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HomeMy WebLinkAbout0219 HINCKLEY ROAD J a� 9 74;✓CK�7 411 t U I ' .II 1 1 Oxford® NO. 752 1/3 �SSELTE 10% . :F o o TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application.# `�&t Health Division Date Issued B 13/ 441e— Conservation Division Application-Fee I Yb V Planning Dept. Permit Fee ' -11 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address ? ,�� �,�� Village Owner 42444Zf ele Address Telephone Permit Request ,�,I/.� �� a2 FJe e eel A/- o �j � I w,,w jr,S 4= /''d ki'l,601 4AZ feet 4�d Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay DU'LDiNG DEP IT, Project Valuation Construction Type /,!J 70�1,..Oa OCT 2 02016 Lot Size Grandfathered: ❑Yes ❑ No If yes, attaq�s�pperting documentation. Dwelling Type: Single Family , Two Family ❑ Multi-Family (# units) vF BARNS-FABLE Age of Existing Structure Historic House: ❑Yes ,&No On Old King's Highway: ❑Yes ;SNo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other E UiLDING EPT. Basement Finished Area (sq.ft.) Basement Unfiq`iske!ve �.ft) Number of Baths: Full: existing new H. f:�.x new l�Wqi q LE 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`'v_C rg l Telephone Number ;�541 Z J f Address License # f lJ/s Home Improvement Contractor# /6s'3ssL Z Email�J ��/�G�P��,��J�SI �.,�, KC)Ny Worker's Compensation #1&�'t�� 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 r Towel of Barnstable Regulatory SEt''4%ICES FtARVSrAEi�, Ricbard V.Scaii,Director t6 0 Bui ildisig Division Tom Perry,Building Commissioner 200 bilain Street,H-drtnis,-1viA 02601 Wmv.tosrn.barnsfablc-mains Off,= 508•562-40 3 .Fax: 508-7190-6230 Property Ovvn.erMuSt C:oinplete and Sign Tbis Section I, a�c Y t aS77t:1"Cii Lb@ Sl]Ii�ta.';)1i,+7�tlV hCrcbyaurliome �? �.v � 1�..jL` ( 1 f'.j ! tCl CL on m-..behalf. ir.ail LII.`m--s ^:latiae to �vrlc aut�aliaee 3y cizis b ,i slim, permit applie:.tion for: a.O9 VoCkLel k Mdress oz J ou j 'Poo'fc'r_c es and alamnzw aiC Lhe cspozi53t]1lLt}%o1 t.tst: KpplLcart. Pei?1S _ are not to clue filled or uL liled bcforc fen re , ir.�Lit?Icc; ar.jcl-all IS.Pqd 1 i f '2u a ��p Pj ic ajit tt j l'nnt;�ti,nie PIir L ivac>4,: V=i'ii:a l�'��.'�F:�i•'r��.11SaC!�iY{}(:i� � r , The �'o»tmort�veraltlt of Mrtssrtchusetts Deprcrtrrr.ent oflnatatrialAcclrlents 1 Congress Street, Sulte 100 Boston , MA 02114.2017 • WIM Mos.-go v 11 a Irb11'urkers' Compensation Insurance Affldavlt; Bullders/C'ontractors/Electr TO BE FILE,D WITH THE PERMITTING AUTHORITY, iclans/Plumbers, Ilcant Informati n Name(Business/OrganizatioNindividual)' l'' Please Print Le iU1 .._._ i/y .l Address. City/S�ip,"Cock ,�, Phone #; � �.Arc you nn employer? he appropriate boxi I.zi am o employer with ,^ ' employeos(full md/orpart.time),' Type of protect(required) 2.[31 am a sole proprietor or partnership and have no omployoos working for me in any capacity.(No workers'comp, insuranco required.) 7. C� New eonstl�uetion 7.�I am a homeowner doing all work myself rNO workers'comp, insuranco required.)i' Remodeling a I am a homeo+vnor and will be hiring contractors to conduct all work on m 9' Q Demolition ensure(hat all contractors either have workers'componsation insurance or pro rsolo I will 10 Building addition proprietors with no employoes. I I'[] Electrical repairs or additicw.... S,Q I am a general eontrac(or and I have hirod the subcontractors lis(ed on the atleohod shoot. 12,C These sub•contTacstors have omployoos and havo workers'comp, insuranco.r Plumbing repairs or 6 ED we area corporal lon and its officers have exercisod their right of exemptlon per MOIL , 14 Roof repairs 152,§1(4),and wo hays no omployoos (No workers'comp, insurance required.) o Other Any applicant that checks box NI must also fill out 111e section below showing their workers'compensat(on ' Homeowners who submiflhis affidavit indicating they are doing all work and then hire outside contra IConuac(ors Ihal check this box must attached an addi(ional sheet showing(he name of the subcontra policy Information. F employees. if Uic subcontractors have employees, °tors muss submit a now arndavi(indicoting such. they mull provide their �vorkers'comp ctors and slate whether or not(hose enii(ios have /rrnr an employer that is provlrllrrcp workers'eotnpe�rsatton l,rsrrrRrrCe or olioy number, infornmtton f rrry etrrployees, Below is (Ile Insurance Company Name —� P y a,:rl/ob site Polrcy a or Self ins. Lic. Job Site-Address: Expiration Date: Allach a copy of the workers' �n r, $ett ! p on policy doe oration page (sbowing the Policyr numbor-and Failure to secure coverage as required under IvtQL e.