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HomeMy WebLinkAbout0011 MARSH LANE // /�ARS1I C-RN6 ;' ACTIVE Bowers, Edwin From: Bowers, Edwin Sent: Friday,April 19, 2019 8:38 AM Tcr 'asweet995@gmail.com'. Subject: Permit/Application:TB-19-1268 at 11 MARSH LANE, HYANNIS for Building - Siding/Windows/Roof/Doors This letter is in response to application number B-19-1268. Your application is denied as submitted for the following reasons: 1) Incomplete construction documents as required by Chapter 1 Section R107.1 of the MA amendments to the 2015 IRC (9th edition 780CMR) And, if aggrieved by this notice; to show cause to why you should not be required to do so, you may file a Notice of Appeal(specifying the grounds thereof) with the State Building Appeals Board within forty-five (45) days of the receipt of this notice. 1 �6 ......)J.VR" pic rC�, Application numb n 9 X-V EA.j!� � 1� ,: P Date Issued................................................................. MASi ' 0 APR 1 '7 2019 Building Inspectors Initials. A TOWN OJ bARNS-FABLE pi Ma Parcel....3 TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: A4w# L-JVJ(-�iCJ/ ERA+ STREET VILLA E Owner's Name: ueg� Phone Number 0 j] Email Address: q(Jf ,d>° o;)C omC4,Srt. net Cell Phone Number Project cost t5—T 7 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: c4 ra-;,-t Date: TYPE OF WORK 0 Siding Windows (no header change)#3 0 Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to U) tr0lo — CONTRACTOR'S ORMATION Contractor's name �dl ��" F6 Home Improvement Contractors Registration(if applicable)# / 73 r7ir (attach copy) Construction Supervisor's License# 0 Vp Q3 (attach copy) Email of Contractor_%hiAqL ( . Phone number ALL PROPERTIES THAT HAVE STRUCTUR-a OVER TS YEARS OLD OR IF THE SUBJECT PROPERTY lS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORICAPPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER...:........................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under t rules and regulations for Licensed Construction Supervisor in accord ce C the Massachusetts State Building Code. I understand the construction i on procedu e , ecific inspections and documentation required by 780 CMR and t o f Barnstable. Signatur Date 7 - APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance i Home Improvement Agreement: Page2 Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of iWindows A more detailed description of the work to be performed is included in the section entitled Scope o Work which appears on page 0 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 03/28/2019 Approximate Finish Date: 04/25/2019 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your i nse t and verifying your email address above, you confirm that you have access to a computer that can c e and open emails and PDF documents. tialing this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the vwer l Terms and n itions nd State Supplement, if any. You further acknowledge receiving a co e opy is Ag p it to protect your legal rights. X 01/31/2019 1 The Home Depot Customer's Signature Date Service Provider Name X 01/31/2019 I 908 Boston Turnpike Unit 1 Co-Sig er 'f applicable) Date Service Provider Address X 1 101/31/2019 Shrewsbury MA 01545 Signatur n half o Ho e D pot Date City State Zip R-1-073-13-00016 Service Provi er Phone Number Service Provider License Number The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 4601`I HOE Customer Agreement(24 Jul.18) V 0.1.8 v z f� .r W o"A U%eiib14k S t lt7.s,aM ±s fDj*- w..�+•ir�.+r•`v'^+�*'+ jJM1� i�;i q:1C T� FcnFx3ii'�iRfk4' R�_ 7T-T4 ..:.: L � _ �y[y cis1�Lat FT � S�# ' S a i CP ,. C4��merlead/.Po MA Usl A city _ fibr ion# Wbrk Pton 00 Pion Customer,Email Address € R 0SUGATION BY K. V'tAiXG WRITMM N0710E'TO HOME bE P T: f IR b Eno ? §� 164 Address City ycal or Ems* � r�^�~ �xc�►�d��.azr� Sew.` ErpAWAdd BY M NIG14 'ON THE THIS 0 BUSINESS DAY AFTER SfGMN , dNLESS1ME$TATEol- UPPL Myy�� E;WTµwP VIDES ORMTO �-DI y{y�q]��r a�y�[- A�E� WPEFt��yt�o,CONTA . yy . �k P R SM f NE AFTFA-140 J•M 'iV� � # SV �'1fO•MR,1.X`OU;.)35. # SxA' � ''"Th T�� M-a Po-tip, l•Ar<` �6l.apij EyiN�yy,��y�y�Mapp}/fi t E # i E P{yN M�ry`E ;A�}T/K�yp�j�s YOUR tpSE ' (y�t Jsj�;yy� �\��e,�AN0 f ��/�Ury■8 A(■��' #`{��1{.4 �j�[)�iE Si'�ME 3ONDMO S ",EN IDEUVERED,.'A � �R��('�• JN43ll.e op:iTi �RIALS-DEUl IMt� '!a! TO YOU.ORNOO-MA T 140 E' E� "S� ESE ` THE LAW REQUIRES THAT T E�#oME DE-PAT Q E7�'C�1t',NaTr Efo E�$�f��NC��1lb�#�!�a##T TO CANCEL PLEASE SIGH FIDW`OA KNOW 44' 004"91 IT AL AND WRMEN'Nor r�, ,y i # ! t t atho ract PiFGB i is Tax; to ttRaPd + gCd , 'A€£an*. Ay B�r-G�aaaCef # 633 Scanned with CamScanner • i i v.seam.a myr'aac�F:elt s �3i�8�¢�s3dCi.',.