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Home My WebLink About0046 HIGHLAND STREET - � . � i Parcel Detail Page 1 of 3 Logged In As: Parcel Detail Wednesday, December 14 2011 Parcel Lookup Parcel Info __._ Developer �_07- Parcel ID j 3153 Lot `- Location 46 HIGHLAND STREET -- --I Pri Frontage'89 Sec Road 1 Sec Frontage Village jHYANNIS Fire District(HYANNIS —� Town sewer exists at this address Y -Road Index`0710_ _____._, ___.._.__----•_.I Interactive Map _,w Owner Info ~—Owner iMUTCHLER, MARLENE&THEODORE A Co-owner %COM&R, SUSAWE Streetl 1 139 MORGAN ROAD _ I street2 City;CANTON� State lCT zip06019-200 Country! j Land Info Acres 10.24 Use!Single Fam M61-01 I zoning 1136 Nghbd 0106 ---- Topography Level — _-.--------I Road;Paved. ___._._.�---- .--•_—__—I Utilities IPublic Water,Gas,Septic I Location i I Construction Info Building 1 of 1 Year hoof ip I ext(Wo 1900 od Shingle w Built! Struct'Gable/Hi wall I gwI Living ____ ___ Roof� __gin__ m AC Area i2103 cover l"12 F GIs/Cmp I Type!None ------�__.__ Int r_ Bed Style Conventional Wall;Plastered Rooms:3 Bedrooms J Model Residential J Int!Carpet�� Bath 2 Full^� y Floor' Rooms Heat r_. Total r-..__._—__.-..-------- Grade Average I I Hot Water 7 Rooms Type Rooms Heat f ---_-- Found ;— �_... —. stones i 1 Story F A I Fuel I Oil ation;Come. Block Gross 3951_ Area Permit History. . http://issgl2/intranet/propdata/ParcelDet.ail.aspx?ID=24698 12/14/2011 - i f Parcel Detail Page 2 of 3 . J Issue Date Purpose Permit# Amount Insp Date Comments 07/15/2003 Window Replac 70129 1$3,480 112/16/2003 00:00:00 Visit Date -� v Who Purpose 11/07/2011 00:00:00 Denise Radley Change of Address 09/19/2011 00:00:00 Pamela Taylor In Office Review 08/16/2010 00:00:00 Michele Arigo In Office Review 01/09/2009 00:00:00 Michele Arigo . Change of Address 07/25/2008 00:00:00 Michele Arigo Change of Address 07/22/2008 00:00:00 Denise Radley In Office Review 05/28/2008 00:00:00 Tony Podlesney In Office Review 12/16/2003 00:00:00 Martin Flynn Drive by inspection only 03/18/2002 00:00:00 Paul Talbot Meas/Listed-Interior Access 06/15/1988 00:00:00 IML Sales History ----- Line Sale Date Owner Book/Page Sale Price 1 02/17/2010 MUTCHLER, MARLENE&THEODORE A 24371/146 $1 2 10/09/2007 VIEGAS, MARLENE F 07P1181EP1 $0. 3 01/11/2007 VIEGAS, MANUEL F 21689/300 $0 4 12/13/1962 VIEGAS, MANUEL F&MARJORIE 1 1184/15 $12,000 5 1170272011-_C_OM R USAN E 25810/10 $274,500 Assessment History - _ Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2011 $180,200 $3,000 $12,000 $126,900 $322,100 2 2010 $180,100 $3,000 $12,300 $128,900 $324,300 3 2009 $228,100 $2,400 $9,800 $151,800 $392,100 4 2008 $205,000 $2,400 $9,800 $162,500 $379,700 6 2007 $204,300 $2,400 $9,800 $162,500 $379,000 7 2006 $187,400 $2,400 $10,100 $162,200 $362,100 8 2005 $160,600 $2,300 $10,400 $128,700 $302,000 9 2004 $143,200 $2,300 $10,500 $109,400 $265,400 10 2003 $115,400 $2,300 $10,800 $29,100 $157,600 11 2002 $117,200 $2,400 $10,800 $29,100 $159,500 12 2001 $117,200 $2,400 $10,800 $29,100 $159,500 13 2000 $91,400 $2,300 $11,200. $24,800 $129,700 14 1999 $91,400 $2,300 $9,000 $24,800 $127,500 15 1998 $91,400 $2,300 $9,000 $24,800 $127,500 16 1997 $89,000 $0 $0 $21,700 $116,000 17 1996 ' $89,000 $0 $0 $21,700 $116,000 18 1995 $89,000 $0 $0 $21,700 $116,000 19 1994 $79,600 $0 $0 $25,100 .$110,700 20 1993 $79,600 . $0 $0 $25,100 $110,700 21 .1992 $90,800 $0 $0 $27,900 $125,500 22 1991 $110,400 $0 $0 $40,200 ' $160,900 23 1990 $110,400 $0. $0 $40,200 $160,900 http://issgl2/intranet/propdata/ ,arcelDetail.aspx?ID=24698 12/14/2011. Parcel Detail F Page 1 of 3 aV/ Logged In As: Wednesday, December 14 Parcel Detail . 2011 Parcel Lookup • Parcel Info Parcel ID(307-153 _ Developer I ( Lot Location 46 HIGHLAND STREET Pri.Frontage l89 Sec Road FrontaSec ge 7 Village JHYANNIS I Fire District I HYANNIS Town sewer exists at this addressY2S" Road Index 0710 4 t Interactive Map -_Owner info Owner MUTC ELH R, MARLENE&THEODORE A Co-Owner %COMER, SUSAN E I Streetl 139 MORGAN ROAD _I Street2 — — _ — City ICANTON State CT Zip j06019-200 Country�— Land Info Acres 10.24 use ISingle Fam MDL-01 I Zoning RB Nghbd[0106 Topography Level �"--_-- - " � � Road Paved Utilities 1Pub1ic Water,Gas,Septic Location I m — —. Construction Info Building 1 of 1 Year 1900 Roof Ext Gable/Hip all Built Wal Wood Shingle _., Struct Living 210�—� Roof As h/F GIs/Cm None � y Area � C AC over p—� Type I Int Bed Style Conventional Plastered 3 B ooms �.. Wall Rooms Model Residential �� Int Carpet Bath 12 Full , , Floor Rooms Heat Total 'Grade Verage _ ( Type Hot Water ) Rooms 17 Rooms Heat Found stories 11 Story F A Oil Conc. Block Fuel ation Gross °395"1 Area • Permit History http://`issgl2/intranet/propdata/ParcelDetail.aspx?ID=24698 12/14/2011 Parcel Detail Page 2 of 3 Issue Date Purpose Permit# Amount' Insp Date Comments 07/15/2003 Window Replac 170129 $3,480 12/16/2003,00:00:00 Visit History Date Who Purpose, 11/07/2011 00:00:00 Denise Radley Change of Address . 09/19/2011 00:00:00 Pamela Taylor In Office Review 08/16/2010 00:00:00 Michele Arigo In Office Review . 01/09/2009 00:00:00 Michele Arigo Change of Address " 07/25/2008 00:00:00 Michele Arigo Change of Address" 07/22/2008 00:00:00 Denise Radley In Office Review ; 05/28/2008 00:00:00 Tony Podlesney In Office Review 12/16/2003 00:00:00 Martin Y i FI nn Drive b ns ection only , Y p 03/18/2002 00:00:00 Paul Talbot Meas/Listed-Interior Access 06/15/1988 00:00:00 ML I f . Sales History Line Sale Date Owner.. Book/Page Sale Price 1 02/17/2010 MUTCHLER; MARLENE&THEODORE A" 24371/146 $1 2 10/09/2007 VIEGAS, MARLENE_F ,. 07131181EP1 $0 ' 3 01/11/2007 VIEGAS, MANUEL F 21689/300 $0 4 12/,1.3/1962 �,,VIEGAS,MANUEL F&MARJORIE l 1184/15 $12,000 5 1_-1/02/2011 COMER,S S W E_0___-- 7 25810/101 $274,500 Assessment History Save# Year . Building Value XF Value.-, m OB Value Land Value -Total Parcel Value 1 2011 $180,200 $3,000 $12,000 $126,900 $322,100. 2 2010 $180,100 a $12,300 . 8,900 $324;300, 3 2009 $228,100 $2;400 19,800 $151,800 $392,100 4 2008 $205,000 $2,400 $9,800 $162,500 r$3791700 6 2007 $204,300 ; $2,400 $9,800 $162,500 $379,000 7 ;2006 $187,400 $2,400 ' $10,100 $162,200 8 2005 $160,600 1$2,300 $10,400 a$128,700 $302,000 9 2004 $143,200 ;$2,360 $10,500 $,109,400 . -$265,400 10. 2003 $115,400 ',$2,300 $10;800 $29,100 $157,600 11 2002 $117,200 i$2,400 $10,800 $29,100 y $159,500 12 2001' $117,200 $2,400 ' $10,800 $29,,100 $159,500 13 2000 F" $91,400 ,$2,300 $11,200 $24,800 $129,700 14 1999 $91,400 $2,300 $9,000 $24,800 $127,500 15 19,98 $91,400 $2,300 ' $9,000 . $24,800 $127,500 16 1997 $89000 , $0 $0 $21,700 $116,000 17, 1996 $89,000 $0 $0 $21,700 $116,000 18. 1995 $89;000 " $0 $0 _ $21,700 $116,000 19 1994 $79,600 "" . . $0 $0 $25,100 $110,700 20 1993 $79,600 $0 $0 $25,100 ;', $11J0,¢700 21 1992 $90,800 $0 $0 $27,900 $126,50.0 22 1991 $110,400 $0 $0 $40,200 $160,900 23 1990 $110,400 $0 $0 $40,200 $1601900 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=24698 12/14/2011 Assessor's map and lot.,number ........:........... ....... �TW SYSTM c. ✓✓`� 1 FOSTAi.LED IN COMP IA NM Sewage Permit number ..",rl4c...::• ..�f. C i .I'I"si ARTICLE 8d, SAT ETHE MIT Y -1-TOWN OF M4WW" S BAUSTABLE, i MML 9 BUILDING INSPECTOR APPLICATION. FOR PERMIT TO .. s `f .................... ... ...... ......................... TYPE OF CONSTRUCTION ...... .... . .. . .. .......................... ! .........6..............19.24, TO THE INSPECTOR OF BUILDINGSw The undersigneed/ hereby applies for a permit according to the f/ol�lowiJn�g information: / ...11�I �ht!1!S�L�l1?a...�:..... . . . . .. .. ..........7 ..... !. .�1... �. Location ....... .. a ::. .. ............. ...:.... ...................... �I ProposedUse ....................... . . ... . .. ...............................................................................`................................................... Zoning District ...................................Fire District . ............. . ... ., .... ................ OIL Name of Owner ... :... . . .. . . . . ..... ...V. . .'. , ...Address ....y .......,1 . . .. ..... . ........ ... ................ Name of Builder ... .... � ....... ...,l. /Q ..............Address ....... � ..... ..�1.....1 ......1,! ....... Nameof Architect ......... �./ ....... ...................Address .......... .................................................. U Number of Rooms .�.�� . . . . . .Q,�..x ...........Foundation .....;; ........ ..... .. ..............................:............ Exlerior . ........ ....... ... .. . ..................Roofing ..... :. ..