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HomeMy WebLinkAbout0047 DOLPHIN LANE qo SeA- t)eAPNIAl C i i i i i' Assessor's map an d lot number .. .............. .... T E Sdwage Permit—number ........ ............................................... t 33ARNSTLBLE, House number .......................... ................ ............................. 90 NAB& 1639- N % TOWN OF BARNSTABLE , BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...... ......... .................................................................. TYPE OF CONSTRUCTION- ...... ........... ........................................................... ............Jqp..........S.......19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to, the following information: Location /�z/)....2,�*.e........... ....../A.................................................................................... ProposedUse .......len,1.4............................................................................................ . ..... . ................ 0;e;',*.�/ ........................Fire District Zoning District ......./e A&....... ......... .....z!.7 .........Address .......5.17.... -13 Name of Owner .....7,4Z.. . ....................... a.................. Name of Builder ......(.v ell ..........................Address ....... /!6....... � zq Name of Architect ... ............................Address ...... g..... Numberof Rooms ...... ........................................................Foundation .....%.54? IlUe.............................................. Exterior ............................................................... ....................Roofing .......... ........ Floors ......... 00em�w .zl�ev .............Interior .................................................................................... Heating ....... ..........................:................................Plumbing ..................1901,72.................................................. Fireplace .........xpewe...........................................................Approximate Cost ....�'Iedl 4 .......................... .................. Definitive Plan Approved by Planning Board --------------------------------19---------- Area ..... ................. Diagram of Lot and Building with Dimensions Fee ........161.�11........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....AW....../....... ................. Construction Supervisor's License 4?Y-22.............. CLARK, DR. KENNETH 28382 Build Cazabo No T...:............ Permit for .................................... Single Family Dwelling. ............................................................................... 47 DOlphin Lane Location ...................... .......................................... . .................... Dr. Kenneth Clarri Owner ................. Type of Construction ...............Frame.............. ............ ................... ..........................7................................ Plot ............................ Lot ........................;......... s. Permit Granted ...... .......19 85 Date of Inspection ..... ...............................19 Date C6mpleted ...........7.............. .19 0 01 Assessor's ma and lot number p a.. .. ......... ....... THE T� Sewage Permit number ...................... .......: d� o� l Z MA"STLELE, i House number ....... ........................ .......... .......... 9w rba 3 9- �0 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....11;1.T.I1f.IC" .........C. ,7al..46................... 4 1 , TYPE OF CONSTRUCTION .... �O........... ........................................................... :........ ,.,J.P .........�, TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies. for a permit aaccccordingfto the following information: VLocatio ! //.li/?:... � !.l� �!� /1/!.`...... . .......:..................... ProposedUse .......Aall,-4.............................................................. ..................:....:.:. /.............. . Zoning District ...... ,?.......:.. ......................:...........:....:..Fire District .... ... . . .....:..,�1 2 lr—k,..:..�........ _ r. Name of Owner ..... /. {...... 1 ...........: .......,. .........Address ... j� ' Name of Builder ..-1! 1 ...../ '...........................Address �� �'.:..17.. ..... fr�l..T � 11/ / lfName of Architect zmvy../../.1-1./.✓ .'...........................Address , �1..'..f �f�.f✓ f..1...f�`.. lNumber of Rooms ,( ...... .........................................................Foundation .....,S,�i1G�r'..:!