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��c����7�i2�E7 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION OF Map Parcel Application # Health Division LIE +' - A� o Date Issued(v Conservation Division Application Fee Planning Dept. - Permit FeeFM i f Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address. ' 5C Edt0PtJM Sed L LPdNP__ Village Owner _DOeCRA4 Vy _ Address Telephone �C*-)g .Permit Request AiD'D -TQ 15,Wk511 Ned M ; C_K IZX 12.G 5eL17104 14-X V0 orA —TCZIPLV,- 2.,X'22 d_->,tQtV - vW 2X�i�T-�e�1StS . n I � U3 (off �►-� �G1 N Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatiod�}`� Construction Type Lot Size ArpftaG 11,5M Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family )iq Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ;dNo 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 IProposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name _Or � Telephone Number / Address `7 License # _aq w � ���13 Home Improvement Contractor# 1567-70 Email 'S• l�) C��Cs'T� N� Worker's Compensation # T�I Wd,426 al I ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO� 7�>1�� SIGNATURE DATE FOR OFFICIAL USE ONLY `APPLICATION# DATE ISSUED MAP/PARCEL NO, a ADDRESS VILLAGE F ` OWNER DATE OF INSPECTION: FOUNDATION FRAME ` INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE,-CLOSED OUT ASS-gG-TION PLAN NO. ' The Commonwealth of Massachusetts Department of IndustrialAccidenis Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly - Name(Business/Organization/Individual): Address: Z67) t> N Al >TSC4 1>9--, City/State/Zip: 1V p_� 'T'4 Phone#: 2AO 42,Sb Are you an employer? heck the appropriate bog: Type of project(required): 1.(fI am a employer with Z— 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 workingfor me in an aci employees and have workers' Y capacity. �• inctrran�e# 9. ❑Building addition [No workers'comp. insurance comp. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 121J Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: , Policy#or Self-ins.Lic. Expiration Date: 7�r✓' Job'Site Address: L. 1.445 City/State/Zip: N.1NJA14A& �YWi Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correc4 Signature: Date: (o Z Phone#: i�5 0:25 d1' Official use only. Do not write in this area,to he 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in-a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of dwelling a w llm house having not more than three apartments and who resides therein,or the occupant of the g � P P dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have. employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicease applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Iuvestigatians 600 Washington Street Boston,MA 02111 Tel, #617-727-4900 ext 406 or 1-V7-MAS8AFB Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia - " f t , ,4ccnt� £-CERTIF�CATEQF"LIAtLiTY I,�ltlR1NC£E �ATE� oW► Tti1S GERTiFiCATE 1S 15StlID3 AS A MATTER QF iNfOR1NATit)N QNLY:IIND CONFERS M1f0 tilL�tTS UPON THB CERTIFICATE:,HOLDER. a f CERTIf=GATE DAESPIOT AFFtRMATINE�Y QR NEGATlUELY gMEND, XrEND L9R ALTER THE"COVERACaE AFFORDED,BYTHE PC1tlCtES`k "BELOW Tti1S CERTiFICA1TE QF tP1SURANCE 'DOES"NQT Ct?t�STiTtITE�A CONTRACT BETWEEN THE tSSU1NG IN3URl R(S)'AUTHORIZED REPRESENTATl1lE OR PRQ13UCfR,T1N0 T91E CERTIFICATE HOLDER t iMPORTANT !(the certrficate holder is an aDDf110NA1 tNSURED,the, 1 Icy(Ies►.must Lae endorsed it SUBROGATION fS WA(VED sutyect to the terms and eortddwns of the pokey certarn palines may require an endorsement A statement on>hIs cerhecate does slot coirfer nghts;to the a " :C8f1{ilCate;.h01�@r'iflGeU'OTSIiCh:enC�QfS@ITlent,$'..�r:,,u i .�`l,:r.�,:rr r. ...,a.�"a,,,fiR_� •� nx"ti'��,` ", h,A „c'. ,, :.r_� ^}r n_t., ,r,�4�.ae.,., .* 1"0.,� � ,y PRDOUEEI� r r e r Nf4A7E CiUS101Tler$BMCB Depar6nent 941 S27 95Q0 s F 941 927 9551 Cennalrus,LLC k i �$ e�c�a � firn ate Fw�" M ce es nalrus.cam C e n Cl U 711,South Osprey;Suite 2 �, v INSUREak$AFFOROIN6i dDVERApE j .t f ¢, N Sarasota,FL 34236 % . � a l .INSURER A, �aUard inSUran COm en p rfig y +f r `"u ;:..a* }M.w 4S dNSUR� � �' :,�>•' {h C k�.�1.3 r INSURER 8; rr4-3+ .�..-Y.a•At'i,' kr''§'r 'ice h4w�-rig--+.yt.-.�.e �r �„.. . 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J y I , �i d✓ � t '� t; n� i1 A w �z r ' tiT t > �� 1 "+*. 1 y'f :' a as Ck4 i� �, deb u, ix sva"a y'Flf �, 1At{d $'ti t1 aV h yu } ,' ,r N- Y s GERTfFICATErH4LDER ..x).: ,'tr. .a rrCANCEL'LATION r t' ,} rs q}ff 1-. h q f rt{t' `,�; t t +s, a S}.rr ax r.• ,r•-a n�Ary :,.t:.: kla,�,{r;, e,:9?f, t'rc l * Stephen Ktttg r rr i hat SHOULII ANY QF THEA$4VE t1ESCRIBEO POLIC(Effi 1'1E C NCELLEt)BEFE?RE 79 D M dbbbh Dnve c, + r THE ,E%PiR%CT(ONa RATE ;THEREOF NOTICE"WILL BE CELIVECtED"IN .� 'x ^F. r k: ' ` �r•� r: *x, ACCORDANCE WITH THE PODGY PROVISIONS. s n r} $. p' f West Yarmouth,MA 02873 F 9 n ro7$ 4 s ^r sJ'r �ia is�i,n t el*, + F}t .: A v v s a" r: '#i e �A4THORIZEb REPRESENTATIVE. fi V x t , s 9, -:t a M y: � � �'' � �'4� t � ,� � � ��©1!)88 2010 ACORD CORPORATION Ali rights resented ' { ACORQ , (Z01ttN16) Th@-ACORD rant@ artd iogoare regtstered marks of ACORD ial i,- j ,+ N s� > it jLds�� big t�r�g� ��v } rC to .t -5 Yt � a• m lyrit f +w arr 7t y �x� � � hh'i! � ..,• -: i .