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Home My WebLink About0056 IRVING AVENUE =CYi NCy '�y� n TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �1 Application # 0�6 forty Health Division�Z3—Iob1 obl�h'� Date Issued Z lO L Conservation Division Application Fee cam_ Planning Dept. Permit Fee o� S Date Definitive Plan Approved by Planning Board SEPTIC SYSTEM MUST BE ` INSTALLED IN COMPLIANCE Historic - OKH _ Preservation / Hyannis WITH TITLE I ENVIRONI1ENTAI 0- AND Project Street Address I/f l�� /RUC TOWN REGULATIONS _a Village Owner Address Telephone (asQ Permit Request / h 1 aw l®� �i /Cc�[�S� L !S21 /3 L Tb G�� ( 9 x 1,99 0mod-1 e- 5 77 iu& /3,q-Fr4 5 0-) Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 115409 Construction Type. Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure-, Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing 7-.7Mw Total Room Count (not including baths): existing new First Floor:Ro om Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air,: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stave: 4Yes ❑ No CD Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: 0 existing,,❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: - x Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use � (�Il- 1 Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name J !/ ►/ �� L Telephone Number Address "/ - License # Home Improvement Contractor# Worker's Compensation # �r> 3 0 l t l ALL CONSTRU TION DEBRIS RESULTING FRO THIS PROJECT WILL BETAKEN TO 07 fi ' �S s ke SIGNATURE DATE �I36 - FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED MAP/PARCEL'NO. ADDRESS VILLAGE OWNER i DATE OF INSPECTION: FOUNDATION . FRAME F, INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 't PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT ' 9 ASSOCIATION PLAN NO. z The Coil monivealth ofMassachusetts Department of industrial Accidents K. Office of Investigations 600 Washington Street h � Boston M-A 02111 w ww.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Zf7J. l Please Print Legibly Name (Business/Organization/Individual): -y y K / ram Address: � '�-�-- City/State/Zip: ff"k"f S . Mt 02&0 / Phone#: (60-V r7 9 , -1�4 l l Are ,yyoou an employer? eck the appropriate box: 'Type of project(required): 1.� 1 am a employer with a0 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. ❑Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' coin insurance.$ 9. ❑Building addition [No workers' comp. insurance p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11.0 ' 3.❑ I am a homeowner.doing all workPlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §l(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. r 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. Insurance Company Name: P47W7?®A.( 'I AI C�O Policy#or Self-ins.Lie.#: ® Expiration Date: �lL/ _ Job Site Address: N Wwb /wC— City/State/Zip: gwm/S �'Or� a Y/ 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 c er the pains and-penalties of perjury that the information provided above is true and corree4 Sienature: Date: Phone#: Official use only. 'Do not write in this area, to be completed by city or town official City or Town: Pe li rmit/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#: ® CERTIFICATE OF LIABILITY INSURANCE DATE,M � 1l25/201YYYI 2012 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). cONT PRODUCER NAME: Erica H.O'Connor HART INSURANCE AGENCY,INC. PHONE (508j 759-7326 FAX (508)759-7366 243 MAIN STREET ArcE-MAIL No PO BOX 700 ADDRESS: BUZZARDS BAY,MA 025320700 INSURE 3 AFFORDING COVERAGE NAIC H INSURER A; ARBELLA PROTECTION INS CO 41360 INSURED EJ Jaxtimer Builder,Inc INSURERB, ARBELLA PROTECTION INS CO 41360 48 Rosary Lane INSURER c: ARBELLA PROTECTION INS CO- 41360 Hyannis,MA 02601 ARBELLA INDEMNITY INSURANCE COMPANY 10017 .INSURER D INSURER E: a 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 