•i$2, §25A is a criminal violation and/or ono•year imprisonment, as wallas civil penalties in the form ofa STOP tiyO expiration date). day agairist the violator. A copy d'f,tl;is statement may be forwarded to the Office °n punishable by a fine up to.$1,500 00 coverage verification, ORDER and a fin of up to$250 Q0 --------- of Investigations of the DIA for insurance /rto hereby cart y utrrler the pains ntcrl penalties o f per/ury t/tat 01611(/brtnatlon provlrled above /s true and correct. Si nature. i''�•; ton a. Z� . Official use only. Do-llol svrtte ltt t/tls area, to be completed by city or town of clal City or Town, :I IL6. uing Authority�w Permit/Llcense h�--�— Il oard of Hea b( 2rBuilding Department 3, CI /I'o�ther h vn Clerk 4, Electrical Inspector5, Plumblag Inspectortact Person; Phone dI jl Massachusetts Department of Public Safety Board 6f Building Regulations and Standards s License: CB-100906 Construction Supervisor. � HENRY E CASSIDY�c 8 SHED ROW �: .I r! r�J'\ WEST YARMOU;YH Expiration: Commissioner 11111I2017 I l�t3arG�12 c?4 r s Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite S 170 Boston, Massachusetts 02,116 Home Improvement COnrtractor Registration Reglstratlon: 153557 Type: Private Corporation ' Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE SO, YARMOUTH, MA 02664 ; r.''Upda,te,Address and return card, Mark reason for chnnge. $CA1 4, zoMosru (] Address ❑ Renewal CD Employment U L,ostCgl.c �ce amr�)oe�uver�/G/o�'O/G�rWaa.c�udolt`o \ orncc•o.rConsun)cr Afrnlrs& 130s111ess Regulntlon Ucense or registratlon valid for Indivldul use only OME IMPROVEMENT'CONTRACTOR before the expiration date,'If found return tot eg.lstratlon: '40007 Type: office of Consumer Affnlrs and Business Regulation j xpirallon;:;:;1;1;4:5/20.1.6 Private Corporation 10 Park Plaza •Suite 5170 � •.•: ;�..., Boston, MA 07116 CAPE COD INSUTATa'ON:;:INC'..•; HENRY CASSIDY ie REARDON CIRCLE._ . 50. YARMOUTH,MA 02664 Undersecretnry 9- y id WI lit sign •e "�� CAPECOD-27 CLEDDUKE CERTIFICATE OF LIABILITY INSURANCE DATE 7/1/2 DIYYYY) 7/1/2016 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 NAME: CONTACT NBarbara DeLawrence NAME: Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/c No Ext: ac No): South Dennis,MA 02660 AI DRRss,bdelawrence@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company INSURED INSURER B:Safety Insurance Company 39454 Cape Cod Insii{laf)on,.� o". }' ` INSURER C:Endurance American Specialty Insurance Company 41718 Inc.;"=?°';;.,: 18 Reardon Circle INSURERD:Atlantic Charter Insurance Company 44326 South Yarmouth,MAA2664,. INSURER E INSURER F: COVERAGES CERTIFICATE`::NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THEPOLICIES OF;INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY;:;REQUIREMENT .TERMzOR,CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY,PER FAIN THE-INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUGH::POUCIES LIMITSISHOWNiMAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE °' INSD NND POLICY.