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0722 MAIN STREET (HYANNIS) (9)
(jr�uaL Sn� r � a i �9�/�y34,a37 �f-elms S� ' Town of Barnstable Building Post Th�sGard So That�t'is Visible,From the Street Approved.Plans Must`be'Retamed on Job and=this Card Must be Kept PostedUnti!Final Inspection Has Been Made � b q �3 °` ,where a Cerfificate;of Occu anc s`Re'"u�red`such Bu ldin s all Not be Occu ied until a:Final Itts ectiort has b"een made Perm*l 1 -�� _ �.� Permit No. B-17-4232 Applicant Name: CARLOS`H FIGUEIROA Approvals ' Date Issued: 12 06 2017 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 06/06/2018 Foundation: Location: 724 COMMON AREA MAIN STREET(HYANNIS), Map/Lot 308-283 OOA Zoning District: Sheathing: Owner on Record: ZEGER,JOEL E TR 5 s Contractor'Name: uCARLOS H FIGU_ EIROA Framing: 1 Address: PO BOX 1979 - Contractor License CS 104107 2 r MASHPEE, MA 02649 Est Protect Cost: $6,000.00 Chimney: Description: RE-SIDE PART OF BUILDING Permit Fee: $160.00 Insulation: Project Review Req: Fee Paid:, $160.00 Date 12/6/2017 Final: Plumbing/Gas k � Rough Plumbing: Building Official Final Plumbing: 4r This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and tho?approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. W Electrical SV OT The Certificate of Occupancy will not be issued until all applicable signatures by theipuHding and�ire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: ` ' y Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION loo? /�� ( — Map Parcel 1JJ Application Health Division ® ` Date Issued 06 /� Conservation Division � Appli a i Fee Planning Dept. Permit e Date Definitive Plan Approved by Planning Board m _ - — �rnq/G Historic - OKH _ Preservation/ Hyannis 0 Project Street Address 7 Village l G/ /t/✓- l^ S Owner LWAddress Telephone r 4 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation G - 0U)Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number -� 3 1 FS Address Z� C tti�— ����7 Al License Ze l G Home Improvement Contractor# 7 7 Email Worker's Compensation #,-W(-, -701.) ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 11� FOR OFFICIAL USE ONLY APPLICATION # v 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. r: I � 1 Commonwealth of Massachusetts y,�r Division of Professional Licensure V Board of Building Regulations and Standards ' Constr4tt—IMN S rvisor CS-104107 , Fires: 08/25/2019 A CARLOS H FIGUEIROA 20 CAPTAIN N ES4lD k w SOUTH YARMOITH Commissioner The Cormriromreadth of M'assadliusetts Department of rndustrzal Acddez& Office a,f IrnVes4adons 600 Washington S6wet Boston,AA 02111 wren masmgovIdia Markers' Camzpensatian Insurance Affidavit:BuilderJCuntractars/Mecbiians/Plumbers A Ucault I]>forinatian Please Prm bl N.fRnsin�ccg��� (� Address: Cij/Statef is 41 Phone Are you an employer?ChecktAe appropriate box: ' Type of project(required): 1.❑ I am a employer.witlr 4. ❑ I am a general contractor and I 6. ❑New oonsfzucEian employees(fu11 anNor part-limed* 'have hired the sub-coatrac-toss 2.al am a sole proprietor orpartaw- listed an the attached sheet 7. ❑Remodeling ship and have no employees These sub-confractors have g_,❑Demolition wading for me in any capacity. employees and have workers' [No wadcers'coup.msura„ce comp-msuranml 9. ❑Building additica requiied] 5. ❑ We are a corporation and its 10!❑Electrical repairs or mans officers have exercised their 3.❑ I am homeowner doing all work 1L❑Plumbing repairs or additions o workers' right of ese� 12 Roof repairs. per MGL repairs i re a d-]T c.152, §l(4)6 andwe have no employees-[No wo&em* 13-❑Other cop-insam=required-] *tYrcy appHcsat&atcherJmbox ff1 nmst also EUoE1the section belawshowug ibeirwader'compenm&n Perky inE=Mxtion_ t Hamemaem wbo submit this afiidatdd n feeding they axe chino ati weak aid&ea hire ou=&contmctors— submit a new affidaest indieatmg sacTi fContactprs*&check this boa m=sttache d an additional shed sbouing theaame of&a sob-coatmcts=a stye whether or not ftse emidu brae employees.If the sob-contactan have employees,dLey amsr pmnide their workers'romp policy numbez I am an errtpia,�rr flerrtisprauieiircg workers'cot�rensrrlirrn ites�irartce,for:ors*enrpiny�ees �e�ity it Elie policy anri jab site infornrezfian. . lmsuraaceCompanyName: A— ,— Policy#or Self-isss Lic. 44(,y G 400 3 d M-q-�q )0I 4 A Ekpiration Date: -O 3�/ Job Site Address: \/,d/,yyr(City/StRW;?�p: /A-4u Attach a copy of the workers coanpensationpoHcy declaration page(shaving the policy numb and expiration date). Failure to secure coverage as requiredunder Suction 25A of MGL c-152 can lead to the impositim of criminal penalties of a fine up to$1,50Q0Q andlor one-year imprisonme t,,as we11 as civil penalties.in the form of a STOP WORK ORDER and a fine of up to$250-0Q a day against the-violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofthe DIA€or insurance coverage verification. Ida ken aby esrlrfy u) tha pains andperrrafties tafpesrjury thatHis informatimrprvn i Waben a ik bare and correct Sit udare: Date: d Phone ik Oocial um only. Do not write in dais area,to be compfetesd by city artown aficial. City or Town- PermitlLicense# Issuing Authority(curie one): 1.Board of Health 2.Building Department 3.Q yfrown Clerk 4.Electrical Inspector S.Plumbmg Inspector 6.Other Contact Person: Phone 0: ° ` formation and Instructions Massachuseft G eb=g Laws chapt r M requires all empIoyers to provide WC6-,='compensation for their e :rpIayees- Pmsrrantto this statute,an employee is deemed as.'