ANYREQUIREMENT,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. I�TRR - ADDL SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MM/DDNYYY MMIDD/YYYY A GENERAL LIABILITY 8500042039 01/01/2012 01/01/2013 EACH OCCURRENCE $ 1000000 DAMAGE TO RENTED 300000 COMMERCIAL GENERAL LIABILITY- PREMISES Ea occurrence $ CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 5000 PERSONAL&ADV INJURY $ 1000000 ' -GENE RALAGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2000000 POLICY PRO- LOC $ i B AUTOMOBILE LIABILITY 21662400004 01/01/2012 01/0112013 EOaaccclidentSINGLELIMIT 1000000 .BODILY INJURY(Per person) $ ' ANY AUTO - - ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS N PROPERTY DAMAGE NON-0VJNED Per accident $ HIREDAUTOS AUTOS $ C UMBRELLALIAB OCCUR 4600042040 01/01/2012 01/01/2013 EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2'000'0OO DED RETENTION$ $ D WORKERS COMPENSATION 0053890111 01/01/2012 01/01/2013 V We sTATUT oTH• , + AND EMPLOYERS'LIABILITY. _ ANY PROPRIETOR/PARTNERIEXECUTIVE Y❑ N/A E.L.EACH ACCIDENT $ SOO,000 OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,descnbeunder - E.L.DISEASE-POLICY LIMIT S - 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS r LOCATIONS r VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) t , E - - k ` f CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE. SHOULD ANY OF THE ABOVE DESCRIBED,POLICIES BE CANCELLED BEFORE 200 MAIN STREET THE, EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HYANNIS,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. s � AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD . , f . Office of Consumer Affairs and usiness Regulation 10 Park Plaza Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 110609 Type: Private Corporation + _ w Expiration: . 11/3/2014 Tr# 233027 E J JAXTIMER', BUILDER, INC. ERNEST JAXTIMER . 48 ROSARY LN L HYANNIS,.MA 02601 r pdate Address and return card.Mark reason for change. , Address Renewal F-1 Employment Lost Card JPS-CAI 0 50M-04/04-G101216. „ �"' rCQe License or registration valid nvidu use on Office of Consumer Affairs&B mess Regulation lid f idi l only y n HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 110609 Type: Office of Consumer Affairs and Business Regulation Expiration c11/3/2014 Private Corporation 10 Park Plaza-Suite 5170 ¢° _ Boston,MA 02116 E J JAXTIMER,BUILfDER I_NC ERNEST JAXTIMER 48 ROSARY LN HYANNIS,MA 02601 Undersecretary Aot valid without signature 1 i4lassachusetts --Department of Public Safety _ Board of Building Regulations and Standards C uns!ructiun;Supct'l isii!• License:CS-003251 •ERNEST J JAI-TIlVIER '.- -48 ROSARY WE HYANNIS IVIA 02601 J,�.• /� 1:';. expiration 1 Commissioner 01/14/2014 26196 A Town of Barnstable Regulatory Servicesg rY 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: 509-790-6230 Property Darner Must Complete and Sign This Section If Using A Builder . I n vi lr n G ,as Owner of the subject property a hereby authorize s +1 !'?'2 e r to act on my behalf, ili all matters rclative to work authorized by this building permit application for. ry n a ` 0 2w'�7 (Ad s of Job) Siviature of Owner Pate C(CIO - lhdr Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. ` C:\Usm\deco113t1AppData\Local%Ecrosoft\Wimdows\Tempotary Thtemet Fibs\ContentOutlooklAbV87AAZ\ Vuss.doc D 0.4-A A71 7 1 n PRELIMINARY DRAWING TOWN OF 2,ARINNTA18,!E FOR DESIGN REVIEW II 2012 Nov 39 z AN 9: 2`) ow N NF:W WdOON .. EXIS Door. roeumHE%ler. D Ivi o HALL oP I ' EXIST. T� REMODELED PATIO BEDROOM I bDOw l �yoo k ju6s. N ----_ j I r • 9 j"J I I 4�M7'6' LINEN IAI d I _ Z . ----I NEWF➢78 M1ED • NEWEkQM WICH - �E OIBWINOPAONO NIT Ira:a -___i OONNWA�LLOOA FR HDOORW NEW WARATEFRM _- __, rm WINDOW .FRONT ELEVATION. EXIST. I __ DINING — 9 -- -- - A EXIST. • � EXIST. O NEW GARAGE _ MUDROOM Door. EXIST. Ewn. NEw FRO " KITCHEN DOOR &RA oln FORNWFLOOR ° slDar. maer. . DVr FLOOR PLAN LEGEND: EXISTING WALLS C CONSTRUCTION TO BE REMOVED o NEW CONSTRUCTION REAR ELEVATION SCALE: DRAWING NO.: �NM.dI«.