=,NU.MBER MMIDD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY q r EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR CBP8263063 04/01/2016 04/0112017 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 s +` PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIE$;PER GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- PRODUCTS-COMP/OP AGG $ 2,000,000 JECT LOC t $ AUTOMOBILE LIABILITY 7=7COMBINED SINGLE LIMIT + Ea accident $ 1,000,000 B ANY AUTO 6232707 COM 01 '" ` 04/01/2016 04/,0,1/2017 BODILY INJURY(Per parson) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED "+ k' PROPERTY DAMAGE gUTOS ' $ Per accident X UMBRELLA LIAB X OCCUR 2ACH OCCURRENCE $ 2,000,000 C EXCESS LIAR CLAIMS MADE EXC10006635001 04/01/k16 04/01/2017, �AGGREGQTE $ 10 000 DED X RETENTION$ t '_Aggregate_ $ 2,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN o- CE00431902 ` , 06/30/2016 06130/2017 "E 4rE?CH ACCIDENT'. $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A - (Mandatory In NH) , c E.L.DISEASE EgEMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below a ' r v. E.L.DISEASE-POLICY LIMIT ;$> 1,000,000 r DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLE$ (ACORD 101,Additional Remarks Schedule may be•attached If more space is required) .,. Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liablllty-wiien required by written contract or agYeementwith the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE V 1g u)Iders THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN 94A CO erce Park Sokth ACCORDANCE WITH THE POLICY PROVISIONS. Sou hatham,MA 02659",,,.. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD n R - 0 OF BAP1N STAb- CAPE CW INSULAT10N`i [ E - it : . 9 L PIBlR OLp39 3[AMlR99 SPRAY FOAM AUSDENOED BATTS GUTTERS INSULATION CEIliN05 1-800-696-6611j't, Town of Barnstable Regulatory Services Building Division ` 200 Main St € Hyannis, MA 02601 " Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below...Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has.been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal &State Requirements. - Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes' Floors/96-�es ( X)` O-. ( �� ) • ( ) - ( ) I • Walls ( : ) ( ) (_ ) ( ) ( ) Sincerely , Wpeod dry Jr, il esident sulation, c. i a i ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION L - Map to Parcel Application # 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 AM 410 c_W'-- ( l t� Village t� f Ati OV& 1 Owner I.—O CAOCJ \eS- Address Telephone S DT, 9 S -7^ 91 7 Permit Request ►1AA0A-cotJ/ tw,> 1 u Cellu)oe_ 4-o 46M,—ProAq Vn k e is S;11 P)64--5 Alysr'e-I ✓gAtc_ Ai+Y_"►-e.,t /LA��q Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0100 Construction Type r� f'�NS�•� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family t ' Two Family ❑ Multi-Family (# units) Age of Existing Structure 19 S `t 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 CD Number of Bedrooms: existing _new ; Total Room Count (not including baths): existing new First Floor�Boom Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woodcoal stone: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑:existing cU neuW1 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 CAae. Ca Telephone Number SDT-7?S-1a l q Address SS AS • License VH&I-AIn /ntq• D"o Home Improvement Contractor# /S3 S-7 Worker's Compensation # 'tuc ( sgS s9'41 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR /`�— DATE �� FOR OFFICIAL USE ONLY K. APPLICATION# DATE ISSUED ' MAP/PARCEL N0. ADDRESS VILLAGE x OWNER. i DATE OF INSPECTION: FOUNDATION s FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. R Test a; Rreet L �' '- �. NCE Ii[14ERt:�� & HOTNi REPAIR T {✓�J tT•) �! 400 F (51 � �7Jil-24 5 'L' 1'L D d d^�.'„y'� k �a a Oa�t A`'��d'k r l���`t '117 on all,1 ae5 wJd;�ffF,i?c7f G?fi 1 3z Lre .G3J`v HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. I ' -A ;' ' _:f'r hereby consent to and agree that weatherization work maybe done by the Weatherization Program of Housing Assistance Corporation ( herein after referred as "Agency") on the property located at: ' �, The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some•of the following measures: Weather-stripping&caulking of windows and doors,insulation•of attics, sidewalls &basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency" its agents and employees to travel onto.or across said property with such equipment and M- aterials as may be necessary to perform weatherization work on said property: ` 2. The Housing Assistance Corporation reserve`s the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization" work is completed. - I have read the provisions of cement a listed and freely give my consent. w 'Home Owner: (Signature) '' s Date: `' .. ,( ,✓_ r' Agent: (signature) Date: r'\ .. HAC approved Weatherization Company: ��LJ/41� Caliber Building&Remodeling Cape Cod Insula ' Cape Save Creswell Construction Frontier Energy Solutions Lohr& Sons Peter Smith Resolution Energy - Rock Solid Construction + All Cape Insulation . .