+.I.... ........... Floors ....... . .... ..................................................................Interior .... .. .. . ............... .. :......... ............................... Heating ..... . .. ..... .. .. . ....................................................Plumbing .......................dd......../.................................................. Fireplace ....................t;�..................................................Approximate Cost .........D�...( .. <.. ..a......:............. . ....... Definitive Plan Approved by Planning Board ________________________________19--------. Area �•...... ......... ........ ............. Diagram of Lot and Building with Dimensions Fee ............. ............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH ! e I: I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... � ?.. 61...... ... ........................ V1egaa, Manuel F. � _~ 17428 ~�^a��^ to single � No .--.--.. Permit for -----.---_--. family dwelling ---`-------^^--' 46 Highland 1-motion .................... � . Hyannis ----.----.---------------.-- � . � . Mannel F. V1egaa Owner ------------------.---' frame Type of-Construction -------------- Q = `�~ --------------------------. A Plot ---' �� ^ �4 �----- ----------'. o Permit rr~n�a6 — 7 lg 74 -- ------------. � ' Dote of � � ' ' . Date C;mp|ete6 . m~°/..\). r ' -- PERMIT REFUSED / — lP � ��.—.--------.---------.. ~+ --------------------------. . � ^.,---.-----------.--- -------. ..-----.---.—~----,—.------ . . � ............................ � ~ ' . . . - *'proved ................................................ 19 � J ' � --------------------------. . ^ --------------------.---.—,. ' / � ' . � '�,...v.';^a.•n�at�,�- ,... . _.....,..,�r-r ;�.... � ,:� (.�r"'� 'v�^ ✓Yr1'z�,C'� �'t'.,i �.. tcb:::: ,�n^'.,�*v 1s �.yC�,k;,n`-�.l^"a^'.,r..:..rn ._ .� ..� t•. p� �:" •, � - a -.-`o�:.,� �e ?,?.' ♦ � a �.::5;}�".�.i x..' s`y,y� ,,�ti,i• rr�';�r'�..: ..px..a.J�u.+ Assessor's map and'..lot number .................... ..- :�S " Sewage Permitnumber. ...�t a I A:�!...:.../ail!4..!ra�.<a... /Jr�I/✓bvt ?/(0 Z �, .... 0 FTHETo�q -} TO" N OF BARB N S T A B LIE g BAHHSTABLE, 0 39. B U L 0 18 10 S P EC TOR O : a 6 , ",tzJfi � �APPLICATION FOR PERMIT T .....,... � : ................................................� ri TYPE OF CONSTRUCTION ........::((s.r. f` s ,. . . d 2 . ........`. . ,t�.•.. . ,-a2{'I•f:R: ............ .......... ...... ...I. ......... ...............................` ................ .. ,... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the .following information: Location - ` .. .. ..t:. ............. 'x! ' a -5/4 f1 ✓�°................................... � ` "r,�.................... ....... .......:.... Proposed Use ........ .. ..... . ... ......... .. Zoning District.'..*...:: f y...... :...: Fire Dis4nct ::E i, _ ,� ................ � fp ...+ .....:E. ryt ti 'Address' ...........................................f F f Name o'f,Owne + ........................... l a 7r ..x•.:l• •(!•, •••. ••••• Name of Builder''`:. .... r b o a�P�r�......:..........Address: >...... . t ' t :..fi. `.:............ Name of Architect f ....... "...T,4 f:?.....,. ......... .....:..Address... ''.. ...'. .:. :........................... Number of Rooms f X. f 5..., ...!........ .:`. Y .; ........,..;foundation •..:.. 5...: .k ..... Exterior .... ...4r r. .: .................Roofing- .............:.. ... .. .. C€4r.. ............ i Floors ....................Interior ...........r':. ti. .............. i.,� E. t.............................. Heating .....� ................................................Plumbing ` Fireplace .................... :t.. ..i;`::.....................:...........................Approximate Cost �,�...................................................... Definitive Plan Approved by Planning Board ________________________________19-------- . Area ........� ........................... Diagram of Lot and Building with Dimensions Fee "• l................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH ' �C,.-`✓er�... �,{, r.�a..„ ,,'v.�f,.Y.�.��•� ,�b;rti itC"r r _ . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... .......... Ft, ........... ........ ....................... Viegas, Manuel F. ' 17428 : No Permit for --3 to ngle ` s .......family dwelling - ... ........ ......... ;. Location 46 -High land: - _H annis ' Owner Manuel F. Viegas " .. ......................... Type of Construction frame...................... Plot ............................. Lot .. ............ Permit Granted .......No.i.Pmtnhp-..7............19 74 Date of Inspection ................... .................19 -Date Completed PERMIT REFUSED ....................................... ...... 19 ................ .................................... ..... ......... j Approved 30 THE.T°�� TOWN OF BARNSTABLE �r� L BAHB9TADLS, i 9� AM 0p39. YAP�•� DUILDI GA SPEC s0 �- ". 1 APPLICATION FOR PERMIT TO .... .... ' `.......................................................................... p� TYPE OF CONSTRUCTION ...... .f. ✓✓6.` .t........ ......1t.'..:............................................................ ....... ..........9...................,9..La...� TO THE INSPECTOR OF BUILDINGS: .,._The.undersigned hereby applies ffo__ra permit.-i according_to. the following informations - Locations..... `r'�...........�7. ... . .... . .......................................................................r.................... L ProposedUse .... r .. . t. ........................................................................................................................................... ZoningDistrict ........................................................................Fire District .. .... .. ?......................:......................... r Name of Owner .. ..4.. .. :.. . ... ......................Address ..... .G� d�" ... . . . ...................................... 6 � Name of Builder ...e........ ... . ........... ... ....... .r( ............Address ...... •I......... .. . ...............,�f o G�....P. ...... Nameof Architect ...................................................................Address .................................................................................... Numberof Rooms ......../.........................................................Foundation ...... ................................................. Exterior .....1(1/ .........................................................Roofin ...... .. .. . oe,,,�6......................... Floors ... ............................................................Interior ..... ..................................................... Heating ........'..:......................................................................Plumbing .................................................................................. Fireplace ........—.....................................................................Approximate Cost ..... ........1 a. s�a.......................... ....... I ` Difinitive Plan Approved by Planning Board ________________________________19________ . Diagram of Lot and Building with Dimensions cc2 r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... ........................... .......... .. l . ................. T viegas, Manuel DEC 31 1970 No ...11507... Permit for .,,demolish garage t. .................. ...........& bebuild................................................ Location .........�6..A?ghland„Stree.t .... ................ .lyanni s......................................... Owner Manuel„Vegag Type of Construction ..............fxam.e................ Plot ............................ Lot ................................ r Sanuary-8 68 Permit Granted ....19 ± Date of Inspection ../.�.f ... ...............19 Date Completed .............. ....... ...............19 60 PERMIT REFUSED l' ................................................................ 19 ............................................................ ..... ... I ............................................................................... ............................................................................... 1 � i ............................................................................... 3 ' 1 Approvedr.............................................. 19 I _ 1 ............................................................................... ............I.... ......................................................... : f 01tQt5- oFsHWET Town of Barnstable *Permit# Eepires 6 mantles from issue date Regulatory Services . Fee r� t `$$ Thomas F. Geiler,Director �TED MA't h Building Division Tom Perry, CBO, Building Commissioner NO Main Street, Hyannis, MA 02601 www.town.barnstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 1 /t t? n�1 ,(' u c;1, . S Eg-residential Value of Work9 ��Q, Up Minimum fee of S35.00 for work under S6000.00 Owner's Name&Address 11A w/el,7t f— 'IL �Ii�C3 C/!o V � /y/y y`C'1 j� l�'V— S Contractor's Name 1 f�j,�, S l3�i)r�c��,try Telephone Number,<29 '-,3 LS c'P.5— Home Improvement Contractor License#(if applicable) 14:91 7 Construction Supervisor's License#(if.app.licable) ❑Workman's Compensation Insurance n... =.s� - P Check one: ❑ I am a sole proprietor iyj M ❑ I am the Homeowner [lI have Worker's Compensation Insurance ` otM () B1��'�S p A�`t$`w�.' Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) (�Re-roof(stripping old shingles) All construction debris will be taken to �Ll e G, ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side. #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit formS\EXPRESS.doc Revised 070110 The Commonwealth of Massachusetts r ,; I Department of Industrial Accidents i h Office of Investigations Ei t"ri i - ` 600 Washington Street. Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Name Business/Or anization/Individual .: lbey--t a cai/ fir Address: LJ` 'ysT 11. ( - City/State/Zip: d?60,,,Phone #: )kreyoouu an employer?Check the appropriate box: Type of project(required): 1. P am a 4 employer with . ❑ I am a general contractor and 1 / -n • 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner-. listed on the attached sheet.$ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.,insurance 5. ❑ We are a corporation and its required.] ' officers have exercised their 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or,additions myself. [No workers' comp. c. 152, §](4),and we have no 12.�oof repairs insurance required.) t employees. [No workers' 13.0 Other comp..insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site + information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the-workers'compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK.ORDER and a fine of up to$250.00 a day against the violator..=Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. -I do hereby certify under the pains and penalises of perjury that the information provided above is true and correct: Signature:' Date: Phone#: Official use only. Do not write in this area;to be completed by city.or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: r 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 thereto shall not because 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, §2-5C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy isTequired. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston,.MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www_mass.gov/ciia T , ti Town of Barn-stable ` Regulatory Services • f �u& Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,bAA 02601 . www.town_barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder I,_ A��Ve- as Owner of the subject•property hereby authorize � /� to act on my behalf, in all mailers relative to work authorized by this building permit application for: , f (Address of Job) Signature of Owner Date Pant Name If Property Owner is applying forpem-iit please complete. the Homeowners License Exemption Form on .the reverse side. i d Town of Barnstable �oftt ray hw� o Regulatory Services Thomas F. Geiler,Director Building Division PrFD Tom Perry,Building Commissioner 200 Mani-Street, Hyannis,MA 02601 www.to wn_b arnstabi e.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXElY=ON Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# cURRENT MAILING ADDRESS: eityhnwn state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HONLEOWA'ER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which.thcre is, or is intended to- be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constr4cts more than one home in a two-year period shall not be considered a homeowner, Such "homeowner"shall submit to the Building Official on.a form acceptable to the Building Official, that he/she shall be responsible for all such work-performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that,be/she.rmderstands the Town of Barnstable Building Department and r ements and that he/she will comply with id minimum inspection procedures equn' mp Y said Procedures and requirements. Signature of Homeowner Approval of Butlding,Offiicial Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeownv paforrning work for which a building permit is required shall be exempt from the provisions II' of this scc don.(Secdon 1 o9.1.1 -Licensing of construction Supervisors);provided that if the homeowner ergagrs a,po-son(s)for hirt to do such work that such Homeowner shall act as suprrvisor." Many homeowners who use this rxcmption arc unaware that they art assuming the responsibilities of it supervisor(sec Appendix Q, Rulcs&RegbIations for Licensing Construction Supervisors,Scction 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would wi th a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of hislhrr responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the rasponsibilitics of a Supervisor. On the last page of this issue is a.form curtly used by several towns. You may care t amend and adopt such a form/certifreation for use in your community. .F ". tt NOTICE NOTICE. TO, �, TO EMPLOYEES EMPLOYEES i The Commonwealth of Massachusetts-. DEPARTMENT OF INDUSTRIAL ACCIDENTS =V 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 . As-:required by Massachusetts General Law, Chapter 152, Sections 21,22 &:30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned. chapter by insuring with: . ASSOCIATED WDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54.THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY W 0 05/16/2010 d- 0 16/2 1�1 A C 700807101201 5! 0 POLICY NUMBER EFFECTIVE DATES PO Box 1945 Kerry Insurance Agency Inc N. Eastham, MA 02651 (508)25.5-8000 NAME OF INSURANCE AGENT ADDRESS PHONE Albert C Pease dba Albert C Pease III Builder 95 East Hill Road Wellfleet, MA 02667 EMPLOYER ADDRESS 04/23/2010 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY)F DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation'Act..° A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER '� 1�1;tssachusctts- Dcpaitmcnt of Public Safct� — J Board of Building Regulations and Stamlardsaa�g .:Office of_.ConsumerAffairs<&Bu"siness Re elation:: Construction Supervisor License . License: CS 36407 HOME IMP.ROVEME,NT CONTRACTOR . Registration,'�'1•.01471 Type: Restricted to: 00 _ Y> Expiration 6/26/2012 Individual ALBERT C PEASE ALB ERTC. PEASE = t ' 95 EAST HILL RD WELLFLEET, MA 02667 x r . Albert:Pease t 95.East Hill Rd �— - Wellfleet, MA 02667 Unders c e ar e r t y 4xation:.5/13/2012 Commissimlel Tr#: 24082 �y j ;A t s License or;cegastrat On uand forandiv�dul use only before the expiration date. Office of Consumer. If found return to. "` 'i i 10 Park Plaza_ Affairs and Bus. ness Regulation- Boston, 5170 , MA 62116. Not valid without signature . ...... Z /S Town of Barnstable • *Periuit �FIHE Tpk, Expires 6 months from issue date r' lZeulatory Services Qe pan MASS-te,� Thomas F.Geiler,Director PR-XESS �" '� 16g9• �0 J� II t� �ATf0PMA Building Division Tom ferry, Building Commissioner JUL 15 200 200 Main Street, Ilyantus,MA 02601 Office: 508-862-4038 TOWN OF BARNSTABLE Fax: 508-790-6230 EYPRI♦;SS PI+;ItMIT A.Pl'L�CA,TION - RESIDLN'I'IAL ONLY- ° Not Vatid without Iced.Y-Press lmprint Number 3D r Map/parcel N . Property Address Value of Work Residential r aL Owner's Name&Address Telephone Number M; Contractor's Name Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 21�orkman's Compensation Insurance -` Check one: ❑ I am a sole proprietor , VIm the Homeowner " have Worker's Compensation Insurance c JLZ✓ Insurance Company Name - Workman's Comp.Policy# l O b -� Permit Request(check box) old �kRe-roof(stripping g ) u s hin lesa r Gom over existing layers of roof) Re-roof(not stripping g 4❑ Re-side r -t" ca aF Value ,► (maximum.44) " r &Replacement Wuidows: U- � Other(specify) •y *Where requited: Issuance of this permit does not,exempt compliance with other town depar anent regulations,i.e.tl stone,Conservation,elc Whe q u j Signature \ U 1V Q:Forms:expmtr9 F CAPIZZI HOME IMPROVEMENT INC . r SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6 STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY. FOR A BUILDING PERMIT I, OWN THE PROPERTY LOCATED AT IN ��c7 MASSACHUSETTS. I HAVE AUTHORIZED TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSTTS STATE BUILDING CODE. I GIVE MY PREMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 180 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: i LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: c2w I tLw�c APPLICANT'S ADDRESS: E APPLICANT'S TELEPHONE: 508/428-9518 ff RESPONSIBLE OFFICER: I RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: ACCEPTED BY DATE THIS PAGE IS ILPART OF AND IN CONFORMA CE WITH PROPOSAL # M1•r" Vr(MMMftl0.'bd�MJeMW.Y.91'.!MMh4ltiMrve .:!.iyN.l,!ryPgtl.n.,wep:nM f1.t il.:t +{ry,l';', m::z':n9,fu4r v w..t�.:ti y.