�ro1.N.,d.ed I aF COTUIT BAY DESIGN.LLC NEW ADDITION/REM DELINCB FOR: _ N aw a_ k 43 BREWSTER ROAD �^�� 1/4 —1-0 MASHPEE MA. 02 649 BLADES/ENGELHORN RESIDENCE +v�i+mou m�rm,�.„u, DATE: 1 s�2o/zo�H 5l4606 aAP502392' TOWN OF RARNSTABLE • BAPM • E ;ABLE ! ��, 4s i 1 %639. ' Town of Barns ta�b�e _ Regulatory Services Thomas F.Geiler,Direc Building Division V7 Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 L Property Owner Must Complete and Sign This Section If Using A Builder I I I- Y1 ,as Owr'ier of the subject property hereby authorize M e_f— to act on my behalf, in all matters relative to work authorized by this building permit application for: T�-v n erA (Addrels of Job) J�g J/�7ye il b e Zq, ZO Z SigKature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content Outlook\DDV87AAZ\EXPRESS.doc D o..:—A n71 i 1 o I 4� 'Town of Barnstable *Permit � � Expires 6 months from issue date . Regulatory Services Fee . Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town,barmtable.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 ',� Q Property Address Aco fi 1 /S ❑ Residential Value of Work Minimum fee of$25.00 for work under S6000.00 Owner's Name&Address Contractor's Name t "k!�; �l&. Telephone Number J d Home Improvement Contractor License#(if applicable) / / (/6 Construction Supervisor's License#(if applicable) [21�orkman's Compensation Insurance} Check one: �, ! J y 1 ❑ I am a sole proprietor ❑ I am the Homeowner S 3 s l� M/flhave Worker's Compensation Insurance OWN F BOARNSTAB1 E Insurance Company Name � ' Workman's Comp.Policy# 'bV oo & 110/ d®V q Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) lam'x �e-roof(stripping old shingles) All construction debris will be �b�,qstaken to Qa ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement'1Vindows/d6ors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e..Historic,Conservation,etc. ***Note: Pro rty Owner must sign Property Owner Letter of Permission. �� _ y of the Home Improvement Contractors License is required. ��' � e-��. UU6 SIGNATURE: Q:Forms:expmtrg Revise061306 Department of In Accidents ! f Office.of Investigations d 600 Washington Street Boston,.MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information Please Print Legibiy 'f a]]le (Business/Ora ni zation/Individual): c/ ' cJ • �� Y�� C ' LfQQ address: ''[U F-051u' 'ity/State/Zip: a rl 6 ts, Phone#:: re you an employer? Check the-appropriate box:. Type of project(required): with 3C7 . . ❑ I am a general contractor and I ��am a� employer4 tt 6. New construction. employees (full and/or part-time).* have hired the sub-contractors ❑. . I am a sole proprietor or parer- listed on the attached sheet t ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or_ additions required.] officers have exercised their I am a homeowner doing all work right of exemption per MGL I I-El Plumbing repairs or-additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.2Roof.repairs insurance required.] t employees. [No workers' comp. insurance required.] I3.0 Other F ty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' 3meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. . m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site �rmation. urance Company Name: ,icy#or Self-ins.Lic. #: � 6�! ®/�� - Expiration Date: 1 OI &,�-Ciyl Site Address: U tState :ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).` : lure to secure.coverage.as.required under Section 25A of MGL c. 152 can lead to the imposition.of criminal penalties of a - up to.