` �, a h: + �y s ra fi}�r � �z:-��"lt,x if) ,W��F �4y�+' h}* � Y . Xe e� Office of Consumer Affairs&Busi es R��la ooJeG7r _ ME IMPROVEMENT CONTRACTORLicense or registration valid for individuI use only egistration before the expiration date. ;156270 If found return to: ;vExpration 6/19/2015; Type'. Office of Consumer Affairs and Business Regulation ` DBA 10 Park Plaza STEPHEN KLUG FINE BUILDING&`,FINISH Suite 5170 Boston,MA 02116 . STEPHEN KLUG r 79 D MIDTECH DRIVE W YARMOUTH, MA 02673 - 4 �1 Undersecretary Not valid without signature j Massachusetts -Department of Public Safety �✓ Board of Building Regulations and Standards Construction Supervisor License: CS-093441 i- STEPHEN KLUG, 79 MID TECH DR s W YARMOUTH:MA0�26a 3, Expiration Commissioner 05/07/2015 t L ` oFVE,� Town of Barnstable Regulatory Services + EAMSTA M Thomas X.Geiler,Director Building.pivision Tom Perry,Building.Commissioner 200 Main Street Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: .508-790-623 0 Property Owner Must -Complete and Sign This Section - _ - If IJsin�A Builder I S as Owner of the subject property ' l p Pert9 . hereby authorize. V ;� �� to act on my behalf, in all matters relative to work authorized by this building permit. (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. Signature of Owner Signature of Applicant Print Name Print Name. Date QTORM&OWNERPERMISSIONPOOLS 6/2012 THE r 1.0W111 0t Barnstable Regulatory Services . .13AMS-UHra, . Thomas F.Geiler,Director . K 161¢. ��� Building Division ATE A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAIL NG ADDRESS: 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 considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she.shall be responsible for all such work performed under the building-permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that 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 L Approval of Building Official 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 t amend and adopt such a form/certification for use in your community. Q:foimschomeexempt DECREE AND ORDER ON Docket No. Commonwealth of Massachusetts PETITION FOR The Trial Court FORMAL ADJUDICATION ' Probate and Family Court Estate of: Barnstable Division Elizabeth F. Doty N First ame Middle Name Last Name Also Known As: Date of Death: January 9,2014 After a hearing or on the uncontested Petition for Formal Adjudication filed on ate THE COURT FINDS: 1. The Petitioner is an interested person and has filed a complete and verified Petition. 2. The Decedent died on January 9,2014 ® domiciled in the above named County. (date ❑ a nonresident of Massachusetts, but leaving an estate in the above named County. 3. Any required notices have been given or waived by all the interested persons. 4. Venue is proper. 5. The Petition was filed within'the time period permitted by law:* 6. ® The Will dated May 20,2009 with codicil(s)dated ate date(s) referred to as the Will, is valid and unrevoked. There are no known Wills,that have not been expressly revoked by a:'* later instrument. The Will is the Decedent's last will and is admitted to formal probate. ❑ There is no valid Will. ❑ The prior informal finding as to testacy is set aside. ❑ The Will dated with codicil(s)dated ate) date(s) , referred to as the Will, has been lost, destroyed or'is otherwise unavailable. The above-referenced Petition states the contents of the Will. The Will as stated in the Petition is valid and is-the Decedent's last Will. ❑ The instrument dated with codicil(s)dated• is not a valid Will, ate date(s) ❑ The duly authenticated copy of the foreign Will dated ' ate with codicil(s)dated along with the duly authenticated certificate of its legal date(s) custodian are true copies and the foreign Will has become operative under the law of 7. ❑ Other: A TRUE COPY ATTEST REGISTER MPC 755(3/19/12) page 1 of 3. DocketM. Estate of: Elizabeth F. Doty n' first ame Middle ame ast Name 8. The heirs of the decedent are ® as stated in the Petition OR ❑ as follows: Name and Address of Heir. Relationship to Decedent 9. ❑ Any Will to which the requested appointment relates is or has been previously formally or informally probated, 10, ® 1 he person whose appointment is sought has priority entitling that person for appointment. OR { ❑ The Court finds that those persons having priority for appointment are not qualified to serve or, although given notice of the proceedings, have•failed to request appointment or nominate another for appointment, and that administration is necessary. The following person(s) is/are qualified to serve. Deborah Wean First ame tit.— Last Name First ame M. ast Name 59 Mainsail"Lane (Address) mt, o.etc. ress (Apt,Unit,No.etc. Hyannis MA 02601 ity own (State) (zip) (City/Town fate (zip) Primary Phone#: Primary Phone#: THE COURT DECREES AND ORDERS: TESTACY DETERMINATION• 1. ® The'Will is admitted to probate. •❑ The Decedent died intestate. r ❑ The instrument is not admitted to probate. 2. The Decedent's heirs are as found above. APPOINTMENT OF PERSONAL REPRESENTATIVE 3. The ® aforementioned OR ❑ following person(s) is/are appointed or confirmed as Personal Representative(s) (hereafter"Personal Representative"): . first Name, M.L Last Name A TRUE COPY ATTEST W A MPC 755(3119/12) TE of 3 Docket No. Estate of: Elizabeth F. Doty First Name Middle Name Last Name bijr (F6'-,+1-,4 4. The Personal Representative shall serve: in unsupervised administration. ❑ The Will directs unsupervised administration. ❑ The Will directs supervised administration, but the Court finds that circumstances bearing on the need for supervised administration have changed since the execution'of the Will and there is no necessity for supervised administration because: ❑ in supervised administration because: ❑ Decedent's Will directs supervised administration. ❑ The Will directs unsupervised administration, but the Court finds that supervised administration is necessary for protection of persons interested