+;.Lj--tiil1-•=:i;=!lC.i_•,!05{ii.1i :1?I':ri'(i:_:v�l:il::a.iE2iti8 C•:..{.l' r ••,�•-••• •r-i..� +u..o. ii.�o na, iV; Y'iOVGrronraD Rogers & Gray ins. rage: uuz Client#:4597 CCINSUL '-~aCORD,M CERTIFICATE OF LIABILITY INSURANCE D;E(WDDNYM 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 WANED,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 N CONTACT Name: Margaret Young Rogers 8 Gray Ins.So.Dennis PHONE 508-760-4602 434 Route 134 A1C No Ext: AlC,No: 508-258-2102 P.0.Box 1601 ADDRESS: youngma@rogersgray.com South Dennis,MA 02660-1601 CUSTOMER ID 9: INSURERS)AFFORDING COVERAGE NAIC N INSURED Cape Cod Insulation Inc INSURERA:Peerless Insurance 18333 455 Yarmouth Road INSURERB:Ohio Casualty Insurance Company Hyannis,MA 02601 wsuRERc:Atlantic Charter Insurance INSURERD:Commerce Insurance Company 34754 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE SR POLICY NUMBER MM/0D EFF �DCY EXP LIMBS A GENERAL LIABILnY CBP8263063 04/01/2011 04/01/2012 5PREMISES CCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY a occurrence) $100,000 CLAIMS-MADE 7 OCCUR - P An one rson ( y pe ) $5 000NAL&ADV INJURY $1,000,000ALAGGREGATE - $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO Lac $ D AUTOMOBILE LIABILITY 11MMBCKVMK 04/01/2011 04101/2012 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILYINJURY(Peraccident) $ X.HIRED AUTOS PROPERTY DAMAGE(Per accident) $ X NON-OWNED AUTOS - $ B UMBRELLA LUUi X occuR 0001254514645 04/01/2011 04/01/201 EACH occuRRENCE $1 000 000 EXCESS LIAR CLAIMS-MADE DEDUCTIBLE _ AGGREGATE $1 000,000 X RETENTION 10000 $ C WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WCA00525902 06/30/2011 0613012012 X WC STATU• ORTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN LIMIT $SOO,000 OFFICERIMEMBER EXCLUDED? WA E.L.EACH ACCIDENT (Mandatory in If yes,describe under E.L.DISEASE-EA EMPLOYEE s500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 71 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) Workers Comp Information Included Officers or Proprietors (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2609109) 1 of 2 The ACORD name and logo are registered marks of ACORD #S68575/M68179 MEY i The Commonwealth of Massachtisetts' .r Department of Industrial Accidents Office of Investigations 600 Washington Street l Boston, MA 02111. . yy www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `Please Print I.,e ibly Name (Business/Organization/Individual):_CA tP .5V (' 1 -t j f04 S,J(' Address: ►�' Ci /State/Zi ty p: � t Phone #: 5-0 'oc- .-M -- j � Are you an employer?-Check th appropriate box: Type of project(required): 1.[� I am a employer with 4. ❑.1 am a general contractor and I —ZQ 6. ❑New construction eingloyees(full and/of part-time).* have hired the sub-contractors 2_❑ I am a sole preprietor.or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for mein any capacity. employees and have workers' No workers' comp. insurance comp. insurance. $ 9. Building addition requi red.]ui 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions q l .3.❑ 1 am a bomeowner.doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself.-[No workers' comp: - right of exemption per MOL 12,0 Roof repairs insurance required.] t. a 152, §1(4), and we have no employees. [No workers' 13.7 Other 6Ag4k14,;EQ t I Qh comp. insurance required.] "Any applicant that checks box C must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have cmployccs. 