTH I OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Tow n rding the above construction. c Name ..... �. ............................................ Construction uperviso s License ��'` 0....cl�. . HYANNIS PORT CIVIC ASSOCIATION I No ...30.?9 7. Perm for REMODEL CLUB a ............................... West -Bea 3. h. C ub .. .... ...... . ............................. Location .......9. ae A 7enue HSat nis ort _ -Y........Qniis.... .ort Civic Ass �: y' Owner .. Hy�...a.�. ..... o ,iation Type of Construction .........$......Frame c:t w ................. �.. ........,ei. .... ............................... 1 y Plot ............:".............. Lot ............:....... r-. Pefmit_Granted December 1`7, -- 86 Da4'of inspection ............ ..19 4-- bate,Completed r- 15; l - J �" t r Na F _5 r > � f '• 1 y Assessor's map,and lot number ....... .................................. . ' � Gor^w.Ca-i��5 �°-�- THE S � Sewage Permit number �F... ....... . 6......1.0. .7....~... '[�ti� 1 � ►�, d`�Q ♦� { 33A"STLDLE, Z i t ? R 4'' ......1 (?4- �.i 9 rnea House number ..................�........:... .................. 4 00,o�s63q. 9 q 'Fp MFY a. TOWN OF"BARNSTABL.E �E BUILDING INSPECTOR . "" APPLICATION FOR PERMIT TO ....... � ft){)U Gi 4 t`. ......... . . ............t.............. . % t -�„ L�.9� t k Y - TYPE OF CONSTRUCTION .........1 ....... �....... ..........................! .. �... '................ ........ 6WW6..................19........ TO THE INSPECTOR OF BUILDINGS: - ?f r The undersigned hereby applies'for •a permit according to the following information: Location ..... /�i ` ....... `ir!,t.........r7 .:.........`; (... . :.f_�y .................................. 1 Proposed Use 4. M"tL�I� !- ......... n. .:. ..... : ...... . . ..- ........ ......................................... Ci rj Zoning Di.str ct" ; ' 't........................... ..............4 Fire District, 4 \�ANKS......................... Name of Owner #'Name of Builder .. :. f ,��"/.... ......U ,i(:I r .. Address ...... (^....... C 1l� .... .....:._ .. ...E_'1 Name of.Architect ...........".............1. . ...................Address ..... ......... ...t..., y........ ........, .... �. 1' Number of Rooms .......................Foundation .. Of)� ( f{t�-�'.:. .f'� ZT �.......... ....... Exterior .:. � `.�I^?. ..�:...r..f.P! .. !............Roofing n....l ........................................................... Floors :..................!.:......`. Interior .................................................................................. ........ .................................. Heating ! E= .............Plumbing `ems' - Fireplace d.7 t)J ...��.1�1(.......................�........................................Approximate Cost ......�. .... ........................................................ U - - IL Definitive Plan Approved by Planning Board __________________________ 19 - r�}C1'� �A`rea `.... `.............. b _ Diagram of Lot and Building with Dimensions Fee ................................ '+ SUBJECT TO.APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGSr ;f'� I hereby agree to conform to all the Rules and Regulations of the Town of (Yrnstdble,-regarding the above construction. t l f Name ... ! ........... Y Y Ot ?. Construction up License .... .. ......, f. HYAiNIS PORT CIVIC ASSOCIATION A=286-031 No ..3.0.2..9.7.. permit for ........TZ.P-MQde-1...C.1-U b West c Beah .......................... Location .9...Da..............le Av .. .. .. QXIUe............................. HyannispQ .................. ............. . r.t.................................. Owner .......HYaMX!i.s...P.Qr.t...Clvic...As-sociation Frame Type of Construction .......................................... ............................................................................... Plot ............................ Lot ................................ December 17, 86 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ......................................19 414 b b,,,,45, b-A f/;14�s r , TOWN OF BARNSTABLE BUILDING PERMIT APPLIC.ATION Map Parcel EEO- INSTALL Permit# ���7 Health Division -�5'• ���� j IPAtssued Conservation Division Fee �1�0 Tax Collector Z Treasurer ���t.iLYt-��� 41t6J & • . • Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address U 4 LC hN F: `, u-E Village Hyannis Pott) Owner W E! YbE&CW n,l_rt,6 Address tbA-i t~ hvO , 4YAN N,tS -PoCT- Telephone Permit Request Roof Work — Replace roof shingles CED iQ S Square feet: 1st floor:existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 516 0 0 ' Zoning District- Rf- I 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: ❑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 s ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name E _.1 -.T ax t i m e r., R Li 1der., T n c Telephone Number 7 7P-4c)11 Address 48 Rosary Lane , Hyannis License# 00.3251 .Home Improvement Contractor# 110609 Worker's Compensation# WC97695028 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Macomberls