in the estate because: ❑ The Court finds that supervised administration is necessary,under the circumstances, specifically: Unless further restricted below,the Supervised Personal Representative may exercise all of the powers of Personal Representatives except the power to make any distribution of the estate with prior order of the Court 5. The Personal Representative shall serve: ® Without a surety on the bond because: ® The Will waives the requirement of a surety bond. ❑ All of the heirs or all of the devisees have filed a written waiver of sureties on the bond. ❑ The Personal Representative is a bank or trust company. ❑ The Court finds that sureties are not in the best interest of the estate. ' ❑ with ❑ personal ❑ corporate sureties on the bond, ❑ A Demand for Sureties(MPC 360)has been filed. ❑ The Personal Representative's prior bond is re-examined and approved. A TRUE COPY 6. ® Letters of Authority for Personal Representative shall be issued. ATTEST ❑ Previously issued Letters of Authority for Personal Representative are co 7. The Court further orders: ' - REGISTER Date 1 �< Justice ❑ Magistrate MPC 755(3/19/12) page 3 of 3 LETTERS OF AUTHORITY FOR Docket No. Commonwealth Trial Massachusetts tachusetts PERSONAL REPRESENTATIVE BA14Po547EA probate and Family Court Barnstable Probate and Family Court Estate of: 3195 Main Street Elizabeth F Doty PO Box 346 . Barnstable, MA 02630 Date of Death: 01/09/2014 (508)375-6710. To: Deborah Wear .59 Mainsail Lane Hyannis, MA 02601 • f P You have been appointed and qualified as Personal'Representative in Supervised ❑X Unsupervised administration of this estate on May 21,2014 (date) These letters are proof of your authority to act pursuant to G.L. c. 1906, except for the following.restrictions if any: ❑ The Personal Representative was appointed before March 31, 2012 as Executor or Administrator of the estate. ■ (Do Not Write Below This Line-For Court Use Only). ■ j CERTIFICATION r I certify that it appears by the records of this Court that said appointment remains in full force and effect. IN TESTIMONY WHEREOF ! have hereunto set my hand and affixed the Pal of said Court. two .. Date May 21,2014 . Anastasia W Perrino,.Register of Probate MPC 751 (3/31/12) Town of Barnstable kPefi'rf]it# p� Expires 6 r¢outl on e Regulatory Services Fee - Y BAHIVSTtiBLE, • - - v , $ Thomas F.Geiler,DirectorfL FD MA'I s Building Division Torn Perry,CBO,.Building Commissioner 200.Main Street,Hyannis,MA 02601_ www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Prope y Address �.I�v� Residential Value of Work_ S _ Minimum fee of$2S.00 for work under Owner's Name&Address 4V4 (/®7`y Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) 4 Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Che 'l am asole proprietor ®PRESS PERMIT ❑ I am the Homeowner DEC 1 7...2008 ❑ I have Worker's Compensation.Insurance Insurance Company Name_ t��.�t�✓S W QF BARNS LE Workman's Comp.Policy Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roo of stripping. Going over existing layers of roof) ❑ -side Re B lacement Windows/d�fs/sliders:O Value p (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. **Note: Property Owner must sign Property Owner Letter of Permission. A co of the mprovement Contractors License is required. SIGNATURE: :n c C:\Users\decollik\AppData\Local\Microsoft\Windows\Tempos Internet Files\C nt.0utlook\MY7NB4IL\EXPRESS.doc _1 Revised 100608 � t :r n The Commonwealth of Massachusetts Department of Industrial Accidents 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 Legibly Name(Business/Organization/Individual): Address: City/State/Zip: C".011tt VIff Phone.#: Are you an employer?Check the appropriate box- Type of project(required): 1.El am a employer with . 4. m a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2:0 I am a sole proprietor or partner-' listed on the attached sheet. 7.. 0 Remodeling ship and have no employees These sub-contractors have 8. Ej Demolition workingfor me in an capacity. employees and have workers' Y P tY• # 9. []Building addition [No workers'"comp. insurance comp. insurance. 10.❑Electrical repairs or additions required.] 5. 0 We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no � employees. [No workers' 13.[]'Others comp.insurance required.] "Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy infomnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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: T:?!2 y La Policy#or Self-ins.Lic. #: f"�� �Jy� �� O� Expiration Date: Job Site Address:_ L5V /�2/Al 5;4 I City/State/Zip: d f/ywoy S Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one-year 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 statemerit maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c yy un r e pai and penalties of perjury that the information provided above is true and correct. Signafore: Date: o� / Phone#: Official use only. Do not write in this area,to be completed by city or town official ."City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical.Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their.employees: Pursuant to this statute,an employee is defined as"...every person in.the service of another under any contract of hire, express or implied,oral or written." . An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write,...."all locations in _(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-774 Revised 11-22-06 www.mass.gov/dia A CER n ICATE OF LIABILITY INSURANCE DATE(NH MrffM T04/08/2008 WDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF ANFORMATION CHLEGIA;' INSURANCE ONLY AND CONFERS NO RIGHTS UPON . THE CERTIFICATE HOLDER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 4 MAIN ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. EST. YARVIOUTH, MA G2673 INSURERS AFFORDING COVERAGE NAIC# wimm INSMERA: NORTHLAND INSURANCE sul Buckmiller INSURER B: TRAVELERS.INSURANCE RA BUCIQiILLER ROOFING INSURER C., INSURER D: yanaiss, MA 02601 INSURERE: -- :OVERAGES THE POLICIES OF INSURANCE LISTED .BELOW HAVE BEEN ISSUED TO; THE INSURED NAME 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. POLICY EFFECTIVE POLICY EXPIRATION . .TR JNSRD TYPE OF INSURANCE POLICY NUMBER DATE(MWOWM DATE(RWDD" LIMITS GENERACUANUTY CP46859504 05/15/07 05/15/08 EACHOCCURRENCE s,1,000,000 UAMAUhIUKt:NItU 50,000 I X COMMERCIAL GENERAL LIABILITY - PREMISES(Ea occ a ce) s. — — CLABAS MADE OCCUR MED EXP(Any one person) s EXCLUDED r PERSONAL B ADV INJURY $1,O D0,000 GENERAL AGGREGATE s2,000,000 GEM AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPIOP AGG s2,000,000 PRO- POLICY JECT LOC - - AUTOMOLE UABIUTY Rd - COMBINED SINGLE LIMIT s ANY AUTO (Ea accidetd) ALL OWNED AUTOS - BODILY INJURY- s SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INJURY s NOµOVYMED AUTOS - (Per aecl,ftm) ... PROPERTY DAMAGE $ (Per acoidenl) GARAGE UABILITY - AUTO ONLY-EA ACCIDENT s . ANY AUTO - - EA ACC s --_ OTHER THAN ...___.._.. _ . AUTO ONLY: AGG s EXCESQXIMBRELLA LIABILITY. - - EACH OCCURRENCE $ . OCCUR El CLAIMS MADE AGGREGATE s DEDUCTIBLE p I - RETENTION $ s B WORKERSCOMPENSA7IONAND 7PJUB-743OA7-07 04/11/07 04/11/08 X I .. TORY LUrtRS. � ER _ EJaPLwmsuaBluTr 7PJUB-743OA7-08 04//11/08 04/11/09 E.L.EACH ACCIDENT $100,000 AW,,PROPRIETORJPARTNERIEXECU lVE -- OFFICERIMEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE s 100,000 . R yes.describe under YES -- SPEC PROVISIONS E.L.DISEASE-POLICY LIMIT s 500,000 OTHER - _ eSCR Vnai OF OPERA7IONS r UXAMONS r VMCLW I EXCUISONS ADDED BY ENDORSMWT r SPMAL PROVISIONS _ 'HE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PAUL BUCIQIILLER :ERTIFICATE HOLDER CANCELLATION :OREY &COREY SHOULD ANY OF 7NE ABwEB® POLICIES BE C/UtcELLED BEFORE THE ExwRAnON 1699 FALMOUTH RD #115 DATE THEREOF, THE/IBSMPNG INSURER WILL ENDEAVOR TD MAIL 21 DAYS WRITTEN &NTERVILLE; MA 02632 NOTICE TO THE CERTIFICATE HOLDER WED M THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR Y LUI Of ANY IOND UPON THE INSURER, ITS AGENTS OR . - REPRESENTAnVdl �' 1% AUTHORIZED R ESENTATIVE 'AX: 508-775-0155 - --RD 25(2001108) ` �/ ©ACORD CORPORATION 1988 f l , I �oi�,islulwptl Z 9ZO dW'3l1IA2331N30 IS ltlAHl(OW3l2 4d6F9O6 ,0 S 320?0 W WQH 130v),91:i00 S1N3 �. j. 58L89Z #!1 040Z1919 9909£6 uol eais►liab HolOVHINO01N3W3AOHdW13W0N 2a BuiP1►nH�i�3° �g Sp�ep��,3g1nrr�+�0 -omawryuuea rd of Building RegBoaw sa✓n fStandae ds Construction Supervisor License License CS 2881 Exp1;-"lion 21 4/2010 Tr# 18166 1 Restrictio iEt o n OUP CHARLES E COREY €- f: 1694 EALMOUTH14 CENTRERVILLE,MA 6'2 i Coinmiss�oner T_. i a _ i V5C On`y �\ •. ,�a��;aoU�oto, e vats` oa�et aa�as , t<Woo atie 1{��a�a Stagy � Se oC tat�oo g�;ato30� �t eo ethe e�Q aio�R�e�n'1 \1 bet ov oY�a t` Bpi Psb�a pZ�pB - '�� Bostoo, oat�te • j TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -p Map Parcel Application# Health Division Conservation Division Permit# Tax Collector Date Issued Treasurer Application Feed Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address �� A" Village Owner D� 0 L. 'C Address Telephone c �� Permit Request ) ^}t`tij T G-45WC,8& f�S A i CS :CA-3,- /' �- C Ptnoclzm . Square feet: 1st floor:existing proposed 2nd floor:existing proposed To411new Zoning District Flood Plain Groundwater Overlay t Project Valuati Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting dot;`entation Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) `P Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: Yes ❑No Basement Type: mull ❑Crawl td Waallkout ❑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 _ 6 Total Room Count(not including baths):existing 6 new First Floor Room Count Heat Type and Fuel: ❑Gas Vii1 ❑Electric ❑Other g Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stov6: ❑Yes a ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing. ❑neK size C i `'FF Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: E .r a > Ci Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# can r^ Current Use Proposed Use BUILDER INFORMATION Name Telephone Number C Address 1 License# 01 . Home Improvement Contractor# i� , N � Worker's Compensation# LOC ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO COS) FI , SIGNATURE DATE d FOR OFFICIAL USE ONLY. PERMIT NO. DATE ISSUED MAP/PARCEL NO. - ADDRESS VILLAGE, , OWNER - ' i • DATE OF INSPECTION: ` FOUNDATION FRAME (CJ�C --1. -0 INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL r FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. • 1 r_ e Commonwealth-of Massachusetts Department of IndustrialAccidents Office Of Investigations =j T 600 Washington Street x« Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgenization/Individual): Address: — -� City/State/Zip:_ lbw Phone#' ire you an employer? Check the appropriate boa: Type of project(required):. �a employer with _ 4: ❑ I am a general contractor and I employees(full and/or part-time).* have hiredthe'sub-contractors 6. New construction ❑ I am a sole proprietor or partner- listed on the attached sheet,1 7• ❑Remodeling ship and have no employees. ' These sub-contractors have 8, ❑Demolition working for me in any capacity. workers' comp.insurance, g, ❑Building addition [No workers' comp,insurance 5. ElWe are a corporation and its required•] officers have exercised their 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL. 11.