—every person in the service of another under auy contract of hire, e cpress or i mpIiech,oral or s Air err p&yer is defined as"an incliYidna.I,partnership,aWDdad6m,corporation or other legal entity,or any two or more of the fzsregoing engaged is a Joint enbrpase,and iaclndmg time legal j=preseutaiivm 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 horse having-not more than three apartments and who resides fhmmin,or the occupant of the - dw Ui g house of another who employs persons to do Mafitmancq,congk7ac(ion or repair work on such dwelling house or on the grounds or building appartenatrf thereto shall not becanse of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also stales thmat'every state or local licensing agency shall withhold fhe issuance or renewal of a license or permit to operate a business or to construct buildings in the commoawealfh for nay. applicant who has not produced acceptable evidence of compliance wifh the nsm a_nce.cove-rage required." Ad ditdonaIly,MGZ chapter 152,§25C( )states"Neither the commonwealth nor ally ofifs political subdivisions shalt EM mtD any conirart for the perlbmmanee ofpnbho work uabI acceptable evidence of compliancevAifi the insmanCE.. rez m cnfs of dais chaptEr.have Been preset to the contracting avdhority." Apphcamts Please fill out the workers' compensation affidavit completely,by chwJking the boxes that apply to your situation and,if necessary,supply snb-contia r(s)namne(s), addri ss(es)and phoneme— ex(s)along with theirceriificate(s)of n. ce. Limited Liability Companies(LLC)or Limited Liability Partnerships(I.I P)wifhno employees other.than the members or partners,are not rimed to carry woAcros'compensation insurance. If m LLC or LLP does have employees, a policy is required. Be advised that this affidayit maybe submitttd to the Depa-Lt a mt of Industrial Accidents for confamaiion of insurance coverage Also be sure to sign and daft:the affidavit. The affidavit should be r,t =,—,d to the city or fawn the the application for the permit or license is being rcgnesl5d,not the Department of . Indnstrial Acci enfs_ Shoutdyou have any questions regarding the law or ifyon are required to obtain a workers' compensafion policy,please call the Departmert at the number lisind below. Self-msared companies should enter their self-7T sma ce license number on the appropriate lime. City or Town Officials f - Plmse be sure that the affidavit is complef$and pre 3t d legibly. The Department has provided a space at the bottom of the affidavit for you to frill out in the event the Office ofInvestia ons has to co>mlact you regarding the applicant. Please be sine to fill in the permit/Iicemse munber which will be used as a reference mmnber. In addition,au applicant ffiat must submit mnultrpIe p ezanit/hcense appht Ehons many given year,need only submit one affidavit indicating cua-ent policy informationn(ifary)and under`Job Site Address"the applicant should wuta'aIl locations in (may or town).—A copy of the-affidavit that has been officially stamped or mamiced by the city or town may be provided to the applicant as proofthat:a valid affidavit is on file for fufine'pemi!s or licenses A new affidavit must be filed out each year.Whew a home owner or citizen is obtaining a license or peinnit not related to any business or commercial ventiue (i.e. a dog license or permit to bum Ieavm etc.)said person is NOT required to complete this affidavit The Office OfTUVeStigatiOnS would Irke to thank you in advance for your coopm-aflon.and should you have any questions, please do not hesNte to give us a call. The Departm enfs address,telephone and fax number Thu, tt1 of MassachLUSCM Departmmt of 1udustdal AoDideat% Office of XnVft%V9WO-= Bad MA(M I I T(,-L 4 617' -4900 cxt 406 car 1-977 MA SSAFE Fax#617 727'74 Revised 4-24--W � v� f °F r Town of.Barnstable ti Building Department " STABLE M,+as. Brian Florence,CBO 059. Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This.Section If Using A Builder I, �iaeL �e(o'CR re e— p , as Owner of the subject property hereby,authorize G XeM 0410/N.G to act on my behalf, in all matters relative to work authorized by this building permit application for: Al 92 (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature o n Signature of Applicant u �-� Eeqg-C" Print Name Print Name Date Q:FORMS:OWNERPERMLSSIONPOOLS Rev:10/17 Town of Barnstable F'THE rqk� Building Department r o� Brian Florence CBO Building Commissioner snRtvsrns�. . 200 Main Street, Hyannis,MA 02601 039. ArFD MA'tp www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LACATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: y city/town 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 HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there 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 constructs more than one home in a two-year period shall not be consideied.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 hermit. (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 he/she understands the Town of Barnstable Building Department minimum inspection.procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official a 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 homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 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 with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. r `""F0.`� � � ,«�'� r�t F ' \. �t'�" �" '�'� ,� �v `t5,•. 33 sa �, wavy*rs ,wmm� s { s�.,?', ., � :`SnN i 3 irv�.F �1 i �'g I e; JisvisionslimagesI00 j16�56 j47.jP9 :»W:<x... .:,<«�a-t ,,,�_,..�,.-.xw�xx .,»;,,:..�.....w»r�,......,,,; :x-�...ro ,..w,.,.HA.ir >•,.:.a.., rrx::...:.m:.. r...-..aw.:>...,:»:,» x �.m.....,......�,.....;....:.,...:,.