Dum ster SIGNATURE DATE _ Y1,25,616 FOR OFFICIAL-USE ONLY PERMIT NO. -, DATE ISSUED J 4 MAP/PARCEL NO. _ ADDRESS' A .VILUAGE f V OWNER DATE OF INSPECTION: t Y FOUNDATIONS FRAME INSULATION FIREPLACE y ELECTRICAL: ROUGH y FINAL ! _ PLUMBING: ROUGH. FINAL GAS: ROUGH FINAL, FINAL BUILDING -- DATE CLOSED OUT ` p ASSOCIATION PLAN NO. 4 t The Commonwealth of Massachusetts ' Department of Industrial Accidents Office ofifnrestigations -_ � 600 Washington Street v` Boston,Mass. 02111 ; Workers' Com ensation Insurance Affidavit name: E. J. Jaxtimer, Builder, Inc. location: 48 Rosary Lane city Hyannis MA 02601 phone# (508)778-4911 ❑ I am a homeowner performing all work myself. ❑ I am a sole ro rietor and have no one workin in any ca acity ❑x I am an employer providing workers' compensation for my employees working on this job. company name: E J- Jaxtimer, Builder ,' Tnc ` address:. 4$ >Rosa'i^y Lane city Hyannis MA _02601 :.phone#. ( cif1R)77R_aAl insurance co. Eastern Casualty, olrcv# /%/ ❑ I,am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: ' como any fin ine: address: cityX phone#..< insurance:co. olrcv# cc omaanv name: address: city- phone#44 ......... .:.... .:...:..: insurance co.:. olicv# Fafiure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may b or warded to the Office of Investigations of the DIA for coverage verification I do hereby certify r he pains and penalties of perjury that the information provided above is true and correct . Signaturet:r. Date _ Print name J. Jaxt imer Phone# -(508)778-4911 h official use only do not write in this area to be completed by city or town official city or town: permit/license ft ❑Building Department []Licensing Board ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised 9/95 P)A) , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ZFZ7 Parcel d Permit# � J Health Division Oq Date Issued Conservation Division Fee Tax Collector Treasurer D III Planning Dept. AppmW of fart only, No f0d s %-"atoorkA Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address wa-4 1pe,4 c�_ Ave, Village ka Owner ` Address Telephone Permit Request 2--`" 2,6 Lt u �/►cw� ��, �" ZO -° � t �s r-o r Dig Square feet: 1st floor: existing . proposed 2nd floor: existing proposed Total new Valuation 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: ❑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# Current Use Proposed Use ® 1 �- BUILDER INFORMATION Name Akt eo'a, T&f �- l6 C. Telephone Number Address 3 v i (714 R4V dV+L fu License# Home Improvement Contractor# "I��z y f r ► 0 7 Worker's Compensation# iv e-c- Sze 0 ` q q o e) X)o�f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE d y FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED ` x MAP/PARCEL NO. _ ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME r INSULATION FIREPLACE - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH . 0 FINAL +G& GAS: ROUGH FINAL 4 FINAL BUILDING 1.Y DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office 911,11VO fNSHMs 600 Washington Street t Boston,Mass. 02111 '3 Workers' Compensation Insurance Affidavit law name: location: city hone# ❑ I am a homeowner performing all work myself. ❑ I am a sole rietor and have no one worlds in ca achy MO, e to ravidin workers' compensation for my employees working on this job. Lb�I/am mp 3'�P ::: .......::::: ...:::::.::.:::::.......::.::::::. ' :. ::...............:.::..::::: ::::.:.......:.::.:::::.::::..........::::::::.:::.:.......... .................... suns �.,, �'F ' .. Q COmA any n A .... .. ..:.'::':::4::':. ;.;.. . q ::.:::::.:.:..... iiY�:ivii '::.:: .....ii:� `:fii?iii:':i'�::.+:;:��. ''..":::• i'::xx ;:i::i :::;isi::::i':::ii:<::i:::::�'`:;:i::: �.:'''..... .::i ntldress� Ic ......... .... #::::::>:::'.:.. :;�'''< ,<.:_;;:.;;:.:: ....... .; < Xx ME ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have workers' compensation polices.- the following w mP...................P .....::.<.....: :::.::::.::::::::.;:.;:.;:::. :::::::.:::::::::::::::.::.::.::..... ::.;:.:;;.>:::.:::::::::::.:::::: .::::::.:::::............:.::.: com an. name: ?< '�3$3'' >..... ` 2±<[ `' ?<< r ' %-�;';;<;s'r ;'2< ............ : ;:;:: : ;:;;<:<a::::;::`;;2i:::::;: ::;::;;:::ti 22 :? ;:;;;::::::;;',:::;:;:;:?::;:::;:::::..;:.:. ste YS :............. ...... ........:................ ..........:: Itit ndinran ....... :adtliess� X. ONE= x. ..............;:.;.. `H on TIgII181tCC CO.<;' �ll More to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,50 M and/or one years,imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certf under the p d penalties of perjury that the information provided above is true and correct i Signature Date $ D Print name !�� Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office OHealth Department contact person: phone#; ❑Other. (mined 9ro5 Prep R Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. , . 