$1;500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine .ip to$250.00.a day against the Violator. Be advised that a copy of this staternMitt maybe for-warded to tue 01"fice of. -estigations of the DIA for insurance coverage verification: v hereby cerd r the pains and penalties of perjury that the information provided above is true and correct nature: Date: me#: Official use only. Do not write in this area,to be completed by city or town official. A, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing Inspector S.Other ontact Person: Phone#: Client#:2093 2JAXTIMEREJ D.M CERTIFICATE OF LIABILITY INSURANCE 0DATE(MM/D 3/17/08DNYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling 8r O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE -> --- ~- HOLDER.THIS CERTIFICATE DOES NOT`AMEND;EXTEND OR -' Agency ALTER THE COVERAGE AFFORDEDxBY,THE POLICIES BELOW. _ 973 lyanough Rd., PO Box 1990 p „ Hyannis, MAw02601' w ) INSURERS AFFORDING COVERAGE2qr- , NAIC# �. INSURED =' ' ice: t INSURERA: Acadia Insurance?_ i E J.Jaxtimer:Build'er, Inc. wsuRERB: 1 'i ,,�',: ►zi Ernest J:&Marie T.Jaxtimer ; � INSURER C: _ +� 48 Rosary Lane - Hyannis, MA 02601 .INSURER D:$ INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADD' POLICY EFFECTIVE POLICY EXPIRATION LTR INSR TYPE OF INSURANCE POLICY NUMBER DATE MM DD DATE(MMIDDIYYI LIMITS A GENERAL LIABILITY CPA010264814 01/01/68 01/01/09 EACH OCCURRENCE $1000000 N:_C!1M MERCIAL GENERAL LIABILITY ° PREMISES (Ea ocTED $25O 000 CLAIMS MADE aOCCUR MED EXP(Any one person) $5000 PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- LOG JECT AUTOMOBILE LIABILITY w COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS' .-a BODILY°INJURY SCHEbuLEDrAUTOS,«t1,1 A'p` rt _ (Per person) $ I ?7 HIRED AUTOS.. * ..., r .. .., .. S Katy ry' _ Y I BODILY INJURY } NON,OWNED AUTOS (Per accident) $ a= PROPERTY DAMAGE' $- (Per accident) - GARAGE LIABILITY., °`� AUTO ONLY-EA ACCIDENT $ 1 . ANY AUTO OTHER THAN . EA ACC $E AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUA010264914 01/01/08 01/01/09 EACH OCCURRENCE $2 00O 000 X OCCUR CLAIMS MADE' AGGREGATE s2,000,000 $ DEDUCTIBLE $ X RETENTION $O $ A WORKERS COMPENSATION AND WCA0204550.11 01/01/08 01/01/09 WCSLIMIT OTH EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $500 OOO ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLOYEE $500 OOO If yes,describe under ? SPECIAL PROVISIONS below E.L.DISEASE-;POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS t In i Operations performed by the named insured subject to policy conditions and exclusions. J3:1 � W E.J.and Marie Jaxtimer are included under the workers compensation policy. tv ct7 r CERTIFICATE HOLDER CANCELLATION I e t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10_ .DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #51277 LS1 0 ACORD CORPORATION 1988 Board of Building Regula ions and Standards , One Ashburton Place.= Room 1301 a� Boston. Massachusetts 02.108 Home Improvement ,Contractor7!on' 1106 09= Private C poration1 7'11/3/2008 Tr# 24 39E J JAXTIMER, BUILDER, INCERNEST JAXTIMER48 ROSARY LN HYANIVIS NIA 02601 - , , ; � Update Address and return card. Mark reason for change. 7-4-, j Address Renewal Employment Lost Card DPS-CA1 Co 50M-05/06-PC8490 a ✓dieoryivriaad /� y { ��ade ' Y I'i LlI/eCLGL1L � 1 15:.'" Boat d ofiBmidinr Re ulations,and Sta " 1 tuGeb6 # darns r i''SG. ( ! Construction Supervisor License License ;CS 3251Xi- i` p ,�� xptr-.atio5� 1/14/2010 Tr# 13629 _ sM n r f ERNE ST J„'JAXTIn� Y 48 ROSARY "1y HYANNIS MA02601 .t Commissioner r E Town'of.Barnstable ' F1HE�p . Regulatory Services RAXNM X4 * Thomas F.Geiler Director ., �pTED MPS p1� Building Divis1OII Tom Perry, Building Commissioner 200 Main Street, Hyannis;MA 02601 ffice:. 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Seltti'on If Using A :wilder (SSA�� o2 y as Owner of the subject property hereby authorize ��•� •�� it ncto act on my behalf, in all matters relative to.-work authorized by this building pexmit application for: 1010 a6q'% M,4191, (Address ofjob) Signature of Owner Date C.Au Asa ��iSSin,' yV Y) Print Name. • Q:FORMS:oWN-ERPERMISSION