�'.•.L ti}iitl,pyllP .. .. ""'�`• . .' .. - .. .54� ✓/t�! t009lNlfOftt�� O��.Q4JQQ�l�IQAQ� t4 1� Board of Building Ilcgulations and Standards I n HOME IMPROVEMENT CONTRACTOR Registration:0 100740 atir'' Expiration: 6/23/2004 { 'Type: Private Corporation , CAPIZZI HOME IMPROVEMENT, R{romas Capizzi,)r• ? 1645 Newton Rd. Coluit,MA 02635 Administrator �.f� �e V�o�fmrvfr�ucirl/� n��add�c�iudel�d T s .. b BOARD OF 13UILDING REGULATIONS r . 'License: CONSTRUCTION SUPERVISOR Number: CS 057032 , 1311thdalo: 09/26/1963 s � , ,rat: � _• _ t, +•. a ,� Expires: U9/26/2003 Tr-no: 579U M . Restriclod: OU TI IOMAS X CAPIZZI Jft 200 PERCIVAL DR W 13ARNSTAI3L.E, MA 0263G0 Adminislralor f Town of Barnstable *Permit# �� 'Expires 6 ruonths fr issue dntr — Regulatory Services Fee S nnMsrAsr eMAM . 1659. � Thomas F. Geiler,Director . EbMAr� Building Division PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 a L C k 4 2 011 www.town.bamstable.ma.us Office: 508-862-4038 -TOWN EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Vand without Red X-Press Imprint Map/parcel Number 1307 — 15-3 Proper Address L4& H, y1 La yut If Residential Value of Work ZS O Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 141 W &Mi Ske.&A 60me-y Contractor's Name �1 (� K`�� Telephone Number_ 7 7 4 Home Improvement Contractor.License#(if applicable) 7i g;o Construction Supervisor's License#(if applicable) I p 15-410 �6Workman's Compensation Insurances Check one: I am a sole proprietor ' I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company-Name I YYa.U t,L�y`S.�VC� 4 (A.S( x��.t D t I�1 �CA Workman's Comp.Policy# ��V'►j "��'��j� �"� —' 1.� --� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of root) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value (maximum.35)#of window_ M licre required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. " "Note: Proper-Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE:-: C:Users dccollik AppData Local Microsoft Windows Temporary Internet Files ContentOutlook DDV87AAZ EYPRESS.doc Revised 072110 The Commonwealth of Massachusetts ` Department of Industrial Accidents • Office of Investigations f 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly. CA 1� Name(Business/Organization/individual): G� L . C -�1�'V),:_J .. Address: City/State/Zip:Wr 02- 7 Phone #: '77 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I . employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor-or partner- listed on the attached sheet. 7. M Remodeling ship and have no employees These sub-contractors have g• Demolition workingfor mein an ,ca aci employees and have workers' y p �'• 9. ❑ Building addition [No workers' comp.insurance comp.insurance . required.] 5. ❑ .We are a corporation and its IO.❑Electrical repairs or additions q ]� 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs t insurance required.]t c. 152,§1(4),and we have no . employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and-state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. _ r Policy#or Self--ins.Lic.#: '7 (oW7-7-- Expiration Date: Job Site Address: `. i�kwyR City/State/Zip:.,qtaS V r Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). -Failure to secure coverage as require&under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as.civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day`against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent under the pains and enalties of perjury that the information provided above is true and correct. Si afore: Date: )l Phone#: p 77` Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 1 City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: VDAC TRAVELERS WORKERS COMPENSATION " AND EMPLOYERS LIABILITY POLICY A TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB-9806M77-4-11 ) RENEWAL OF (7PJUB-9806M77-4-10) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA NCCI CO CODE: 13579 INSURED: PRODUCER: ' KENNEY, DAVID L MARSHALL K LOVELETTE INS 300 BUCK ISLAND RD UNIT 4B 396 MAIN STREET WEST YARMOUTH MA 02673 PO BOX 836 z WEST YARMOUTH MA 02673 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 06-02-11 to 06-02-12 12:01 A.M.,at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit . o= Bodily Injury by Disease: $ 100000 Each Employee C. 'OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A 0 r, D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY DATE OF ISSUE: 06-03-11 SS ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT 701 PRODUCER: MARSHALL K LOVELETTE INS .25F4J 002622 �rrsrna�, 39. Town of Barnstable- Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 ' www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790=6230 Property Owner Must Complete and Sign This Section If Using A Builder I ,as Owner of the subject property hereby authorize 4.)k to act on my behalf, in all matters relative to work authorized by this building permit application for: ddress of Job) Signature of Owner ate Print Name If Property Owner is applying for permit,please complete the Homeowner's License Exemption Form on the reverse side. 'C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doe Revised 072110 tr • f, • Massachusetts- Department of Public Sateth _ 1. 4I Board of Building Regulations and Standards E. Construction Supervisor License License: CS 89280 DAVID L KENNEY ' 300 BUCK ISLAND RD U-4B ' WEST YARMOUTH, MA 02673 C-7— Expiration: 1 0/1 41201 3 DICYII� ( nunisime,• Tr#: 4424 W.a'ARIOk! MAC ..0267$-2544 P �-7� ✓fie �ammzonweall� a�/�aaaac�ivaelta Orfice of Consumer Affairs&Busim-ki,Rq ulatiun HOME IMPROVEMENT CONTRACTOR Registratioi ,1'65466 Expiration {2/22/2012 Tr# 293594 Type 2u lnd>vi i�fal DAVID L.KENNEY tL DAVID KENNEY' ; 1 _ 300 BUCK ISLANI� ?D -- WEST YARMOUTH,NIiK:02673 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature -- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION, Map 3 7 Parcel IS3 ,„ Application # Q0.1 6 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 410 Village qpjjq V,S Owner Suz D E. 6_0-A 6�, Address 1-39 14ovcAL-_.7'Rt C A tom Cr- p60 iq Telephone 4 60- C0R 3 — 1:99 BG Permit Request Lc>y- WPrL_-S MnV? r ' ' Gi ti4-►,1� `�bP�tfi f�U y t� �te� ��4-�. `gol�� Square feet: 1 st floor: existing `proposed 54%4-2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5000 Construction Type woo'n Lot Size 24 6LrA:;5. Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure rs Historic House: ❑Yes $No On Old King's Highway: ❑Yes No Basement Type: X Full ❑ Crawl ❑Walkout %Other 4.v/ Lrn-w L s1Pnr_4_— Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) IDa , Number of Baths: Full: existing 2- new Half: existing © new Number of Bedrooms: 3 existing O new Total Room Count (not including baths): existing 7 new © First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Central Air: ❑Yes XNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn O existing 0 news size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:. _ n r Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ C<nmmercial ❑Yes G No If yes, site plan review# _ Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name _ pCur1>. Telephone Number `7.74 — 36g � ©v�S� Address '3©0 T>ocr- La & License # a: Home Improvement Contractor# 1 (2�� b�J _ Y19amout w 14 t Q),6-7 5. Worker's Compensation # _?JPJ U-6 -Tb0&M Z'-4—II ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I k . FOR OFFICIAL USE ONLY 4 KIT APPLICATION# •DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE - OWNER ,y 4 DATE OF INSPECTION: r FOUNDATION ft r FRAME INSULATION' FIREPLACE ;t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL " ,GAS: ROUGH n: .. FINAL .,,_FPNAL BUILDING s of i -DATE CLOSED OUT ASSOCIATION.PLAN NO. r f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 WwW-mass guv1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly a Name (Business/Organi ation5ndMdual): ��►, C Address: "T5UuG City/State/Zip: Phone#: '7`7 L4 —3 (ve% —d SS Are you an employer?Check the appropriate bar; 1.❑ I am a to Type of project(required): ernp yes with 4. ❑ I mm a general conitactor and I Ioyees(full and/or'part-time).* have hired the sub-contractors 6• ❑New construction. 2. I am a sole proprietor or partner- listed on the attached sheet. 