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 prese�ed to the contracting authority. t ,� Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and names address and hone numbers along with a certificate of insurance as all affidavits may be lying company P DPP Ymg mP Y 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 Department of Industrial Accidents. Should you have any questions regarding the"law"or if you r not the ep . being requested, _ . oh lease call the 'on are required to obtain a workers compensatt policy,p 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 permi0icense number which will be used as a reference number. The affidavits may be retumed io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Oiflce of leves"98dons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 flAY-7-2004 12:23 FROM:MULLEN & FITZMRURICE 1-781-749-9167 TO:15084202705 P.1/1 bb�aa/zaa4 Y;L:14 5YJi94LVJGtf�� FuYiticl4wV IC1Vt , .,..� vs. Town of Barnstable Regulatory Services was Thomas F.Gen",Dteeam Building DivWon Tom Pem, Dig Cammh aneir 200 Main gtrCC4 Ryan"MA MWI office: $084624038 Fax. 508-790-6230 Property der Must Complete and Sign This Section If Using A Builder as Owner of the subject property b., by authorize t. c. to act on z 1�eb its all mamas relative to work anthozzrd by this bailding psmit appliemtiear for (Address .of Job) signatm of der bate A r ' Pit Nme r �j cetlffi isunm G�sre�� REGISTERED ISSUED BY Date treated or � APPLICATION manufactured * * � Academy Tent & Canvas CONCERN No. 5035 Gifford Ave. 03/08/2000 1'F ETAF% -419.01 Los Angeles, CA 90058 (323) 277-8368 This is to certify that the materials described below hereof have been flame retardant treated(or are Inherently nonflammable). FOR AMERICAN TENT&TABLE ADDRESS 381 OLD KALMOUNTH ROAD CITY MARSTONS MILLS STATE MA 02695 Certification is hereby made that: (Check"a"or"b') _ (a) The articles described below this certificate have been treated with a flame-retardant chemical❑ approved and registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regula- tions of the State Fire Marshal. Name of chemical used............................................................. Chem.Reg.No......................... - Methodof application..................................................................................................................... X(b) The articles described below hereof are made from a flame-resistant fabric or material regis- tered and approved by the State Fire Marshal for such use; Fabric has been tested and passes N FPA701-96. VINYL F-419.01 Trade name of flame-resistant fabric or material used ................................... Reg.No. ............ The Flame Retardant Process Used ..w[[.Not...Be Removed by Washing (will or will not) i David Bradley By Tom Shapiro - President Name of Applicator or Production Superintendent Title THIS FABRIC WAS USED IN THE MANUFACTURING OF THE FOLLOWING. 2EA 30X30 U/W 2PC TOP ONLY 1 EA 20X30 U/W 1 PC TOP ONLY 3EA 30X10 U//W MID ONLY 4EA 20X10 U/W MID ONLY 42EA 20X20 U/W 2PC TOP ONLY 4EA 10X10 U/W MID ONLY CONTROL NO. CUSTOMER ORDER NO. 40389 39896 CUSTOMER INVOICE NO. YARDS OR QUANTITY COLOR STYLE DATE PROCESSED "**ALL MATERIALS ARE CERTIFIED BY THE CALIFORNIA STATE FIRE MARSHAL AND MEET THE REQUIERMENTS OF;NFPA 701 AND UL 214***, client#: 16103 AC®RD-� CERTIFICATE OF LIABILITY INSURANCE 05105104DIYYYY) PRODUCER , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION l Dowling 8.O' Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency, Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 222 West Main St. PO Box 1990 Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC 0 INSURED INSURER A: Associated Employers Insurance Compa American Tent and Table, Inc. INsuRERB: I P.O. Box 1348 INSURER C:- Marstons Mills, MA 02648 INSURER D: i INSURER E' COVERAGES THETHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING A14Y 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 T C ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLI EFFECTIVE P LICY XPI TI k LIMITS LT R NSR TYPE OF INSURANCE POLICY NUMBER AT MI NY DATE(MMIDOMNY1 GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE n OCCUR MEd EXP(Any one person) $ PERSONAL d ADV INJURY $ GENERAL AGGREGATE $ GEN•L AGGREGATE LIMIT APPLIES PER:I PRODUCTS-COMP/OP AGG $ POLICY E C LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO _ ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) F_ NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) PEXCESSJUMBRELLA AGE LIABILITY I AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ LIABILITY EACH OCCURRENCE $ OCCUR SJ CLAIMS MADE I AGGREGATE $ $ $ DEDUCTIBLE - RETENTION $ WC STATU- qTH- A WORKERS COMPENSATION AND WCiC5004440012004 04/23/04• y 04/23/05 X EMPLOYERS'LIABILITY I E.L.EACH ACCIDENT $100 000 ANY PROP RI ETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE•EA EMPLOYEE $100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ID_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(1001/08) 1 of 2 iS34226 MA & ACORD CORPORATION 1981