�! �"............................................... Exterior ......................................................:............. Roofing Floors .rG1�y�'..�Tl�/ � .�X. .Interior,�............ ........ Heating ....... .._...................................... hh ........................................ Fireplace ........AM ............................................................Approximate Cost ....llwe:4V.......................................:::....... Definitive Plan Approved by Planning Board __________________________19________. Area .....A ..'f'................... Diagram of Lot and Building with Dimensions , g g Fee :.... . ................. i -. y SUBJECT TO APPROVAL OF BOARD OF HEALTH F ----- N OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. A Name . ...... ............... Construction Supervisor's License7K . ................. CLADK, D&. K8N0EI8 A~268-176 . ( 28382 Boiu No� ----- Permit for --.—ld---Cao---6o....... __.S le .Fami ..DweIlio8_______. ^ �7 iu Location — ......Lane _.����� —___-------- ' Centerville - ----'----------------'----- | ' ' Owner Dr; Kenneth Clark --- -.----_----------_—. ' - Type of Construction on -------------- --------------------------. .. ' . Plot --------- Lot ................................ _ . - ' ' Permit G,onx*6 —..�n ��5°--.}P 85 ` , , Dote of Inspection .......................... --]V _ Date Completed ................................. --]9 . ' \ , ~ ' - . ` ~ ~ _ ' ^ ~ . � ~ ' ' , | � � T Town of Barnstable *PQ, #4(DExpires 6 monthf from issue date Regulatory Services Fee -� � SARNSTABLE, * . 1639. MAC• Richard V.Scali,Director Ajfp MP't a - - u-i. in.gT_i--i n Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY C7 I "1 Not valid without Red X-Press lmprint Map/parcel Number (/Co� Property Address 7 00 / Residential Value of Work$ /Minimum fee of$35.00 for work under$6000.00 Owner's Name&Addressi/��f Contractor's Name Ael r aN-f7 //V Telephone Number W 7Z4 1 Home Improvement Contractor License#(if applicable) Email: ooed) yl/ k 00 Construction Supervisor's License#(if applicable) �99 Ito D<orkman's Compensation Insurance _ Check one: ®PRESS 1 ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insuraanc'e L Insurance Company Nameb Workman's Comp. Policy# TOWN OF BARNSTABLE Copy of Insurance Compliance Certificate must accompany each permit. Permit RequesV check box) - //,, e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �jVAY `� . ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 c9X of the Home Improvement Contractors License&Construction Supervisors License is red. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 o Ctarr inanrc &of-Massachmseffs D'eparftnent of huLustr id Accidents - _ Brrstaq,,MA ll? I _� - - WtVTfV.l`titX.S�ga�511�71� - Workers' CompensatiaxtInsuran.ce Affidavit:Builders/Contra:ctorslElertriciansMumbers Ap-H.cant Infczgznafion Please 1"riaf Legibly IName / l012. Address:— Gifyl tatJZip: _ Phone 77 A71.'ra an eurployer7 Check fhe appropriate bim: T of o-ect :r C 4_ 1 am s.e om al contractor and I e 1 t - 1_ a eu�ployer witlt_� ❑ 6_ ❑het oonsfns oa ej�loye:es(full andtospat#time3* have hi.--edthe sub•contr& fors. 2_❑ I run a sole proprietor or partner- listed on the allied sheet 7- ❑Remodeling T`hene sub-contractors have s as d have,no employees and have workers' c ' S_ ElDemolitioa working for me.in any ci emploS, Y � ��_ 4_ ❑Building addition Fo:workers' corop_in�e cep-msurauoa 5_❑ 1�ie are a coTorationandd its 10_.❑Electrical regains or additions 3.❑ � I offices hmoa exercised their I am a hnm�svn�s doing all tivorls_ I1_.❑Plumbing repairs or additions. right of e\�'* Lion per MGM �orig rr€-ysel£ [No worb�rs'comp-- 12_. f . at,cttrxnrerexinired- 1 c- 152,§1(4� and weffzve,no . employ-e':�S_[NCY wmim& 1-3-0 other comp_insurance required.j -Any spptixmt fnxt chords box r1 IImst slso fill oat the section i3_Iow ch�a fneir,work��comV enszlioa policy iufurm t Homecwa�s a�submit ihis s,s�dsvif i &c�v WeY ara=g:n'n a a-d thm hire outride caufracmrs umsi snbmit a ne—w;E.�'YvA mar do mx:h- ascmrs test check this bar matt sttEidLd au sd3itionsI seeet shacrmg the nme of the sad omit- s xnA state xhef�ec nEXLut thas-e Md6es hxm r�mInyecs_ Ifte snb-coai�ctucs lyre eurplay�s,[h�snsi pxu-ide t<�-tvo€k�s'comp_polio numhez �€otn an sutpL`ay.