7.. Remodeling ship and have no employees These sub-contractors have 8, [I Demolition working for me in any capacity, employees and have.workers' [No workers' comp. insurance comp.i11surancO 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10.11Electrical repairs or additions 3,❑ I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additionsmysel£ [ o workr ' comp, right of exemption on per MGL m �� ce required 12. Roof repairsC. employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy iufurmatioa Fiameowners who submit this affidavit indicating they—doing all work and then hies outside coutrectors must submit a aew affidavit indicating such $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stata whether or not those eatities have employees If the sub-contractors have employees,they must provide their workers'comp.policy cumber, mber, I am an employer that is providing workers'compensation insurance for my employees. Below is the poficy and joh site. informradon. lnsurance Company Name: Tj Policy#or Se1f--ins.Lic. 4 Expiration Date:�2,� ZQ� Job Site Address:_ L4 6 b � V City/State/Zip: A-VJ UL's _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration-date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or One-year mzprisonment, as well as civil penalties in the fowl of a STOP WORK ORDER and a tine 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 luvestigalioas of the DIA for insurance coverage verification I do hereby certrfy under,the-pains and penalties ofPe7uY that the information provided above is true and.correct Signature, Date: 4q5D Phone#: 'I'7 L# Offic:th not write in this area, to he.completed by city or town off ciaL City Town: PermitUcense# •�' Issuinrcle one): I. Boa .Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector fi. OthConta Phone#: .� V DAC AW TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB-9806M77-4-11 ) RENEWAL OF (7PJUB-9806M77-4-10) ' INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 11 NCCI CO CODE: 13579 INSURED: PRODUCER: KENNEY, DAVID L MARSHALL K LOVELETTE INS 300 BUCK ISLAND RD UNIT 4B 396 MAIN STREET WEST YARMOUTH MA 02673 PO BOX 836 WEST YARMOUTH MA 02673 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 06-02-11 to 06-02-12 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: - MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits.of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100006 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A D. This policy includes these endorsements and schedules: o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 0 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 06-03-11 SS ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT 701 PRODUCER: MARSHALL K LOVELETTE INS 25F4J 002622 r, Massachusetts- Departmcot of Public Sufct} Board of Buildin--- XMI Re��ulations and Standards £ / • Construction Supervisor License License: CS 89280 ER 204643, DAVID L KENNEY , I 300 BUCK ISLAND RD U-413 � a {.. WEST YARMOUTH, MA 02673 Expiration: 10/14/2013 ©if1Fl1. b I . 36 g ( tmnuissioncr Tr#: 4424 j. W RN1t�iJT 026734 4 . a � r ✓fie Toamromoozuiea�Z o�;_�aaacu.�,ka Office of Consumer Affairs&BusitM55 Regulation HOME IMPRI—VEMENT CONTRACTOR Registratiori�,,1'65466 Expiration -,2.t22/2012 Tr# 293594 - Type Q�;` indtdldual 1 ; DAVID L.KENNE,Y' ,. DAVID KENNEY <_,a 300 BUCK ISLANDRbQtJN1T:4,B � e — WEST YARMOUTH,`tilli4:026T3 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 I ~Not valid without signature _ i a- • snaxsrMM �,� Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Lmev' ,as Owner of the subject property hereby authorize g WV AJ to act on my behalf, in all matters relative to work authorized by this big permit application for: 1 �l (Address of Job) Signature of Owner baie CO VIA.t'jr Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side.` r C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 of ,�r• Town of Barnstable *Permit a ' OExpires 6 nont ronr issue Jute a Regulatory Services Fee HARNSPABLE + % 7� v Mtnss. $' Richard V.Scali,Director a ( (/ J 1639. �0 - 0QED MP't Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 r -sww_town.bamstable.ma.us Office_ 508-8624038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY - „ -7 (S� Not6'ulid without Red X-Press Imprint Map/parcel Number iy . y, W 4/ / .� y �I S Property Address Gnu � dResidential Value of Work S 3, 3 L( Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address I 12.^ [ n.,9+e r - Contractor's Name WAADW QOA4 Telephone Number p'F e3�sD� Home Improvement Contractor License#(if applicable) 1& OZ,!r- Email: Construction Supervisor's License#(if applicable) 87 Z7 7 Z Vorkman's Compensation Insurance Check one: �t �+ ❑ I am a sole proprietor ❑ [am the Homeowner NOV v [have Worker's Compensation Insurance 2017 Insurance Company Name ABL.F . Worktttan's Comp.Policy# 22 W,C_I_T 26 Copy of Insurance Compliance Certificate must accompany each'permit. ' Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ e-side (t�Replacemen[Windows/doors/sliders.U-Value 7-1 (maximum 32)#otwindows #"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 copy of the Home Improvement Contractors License&Construction Supervisors License is equired. RE: SIGNATU C:\UsCrsADecol i ata\ cal\\-ticrow , mduws\Tempoctry Intemet Files\Content.outlook�?P101 DFIR\EXPRESS.duc Revised 04021 °WlndoW World of Boston,LLC, MAH1sm6ozsl:' atlon Ofices&Showrooms 01 ACummingsPk 3095OldOakStreet Federal 1D'# Woburn MA 01801 Pembroke,MA 02359' (7s1)s3a-aao5 (781)826.6261 .2 74 4 91 66 5 'Simpiythe`Best fair Lesa www.WindowWorldofBoston.com ustomer Phone(h): r Install Address: City: AlAl State;MA ZipO E-mall WINDOW WORLD GLASS OPTIONS _1000 3eries3tngle hung All Wetd 5189. . 7 SofmZone Efite 2000 Series DH Mech%Werdeii Sash $216' . _"Oipte Glazed TGV $195 4000SeriesOHAll-Weld $225 (•S'erres60Co09y) _6000 SerZ DH Afl-Weld $260- , WINDOW OPTIONS / 2 Ule Slider "af Glass Breakage Warranty $16 ilhukaFp _3UteSNder pnmans t?Nvivu' $546' 1/2Saeens $9INCLUDED Picture/Fired Lit $$54 j Foam Insulation onJombs and Head $11dNCLUDED Awning $280 Double Strength Glass, $15 INCLUDE. easement WO Locks(>26"j $5 6VCLt1DED _2 rate Casement. $596. Full Screens $22 _3:LiteCasement ivj',*Is) pri:ris,tii. $880. Colonial Grids(Cgntduietl/Flat); $45= Basement Hopper .S334: —Prairie Grids S51 _Bay Windovr•Soffit Mount/INS Seat;$2660: —Diamond Gdds $fig . Bow Window-Soffit Mount/INS Seat$2785 SimuFated Dlvlded Lfte $132 Tempered DH Sash(BSO)(TSO) $65 ... . _Garden Window $2040' Obscure Glass(BSOj!,(1 SO) $35 _Specialty Window $ =odei style(40(80 ors0/d0) $�o �Betge/Almond Soo _FoarnEn handed Fremei $35- _Woodi3rain,nterwr(Sedes4000fsdquonty)$100 PRE 1978 BUILT HOMES(EPALEiID;SAfERENOVATIOAn {Light Oak/0adr`Oekl Cherry y fox U/ood C"Lead Safe Practices Required $30 Brownxteiiar Rrob Exte My.HOME WAS BUILT IN THE YEAR./90'j.1nitIa _ iiWch mrize/AmericanTeirs)$100 _Designer Color`E rior $175 MISCELLANEOUS Custom Exterior Aluminum Cladding Window:Coiw—d ILL I /1�7� O TeMured 375 {�Smacth$76 g; �j O Inside 01ssr0 Facing Color h//f1j NON CUSTOM DOORS —Metal Windmv Removal $50 _V nyl Ro0'mg Patio Door 6tL or Eft $1pg5 —New Construction lfinyl Removal $17'S _Vfriyl Railing Patio Daor:ant, : sli95 —Specialty Window ExteriorTrim* $_ _Add to base price for Custom Rolling Ma.Door'$1250 :.. MWI to Form MUIti Unit $30 _,French Ran Sliding Pero:Deer 5it or tit $1395 _Install Interior/Exterior Stops M5 JFO _French flail Siding Polio Door eh. $1496 _Install Interior Casing: Starts Ai S9$ Franah Rail sliding Petlo Door sn $1695 . Ihsulate Weight Boxes. $20:. 1 ,_,_CuslornExtefiorCladding :$15o - Rooffor.BayjBowWindows $500 - _Solar2ons eito or ETC Glass $205 _Existing New Const.Ext.Retro'Ftt $150 _Cv ds Patio Door $149 _Removal of Existing Say(tloty $250 Woodgrein Ddeiiws $295 —Repair Sill,Jamb or replace sill nosing $s0. LLL_6itefior Designer Colors $., -- _ 1. F1r11 Sub-SIT(Single)replacement $150 _MtarlorCasdtq 2rR 3i4 $175 / Mullion Removal, ` $30 , _Hardles•�Opdorrs $. —(New Conversion Ext Retro Fit: $350 ,'.