��....,,,,.:,.�..�._�.,,,,.. ,..a,,,r�..<...:..... -,... ....,.... ..k ....,.. .....»..,.�,..»».a-,.,.-.�«« .....r...�..»..,-...,...,r...M..,..,..,.,,,.,.m..�.,,. ..,.N..nr. .....-,...,.-e»,...yw..,,..s,,,..»�e,,.e. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates f cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does:not.give you pecrnission to operate.) You must first obtain the necessary.signatures on this form at 200 Main St., Hyannis. Tape the con ple[eeJ form to the T iwn,Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 076.01 (Town-Hall) and get the Business Certificate that is required by law: " DATE: RV AD/ Ito . Fill in please: APPLICANT'S YOUR NAME/S'.: S�LeI� IC� _1. CCU f�D BUSINESS YOUR HOMEADDRESS:JQ -DDT i 'DE � , f�(An17UG .t ►�1 ��S •i s fa y' f riy rcvv� 1�5(I 'l"!-•1 A Tr-h i S •'(�12MwT ti,.r TELEPHONE # Home Telephone Number�0 fS 3RS-(5Sa r i E-t11kILc 61k tSJ )n O1�1a0 NAME OF CORPORATIONtN� d} SDt. 0 U7rb. NAME OF'NEW BUSINESS % oK NASSA6-ETHEWfA-,5t1N (AiZE TYPE OF BUSINESS HAS IS THIS A HOME OCCUPATION? YES NO x�1 ADDRESS OF BUSINESS. a S L H CN ELS l 4 HAI1� 5 MAP/PARCEL NUMBER W [Assessing) When starting a now business there are saveral'things you must do in order to bean compliance with the rules and regulations of the Town of Barnstable. This harm is,intended to assist you:in obtaining the:information you may€deed.: You:MUST GO:TO 200 Main St. - [corner of Yarmouth' Rd. &.Main Street) to make sure you.have the.appropriate permits and licenses required to._Iegally:operate your business in this town. 1. BUILDING COMMISSIONER' OFFICE This individual has been i or of any al requirernems that pertain to:this.typa of business. uthor Signa . re* COMMENTS zcl U 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This Individual has been informed of the licensing requirements that pertain to this type of business.. Authorized Signature* COMMENTS:. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the cot nplet.ed form to the Town Clerk's Office, 1 st. Fl., 367 Main St., Hyannis, Mid 02601 (Town Hall) and get the Business Certificate that is required by !aw. fi DATE: `�2 Fill in please: s. t, N� �' " APPLICANT'S YOUR NAME/S:� TT MN �IN, �`� BUSINESS YOUR HOME ADDRESS: j I O cJ e-s-I— Lj�u� <4-. ,��- �ci yi 1-9: � TELEPHONE # Home Telephone Number ,5 - q,'5' —2�7 g 0 NAME O.F.CORPORATION: 0 NAME OF NEW BUSINESS �' A�TYPEAF BUSINESS IS THIS A HOME OCCUPATION? YES " NO 'HENN S OF'BUSINESS .' MAP PARCEL'"NUMBER ^ '' �. As i� When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd.&Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1: BUILDING CO MISSION R'iS OFFThis individ I ha d y pe mi requirements that pe ain to this type of business.' Aut d S' natur COMMENT v I .oriz R Co "Q d 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** . COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664t3 Tel: 508-398-0398 Fax: 508-398-0399 3/26/12 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 724 Main Street,Hyannis has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-30 cellulose All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ® � Parcel of 8 3 Application✓ Health Division Date Issued IfConservation Division Application Fee 6� Planning Dept. Permit Fee 0 Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address �c�W (,�,1 e Villa9 Owner_ 7Oe 1 Zaaeef Address �BX I fee, Telephone Permit Request A da R- 9 c e Il w I Ase -�-d l o n r ; 9 �= her OV-S to ©P&A r` er a,nd Walls . �- 3 0 004105e -to &+V 0 a,(\d Square feet: 1 st floor: existing proposed 2nd floor: existing proposed _ Total new Zoning District Flood Plain _Groundwater Overlay Project Valuation ' gb Q Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ® Two Family Cl Multi-Family (# units) Age of Existing Structure 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 Number of Bedrooms: existing —new Total Room Count (not including baths): existing _ _new First Floor Room CountM-�" O Heat Type and Fuel: ❑ Gas ❑ Oil 0 Electric ❑ Other _ -- Central Air: ❑Yes 0 No Fireplaces: Existing New _ Existing wood/�oal stove; ❑Yes ❑ No .: Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing i+nesize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: v, M Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial X Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) c o p Name ��I��01�(h Mc, Llej CAte 50WO Telephone Number _ JO�1�3gg��390 Address vo+i ton pry-8 License # M C 0 of� _50wA L Ot.�°f)0(�,�'h��R�a6 Home Improvement Contractor# 1 �� 3 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO �aC Mom} SIGNATURE DATE 3 FOR"OFFICIAL USE ONLY APPLICATION# T DATE ISSUED s� MAP/PARCEL NO. — r _ f ADDRESS VILLAGE . OWNER r DATE OF INSPECTION: i FOUNDATION FRAME r INSULATION: t. FIREPLACE f ELECTRICAL: ROUGH FINAL i '1 PLUMBING: ROUGH FINAL t GAS: ROUGH a FINAL , FINAL BUILDING'' DATE CLOSED OUT t ASSOCIATION PLAN NO. i i L, The Commonwealth of Massachusetts r Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Apollcant Information Please Print Legibly NaMe(BusinesslorganizationlindMdual): M l(I U A ei AC-C,14 s s a4 1)(131k G SA U Address: J-C_ City/State/Zip: Y,% MoqJU Oft U4gone#: Are you an employer?Check the appropriate box: Type of project(required): I.[K I.am a employer with 1. 5 4• ❑ 1 am a general contractor gild 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 die attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have. $: ❑ Demolition. working for me in any capacity. employees and have workers' q ❑ Building addition [No workers' cotiip. insurance comp.insurance.- .required.] 