�r that i�prasddirrg strorkars'catt�arts�.lion aztrrtrancs}`ar rtty etrr�Iny��s. �elvtF is tftz paUc}attdlob azt� ir��atmafia:rr< �� ` /Q � •- . , Ins nanca Goaipatr 1`£ame._' 6 ���Z��L Policy 4,or S 1f ins Ile n Expiration Date: µ Job Sitesddt�: it�,�st��erzip: Attactx a copy of the-imrkers'compensation policy dedarstion page(showing the police nn ber. anal expiration.date). Failure to secare caverage as requiredunder Sectioa 25 k of_MGL c 152 can lead to the imposition ofcr mival penalties of a fine up to$1_500.00 and/or oue-gearimpnwnm mI,as well as civil penalties in the fora of a STOP WORK ORDER and a fine ofup.to$250.00 a.clay against the violator_ Be advised that a copy of this statement may be fGnvnded t a tree Office of Imrestigatioas of tlie DIA for incttrsrnce,coverage veriEcation- 1 da here4,certify t.. tkepruns dpanaL'tors ofl�JLJY 6atthe it€i{�rxtution prm2dRd abr3ue is fro$dnd correct Simatozre: Date: d' _ Phone 11: ©j cjaL use a2Jy. Dv trot writs in this area,to ba completed by caty at town oficraL City-or Town: Pm-raitffAcease# ISS. g-Authority(drde one): 1.Beard of$exIt'h 2.Budd Deparbcaet &'CityffOwn Clerk 4_Electrical Inspector S.Plumbing Inspector 6.Other Contact Peron. Phone#: 6 i \r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute, an ernployee is defined as"__.every person in the service of another under any contract of hire, express or implied, oral or written_" A a employer is defined as"an individual partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.' MGL chapter 152, §25C(6)also sta±ts that"every state or Iocal licensma agency shall withhold-lie issuance or renewal of a license or permit to operate a business or to eonsiz-r!ct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions snail enter into any contract for the pesio_rmance of public work until acceptable evidence of compliance with the ir_sura.nce requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation a_rzidavit completely,by chec:&c,the boxes that apply to your situation and,i.f necessary,supply sub-contractors)namt(s), address(es)and phone n2,m,be,:(s)along with their Ger l"Ecaic-(s) Of insurance. Limited Liability Companies(LLC) or Limited Liability Pau;nersbips(LLP)vddano tuaployees other ham the members or partners,are not regojred to carry workers' compensation M.Sli ante_ if an LLC or LLP does have employees, a policy is required_ fie advised that his affidavit may be�tbz iited to the Depa--uuent of indu_sirial Accidents for confirmation ofLsu-rce coverage, Also be sure to sign and date the affid2vit '11ie affidavit sbouid be returned to the city or town that the application for the permit or license is being requested, not the Departnent of Industrial Accidents. Should you have any questions regarding the IEw-or if you are required to obtai a workers' compensation policy,please call=1 Department at he number listtd below. Self-insured companies should enter heir self-inCllranCe license number one appropriate line, City or Town Officials Please be sure that the affidavit is rsmplete and printed legibly. The Depar:mient has provided a space at the bottom of the affidavit for you to ED out. ,he event the Office of Investigations has to contact you regal- ing the applicant Please be sure to fill in the permit/' tense number which will be used as a reference number. In a.ddi ticn,an applcaut that must submit multiple permitllicense applications in any given year,need only submit one al5Fdavit mdicaang current policy information (ifnecessoly) and under"lob Site Address" he applicant should v rita"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by he city or town may be provided to he applicant as proof that a valid afrda-�rit is on file for future permits or 1)censes- A new affidavit ra ust be/idled out each. year_Where a home owner or citizen is obtaining a license or permit not related to any business or commercial vcature (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this aifidaNdt_ The Office of Investigations would lice 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'saddress,telephone and tax number: Commnnwn-an of Mass achusi�lts Department of Industrial Acc%d,,nts - Q-�fzGe�z�Lzve�fi�Ezan� 640 Wa shDgtan St=t Ttl, 6I 7 727-49-QO ext 406 or I-R 1?