$. . (New Siding Will Not Match); Door Color. / ,, _ tndda words. ,N f,7�1j�N,�L• FOtA1W1„�II�,OWy�lY0NL1�0Aii�8J' Customer declineaL exterior wrap and understands painting and/or.repair may be requ'red InBlal Customer declines grids on windows/doers intUal DISCLAIMExCusmmuisresponsblerotNafcMrwglpcanmotionvbDlhiscoaOract:PaiftStataNg Afarm system discanne aLcancel Building Permit fees b esascat$25.00,HarnaarmeiarMaOeridoAsssclaion latvl;FUstac015hldAprovafChyofBostonpaddngBSldatagcPatmBteesfnoanpeBana (nSlalAtah Customer agrees to a erms o payment as follows! NO_EXTRA WORK N IFNOT I WRITIN,QI; - Bltra Labor B'Materials,:S< i Sife Set Up,Permit,Disposal fl Delivery Fees$' 'S8t139@— /9 �l Sill; TotalAmourit$ custom<ordar oepositsoss s z ck��s. , Balance PAW to Installer 6pon Completion $ O 0 Amount FiLunced 4 —ter/ Wuidow World of Bdsron ardloyates slarW g Ws wodran/ arm bdnp simstaadripy camphted in lays S�ufAj kdetesL Yes No✓ Aay deMft reymred ki id*Cd 6 of the start.ef the giork Sit eliked 31A%dffhe total cOrhtreat pdee pr the acluai cost of arty material of eg7pmeXo a. special order or custom made nature,which must be ordered in advance of fie Od of fie workto assioe thatttie project will proceed on si dealate:fib tint payntera:: shelf be demanded until the donf act Is completed to the sarsfacttorrof both parties. I . AO he=Irnpreveme t conhaatars and.subcontracidis shall be legislated and that ang ingdres about a cmdrad asubeofdractor rilaiN 16 4 repisbedon should W - dhected to:Diffce of CarsrmerAflabs and easiness Regulation,Ten Park Pura,Suite 5170 elision,14A OVIG.'Pborta:(617)9134711 ' 110 walk Shan begin prior to the signing of the cannot and tlaDsiol"al tome over of a copy of suhh cafluact.. tYrdDw ft"dof Boston Oder provision of Chapter.142A o1 the general laws is required to apply far and obtain a.l oonsDuotioo-retatd panels Window World ol. 80mn shall not be deemed respomlblefor delays lathe walk desailled In this agreement caused by rep,lalorX permA granting atfeleies,afdhoritles at Individuals r NoSde:9 the PURCHASER(S)oblaies his owncohairucibnrelatd permits forth work described under Ibis agreamerdm deals viilhumegisteredeonhaetois, IN PURCHASERS)is hereby advised that in the event Of a dispute,Judgement and nofipaymenl,'Ibe,PURCtIASER(S)wgl niit fie;enteteo tomake aclaim or: aapeotian.frdm l0e goaetly lund estabUsh¢d Dy cbep18r142A;k1 G U " You,he,buyer m9T cancel this transaction al any Rate pnorr Io mf mg a he tbtr business ay et The e of M mesa, •oft Notice ol:cancellati0rrmust he Inwrifing pgshnarked no later than fnMntght III the 1161110 ing Wrd business tieµ TNIvindowWdad'hanchise Owned ard Operated h Wlndaw rldotBonon.U.C.underlicensolvarnV ew Vl^Inc: carter.Do n II nfero ere enq Distil spaces.. D IA41"AIA SefesmarcDonot sign Hi afI I blIKspaces. to Ownerf3onotatgrrHlhdreeroerryhlsnkepeees Data" 'eatw oa7 ' White Copy-Original .YeaowCopy"File PlnkCopy Cvstgrner... .-... riayenrarbiriaeescsrrris. - Massachusetts Department or Public Safety Board of Building Regulations and Standards License: CS-072772 Construction S::oerriscr JEFF C STEELE 24 SHERWOOD AVE. .- DANVERS MA 01923 Expiration: iofnmissioner 04/07/2018 G office of Consumer affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR •_ Ei _ Registration: Type: TYPe Expiration: 4/1212018 LLC WINDOW WORLD OF BOSTON,L-C. JEFF STEELE 24 CUMMINGS PARK SUITE 15-A WOBURN,MA 01801 Undersecretary License or registration valid for individual use only before the expiration date. If found return to:Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 ;Not valid without signature 43 ` The Commonwealth of Massachusetts a v Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia «'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Od u 2.{' �j Iazn / r/J SAO LL C Address: l5'H City/State/Zip: 006 n Qma I Phone#: -78 I -q 3 Z - q8 0 5- Are you au employer?Check the appropriate box: Type of project(required): 1.[]3 I am a employer with 5-0 mployees(full and/or part-time).* 7. New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.R I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.E] 10Building addition I am a homeowner and will be hiring contractors to conduct all work on my property. I will - ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�ther W t n Jo�, 152,§1(4),and we have no employees.[No workers'comp.insurance required.] F-e (GI re/, 17 tf j 5 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r Insurance Company Name: (4 F�re Tn s J R fq nl C CO . Policy#or Self-ins.Lic.#: 2. Z WE Crr L ,�;2 a Expiration Date: /- Z 7— IS Job Site Address: Y6 -��i G� (Qnd �j f• City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this s tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi lion. I do hereby cer ' under a pain erjury that the information provided above is true and correct. Si ature: Date: P. Phone#: - �2 - a use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WINDO-2 OP ID: HI ACORD DATE(MNIIDOJYI'"'; i `„� CERTIFICATE OF LIABILITY INSURANCE 05/04/2017 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 1S WAIVED. subject to I the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the 1 certificate holder in lieu of such endorsement(s). PRODUCER COWNP A� Carli Witcher CISR,CBIA,CIC Marsh&McLennan Agency-GSO PHONE FAX 1 3625 N.Elm St Ale Nc Ext:336-272-7161 q)C,No 336-346-1397 Greensboro,NC 27455 EMDAREss:Carli.Witcher marshmma.com C.Timothy Ward,CPCU,CIC INSURERS AFFORDING COVERAGE NAIC i INSURER A:Hanover Massachusetts Bay 22306 INSURED Window World of Boston, LLC INSURER B:Allmerica Financial Benefit j 118 Shaver Street INSURER c:Hartford Fire Insurance Co. 19682 North Wilkesboro, NC 28659 INSURER D i INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TC WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE OLiSUBR POLICY fFF POLICY EXP UNIITS LTR IINSD'WVD- POLICY NUMBER (NIMIDDIYYW) (POLICY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000i MAG RERfErCLAIMS-MADE OCCUR OD6790252708 4/ 112D'7 PREMISES(Ea occurrence rjOO.DOO, ' MED EXF(Arlo one person', 5,000; PERSONAL E ADV INJURY _ 1,000.000! ' GEr"L AGGREGATE LIMG APPLIES PER: GENERAL AGGREGATE S 2.000.000; POLIO`' - ECT LOC "PRODUCTS-COMPIOF AGG S _ 2.000.000! CTHER: _ S AUTOMOBILE LIABILITY y COMBINEC SINGLE LIMIT $ 1,000,000� (Ea acc den ! E n ANY AUTC. _ AW68757615 0616/2016 06!16,'2017 BODILY INJURY(Per Person, i .ALL OWNED SCHEDULED _ AUTOS AUTOS BODILY INJURY(Pei accident? S j NON-OINNEL PROPERT:'DAMAGEiz I HIRE[.AUTCE _ALTOS (Per accidenb i X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 5 2,000,000 j A EXCESS CLAIMS-MADE IOD6790252708 04/01120':7 04/01/2016 AGGREGATE S .DEC) RETENTIONS i WDRKERS COMPENSATION H v PER OT - AND EMPLOYERS'LIABILITY X STATUTE ER C ANY PROPRIETORIPARTNERIEXECUTIVE f< A 22WECLJ2635 01/27/20 1!7 01127WIS EL.EACH ACCIDENT S 500,000 N OFFICERJMEMBER EXCLUDED- �'. (Mandatory in NH) E.L.DISEASE-a..EMPLOYEE 5 50C.000 1'yes.describe under SOC,000! DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached f more space Is required) I - I I i � I i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCF—LED BEFORE I THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH.THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE 1 �(— h i i f C 1988-2014 ACORD CORPORATION. All rights reservec. ACORD 2! (2014101) The ACORD name and loge are registered marks of ACORD + TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION OF BARNSTABLE Map Parcel Application # Health Division °! ' ` E, ?7 �01 Date Issued Conservation Division Application Fee Planning Dept. Permit Fee rl Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner Address c Telephone o, Permit Request ki -`-I.. "3 C. cY`.:r s o!!Z. L Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5,GV Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family O"/ 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 - APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) Name Mike McCarthy Construction Telephone Number, PO Box 52 Address West Dennis, MA. 02670 License# Cell (508) 280-6964 CST -5B633 14IC-1 69393 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY "APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i �• Town of Barnstable °• Regulatory Services SAMRichard V.Scab,DIrector Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 %ww.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property OwnerMust Complete and Sign This Section If Usin�A Rui�dc:r as(?carter of the subject projxny hereby atirhorvx ,d/J to act on my behalf, in all matters relative to work authorized by this building permit application for: Lij A'41L Address of Job) (�Q— ( Ci 3 — V 66 "Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled orutilized befort:fence is installed and all fiml inspections are performed and accepted. ' atone of Owner Signature of Applicant Print Name Print Narne Da Q:FORMS'OW JFRPF_Rht15S1DNPWLti Office of Consumer.Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement CQrtractor Regis tration ' i Registration: 169393 R „ Type: Individual Expiration: 6/16/2017 Tr# 264961 MICHAEL MCCARTHY z` MICHAEL MCCARTHY ` - - .P.O. BOX 52 WEST DENNIS, MA 02670 4sn Update Address and return card.Mark reason for change. SCA 1 to 20M-05/17 Address ❑ Renewal ❑ Employment ❑ Lost Card UlLO CQO'I7Y/920%2GI62GGiL 6�U!