❑Plumbing repairs or additions . myself, [No workers' comp. c. 152, §1(4), and we have no 12,[]Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13,❑Other my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. rm an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site formation. surance Company Name: , licy#or Self-ins.Lic,#: L&Z — — e f - Expiration Date: 6 Site Address: 01 1 r\ �� City/State/Zip; ,s tach a copy of the workers' compensation policy declaration page(showing the-policy numbers d expiration date). ilure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a . :e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office•of vestigations of the DIA for ins ce cover verification. !o hereby certify and a pains a pe at the information provided above is true and correct afore: Date; one#: �- Official use only. Do not write in this area,,to be completed by city or town of t`ciai City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6, Other Contact Person: Phone#: -Information and Instructions - , Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual;partnership,association or other legal entity,employing employees.,However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." . MC-IL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required," Additionally,MGL chapter.152, §25C(7)states"Neither the commonwealth nor any Qf its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)na+Te(s),addresses)and phone number(s)along with their certificate(s),of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance, If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to.the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department.of Industrial Accidents. Should you have any questions regarding the law or if you are required to-obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is,complete and printed legibly, The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy.information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining.a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 and fax number; The Commonwealth of Massachusetts Department of Indwtdal Accidents Mee of Investigations 600'Washington Street Bostoh,IAA 0.211I Tel. #617-727-4900 ext 4G6 or l-8.77-MASSAFE Fax.#617-727-7749 Revised 5-26-05 wwwmass.govidia CONTRACT E ACT Customer Name Cy C'\"6 cc - Customer Signature rj7n �)r M�1zLr/;�U� SKETCH Contract Date 1 0/1 q (, Sales Representative Signature Self_ r ATTACHMENT Customer Phorie -5�3 7��" ?3, __t�=s_,_`��, uv� y��t :i�ct7 Contract Price-1-2 °v-"ciuy `vo Ic I 1 2 3 30 5 6 7 0 9 10 11 12 13 is 10 12 ,0 ,9 20 21 22 23 2a 25 26 22 20 29 31 W 33 11 35 30 37 38 30 10 11 Q 13 1,1 15 16 a7 d0 49 50 51 52 53 fa 55 56 V 5d 59 00 2 n _ y , 1 , . ,c II A43 a 10 " i t , , I 1 — . .a , r ` l ' 16 d .' (1;,%v�"��'. ' .!�?d ' '- 1 T?.,• �}L j v L. -t- . _f - - L { I-._..i__t—._..�. 1I n_ 21 22 4. t r 25 V` �� 1 - a::i . 7-:.". '•':± _ _ , F. ;� r ; .j.:�_ ..t.. 26 27 20 30 M 31 32 13 Jn j 7i NOTES: -- Each box equals one foot unless olherwiso noted.This sketch is a good faith represontation of the work to lie done, it Is understood that all dimensions - derived from this aketch wu approximato,and that ell locations of outlets,light. ' (lxtllraS,I)hl1 Is,inCkS anklA'SWIlChOS aro subject to change If necessary. Town of Barnstable Regulatory Services yMAW. Thomas F.Geiler,Director �A 1639. �0 rED Mo+° 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 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize IN J to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) 6P Signature of Owner Date Print Name Q:FORM&OWNERPERNUSSION - RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings $100.00 Residential Addition $ 50.00 Alterations/Renovations $50.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0041= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= 0041 pl',.If from below 1(:f applicable) GARAGES(attached&detached) square feet x$32/sq.ft. = x.0041= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf, $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00=' (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Projcost Permit Fee Rev:063004 06/08/2006 15:05 FAX 1 781 65`I �t-725 Andrew G Gordon Inc I0001 _ 4 AR WCIP Liberty - ISSUING OFFICE 354 ,Mutual_ Workers Compensation and INFORMATION PAGE Employers Liability Policy ACCOUNT NO. SUB ACCT NP. ' "berty Mutual Insurance Group/Boston 1.344354 0000 Lt$3f;kZTY MUTUAL FIRE INSURANCE CO. POLICY NO. TDO`CD I a:S OFF -E CODE SALES' CODE N/.R 1ST WC2-31S-344359-016 XX X WEST 102 REPRESENTATIVE 3000 2 YEAR :i ASSIGNED 2003 Item 1. Name of BAY STATE BASEMENTS LL C Insured DBA OWENS ORMNG F.111,11SHED BASEMENT SYST FEIN 14 4885527 Address %0 TURNPIKE '1'&EET RISK ID 000182837 CANTON,MA 0 2 Status 46 LINUTED LIA" tIkFITY Ct Other workplams not shtt above S1L'E ITEM 4 Mho IA r ! Mo.Dny Year Item 2.Policy Period:Frotn OS4'0€a` to 05-24-07. 12 OI l stan4rd time at the address of the insured as stated herein. Item 3.Coverage A Workers Co>rtpensattom sr `ance A One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insastsa ; Past14divo of the policy applies to work in each state listed in item 3A.The limits of our liability wider Part T ire; t. Bodily Inlu ,�r-b :Aor-ids"u: 500,000 'each accident. Bodily Inlui r by Disease. SON" policy limit Bodily inlur by Disea4e 1 500,000 each employee . C. Other States Insurance PLrk.