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 informatiots Insurance Company Name: f("44z, rJA _n Sul/'/eXe Policy 4 or Self-ins, L'ic. )C-4 6orz's-9 o t Expiration Date: TO /I;L Job Site Address: a(C( i L) COW—V i City/State/Zip:4VAL)M`S MR• 62-169\ Attach a cop} 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 a 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.. Ldo hereby certify u e pa' and penalties of perjury that the infortnation provided above is trice and correct. Si nature: Date: Phone#: Official use only. Do not write'in~this area, to be completed by city or town official City or Town: PermitJLicense# 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#: 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement CoAtractor Registration Registration: 153567 -J Type: Private Corporation - Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY .. — -.--- --- _- --- 455 YARMOUTH RD. HYANNIS, MA 02601 -•;Update Address and return card.Mark reason for change. Address (] Renewal (l Employment (�-] Lost Card 1 S-CA1 ^v 50M•0Q04-G101216 as ae egu lion License or registration valid for irdivide:l use only Office o mer Affairs R l before the expiration date. 1f found return to: HOM Office of Consumer Affairs and Business Regulation Registration: 153567 Type: - 10 Park Plaza-Suite 5170 Expiration: 12/15/2012 Private Corporation Boston,MA 02116 a OD INSULATIQJN;IN;. C.:•_•, HENRY CASSIDX:; ::.::•:` ,-• . .i.s 455 YARMOUTH HYANNIS,MA 0260d''i; ;- ._ Undersecretary t alid ith t si ture ' N—lassachusctt>- t)rpartnlrnt of PUhlil• SafctN Btturtl tr#'Building Rr�guiatiun.ants "Itartdards CoPstruction Supervisor License License''CS 100988 Restricted to:. 00 ri t HENRY CAS SIDY ?f 8:'SS'HED ROW « ,�•'::��� Vt/1_ST YARMOUTH, MA 02673 �, ' ;�::''' Expiration: I i/11/2011 - 4 u�ini..i„n�•r• Try: 100988 i Town of Barnstable Approved Regulatory Services Fee Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Date: U Home Occupation Registration � Name: Dp�'\i/\t Phone#: SC2 j - 2-7 —c��3�► Address: he G Village: � i a✓►V\t Name of Business: Q 0t���Y\ 4e)fA Type of Business: �(� �+^G Map/Lot: �0 ,> '1 Zoning District Zoning Districts RF and RC-1 require Special Permit from Zoning Board of Appeals. INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the (� following conditions: `� • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will'be generated in excess of normal residential volumes. The use does not involve the production of offensive noise,vibration, smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials, or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have a agree with the above restrictions for my home occupation I am registering. Applicant: Date: Homeoc.doc s TO ALL NEW BUSINESS OWNERS DATE: Fill in please: f APPLICANT'S r °r YOUR NAME: BUSINESS (' YOUR HOM&ADDRESS:-� + j 0 C TELEPHONE Tele h ne Number Home .��j.rro) NAME OF NEW BUSINESS %� -s-OW 16 PE OF BUSINES v� i IS THIS A HOME.OCCUPATION? ES _ O�J_ Have you been given approval from tl e buil ing division? YES� NO j4 �c ADDRESS OF BUSINESS ftk VA"Ok MAP/PARCEL NUM;1BER 1 o When starting a new business there are sevc;ral t ings you mu t do in order to be in compliance with the ales and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained le required signatures, listed below, you may apply for a business certificate at the Tov;n Clerk's Office (Ist floor - Town Hall) or if you get the business certificate first you MUST go to the following office to make sure yo- have w;; ',lie required permits and lice-.ses.. GO TO 200 Main St. - (corner.of Yarmouth Rd, & Main Street) and you will find the following offices: J 1. BUILDING COMMISSIONERSO ICE This individual has be nformed a y permit requirements that pertain to this type of business. Au orized Signature" COMMENTS: 2. BOARD OF HEALTH This individual has,;Ti�, r'ern rnf e of the permit requirements that pertain to this type.of business. Authorized Signatu e' COMMENTS: N6 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informer: of the licensing requirements that pertain to this type of business. Authorized Signature" COMMENTS: Business certificates (cost $20.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town' (which you nest ! do by M.G.L. - It does not give you permission to operate - you must get that throu�'i completion of the processes from the various departments involved. '° "SIGNIFIES APPROVAL FOR A BUSINESS CERTIFICATE ONLY.