5. ❑ We area corporation and its 10.0 Electrical repairs or additions 3.0 .1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL. + c. 152,j 1(4),and we have no 12,❑Roof repairs --,1 insurance required.] 13.®Otherl t #IM_ employees.[No workers' comp. insurance required.]: *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.. t Homtowners who submit this affidavit indicating they are doing all wont and then hire outside contractors must submit anew 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. lam an employer that is providing:workers'compensation insurance for my employees. Below is the policy and job site information. ,- I Insurance Company Name: P.G e 1 o a V -inS Ukf 0.nce c o rn Poo n Y Policy#or-Self- Lic.#: . 3 a. �' / T c� Expiration Date: Job Site Address:__ d- MIL i n S City/State/Zip: A4aAINI5 _ 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 tend 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 o f 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains d enalties erjury that the information provided above is true and correct. S' ature: 4" Date: Phone#: 391&- O.fflehil use only:-Do not itirire 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#: DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/20/2011 THILIe-t TIFICATE 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 CONTME:ACT P N Shannon S errazza Risk Strategies Company PHONE (781)986-4400 FAX o:(781)963-4420 15 Pacella Park Drive EMAIL ADDRESS:ssperrazza@risk-strategies.com Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:SeleCtiVe Insurance INSURED INSURERB:Safety Insurance Company 33618 Michael McCluskey, DBA: Cape Save INSURER C:Technology Insurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL11102041451 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS L R POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAAGE ToRENTff- COMMERCIAL GENERAL LIABILITY PREMI E Ea occurrence $ 100,000 A CLAIMS-MADE ®OCCUR CPPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO-JFCT LOC $ AUTOMOBILE LIABILITY COMBINED tSINGLE LIMIT 11000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS AUUTOSTOSNON-OWNED PROPERTY DAMAGE $ Per accident X X Underinsured motorist BI split $100000 300000 X UMBRELLA LIAB X OCCUR CPPS1994480 0/16/2611 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAS CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ C WORKERS COMPENSATION Executive excluded X O STATU-RY LIMITS FR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN N from coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? F NIA 3297972. 0/21/2011 0/21/2012 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule,if more space Is required) Issued as evidence of insurance. National Grid Corporate Services LLC d b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc. , and Housing Assistance Corporation are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. 484 Main Street Hyannis, MA 02601-3698 AUTHORIZED REPRESENTATIVE Michael Christian/3MS ACORD 26(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS02fionimsini Tho Arnpn nnma onr1 Innn oro ranictorarl martrc of At nRrt Ut%,,:L3IGtJ10 b`J::LJ yl�j&l'�30 YF1Cit U1/bl CAPE p S AME j. J Weatherization 508-398-0398 August 22, 2010 To Whom It May Concern: William J. McCluskey is an employee.of Cape.Save. He is authorized to negotiate contracts and.building permits for our.company. Michael McCloskey Cape Save—Owner, 929-593-5939 cell X Hunt6ngtan.Avenug, South Yarmouth,MA 02664 � ' O ice Wonwsumer Af air and Business Regulation 10 Park.Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement`,;Contractor Registration Registration: 164432 Tvpe: Supplement Card CAPE SAVE Expiration: 10/6/2013 WILLIAM MCCLUSKEY 8201 S. HOURD CT CHAPEL HILL, NC 27516 Update Address and return card.Mark reason for change. -' ❑ Address Renewal Employment Lost Card DPS-CA1. c'3 50M-04/04-G101216 ✓2.L�anr��za�uo a�✓��avaacl uaeCta __ .. _ ... .....___. _ Office of Consumer.Affairs&Business Regulation License or registration valid for individul use only _ �rHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return toc Office of Consumer Affairs and Business Regulation s Registration 164432 Type: 10 Park Plaza-Suite 5170 Expiraton 1U16/20:13 Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM MCCLL*O 7C HUNTING AVE S.YARMOUTH,MA 62664:- Undersecretary Not valid without ' nature r � Housing Assistance Corporation Cape Cod HOME OWNER WEATHERIZATION WORK PERMIT&FUEL RELEASE: PLEASE FILL OUT AND SIGN THISFORM IFYOUARE TH E APPLICANT H OM E OWN ER. I &IrLI,4� 1,41,1A hereby consent to and agree that weat heri zati on work maybe done by the Weatherization Program of Housing Assistance Corporation (hereinafter referred as"Agency") on the property located at: a y In t 7 11&Afl 's_ The weatherizat ion work done will be based on programmatic prioriti Es and availability of funding and it may include all or some of thefollowing measures: Weather-stripping& caulking of windows and doors, insulation of attic sidewalls& basements, attic and other ventilation measuresand possibly replacement of badly deteriorated windows- In consideration of theweatherizati on work to be done at my home I agree to the following: 1. I givepermission to the°Agency" itsagentsand employeesto travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property- 2. TheHousi ng Assistance Corporation reservesthe right to inspect thefuel or utility bill for theweatherized unit on an ongoing basisfor no morethan five(5) years after the weatherization work iscompleted. I have read the provisions of thisagreement as listed and freely give my consent. Home Owner: (Signature) Date: Agent: (signature) Date 2 HAG approved Weatherization Company . All Cape Energy CapeCod Insulation e; ve Efficient Buildings,LLC :l i•V{ .t�k!