%-LkSSAFE Fax is 617-727-T.c 91 Revised 4-24-07 w.mass.gnvz 1 h a DATE(MM ^- �o CERTIFICATE OF LIABILITY INSURANCE /DO/YYYY) (MM2014 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 01005-004 - - NAME CT - HUB International New England aC.NIJo:Ext: (800)564-2444 a,No.: 125 Route 6A ADDRESS: paul.sugrue@hubintemational.com . Sandwich,MA 02563 INSURER(Sl AFFORDING COVERAGE A C# INSURER • A.I.M-Mutual Insurance Company 26158 INSURED INSURER B RLT Construction Inc INSURE RC: 31 Manni Circle -INSURER D Centerville,MA 02632 -INSURER - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN.IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE. INSR SWVD POLICY NUMBER. - - MM/DDY� POLICY M DDY� • LIMITS _ GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occu a ce CLAIMS-MADE a OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY ECT OC A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITYaccident) $ accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $' DED I I RETENTION $ $ WC STATU- OTH- WORKERS COMPENSATIpN X TORY LIMITS ER AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 1 OO,000.00 A ANY PROPRIET,p R/PARTNEWEXECUTIVE Y OFFICER/MEMBEREXCLUDED? NN NIA VWCA00-6015366-2014A 3/16/2014 3116/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 �{Yes describe under E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) .. I CERTIFICATE HOLDER CANC ELLATION 0N CJ Riley Builders Inc PO Box 382 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Osterville,MA 02655 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD isfandSifing and&ofing a division of UTCowhwtim InG 31 Wanni Circe CentetviQe,X4 02632 Hilton Clark July 27,2014 47 Dolphin Lane Centerville,MA We are pleased to submit the following specifications and estimates for reroofing: Strip existing shingles and paper Install 8"white drip edge Install 3 ft. ice and water,shield Install 15 lb.paper to remaining roof Install 30 yr.Certainteed architectural grade asphalt shingles Install ridge vent Clean up and haul away all debris.to landfill We hereby propose to furnish material and labor-complete in accordance with the above specification, for the sum of: Seven thousand seven hundred dollars............... ....................$7,700.00 Terms: One-third-deposit required. Balance in full is.due upon completion. All material is guaranteed to be as.specified. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owners to carry fire,wind damage and other necessary insurance. RLT Construction,Inc.carries General Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. • 4 Date of Acceptance:l.' Signatur Start Date: RI . Signature '& 7elephotne 508.420.5243 and 508.776.8914 Eacsimife 508.420.1776 I , CJ//e Apo r�Ur�a�rr2uit leall� _ S 'YxS�tat"fu.: �,�,.+:�b•>. aa��,i y;�,"fi �3'; h,vk ,�a.tM1� �r�7w vr•r..;2„'�vz �u`� i t !�.1 L t 17 YYI �.•, ` Uffire of ConsumertAffaiis Sc�Busmycss,{Ftgul�toa► jFtt+; cense oF�regrstratron,valid for ui;drvrduluse o 1 ti 4�R { �Vt Y4� �Y Y '�}�11 4�t r 1 �9kM f' S ,� - P•y:,_ y -� OMS IMPROVEMENT CONTRAC7QRI,K�} s ' ; be dredthe exprrahon date`If found return to 3 9 Xratlon: 34286 $ T°je z Office of Consumer Affarrs and Busmess?Regulaton �� EpprationP;R122/20i5}� Cbrrp°ra En"I° ' ♦ " , l0 i'ark PIa7a Suite 51'f0 r � 2116RLTONS7 INC�yp13ALA DING&RCOINr n" yf �� "t?� �{ •tp f x{7{ x:� �,s "y, t9 x �' "4•— a rt y ��a 1}�,"tC'#� �yP Nr 7 �� n�+�s��, yyt s r - t ` RONtIETAYLOE2 � �31 , � 3+llt�e rY�r ISO {t 31 MzANNI bRCLE k'sw y♦ 311 1 a o Undersecretary`' `I'` �,- z n s r l � '�71sd i:� k y �� �`*�f �ty.1 � � � �I ., r :.h t��lr A � }�'if�c`�,. h '' !. xf q ♦ '�ti' �.�, +��w�,_�4!�"�...x _�.._ :rT (♦ a�� �G '�,yJ � h.' � � la �� � �A41,{r "'� �.r�� � '�r� y,� �� I ,� d� .. Puplrc,. afet`/ ards Department°and Stand 1 SachUSetts Regulations ' tAas of Suildl(3 �s r;s`.Ijec�lil i„ Board l na g uCp Ge. Constr S, -0g 99�p i ,,.. a. AYE Pl C O, R SIC' 1 E.1�1iA� �. XOiratron yrr sroner TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map.4- Parcel Application #CA) PP Health Division Date Issued?` Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 97 00A N, � A_ Village P-r. r�f� Owner ��,���-. C�.rk Addresst- Telephone 77 1' 0;C Permit Request U,6 la COOL", 4, � rl2�L4 Square feet: 1 st floor: existing , proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Q,'00'0' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King','sHighwa = ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other c s Basement Finished Area(sq.ft.) Basement Unfinished Area (sq. ) co Number of Baths: Full: existing new Half: existing Jew c Number of Bedrooms: existing —new Cyr Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �� �, r�.,,�a,.,,,.