`1 p 'hree�t the policy applies to the states,if any,listed here: SEE END WC 20 03 0617 D. This policy includes the a dZ.orsemo. is and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium. - The premium fccn Ilk; polar �0 be determined by our Manuals of Rules Classifications Rates and Rating Plans. All information required belo i -ub* cti,14 verification and thane b audit. . Premium f Basis Rates LINE 110 Estimated Per sioo Estimated Total Annual of RE- Classifications Code Annual No. Premiums munera/ion Premiums SEE EXTENSION OF INFORM-A---- ZE'AGI~ ' Minimum Premium $ 500 M� ) Total Estimated Annual Premium $ 1,050 Interim adjustment of premium shallS aade: ANNUAL This It including all endorsemenl °tied thFxewith,is hereby countersigned by policy, i--= Aathurized R sentntive Date OS-22-06 RECEIVE 5 . LAC coat Term Oper• ANDREti r _. � - dic i'oyne!nt Rffiing Basis Pol.KG. Flotue state Dividend=RE� WAL C)F: 05-22- �? ' NR MA 44359-015 GPO 4030 Rl CO }rt Ott 1 pi 0 987 t.dttlonal Council on Compensation Insutgnce WC 00 00 01 A BROKER COPY is JUN 08,2006 01:31P 1 781 659 4725. page 1 s 91te -Co Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 137943 Type: Supplement Card Expiration: 1/29/2007 OWENS CORNING BASEMENT FINISHING`) STEVE SWEENEY 60 SHAWMUT PARK CANTON, MA 02021 Update Address and return card.Mark reason for change. )PS-CAI 0 50on-05i06-PC8490 � Address E] Renewal ❑ Employment Lost Card Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: _137943 Board of Building Regulations and Standards Expiration:' 1/29/2007 One Ashburton Place Rm 1301 Boston,Ma.02108 Type:. Supplement Card OWENS CORNING"BASEMENT-FI tftW�"'VfrENEY �-' 60 SHAWMUT PARK:: CANTON,MA 02021 Administrator ot:va id without signature J1�� ✓ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number,,CS 094632 Birthdate:10/0411970 i} p � r i Ex Tres 10/04/2009 Tr.no: 94632 Restncted: 1 G STEVE A SWEENFtY+ is V. 108 RA TALB'OT S -.,',;''- C WEYMOUTH, MA 02a:9`0'i: Commissioner 1 1 CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and install the Owens Corning Basement Wall Finishing System and related items as described herein at the residential premises set forth below.This proposal shall not become a binding commitment unless and until it has been signed by the Contractor and the Customer. q Contractor: Owens Corning Basement Finishing Systems a division of Bay State Basement Systems,LLC. 60 Shawmut Road,Canton,MA 02021 Telephone#(781)821-0060 Facsimile#(781)821-8552 Federal Tax ID#14-1855297 Mass.Home Improvement Contractor Reg.#137943 Date Customer: Customer Namehy�c�ft�VV( tGASa_L' Ze Street Address City,State,Zipk.y( Telephone(. .> '-77!110 - f. tk ctVe St-lq, 45q This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing System and related items specified herein at the Customer's residential premises identified below: Installation Premises: Street Address City,State,Zip Scope of Work: /f Are Sketches and/or specification sheets attached? WYes' ❑No 'All attachments are incorporated into and become a part of this contract Description of Work/Specifications: U Uv f vs.d C , A r Lip yylylnr-Jl <tNAe�t eL Work Schedule": ` �c`'� 5m0kt ie-&o=r Approximate Commencement Date: V 22 tic. Approximate Completion Date: c_. (y e2L-,c E? "The proposed work schedule is approximate and subject to change Contract Price: ! Total Contract Price: $ 00(, � Deposit with order: $ ❑ Cash Check# Balance Due: $ 6 Terms: m'Cash ❑Finance (Cash terms are 10%deposit,50%on commencement,40%on completion) $ [ 6ZZ>-3 Due on Commencement $ U%-)z Due on Completion DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED SKETCHES,MATERIAL LISTS OR THE LIKE,AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT. YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED COPY OF THIS CONTRACT AT AT THE TIME OF EXECUTION. Witness our hand(s)and seal(s)below on this t�-'�_ day of OAT Bay StateBasement Systtems,s,L/LC./Authorriizzeed Representative: /// Signatu and Title Print Name DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Customer'": "h(TYrA!( 11)10 1- Customer Signature Print N�.�(!Y(� Z.f Town of Barnstable *Permit# O; Expires 6 months from issue date Regulatory Services Fee 0 9. Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner ®®RESS IT 200 Main Street, Hyannis,MA 02601 i" Office: 508-862-4038 AUG q 2004 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDEhTI� F BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number 7 Property Address ti 5i, �fyt�.a.t S esidential Value of Work 7 Q A.-C Minimum fee of$25.00 for work under$6000.00 p Owner's Name&Address CFL./Z, b^*Y .S� JK9,* ,v Sa l I r_V-P A-A, /S !� l�— Telephone Contractor's Name ? v � d� Tel hone Number "! Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orkroan's Compensation Insurance Check one: ❑ I am sole proprietor ❑ the Homeowner I have Worker's CompensationInsnrance Insurance Company Name =Y2 1%0 y S Workman's Comp.Policy# 6 XU A dWI �321 '-A Copy of Insurance Compliance Certificate'must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to S� d ❑Re-roof(not stripping. Going over existing layers of roofl ❑ Re-side ❑ Replacement Windows. 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: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature QTorms:expmtrg Revise063004 COREY fi COREY . "" T _.' Tkaoxfam- 40, f1iA & C• &P,*..