{L �:'!C�><.4 1�! Y1:{lt�l3':_`1f('t�fSlF:'�}+Qiit1't•1! ?.rG'Ir�tS.�.�l)L I,.`/%R?�4}O II� Energy g) i I. MAR-13-2012 TUE 02:58 PM O' KEEFFE LARGAY LAW FAX No. 508 771 3388 P. 002 MAR-1�-101t TUE U�cb� PM MCS FAX No. 500 411 1114 R UU1 I ' I I ARMSTRONG CONDOMMUM TRUST 724 MAIN ST"19T HYAINNIS,MA 02601 i 508 477 8400 3/13/2012 3 1 Town of Barnstable South Street Hyannis,Ma 02601 Att:Building department Location; 724 Main St,,Hyannis Ploase be advised that Armstrong Condo Trust gives permission to RAC to perforta winterization services at the above stated address. Please contact Joel Zeger to gain access to the property, youl Randy Ritz Chairman,Board Borard of Trustees CC: HAC winterization program i r Massachusetts- Department of Public Sufeh Board of Building Regulations and Standard. L�l Construction.Supervisor Specialty License License: CS SL 102776 .. , Restricted.:to: IC '. � r WILLIAM MC CLUSKY 37NAUSET.ROAD WEST YARMOUTH. MA 02673 Expiration: 6/28/2013 Trx': 102776 �t Sign TOWN OF BARNSTABLE Permit BARNSTABLE, MASS 1639. � �fD Mfg A Permit Number: Application Ref: 201106581 20070682 Issue Date: 11/21/11 Applicant: ZEGER, JOEL E TR Proposed Use: OFFICE CONDOMINIUM Permit Type: SIGN PERMIT Permit Fee $ 50.00. Location 724 MAIN STREET (HYANNIS) Map Parcel 30828300A Town HYANNIS Zoning District OM Contractor PROPERTY OWNER Remarks 18 SQ FT FRESH HAIR SALON(ATTATCHED TO BUILDING) Owner: ZEGER, JOEL E TR Address: PO BOX 1979 MASHPEE, MA 02649 Issued By: -77777 777777777 S POST THIS CARD SO THAT IS VISIBLE FROM THE STREET -ASTABLE °p111ET°� Town of Barnstable � ti Regulatory Services 7 11 tTV --8, €il 12: 29 x an MAS& * Thomas F. Geiler, Director 16,39. ArFora Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit# G (o S Building Official approving------------- Application for Sign Permit C 1 D K,�� �j1��----��t�--1'��------'---Assessors No.__Z�efS� Doing Business As:__ [ __ ��sY---,`�G�6i'�__'1'clepholle Sign Location �� S 60y StrceVRoad: ----�a�1` A%R---- YC_� ---------------------------------- Zoning District:_vrn___ Old Kings HighwayP Y s/No yannis Historic DistrictP I No Property Own Name:----- �GL---- C -f f-----------------Telephoi�e:_v� Address:__?2�L i---JS-_6------------------------Village:---U-r,Y1"P ee- _ S Sign Contractor� Name: ^�1---------- 4�------- --------------------1'clehhoiie:_ _7I S-'zo t Mailing Description Please follow die cover dirccboiis. You must have an accurate rendition of•sign with dimensions and location. Is the sign to be electrified? .Y No (Note.: cs, a wiri»g•permit is required) S I Width of building face ft. x 10 =3> _x .10 Check one Reface existing sign-___ or New Total Sq. Ft. of proposed sign (s) Il'you ha ve additional sibyls please attach a sheet 11'sL 1g.eac11,01lc wily dimcrlsiojls If refacing an existing sign please provide a picture of the existing sign with dimensions. I hereby certify that I am die owner or that I haive die authority of the owner to make this application, that the information is correct and that the use and consb-LIC6011 shall conform to the provisions of' . §240-59 through §240-89 ol'the Town Of 13 iing Ordinance. Signature of Owner/Authorized Agent:-- Date — ---_—� _ - SIGNS/SIGNREQU revised]2110 fillNAIR s iMIN 'ar NI, 4 l lot, • S TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a�p 7 ' Q Map (` Parcel 3 Application# `® Health Division Conservation Division Permit# Tax Collector Date Issued Treasurer Application Fee F Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board I� Historic-OKH Preservation/Hyannis Project Street Addre-Vt V\r,W, 'S Village V�\A AV\�A\ � Owner 6 2 cps Address Telephone S-c>S 7Z "� � 'a�►7 Permit Request V C (/ Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District I f Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing ! new" Number of Bedrooms: existing new 4 {- Total Room Count(not including baths):existing new First Floor Room Count 7? C-0 G'3 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:❑existi g ❑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 nn 11 ` BUILDER INFORMATION Name j3kAC— �1'e���-� Telephone Number _ 515S LJ D La) 110 Address 3�� e�� ®fl� (`� License# C�'��� Y Home Improvement Contractor# / (o o Worker's Compensation# ALL CONSTRUCTION DEBRIS RE SU ING FROM THIS PROJECT WILL BE TAKEN TO t A SIGNATURE DATE '3 It P � FOR OFFICIAL USE ONLY 4 I PERMIT NO. DATE ISSUED MAP/PARCEL NO. i ADDRESS VILLAGE OWNER r DATE OF INSPECTION: FOUNDATION FRAME INSULATION 7c• t+ FIREPLACE i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ,E GAS: ROUGH FINAL FINAL BUILDING t1 I f � I r s DATE CLOSED OUT ' ASSOCIATION PLAN NO. t� i ti the Cornmonweatth ofMiusachusetts ' Department oflndustrial24cczdents s Office of Investigations 600 Washington Street Boston,MA 021.11' ' . wwtw.mass,gov/dia ' Workers' Corripensati.on Insur2mce Affidavit: Builders/Contractors/Electricians/Plumbers• A licaut Information Please Print Le ibl Name(Business/Orgmiiation/hdividnal):_ Address: coo\D I� � c City/State/Zip: CeA M f Phone.#: `k 'oK) lg(ZIM to Are you an employer?-Cheek the appropriate box: :Type of project(required);, 1;[�I am a employer with 3 �• 4. ❑ I am a general contractor and T employees(full and/oz part-time),* • have hiredthe sub-contractors 6. ❑New construction . I am whole. ro 'eto ' listed on e 2. r or artne : attache'❑ r the dse Remodeling P Pn het. 7. . R mo ehn P ❑ g ship.and have no employees These sub-contractors have g []Demolition -Working for me in any capacity, employees and have workers, 9, Bu>Idm' addition [No workers' comp,insurance comp, insurance$' ❑ g _ required.] 