+;� Telephone Number PO Box 52 Address West Dennis MA 02670 License # Cell (508) 280-6964 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE b �y C• FOR OFFICIAL USE ONLY w s. APPLICATION# DATE ISSUED }; MAP/PARCEL NO. ADDRESS VILLAGE OWNER 9. + DATE OF INSPECTION: UrFOTIJNDATION1f Fa — FRAME y INSULATION. F. FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 4 GAS: ROUGH FINAL 1 FINAL BUILDING DATE CLOSED.OUT ASSOCIATION PLAN NO. - OWNER AUTHORIZATION FORM VGA (Owner's Name) owner of the property located at Property Address) (Property Address) y herebyauthorize KC1Qa-\f1 U , (Subcontractor) an authorized subcontractor for RISE Enginee ' to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date '- Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Superl isor License: CS-058633 MICHAEL J MCCAR PO BOX 52 W DENNIS MA 6267; 1 .1 /y )I lit �•� c. Expiration Commissioner 04/10/2016 Office of Consumer Affairs and Business Regulation 10 Park.Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2015 Tr# 238121 MICHAEL MCCARTHY MICHAEL MCCARTHY P.O. BOX 52 WEST DENNIS MA 02670 — / Update Address and return-card.Mark reason for change. -' Address ❑ Renewal 'Employment 0 Lost Card SCA 1 Co 20M-05/11 ;/ I The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.rnass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Mike McCarthy Construction Name(Business/Organizalion/Individual):_ PO Box -92 Address: West Dennis, MA 02670 City/State/Zip: CSli:pa§§#.3 HIC-169393 Are u an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 1 4. ❑ I am a general contractor and I — 6. ❑Now construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ I am a sole propridtor or partner- listed on the attached sheet 1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, wotkera'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its l0.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions myself.[No workers'comp. e.152,§1(4),'and we have no 12.❑R f npairs Insurance required.]t employees.[No workers' 13. er comp.insurance required] *Any applicant that eheda box A must also fill out the section bdow showing their workers'compewation policy Wbrmadon. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a new affidavit indicating such. tCoatractors that check dds box must attached an additional sheet showing the name of the sub•conhactm and Hair workers'comp.policy hrf radon, I am an employer that Is providing workers'compensation Insurance for my employees Below is the policy and job site Informatlon. Insurance Company Name: bs-n. Policy#or Self-ins.Lic.#: VW(. 1c-('10 116A6- -:10 HA Expiration Date: Job Site Address: 7 City/StateMp: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to the imposition ofcriminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo tt d e a enalties ofpedmiy that the lr{/ormation provided above is true and eorrecb i Si c: Date: Phone#: Offlelal use onCy. Do not write in this area,to be corripleied by chy or town oflklat } City or Town; Pertnit/Ltcense# 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#: , ACC©® 07 . CERTIFICATE OF LIABILITY INSURANCE DATE /DD/YYYY) 07/10 /zola 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 Ileu of such endorsement(s). PRODUCER 01962-001 fiaOJ/1CT Bryden&Sullivan Ins Agcy of Dennis Inc jUE1O,Ext: (508)398-6060 ,Ne,: (508)394-2267 PO Box 1497 �S�Ess: So Dennis,MA 02660 INMEMIAEEOROW"OVERAGE AIC 0 A.I.M.Mutual Insurance Company _ 26158___ INSURED INSURER 8' Michael McCarthy Construction Inc - P 0 Box 52 f West Dennis,MA 02670 INSURER E COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 'AI-IICH 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. IN TYPE OF INSURANCE I S� POLICY NUMBER FtIR/DD 99 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ �OLICY FUECT I( �OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ i t ANY AUTO BODILY INJURY(Per person) $ ALL SCHED UTOS�ED AUTOSULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ $ A OFFICER/MEMBER EXCLUDED9 ECUTNE Y NIA VWC-100-6017656-2014A 7N7/2014 7N7/T015 E.L.EACH ACCIDENT $ 600,000.00 �((Magndatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000.00 D9SM ON OF 9PERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 j DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space Is required) Workers Compensation Coverage applies to MA employees only. CERTIFICATE HOLDER CANCELLATION Thielsch Engineering 195 Francis Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cranston,RI 02910 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD � J 4 esid tial and Commercial Builder t TT,ON SPECIALIST_ sg CCARTHYC • i �' DES: www. October 21,2014 Town of Barnstable Thomas Perry CBO N) Building Commissioner I-0 QQ 200 Main Strety .s. :. Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#201406296 at 47 DOLPHIN LANE has been inspected by a certified Building Performance Institute(BPI) inspector.All work performed meets or exceed Federal and State requirements Sincerely, Alz Michael McCarthy McCarthy Construction