� C, Qj4 St' It, Pk, A. te710 1684 Falmouth Rd. #115, Centerville, MA 02632 ` - TAKIKO. HNIG-RITAGra a RIBIR11ROOFING July 16, 2004 ELIZABETH DOTY & DEBORAH WEAR 59 MAINSAIL LANE HYANNIS,MA 02601 Phone: 1-508-775-2357 COREY & CORES' hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturers specifications and local building codes. Remove and`Haul Away All of the Old Asphalt Roofing Shingles .. Re Nail All Plywood Sheathing as needed. Supply and Install TAMKO HERITAGE 30 AR: 30 YEAR WARRANTY, 5 YEAR FULL START PROTECTION, CLASS A FIRE RATED, ALGAE RESISTANT, 240 POUND EXTRA HEAVY WEIGHT, SELF-SEALING, 70 MPH WIND WARRANTY, DOUBLE-LAYERED, LAMINATED ARCHITECTURAL STYLE, FIBERGLASS BASED ASPHALT SHINGLE with New England's Exclusive Full Line COPPEI2/CERAMIC STONES with a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT CLASSIC HERITAGE COLOR: t Supply and Install TAMKO ICE & WATER SHIELD WATERPROOF UNDERLAYMENT on Roof Eaves, Under the Step Flashing on the Skylights, Chimney and Gable Walls. Supply and Install 15# SATURATED BLACK FELT UNDERLAYMENT PAPER Supply and Install HICKS VENTILATED ALUMINUM DRIP EDGE on All Eaves. Supply and-Install _ AIR VENT SHINGLE VENT H RIDGE VENT on Both of the Ridges. Supply and Install ALUMINUM& NEOPRENE SOIL PIPE FLASHINGS Clean and Remove Debris from work area after job is completed. TOTAL,INVESTMENT $ 7925.00 Payable immediately upon completion. PAYMENT SCHEDULE: A Deposit of One Half i p O s due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 30 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Please make checks payable to CHAR]LES COREY COREY & COREY Warranties the Shingles and Labor for 10 years. TAMKO Warranties the shingles and labor 100% for the First 5 Years and then the shingles on a pro-rated basis for 30 Years Total. TAMKO Warrants the Shingles up to a 70 MPH WIND WARRANTY. TAMKO Warrants the Shingles to be Algae Resistant for a Full 10 Years. Any alteration or deviation from above specifications,will be executed only upon written orders and will become an extra charge,over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance upon the above work.. This proposal may be withdrawn by us if not accepted within thirty days. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: 7/14104 ACCEPTED BY: SUBNHTTED BY: ELIZABETH DOTV and/or DEBORAH CHARLES COREY HOMEOWNER COREY & COREY Page 2 of 2 Pages. �\ �} e % Board or]], ing n� . MOME�1F gulations Re 1 :tpvEMENT and Sta straii COIV arils 1 -.- T i �Xp�r 13 RACTOR . CORE t z 2Q06 Y f C RL &CORE'/ t�p ES CORE���� _' OEM CEN AIIbIOVTN '.\ »` ENT S TERVILL MA 63 ` `d nistr�to, To WN BON Tower lBarnstable �OF1HE Tp�O 2004 APR G ti fP, 1u1af 9ry Services Thomas F.Geiler,Director SARNSTABIA 9 Mnss. v °-----_ Ilding Division 039• �� CJJt v'Q prFDMP'1a Tom erry,Buil ing Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Y1a6/� f/ Fax: 508 790 6 3 PERMIT# 7 a / 7 FEE: $ �' y SHED REGISTRATION 120 square feet or less A �s ®� Location of shed(address) Village. o H N T M ) ag Property owner's name Telephone number �J Xr �' Size of Shed Map/Parcel# Signa a Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? —y Conservation Commission(signature required) ' PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forrns-shedreg REV:121901 �a Y Q PLAN OF LAND IN -DAR 1\1 ,5- ERARNS-rABI E CO.0 NTY, MASS. SCALE : I = 4-O SEP-F 20, 1982__ PA U L J. K N.I G H T REGISTERED L_ANb -SURVEY0R WEYMOUTH MASS. a P-T ! F`( -THAT 7►-{E � I '01014 L AT.K O hl SFfOWtJ 1 Cdt4 THi S � L Atil Ifj LocA-rQra on TH>-- 6R0 U t4 D AS INDICATED AN L7 GON FO jZMS To TFtE Z o►.1 tNG LAuJS o F .. CLXA- SEPT 3U , 1982 4-8 4 9 5 O C �l N 80 51 ZOO E C.B. 3 -r. W 5 0 0 o I I,S37 S. F. 0 co O ..; om co z I1.3 x4 N r� tli C B- 117. 32 C.B• O 58 51� 20,W m a 4 L o MAINSAI _ PRivATE LANE 0 C.B. c e. (:)WNER KENNE? H F. MURPHY 484 GREEN ST" WEYMOUTH MASS. 2-106 Assessor's map and lot number yeSewage Permit number ................................ ." �� °,► Z BARIF TADLE, i House 'number ........................... �................................... t ! v Mass. ., I ti ppp�039. 6� a WAY TOWN, ,O�kr�r, RNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......•. TYPE OF CONSTRUCTION ... �,� v3< �y�a�/.1.:..s.................................. ............... !7 ..................19....... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: . .. Location ..C� ../�, /.....,`1�/� r ?? ..1. ,.!f/v^;;y� /, ...R ;'•.• ' ..,......... ProposedUse .. ...................................... ...................................,......................... Zoning District ..... ..; � . ... . ....................... .........Fire District .... .:•. . ��� ........................................................ � . Name of Owner .� � '� '. ...d��.��f! .�1�� ( X .....� .... .y� ��. .Address Name of Builder '' / .. i�r�....-r .-� ./��.�.. .�a .Address .���. .1���'�••�.�.r:••�. ..� �...�. !� Name of Architect C . . . ,�,,q.e... ...................Address Al .......................................� Numberof Rooms ............ ...................................:......Foundation �. �r'�� ................................................ 7 t �, " � ........Roofing .. �� ...... Exterior .... . :.. ..'....................�........:.......{.............. .,��.�. .............................................. Floors1 .�,� 'f�; ................Interior K -' q ........................................ °Heating.- .%9 .............. ..........................................................Plumbing ... �`//��` .s�� �.�1� .�?"r �"'� �.................. Fireplace ..... t .............f � ..................Approximate Cost .. :j... Definitive Plan Approved by Planning Board ------------------_----------_19 , Area ........ ` .......r..�....... r r � � Diagram of Lot and Building with Dimensionsj' r�x� Fee .........:.,........y..�...y..'................ SUBJECT .TO APPROVAL OF BOARD OF HEALTH �'V 0 ?Al , � A .