5: ❑ We are a corporation and its 10.❑tlectrical repairs or additions -— ' officers-have exercised their 11.❑Plumbing repairs or additions . 3.❑I am a homeownerdoing-all.vvork•:-- --—— _.. myself,[No workers'comp, right 6f e)emptionper MGL 12,❑Roofrepaizs . . insurance.required]t c, 152, §1(4),and we have no employees, [No workers' 13.❑Other ' comp,insurance required.] *Any applicant that checks box#I must also fit cut the section below sbowing their workers'compensation policy infomnation. t Homeowners.who submit this affidavit indicating they are doing all woik and then hire outside contractors mutt submit anew affidavit indicating such. #Contractors that check this box must attached an additional-theet showing the name of the Sub-contractors and state whether ornot those entities have employees. Iftbe sub-contractors have employees,theymust provide them workers'comp•polid'y number. ; lam an employer.that is providing workers'compensation insurance for my employees. Below is.the policy and job site' information. Insurance CompanyNarne:_ Policy#or Self-ins.Lic,#;- vt5 e `7 45 L l 62)1, a bn 1 �p£� �1 7 ExpirationDate: lob Site Address: -24 LI, City/State/Zip; Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date), Failure,to secure coverage asrequiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine tip tb$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 maybe forwarded to the-Office of Investigations of the DIA for insure ce covers a verification, I ilo hereby certify under th pa' -an ens fperjury that the information provided above.is true and correct: Si afore: Date: Phone Official use only. Do not write in this area,to be completed by city or town official:• City or Town:' Iermit/License# . Issuing Authority(circle one): .1 Board of Health 2,Building Department a, City/Town.Clerk 4,Electrical Inspector 5.Plumbing Inspector .6.Other Contact Person: • - •Phone#' Massachusetts Ceneral 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." MCTL 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,". AdditionaIly,MdL ehapter.152,§25C(7)states'TIejther the commonwealth nor any of its political subdivisions shall enter into any contract for,the perfbmiaace of public-.work until acceptable evidem n e•of•copr?ee Withtlie finance' requirements of this chapter have been presented•to the contracting authority,." Applicants r Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,it necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s)along with their certificates) 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 is required. Be advised that ibis 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 pemvt.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law-or if you are requirea 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 appropriate-line. City or Towri 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 permitllicense 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 markdd by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e, a dog license or permit to bum leaves-etc.)said person is-NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance.for.your cooperation and should you have-any questions, please do not hesitate to give us a call. The Department's address,telephone•andfax number% E`la az � w th of as�rh d3 Dtputmfmt of kdUStMaI A C6d0:tttS o .co of Invest paous BWC IMI MA 02111 TeJ. 617-727-00 ext 406 a.r1 -7-MASSA.FB Fax#617-727-7749 Revised 11-22,06. ��� & NOTICE NOTICE TO - TO EMPLOYEES EMPLOYEES The Commonwealth ®f Massachusetts A DE P RTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-7274900 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 INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070 BURLINGTON. MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC 7016215012007 01/10/2007 - 01/10/2008 POLICY NUMBER EFFECTIVE DATES P O Box 494 Leonard Insurance Agency Inc Osterville, MA 02655 (508)428-6921 NAME OF INSURANCE AGENT ADDRESS PHONE Mark Herbst 35 Peep Toad Road Centerville,MA 02632 EMPLOYER ADDRESS 01/04/2007 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL 1"A MENT 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 DEC-5-2006 05:46P FROM:MARK HERBST+SONS 5084206216 T0:15084777174 P.1 MARK HERBST 35 Peep Toad Rd. Centerville MA 02632 (508)420-6216 Cell phone 774-238-2938 PROPOSAL SUBMITTED TO:Joel Ziegar WORK PERFORMED AT:720Main Street SAME<� `{ Hyannis MA 02601 We herby propose to furnish the materials and perform the labor necessary for the Coonpletion of the following; AJew.Ron Remove I IaLer of eats gg,shingles Install 8"drip edge Install ice &water shield at edge InstalllSlb. felt paver Install certainteed woodsca a 30 r. al ae resr.""start shin les Replace all plumbtn boots Paint metal flues w/rustoleum paint Re lace entire roo area E ride vent 9 350.00 Replace lust west side w/no ridge vent 4 675 00( *Please check and initial choice above Thank You All material is guaranteed to be as specified, and above work to performed in accordance with specifications submitted for above,and completed in a substantial workmanlike manner for the sum of,as spectfied above&verified w/your initials Dollars( )with payments as follow;,full amount due upon completion R Any alteration(s)from above involving extra costs will be-added underwritten agreement,and become a tra arge over and above signed estimate/agreement RESPECTFU I' Signature 12/5/06 ACCEPTANCE OF PROPOSAL; The above prices specification & conditions are satisfactory)we herby accept You are au ized to do workAnd payments win be as:specified above. Signatures) Date: g This;propos may a withdrawn by s ' company if notccepted within 30 days i i y. WX NY � v �,t,,a2 t4`1�C^,�,{� 1 t i.;>, 4 t'I tti; ► rt h`+: ,. '- Y6 .sus ,,1 i. I�/ A :,; �} � iT Wn•.. AwL• � i•+w iw�w++•* r � --' it _ ; ,, i ,•.:_. 