/GCIJJQ.C�CG.IP Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to; jrExpI egistration: ; "169393 Type: Office of Consumer Affairs and Business Regulation rationcfil76/2Q1:7 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 MICHAEL MCCAR',AY--'1"i o ,:;<;a MICHAEL MCCARTHY-.;,?1` �; 6 RANGLEY LN. SOUTH DENNIS,MA 02660" Undersecretary Not lid with t signature Massachusetts Department of Public Safety ' u Board of Building Regulations and Standards License: CS-058633 a" a ' Construction Supervisor MICHAEL J MCCARTHY;;. � i F P.O.BOX 52 071Y � y WEST DENNIS MA 026T0 `°✓ Expiration: ' Commissioner 04/10/2018 TE ACCOrR'V CERTIFICATE ®F LIABILITY INSURANCE DA12/072/07/D0/YYYY) � /2015 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 01962-001 NONTACT Bryden&Sullivan Ins Agcy of Dennis Inc ��I}�e,Ext; (508)398-.6060 No•; (508)394-2267 PO Box 1497 %b%s&: So Dennis,MA 02660 INSURERAFFORDING COVERAGE NAIC# INSURER A: A-I.M.Mutual Insurance Company -33758 INSURED INSURER B: Michael McCarthy Construction Inc INSURER C P 0 Box 52 INSURER D: West Dennis, MA 02670 INSURERE: 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 NTH 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. Itty TYPE OF INSURANCE I yP POLICY NUMBER MM/DD/YYYY MN1ID[j LIMITS L n GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE (RENTED $ PREMISES E Hence CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY RCOT OC AUTOMOBILE LIABILITY Ea accidenBINEDt) SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PPRaOPERT DAMAGE $ AUTOS $ UMBRELLA LIAB i OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ yyoRKKDEEEDgS CCppMM RETENTION $ rE.LDISEASE T TU TH $ AND EMPLOYERS�LIABILITY LIIJ1% OER A AONYIPROPRIETQFjt�F�7�(SR/E1(ECUTIVE Y� N/A VWC-100-6017656-2016A 12/15/2016 12/15/2016 ACCIDENT $ 1,000,0OO.OQ (Mandatory in NH) _ `u ED` -EA EMPLOYEE $ 1,000,000.00 ffb9I 8N'�r OPERATIONS below SE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION Cape Light Compact PO Box 427 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable,MA 02630 THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PRO)/ISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �Q 1 Parcel Application #CXlS 166 Health Division Date Issued Conservation Division Application Fee a� Planning Dept. Permit Fee •� Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village Y% Owner C_ Address 5. Telephone Permit Request _ �� a- Lk, 4 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation J�'^u' Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family G✓ 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 (sgft) Number of Baths: Full: existing new Half: existing t -�I new Number of Bedrooms: existing _new p T k Total Room Count (not including baths): existing new First Floor Rogm 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 Mike McCarthy Construction Telephone Number Address PO Box 52 License# West ennis, MA 02670 Cell (508) 280-6964 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 15-A/��' FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. 'y ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT '` :y ASSOCIATION PLAN NO. The Commonwealth ofMassachttsetts Department oflndustrialAccidents 1 Congress Street,Srtite 100 Boston,MA 02114-2017 WWW mass gov/dia + Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE.PERMITTING AUTHORITY. : .. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Mike McCarthy Construction ox Address:_ west Dennis, MA 02670 City/State/Zip: Cell 08)#280-6964 1UC-169393 Are you an employer?Check the appropriate box: • Type of project(required): l,�am a employerwith employees(full and/orpart-lime).• 7. New construction 2.0 I am a sole proprietor or parincrship and have no employees working for me in 8. EJ Remodeling' any capacity.[No workers'comp,insurance required.] 3.01 am a homeowner doing all work myself fNo workers'comp.insurance required.)t- q• ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole ME]Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired Iheaub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurancc.t 13.�❑Roof repairs , 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.12/Other 152,§1(4),and we have no employees.fNo workers'comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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 stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp:policy number. I anion employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. - Insurance Company Name: AV-1 -1, o Policy#orSelf--ins.Lie.#:_ )CIO Expiration Date: _ ►I Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration-page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c:152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t n' s enalties ofperjury that the information provided above is true and correct, Si ature: Date Phone#: (soh\ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): , 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town of Barnstable Regulatory Services Richard V.Scab,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,VIA 0260I www.townlarnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property O) mer Must Complete and Sign This Section If UsingA Builder i, Ql'►q ,as C hmer of the subject ro xn: hereby authorize. i d/J to act on my behalf, in all matters relative to rk authorized by this building permit application for- ' r' ddress of job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilised before fence is installed and all final inspections are performed and accepted. . ' ature of Owner Signature of Applicant Print Name Print Name q Iv ' Da Q:FORMS'OwN'FRPFRMISSIONKX)LS Y .. i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-058633 MICHAEL J MCC.AR . PO BOX 52 s W DENNIS MA 8 67 Expiration Commissioner 04/10/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston; Massachusetts 02116 Home Improvement COnt2'Actor Registration Registration: 169393 s= Type: Individual Expiration: 6/16/2017 TO 264961 MICHAEL MCCARTHY t '7 ra.t MICHAEL MCCARTHY v' P.O. BOX 52 WEST DENNIS, MA 02670 r. Update Address and return card.Mark reason for change. °,.. Address Renewal j Employment Lost Card 20M-05/11 The Commonwealth of Massachusetts Department of IndustrialAccirlents I Congress Street, Suite 100 Boston,MA 02114-2017 y wwlv.mass.gov/(lia Workers'Compensation Insurance.Affidavit:Builders/Cont.ractors/Electricians/Phinibers. TO BE FILED WITH TILE P1 RA1]TTING AUTHORITY. Applicant Information Mike GCarttby Construction Please Print Leeibly Name (Business/Organization/Individual): P® BOX 52 Address: West Dennis, MA Veil(508) 280-6964 City/State/Zip: CSL-586IA30 IC-169393 Are yoq an employer?Check the appropriate box: Type of project(required): 1.lfYJ71 am a employer with i employees(full and/or part-time).* 7. El New construction 2.O 1 am a sole proprietor or partnership and have no employees working for me in $, Remodeling any capacity.[No workers'comp.insurance required.) 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 1 ama homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I.E]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.irtsurance.t 6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.90ther 152,§1(4),and we have no employees.[No workers'comp:insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informalion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. )Contractors that check this box must attached tin additional sheet showing the name of the stub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer llrat is provl(ling)Porkers'compensation insurance for my employees. Below Is the policy and job site Information. Insurance Company Name: Aar/14 MJgJ, Policy#or Self-ins.Lie.#: M,—b'J-6oi 7 Expiration Date: )a Job Site Address: W11 �� City/State/Zip: Attach a copy of the workers compensation policy declaration page(showing the-policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify an Il al s nnr! allies rjury that Ihei information provided above is true and correct. Signature: Date: � 11 r Phone#: Official use only. Do not)write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): , 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other `` Contact Person: Phone#: r WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATR71Q'PA.GE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. VWC-100-6017656-2014B PRIOR NO. I VWC-100-6017656-2014A ITEM 1. The Insured: Michael McCarthy Construction Inc DBA: Mailing address: P O Box 52 FEIN:**7***3862 West Dennis, MA 02670 Legal Entity Type: Corporation Other workplaces riot shown above: See Location. 2. The policy period is from 12/1.5/2014 -to 12/15/2015 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA` B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in`item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000,each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease. $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 0712979 INTER SEE CLASS CODE SCHEDU E Minimum Premium $550 Total Estimated Annual Premium $29,332 GOV GOV Deposit Premium $7,748 STATE CLASS MA 5479 State Assessments/Surcharges $28,601.00 x 5.8000% $1,659 This policy, including all endorsements is hereby countersigned b P Y 9 � Y 9 Y 12/15/2014 Authorized Signature Date Service Office: Bryden &Sullivan Ins Agcy of Dennis Inc 54 Third Avenue PO Box 1497 Burlington MA 01803 So Dennis, MA 02660 WC000001 A(7-11) �l Includes copyrighted material of the National Council on Compensation Insurance, �VV used with its permission. 