� r _ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above' / construction: (, ; Name � :, � aGr! �� ...................... . t MURPHY, KENNETH A=288-188 2 .,,E 2 No . 422 ....,........... Permit for ...1......Story........................... Sitgle Family Dwelling ; ..................................... .. ... . ............. . .. .................... Location ;,Lot #6 Mail Lane ............................. Hyannis ............................................................................... Owner ,Kenneth. Murphy ....................... .......:.................... Type of Construction Frame ............................................................................... Plot ............................ Lot ................................ # Permit Granted ...S ePt,....3 Q................19 82 Date of Inspection ....................................19 Date Completed 19 z 'ter I K J _ p J PLAN OF LAND IN k F r-j BA R NSTA $LE COUNTY, MASS. SCALE : 1 = 40 SEP7 20, 1982_ �a PAU L J. KN.I GHT REGISTERED LAND 'SURVEY0R WEYMOUTH MASS. THAT THE I.( D AT o N S 14 o W tJ a tii T H 15 P } . c LoCATI~ D o t-t THE G1zOU ►� D AS It,IDICATCD C-0N Fo RM5 T o LkLjS QAR-NS-rABLE MASS. SEPT 30� 1982_ 48 4 7 so v c.B, s 3 0 W .0 .0It 0 q v CD 0 II,S37S. F p m 0 co J Z . 117. 32. G.B. Z0 w a MA I NSA I L PR I VATE LANE o c.B. _ l OWNER : KENNETH F', MURPHY 484 GREEN ST WEYMOUTH MASS: •H 2_106 WX rye TOWN OF BARNSTABLE Permit No. Building Inspector VA"STA , : Cash ------------------------------ AV., OCCUPANCY PERMIT Bond Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ......................................................1 l 9............ .................................................................................................................. Building Inspector FOR �z�6h-4Cc� DATE L` � TIME P.M. M W'rt b� �1 � � FIflNECt , O F �! t 11 �7 AA aKe PHONE V D V 3 RE7LIRNED YOUR CALL AREA CODE NUMBER EXTENSION MESSAGE Sc, S -� LEASECAtL: CI'ii WIi�.CALL A IAGAtt ter t wars ro co SIGNED niv irsal' 4e003 NOTES - I i Date 1 'G �. Hour J !� To WHILE YOU WERE OUT M /q C-- ken j' Can d r t i s Of rn U ►h�-A(. L kt. po M I Phone V50 00 - cl /(/O O ,x Q Area Code Phone Number Telephoned Returned Call Left Package Please Call Was In Please See Me Will Call Again Will Return Important Message A)Lo M -P E P f ko— CAP CL Ivx l vac. -J-1 C12-o - 1c oL d: )ap demo — Q wa— Signed AVERY FORM NO.50-736 PRINTED IN USA I Date �I/��'`/�Jo) Hour To (,',f O r f c,L WHILE YOU WERE OUT 114 aPX44ge' Of 9 r dZP " 14gil DC4,,,- L T Phone - �Q 'q a d t� Area Code ' Phone Number Telephoned Returned Call Left Package i Please Call , Was In Please See Me V'v`'ill Call Again Will Return Important Messa G ham.. h� lhGL a /Uar► Villa 1ze 2) hente u d c l T Sc do c. Signed Oxj/v AVERY FORM NO.50-736 PRINTED IN USA � ����i�l�2� ! ���- �5�� E �� � ;� . � �/� ,� . =�• Complaint cjuiry Report Die, Rec'd by: Assessor's No.:------ Complaint Name: Location \ 4—V Address:_ NUP Originator Name: Street: / Zip. -- Village ` ��Telephone:DIE � '; Complaint17 Description: /4- Inquuy Description: For Office Use Only 7�.%�✓�5��' Inspector's Action/Comments Date: �`i9-G z Inspector. Follow-up G �e -e �e Action Adciia• 'onal Info. Attached White-Dcpv=cnt File Q cop),Distribution: % Yellow-Inspector It_1. f..,Prim Metvm to Office M21239cr) p� - r �9Lk► MASSACHUSET4S .... �' -. eD 1a2 --- -- — - �� OR9' AAAP§ 'a 143 ..35 AC I 145 144 . 17f'L .22 AC AC 146 SS AVENUE .. 2 v 4r ro i 158 16b . 1 d, r20' r20 t 157 37, , �f. 71 rl y 4- �'s 147 ISa 5 p.y 25Ac 72 - .a AC- 8 .xyAc es- . 33At^ .2p1Ac SIR..- -N - - ''pCrr FIDDLERS �3O $\165 - s f z a 164 , .30p m 1`1 t 148 153 159 s�P9G ,o .23 Ac. 25AG y z3pL, z3fL• 111 J z�x s o Ak = O a 16b"1 to0 163 B a °0 53PC d7 p 4 64 $ .zoac 1 152 9 .23AG• v 3w G .. ... - _®.. tb�r v 68 - Atlas Alarm Serving Eastern Massachusetts and Cape Cod a-'oo �� Hyannis Wire Department Wire Inspector 367 Main Street Hyannis MA 02601 John Miller Permit Subject Location: 59 Mains'l Lane (Hyannisport) Hyannis MA 02601 Gentlemen: Please accept this notice as confirmation that as of this date our work at the above subject location has been completed. We hope to have been of service to you. If we can provide you with any additional information, please do not hesitate to call upon us. You may contact me directly at (781) 337-8866 or (508) 540-5507, extension 176. Thank you. JJ I. Thank you. I� Very truly yours, Atlas Alarm Corporation Paul M. Rich President PMR/pv i Corporate Offices • 1239 Washington Street • Weymouth,Massachusetts 02189 • (781)337-8866 © Cape Cod Office • 659A Teaticket Highway • Falmouth,Massachusetts 02536 • (508)540-5507 I GRAPHIC SCALE 20 0 10 20 40 — 1 inch = 20 ft F i S 83`23'10" E 100.08' 0 N 300 Feet _ LOT 6 LOCUS MAP _ PLAN REF` 273-14 DEED REF.- 15499-93 ASSESSOR'S MAP- 288-188 ZONING: RE Lu w ' SETBACKS- 20, 10, 10, ,- FLOOD ZONE. C N w a �����-����������������� •- � PANEL NUMBER• 250001 0006 D a DATED. 0710211992 "e le'll a ' O VERLA Y DIST AP �1Li ° 23 W PLOT PLAN OF LAND 1 ,, .9ft w. I'lleele ,,,,, Co a LOCATED AT ,,,,,,,,,,,,,,//,,,,,,,,/, u . 59 MAINSAIL LANE 35.oft ;;s;;se.....� w ;;ell,;; ; ;;;;; ; � HYANNIS, MA ,,,,,,,,,Ile ,,,,,,,,, , PREPARED FOR.- D. WEAR 81`og 40» W ' MARCH 11, 2011 100.00° , Q *J�, .;#` 4 REV a`$7 REV r VK rN Qd->>N! (croZ- L STEP HE ;�' REV STEP HE LOT 5 J U —TP-4 pt'-e 2 IS TIC' 41 D0 c; YANKEE LAND SURVEY CA%r s = Y- ��c CO. INC. 2,XT -)CAS`t5, ®®®®''r' `® !: gj T? 119 ROUTE 149 �L MARSTONS MILLS, MA 02648 lip � TEL• 508-428-0055 FAX 508-420-5553 YANKEESURVE'YWOMCAST.NET lYlf'li.YANMyURVEY.COM SHEET 1 OF I JOB #V 54708 SH