4 M: If ' C INS Ili w ti ��- ux ��_��' ��(� • � 1 t�1s��� "-� �.,.r wax'�...%+...w.r. ��, ,. z z,r. k„'•" � ,� r � �{ �"`• � '� \� 'd ,,!'�a� �.+• - .�( ��&A ^s i.:11 � ¢ � �•~, k� t,,. 1 tip t� t .+�.� • s Sign Permit BARNSTABLE, * TOWN OF BARNSTABLE 9 MASS � 16339.prF A� Permit Number: Application Ref: 200803326 20070184 Issue Date: 06/20/08 Applicant: OKEEFFE, PETER& ZEGER,JOE TRS Proposed Use: Permit Type: SIGN PERMIT Permit Fee $ 50.00 Location 724 MAIN STREET (HYANNIS) Map Parcel 3082830OF Town HYANNIS Zoning District OM Contractor PROPERTY OWNER Remarks 2 NEW ENTRANCE SIGNS DRAKE BUILDING 12 SQ EACH Owner: OKEEFFE, PETER 8z ZEGER,JOE TRS Address: 218 WEST MAIN ST HYANNIS, MA 02601 Issued By: PC- POST S . CARD SO THAT IS VISIBLE FROM THE STREET Mar 11 2008 4i47PM Sign A Rama 401-8816-5007 p. 1 ,on -25 t# OW40p Joanne Parley 508-771-1190 p,g Town of BartMable Reg► Wory Sears Thomas F.Geller.Dimtor i Buiid*g Division 'Cora berry,8ttlldlag Coffimbdorar 200 Main 8.tme%Wyannls.MA 02601 www.town.barnstableimus ' Offim: 5W462-4038 Fee: 508-790-6230 Perjmit# App nwa for Stn hrntit 3 � AppIiaW: �Aftrcn.#. 30� Doing Budr=At: rtt Tekphanp No.��' ri�.(' jig n L.oaotiQa ,y CQ i�s StraatlRaad: Uq s f Pl Qf- �' ,l o e.n�Va✓�C e 5 1�1 !> rj o r- S� Zontts visttrteti-Old K a RIOWAY3 Yeo/.No RYOR U A9atark Dbuiet? 'lteatfi'ie i l f Propt O W Ntrato: tlr #Le- 5 : c Telephom 40 t-.3: ,511 AddteudLe VU IM Ei 910 Coatrtteor Nap�ie:,,�"�-.� 'a"s..l��,ni�ll (Tedepbotte•��- ������� Mailing.Addr+eas: J�.r} - •J�-�T d64�'1, ,� flascribr4asl 3'ksse draw a diagram of tot A&w%g locaeiob of buildings aid exists signs with•dierxesipm.locatioi and kin o the now sign. This shadd•be drawn on thcrevve Pe side oftbls application• ' u the sign to bo ebectrsf V Y 'o`. (9NQrt:!f a wtri►tg ,a�tr requaxd} *tditb of hulidlna ittcs, _n.z ao= 3 Y� :.io- 3`f Sq. L of proposed sign 1 � I buck;[oat*that I ssn Abe owm ar flat t flare the authority Otite ovAm to m4e this app§oattan.that*a k0toutlon is coral and do the use and ooumoion shall codum to On provisions of#240-59 di oug4r`'t 340f89 of to Town Of 8aresstabla totting Ordisianea. 01poture of OwoerAAutborbed Agents Dale: G fit, Pstmit Pea C cn c, �gn.Phctrsutwitsapprtrved: Disapp mmd' SigdatteraoPBuiidiregOt al: Dram: - _ cc: In order is prKteass app{kstiors wUAsut aehys sail seNiom ratan be t}sdoap[�ttsd• Ln rn Q�+�b6S1SY[euSsltGHwPl.BtiC • 1lrv.AflL@A' I i I � - - Customer: Beltone New England Job No.: Date: 5/16/08 ' Company: SIGII*A*MA NA Order Dale: Salesperson: Address: WHERE THE WORLD GOES FOR SIGNS Sign Dimensions: 48 x 36" Estimate: 724 Main St. Unit 6 City: Comments: Hyannis SlatelZlP: MA 6855 Post Road, North Kingstown, RI 48 x 36 x 112" PVC double sided mounted Phone: 508-771-1199 between two 4"x 4" x 8' pressure treated Fax: Tel. 401-886-5000 Fax 886-5007 posts buried 3' in the ground. :y 480 in 724 DRAKE BUILDING [BELTONE HEARING CRqnj SAMUEL MICHAEL SALON LAW OFFICES OF LOGIE CPA KEITH MCMANUS PERFECT IMAGE NAIL SALON FOR LEASE FOR LEASE 1-917o7`974@5 917.797.4615 _j Customer: Beltone New England Job No.: Date: 5/16108 Company: S) 'W*A*RANA" Order Date: Salesperson: Address: 724 Main St. Unit 6 WNERE THE WORLD GOES FOR SIGN Sign Dimensions: 48x 36" Est mate: city. Hyannis state ' MA 6855 Post Road, North Kingstown, R1 Comments: 48 x 36 x 1/2" PVC double sided mounted . Phone: 508-771-1199 between two 4"x 4"x 8' pressure treated Fax: Tel. 401-886-5000 Fax 886-5007 posts buried 3' in the ground. - � F�1e-r '-; ti�x • 724 DRAKE BUILDING p7oNEHFnaasc SAMMMICHAELSALON ' s �HMcMANus Lpo¢CPA rV_TT A0 O Fo— a LEAss FOa LFASE 917,7974615 917.7974615 Set back-15feet - - -� from.the Toad .Customer: Beltone New England ® Job No.: Date: 5/16/08 Company: Order Date: Salesperson: P Y S1611*A*HAAFA Address: 724 Main St. Unit 6 WHERE THE WORLD GOES FOR SIGNS Sign Dimensions: 48 x 36" Estimate: City: State2lP: Comments: QDD Hyannis MA 6855 Post Road, North Kingstown, R1 48 x 36 x 1/2" PVC double sided mounted P"° 508-771-1199 between two 4" x 4" x 8' pressure treated Fax: TeL 401-886-5000 Fax 886-5007 posts buried 3' in the ground. f- 'oC� C- IL 5 �e-A, P SIX \_ OLD pok���� � o� Town of Barnstable WebMap FullScreen Page 1 of 2 � Q dj 0&5 ; + 4 i 290096 4426 30,8282 v #353� Y 5 ON 308219); 7112 #615 ti t j° ' `.l A002001 I� 348283 t4 290149°'� #�146 t k8151 3085164 308162 13#8o101 s: d ! t I ,. 308002002 �290095 ' ' #760 ° #0 1 t t t i 308001001 ' .F °. - #1161 308150 ° 3054 ; 3081R' #125 !z ` Map Layers EAdd , Remove `"Zoom In I Zoom OutMagnifier s Print It http://www.town.bamstable.ma.us/webmap/assessorsk/TOB WebMapFULL.asp?mappar=3... 