4 I2(k Town of BarnstAble -Permit# E:rplirt rtf/rt rr rr rtsur dare S PERMIT Regulatory Services hee IRS, f T 22 2012 p Thomas F. Geller, Director Building Division ® N 91TDARNTom Perry,CBO, Building Commissioner ABLE-200 Main.Street,.Hyann is, MA 02661 www.town.barnstable.ma.us Off,oe: 308.8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTI'AL ONLY Not Yalld)plrhoar R&t X-Press hrrpria! Mrap/parcel Nurnbar �. Property Add rest Residential Valuc of Work 7? c) Minimum fee of$35.00 for.worli under$6000.00 Owner's Name a Address � r Contractor's Narhe -�P�4)40 e/) Telephone Number -- Home improvement Contractor License#(if applicable)_ /4n9- Conswotion Supervisor's License#(it°applicable) OWorkman's Compensation Insurance Check one: I am s sole proprietor I am the Homeowner [11 have Worker's.Compensation Insurance Insumnce Company Name �lll Workman's Coirtp. Polley /.f,v/ Copy of lasuranee Compliance Certificate must accompany each permit, Permit Request (check box) YRa-roof(hu.rricane nailed) (stripping old shingles) fill construction debris will be taken to (�Re-roof(hurricane nalled).(not stripping: :Going over existing layers of roof) �] Re-9ide #of doors �] Replacement Wind owsldooralslidars. U-Value (maximum.35)#of windows . iwhere required: txsuanet of this permit does not exempi compliance wt!h other town department regulations,i:e. Historic,Conservniion,etc. yNate Property.Owner must sign Property Owner Letter of Permission. ' A copy of the Home Improvement Conrractors License & Construction Supervisors License is r ulred. SIGNATURE: g%wPfiLEjiFowftuildinspen-nit forms=PRESS,doe. rn;uuNls;noq;lnipflenION f,e;a�aas�apun 2r c'LOW` VY 'H1f10Wb dl� Nl 2i3CINEIAVl 61, \ xoO pinecl r � i1 \ { .: .. ..ON I 'XOO d bQ 9TTZO vw`uo;sog OLTS �. S- Id d OT o{;ejodjoZ)a;enud t+60Z/9Z/£' :uol;ejldx3 a m uze ae uol;eln�ag ssaulsng pue sale33�F'aawnsuoD 3o aau30 :ad�(l L6400 t`=':uoi;ei;sl6a�l o;uan;aa puno33I.-a;ep uol;l;aidxa aq;aiojaq; L:. 21010b211NO3 1N3W3n021dW1 3WOH � v�aaovlr�ajynv�g oi uo asn 1n lnl uI ao3 PtIen uol ea slSaa ao asuaal ; ls� aau30 �J'�°rmooaurruooi a f� � ,i i +� Massachusetts- Department of Public SufetN l Board of Building Regulations and Standards j Construction Supervisor -License License: CS 63537 DAVID.R COX. PO BOX 401 MA 02 664 S YARMOUTH.° Expiration: 10/15/2013 s ` r Tr#: 4314 y wa�• a " t (onmutiswncr # a egg' .. ,,. w • ,: .nri:rsau ry�auurar r-evu v. : 0age 2 of 2 Date:7119I2012 11.43 AIA"age 2 of 2 DAVID-2 OP ID:KG ,�►► �� CEWRTIFICATE OF LIABILITY INSURANCE cc�@tt,ItDoeYVY•J 07/19112 Testa CERTIFICATE IB ISSUED AS A MATTER OR INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE COU %OT AFFIRMATtNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY 7+IE 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 certIfIC01111)holder is an ADDITIONAL INSURED,the P011cy(WS)must be endorsed. If SUBROGATION 13 WAIVED,Subject t0 the terms and candltlww of the policy,csrWn poilolas rray raalulre an endorsernant. A statement on this corfiflcate does not confer rights to the geMBale holder to lieu of such endorsements. PROOMR 806.771-1 F5 NOrtirmwd Ins.Agency,Inc. $40 Malin Strs�,Vulto 8 493.2950 WC. Nyannis,MIA 02M -- INsu A�FartDsac roti�tAce — _+��Inlc a NSUMMA:Travlelers Insurance 4:Om an �v David Cox Inc -- �,ti. �_-- P.0.8ox401 INsuaslta:Pr+coe�siv®casualt+�Ins.Co _ — 3 Ya rm oath,MA 02664 3NSURER C: INSJRiFR G: � -� lZRaRF: — COVERAGP1 CER71FIC4TE NUMBER: REVISION NUMBER: THIS 18 TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To ,-mE INSURED NAMED ADME FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHO,THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE !NSURANCE AFFORDED BY THE PIOUCIES DESCRIBED HEREIN 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIESpLI—MISS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rw VIR TYPE OF N MYGE i POtICYta3RA9ffR Ga�FF T7f�Ci."p �—� r--- WYYYYI (W milr T'_). LIMPS +O>Il4OMLL461LI1Y � I _ I `I— --1!cRCHCyUUJ�PEy_a 5 1,4C0,1�(J A CGINNI-'RCtftGDWRALLIAN.ITY f ¢80l481BR79$ I OW14/12 103M4/13 ( 'E _ I IS I PP.Ei,,11's.S Ea;+c�irrea o' S 01.kMSMAJ'E OCCUR ��si Owner* PERSONAL E:.ACV INJ rY S 1,000,OD - - i vErJE;ZAL aGGREGAM S _2,000, GEM:AGGREC+A'@ JNe-APPLI-1aPFF: i I PP S-COM',UP nG!� 5 2,000 PGL14" AL?OId La LIAaIUTY —T 00( 71 h a.. L. -�-- ._ Es cid9r!t�__ E ® AN!'AU'o ! 0679T783-5 i-� 04119A2 04M$/13 aora_r r.v 5'(Pyrpe,s,,0 ; 259, ALL'W NED SCIIBDU LEC ---—-- -- AUTO'; x AUTOS I ,RODl_r IN.URY Isar acc,o ti ' 1, PAL'Tk' HIR:OAUTOS AVTO I JC V1VED MT 100,0� bS ! rPer aCi Wbnti S IUMSRWAA LIAi OCCUR I EACH O=:JR:CV _ S I @>IC6SBLIAe I CL4mi5.O�AD= I �AGGRE?+TE D �=T -ON 6 gRPtERi C *FN4 TIgN --- ANDlPtfr.CMlRli'LtAiILNY Y I N I FLDISEA% ?A -1✓MEMftF EXI:s JI7FA NrAI I *ACCIbEP:t' s 100,�1�111y11!1 ikMVllt NN1 � xus910X742212 OP18M2 07t16/13 EA3H•EA E:'APL,YEF DES�iiIGTIJN Q RA71 INS 1 -PgLI=V L:Mr: is 60, I i 1I1 I t eCR�TIgN q1 opewrIom i LocA-n t V11MCLO®{Attach ACORD 105,Additional Romttiu Sahaduie,1f room warn Is ra pngii David Coax is not covered by the Workers' C=p. policy CERTINCATE N L ER CANCELLATION TOWNBAR BNOULD ANY OF T91E ABOVE OM1119ED POLICIES Bg CANCELLSQ,BEFORE Town of Sarnsmble TFIa EXPOIATION DATE THERBOP, NOTICE wiLL BP DBLNfaRED IN 230 Main SOW ACCORDANCi WITH THi POLICY PRO1444NIL Hyannis,MA 02601 f, AUrNOPJZr;DItEMOGNTAINE 01006.2010 ACORD CORPORATION. All rights reserved. ACORD 29(2010/D5) The ACORD name and logo are registered marks of ACORD I Town of Barnstable Regulatory Services Tbomas.F. Gatler, Director Building Division Thomas ferry, C30 Butldfng Commissioner ' 200 Main Street, Hyannis, MA 02601 www.town.,barnstsble.me.us Office; 308-662-4038 Fax: 508-790.6230 Property owner Must Complete and Sign This Section If Vsing A Builder i'y. ...•.(`�I�.Si1�llJ �� / .. . as Owner of the subject property �.. _.. . _ . hedby auth®raze �ii?1,�1J� t�D�C to act on my behalf, in d matton rohd ve to work withosiaed by this building perr it application for: (Addtess of Job) n n Z! §;;tuft of won" Date Punt Name If Property Owner it applying for permits please oarrzplets the Homeowners License exemption Form on the reverse Ado, y ?die CvmftIOPr7vetdM ofInk Offlel�iarasacFiuselts T�aparnt�tee�e„f'huftPslt'inl,dcti�lettt e of dtlaasta$'aliom 600 WmIfItirotr Sher Begom,l4 02li-I lip '►6HYlf:AP�'S.j�iDtt��d cis •Warkaer:' p ��x�nC.e Affi slit: Baders/�C'oalaacfoiv%l �:Ins/PlumberIr O"M40 an AMW Ntttau��tpratiaolladi�dtstl}: s ,��rr-/�:'�=• � - Pbone A to e�mpYorw?�t<erle dw app�rnpr ste hou [7. vw of project(required). 1 oyw vPi� 4. d aoa is Poeml cmtmctw sad I Nerov ear trtaoa � �S , ktavt:ttft�tqa mD-eomt�ct�ora 2,Q E,tttt►a hole pco�t�arpte�err 1ittEed oa ttte adta+�od e03tr astd two as edgple xbeee bi°j�° [�Dtttna►t;riau weddq dbt two In eutcyr ply e�2oym�and hIve waafcerac' Q l3stildRtS odditioa tm , �.is� ►F.stoma nca. 5. ® We area and its 3• mo t"ltt�tM6' en'dts all�r�o�Dc ��*bave oao vindtbw .®�"Pirs or add (No .00 ' c:g>,c otf woes p�M�3L 12.[�Roof repairs p c. 132,J1(41 Sod we lm ve as her eqgOys".tXQ wwkw, caamp,ink ] yley WW"OW O*d m boa,Masse 410=004*aecd"$*l er Ube dludr °mwwes#idm q lstbnestSao 1 tP4t0�obemtt tbtte�iaterft�dd�+hey.ra,�a�Q�mdt..s[�ldss oaaodsu�eeaos a�.t t+►tiasm�a�a�dsrlt ,ac.+� tint tteet abeei AM#bat MOM OftOsA es edaty W OM+tom tW smm Gf dw 181bcwArmwi=a seem urasffiae or ao<itM oatttiso hems eire+eenyeei, hM dalr wokoW cam yoXr somber. d Itt➢t pPr �'�peaas►P�tl arar�a'ooara ts��'or eati► '� .$ �P�a�►polSay Rtr,i�ab a�Pa Leteo Coagp�ep►Z+�ietao: �y S ar Sedtbe. as boeto:� ,�l R Jab&*Aid N; 61 ,42yVZZ Cttyistaftop. ANAA is ooff aid*n'eo'wVV'"mepetbee8traopolk7 a6cU"d"-FuP(shOwinS&OPO&7mtraolier oa sv&vaom auto. pLom go mum wrearsip es engouvd seder Smofica 25Aot#AG •r- 152 am had to the itoverii"Ofeewsiml peezebieo Off fte vp to$4M.00 aad/ar Omo-yet°impiammmul,as wesu as oivii peaamee 6a tho foam of o STOP WORK()PJ R Iad a @dad 49 to$210.00 a tky spbw do vick mar. Be mdvJw that a DOPY of this O*emwut my be&ewat&d to*a Ogee of lectirelpPtttawe a�ldae 1�11� a aava:aSe veei�iaa. zdv 01040 thapaAw andAwmawm ry Olaf tins Abo,w to API"deli oa"#ft Dote: '119 tD�lafAl rye►®raps Vv not tvrOAr IN tft aroa,to be evApUted by eiiy or topm oj}'idal CW or Tout Portait/L,lcesmao d Imam/Authority(elyde oae): 1,8esr'd of Vvattia Z.Het"aS Depsrftmt 3.Otyffewn Clerk 4.Elsetrleal buperter S.plua bIftg Ir►apeetor d.O&W 1 ; .� •� V 3�- W6R I , I � N5 1� XIS' t•' � !{ I -�+�+vve � { r i f y © t 1 • - -- , d AI 77, I; $w, rtc#)rliIDrd ' 4 * A Y y i @ i A - i- t s t : v 7r 1 r Sz O ' •: � � � � rt -r7 Ad � -