8/24/2004 Re ort " At� �y �Complaint/Inquu�' p Date• f/ i-U o Rec'd by: <—`)/i, �n GL ,� Assessor's No.: Complaint Name: Location Address: WP c�, Originator Name. Street: ViiLzge: State: Zip` Telephone:D/C Complaint _ 4escription: � - (F an re (0 . . . O J Inquiry ODescriptil b M17ULU cl I C 4,1l For Of m Use Only Inspector's _ - Action/Comments Date: inspector. Follow-up Action Additional Info.Attadied SPY Di=budon: t 7dw-Department He Yellow-Inspector pink-Inspector(Return to Office 3fanager) / r� r •�= n �_1A � � 1 =mimm / � 1 I i I 1 1 ' � I +----------------------- CUSTOMER FILE MAINTENANCE --------------------------+ (Action: Find Query Next Prev Browse Output Exit Menu . . . ( Display customer data. I I I Number [ 176025] Last Update [peirsonl] [08/24/1999] [21: 38] I I I I Name [OKEEFFE, PETER & ZEGER, JOE TRS ] THE? [N] I [OZ REALTY TRUST ] I Address [720 MAIN ST ] [ ] Department [TX] I Zip Code [02601 ) Person/Entity [P] I City [HYANNIS ] Customer Type [ ] State [MA] Resident? [ ] I FID [ ] Telephone [ ] GB [N] I Fax [ ] TX [Y] Assoc? [Y] Alias? [N] I E-Mail [ ] Internet [ ] I I Additional Addresses? [N] Special Conditions/Notes? [N] I I I I 1 of 1 +------------------------------------------------------------------------------+ Pam . sU�- 39 XC-co,-, 0 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION q Map s Parcel--A o n N Permit# / Health Division Date Issued Conservation Division Fee Tax Collector � �d- � � Treasurer f .l IZIZ!�9 J Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address n G Village Oils a / Owner �be( Zt)a A(, Address Telephone Permit Request �Q— MON `1 fff Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost I r&Db,"Ub Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Easement 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 BUILDER INFORMATION Name_ `(n O�'1L 4e0oS Telephone Number Address a g' `Det,3 —kb License# OL6.'r y .b Home Improvement Contractor# `I 1�b Worker's Compensation# l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO R SIGNATURE DATE _1�.-ab-qg r FOR OFFICIAL USE ONLY WRMIT NO. DATE ISSUED MAP/PARCEL NO. i rE ADDRESS VILLAGE 'f OWNER DATE OF INSPECTION: r FOUNDATION FRAME INSULATION FIREPLACE M ? ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. s The Commonwealth of Massachusetts Department of Industrial Accidents �a _ OfRce of/West/pattoos 600 Washington Sheet - Boston,Mass 02111 Workers' Compensation Insurance Affidavit name. location citV Ce n phone ❑ I am a homeowner performing all work myself. Q'I am a sole proprietor and have no one working in anv ca acity %%/%%/%//////% % %/////%// /////J/%/%%////////////%///////%/O/////////%/O////,%////%%%%/, I am an employer residing workers' compensation for my employees working_on this job. X. m env n ON > gcare a :.: :>::::.:;::. Insurance co. ::::::,:...::.;:;:'.::. :. 0000000 ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have e followingworkers' compensation polices: ................:::::.:.::::::::.:..._...... : . ....:..:.:::::.:...........:::.. .::::::..::.:.:. :::...:....... . nv Heine: :»:<:;:<;:>';:;:;:' ::>::::>::»:::::«:>:>:::>:<::<;;':::::;:;:;<::;:;.:::::;:::<.:.: .. :.: cons a ;;}};}:<'•:};.>:{;.;;}:<.:;:.>;:<;.::::. xx address. :::;.>.:..::..:.:.::........................... :::.::r. .�.:. >�. .:.:hMe ;::..... `^X. :::...::�::i�::i.`•:�.`::i:'?:'r:::::!:iiyii:S.: ;:i::::::::2i :''�:::::i"i::ii:::::•::i<::�:::: i: ........................................ ..::�::::::•::.:::�::::�........................:::::.�::::•.�:::.�::v::::::::::._:::::::v::::::.�::::.�::::::::::...::::':::::::'::::::::::::::::::::::::::::i:v::�:�iiii+:{}:i<ii:ii?ii:�:�iii: .........::::::::�:::::::::::.:}:v:{4}:{GFi}':•}:::•::::r::::::::::.�::::::v:::::::::::::::•.�:.�:xn..xx:::�"}i}�:::}:}:>.•}i}:^'::t:iC:v:�is>.ii �:�ii:�iii•:::y�... {. { .:....:.::. .. 011 insarenc ....................... ; .......................................................... ,...:.: env :.;..:;;;;::.:;:....: ::;::;';.: ............... :.. .;.....:.;:::.:.;.:..::..:. _ . address: -.. cloneA : . ................................................ :::.:::.:::::::::. :::::.......................................................::::::::::::::::::::::::...::::::; ; ....:..... Fafiure to semis coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage veiiflcatlon I do hereby certify under pains p 'es of perjury that the information provided above is trw•and correct Sig<Iatllre Date 1 a-ao \q Print name `(�A C� e� Phone# LI a a to 10 Ccontactperson: nly do not write in this area to he completed by city or town official town: permitdicense# QBuild:DepubnenD ❑Licen check ifmmediate response is required ❑Selec ❑Healt phone#; "mud W95 PIA) Information and Instructions - Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law",an employee is defined as every person in the service of another under any contrz. 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 o: 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 m the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference munber. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Me of Imlesugadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 NAM $ Department of Health Safety and Environmental Services sei¢ .o Building Division • ' 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 BuiIding'Corntniss,ore Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the'reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered cotmactors,with certain exceptions,along with other requirements. Type of Work: Estimated Cost 1 gbb.b D Address of Work: 73`l 0 ►'� Owner's Name: �D = Z e Date of Application: 7�-a7 --T 2 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law C]Job Under$1,000 Building not owner-occupied Downer pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav Xie 70a9lbmonaAeaL 00,/ aoac/uaelta HOME IMPROVEMENT CONTRACTOR Registration 126480 Type - INDIVIDUAL' Expiration 06/08/00 I MARK HERBST MARK D. HERBST 9abVALON CIRCLE �. ADMINISTRATOR OSTERVILLE MA U655 1 DEPARTMENT OF PUBLIC SAFETY CONSTRTjON SUPERVISOR LICENSE ".. EXPires' 4 AJ� Ries tY 00 E . 49,A�DrON';CIN u � OSTERVILLE, MA 02655 ; ,,,,A Icrd"�d