+J�-"SQTLS Jr_ c€;g s a 3� 40'MAS E � f PA sod(�3 MA i E The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 �a www massgovJdia Rrorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTLVG AUTHORITY. Applicant Information Please Print Legibly Namt'(Business/Organizadon/Individuai): 3 t\f Cy fp 0 CA-f 1 O fl Address:—Y.7q IAA-S�tt n cL0,1 Sf. (It���� �C ��7 City/State/Zip: Fj o -I Phone# !UC. f L/Z 1 Are von an cmpioyee check the appropriate box: Type of project(required):, 1.J 1 a a employer with employees(full and/or part-time).* 7. ❑New construction I (am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4. I am a homeowmer and will be hiring contractors to conduct all work on m 10 a Building addition Q g Y Property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.[—]Roof repairs These sub-contractors have employees and have workers'comp.insurance ` � �1 6.a We are a corporation and its officers have exercised their right of exemption per MGL a 14. ther_ W(M t 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 1-y l AaA *Any applicant that checks box#]must also fill out the section below showing their workers'compensation policy infolmation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +'Contractonr that check this box must attached an additional sheet showing the name ofthe 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 insurancefor my employees Below is the policy andjpb site information. Insurance Company Name: A550cicr�e-d rnel . OA — 6 6LQl r_ Policy#or Self-ins.Lic.#: 70 z 8 2 10 -19 1 ZO 18 Expiration Date:: ��LL.�� - Job Site Address.-a— MAVLI L City/State/Zip: ` *ks Attach a copy of the workers'compensation policy declaration page(showing the policy nudber and ezprh%tion date). Failure to secure coverage as required un . 52,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as.we as civil penaltie in the form of a STOP WORK ORDER and,a fine of up to$250.00 a day against the violator.A cb s statement may b the to the Office of Investigations of the DIA for insurance coverage verification. I do hereby un a the poi sand pen of p ury that tlse information provided abov is tr a and correct Si afore, Date: Yr 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#: ti f Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, s husetts 02118 Home Improve tractor Registration Type: Corporation FBN CORPORATION Registration: 173595 P4M Expiration: 11/02/2020 679 WASHINGTON STREET UNIT#8-197 ! d SOUTH ATTLEBORO,MA 02703 s Update Address and Return Card. 4A 1 0 2OM-05/17 _............................,.................. ..;;....................._...........-...-......................................................................,............................... ........................... .. ��M?I!'l0✓LCOP�Ub O��Q..11�L�El�`.r3• i � � . Office of Consumer Affairs&Business Regulation HOME IMPRO MENT CONTRACTOR Registration valid for individual use only omoration before the expiration . If found return to: Expiration Office of Consumer irs usin s Regule" In j 11/02/2020 1000 Washington t utte 710 FBN CORPO n � Boston,MA 0 8 THOMAS PEACO 679 WASHINGTO UNIT#8-197 Not Without idpiture SOUTH ATTLEBORO,MA 02703 Undersecretary DATE O MIODNWY) A 0 CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CON PRODUCER NAME:C HOuseAcct PHONE (508)695-7938 No: (508)695-0448 Pope Insurance Agency EX 25 Taunton St. (Route 152) ADDRESS: INSURER(S) G COVERAGE NAIC S Plainville MA 02762-2139 IpSUIRER A: NGM Insurance Company 14788 INSURED INSURER B: The Commerce Ins.Co. 34754 FBN Corporation 1NSURERC: Associated Ind.of MA-ARWC 26158 679 Washington-St INSURER D Suite 8 Unit 197 INSURERE: South Attleboro MA 02703 I INSURER F COVERAGES CERTIFICATE NUMBER: CL1881403825 REVISION NUMBER., THIS IS TO CERTIFY THATTHE 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. LTSR R TYPE OF INSURANCE POLICYNUMBEt MMIDD/YYYY MI®IWD LIMITS X COMMERCIAL GENERAL LIABRM EACH OCCURRENCE $ 600,000 50,000 CLA{MS.MADE ®OCCUR MI PRESES � E MEDEXP one $ 10,000 A Y MPT9583F 09/16/2018 09/15/2019 pERSONAL&ADV INJURY E 500,000 GERLAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE s 1,000,000 X ❑POUCY �Q LOC PRODUGTS-COMPIOPAGG $ 1,000,000 OTHER; C� -COMBINEDSI MIT $ 1,000,000 AUTOMOBILE LIABILITY as e ANYAUTO BODILY INJURY(Perpemon) $ B OWNED X AUTOS BBY021 01/0212018 01/02/2019 BODILY 114JURY(Pareeddeeq S AUTOS ONLY PR d E HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY Uninsured motorist BI $ 100.000 UMBRELLA LIAO OCCUR 4&OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ R DTI{ WORKERS COMPENSATIOrd A ER AND EMPLOYERS'LIABIUTY 1,000,000 C ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA 7028271012018 09/2512018 09/26/2019 E.L.DAEASE- AEMENT $ OFFICER/MEMBEREXCLUDED? EL DISEASE-EA EMPLOYEE S 1,000,000 (Mandatory 1n NH) 1,000 000 Ilya dwMe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS WOW DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES"(ACORD 101,Add IMI RamaNta Sahadtdo,may he adacW E more apace Is required) THD AT HOME SERVICES,INC AND THE HOME DEPOTARE INCLUDEDAS ADDITIONAL INSURED WITH RESPECTS TO GENERAL LIABILITY INSURANCE PER CG2010-ONGOING OPERATIONS AND CG2087 COMPLETED OPERATIONS WHEN REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THD AT HOME SERVICES,INC r 2456 Paces Ferry Rd. AUTHORIZED REPRESENTATIVE Atlanta GA 30339 � - C ISM2016 ACORD CORPORATION. All rights reserved. ACORD 26(20161`43) The ACORD name and logo are mgietered marks of ACORD Application numbe ...............r �... ::. 1; issued...........: .L...........1:.... -........ ........... NAM TAO BAR.N5TABM 039° �0� �UL. Building Inspectors Initials........... ... `� 2 5 201 ... ............. illI�I / ............ ......... ................................ TOWN OF BARNSITABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: S n NUMBER STREET GE Owner's Name: H�c,,�e, f / i,� ;sP. Cue s- Phone Number�l Email Address: _e) Cell Phone Number Project cost$ / 3 o — Check one Residential Co mmercial ommercial OWNER'S AUTHORIZATION . As owner of the above property I hereby authorize to matte application for a building permit in accordance with 780 CMR Owner Signature: S e Date: TYPE OF WORK Siding Windows no change)#header 0 Insulation/W( .- ._ g �_ eathenzatton Doors(no header change)# Cdnintercial Doors require an inspector's review J Roof(not applying more than 1 layer.of shingles),. Construction Debris will be going to LL - a(�'' / A? y Grll�sTe-/�'?A�a�i �/I � co r1 CONTRACTOWS INFORMATION Contractor's name �t�an_�Rn�t,'so✓� = .2Av cn We&J Fri���ct7 'nG�OwS Home Improvement Contractors Registration(if applicable)# 17 ,3 L- (attach copy) Construction-Supervisor's License# 01 S-7 07 (attach copy) Email of Contractor Q5 9fci a G/11Q� c Phone number Lqo z Z R -`�XDO ALL PROPERTIES THAT HAVE STRUCTU�S OVER 75 YEARS OLD OR IF TIME SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER...........:.................::............................. *For Tents Only Date Tent(s)will be erected Removed on number of tents total. Does the tent.have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one:Food served Yes - No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s)of each tent ff food is being served at your event please obtain.a Hei lth Department approval between the hours of 8:00arn=9:30 am or 3:30 pm-4:30pm.. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES x Manufacturer# ,Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left'side right side H01MEOWNEWS LICENSE EXEMPTION. Homeowner's Name: Telephone Number Cell or Work number I understand nay responsibilities under the rules and regulations for]Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction,inspection procedures',specific inspections and documintation required by 780 CMR and the Town.of Barnstable. Signature Date x FLICANT'S SIGMA c . Signature bL Date -7 — Z S— l F F All permit applications are subject to a building offwial's approval prior to issuance renewal Agreement Document and Payment Terms Andersen. dba:Renewal B Andersen of Southern New England Y Andersen S Robert Guest MMLACEMEN1 Legal Name:Southern New England Windows,.LLC .' 11 Marsh Lane RI#36079,MA#173245,CT#0634555, Lead Firm#1237 : Hyannis,MA oz6ot W . 10 ResemirRd I Smithfield,.RI 02917 : - H:6178167506 Phone:866-563-2235 I Fax:401-633-6602 1 sales®renewalsne.com '. y ( Contract D 07/Bu er s)Name: Robert Guest 13/18 Conrtate: Buyer(s)Street Address: 11 Marsh.Lane, Hyannis, MA 01601 Primary Telephone Number:.6178167506_ . : Secondary Telephone Number Primary Email: 9 Secondary Email: uestie�comcast.net Buyer(s)hereby jointly and severally agrees to.purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal ByAndersen of Southern New England("Contractor'),in accordance with the terms and conditions:described in this Agreement . Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the tertns of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). . Buyer(s)hereby agrees to sign a completion certificate'after Contractor has completed all work under this Agreement. Total Job Amount: $11,366 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed.must be made by personal check,bank check,credit card,or cash Deposit Received: : $0 $11366 Estimated Start .' Balance Due: , Estimated Completion: Amount Financed: 8-10 weeks 8-10 weeks $11,366 Method of Payment: 'Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date -and time at a later date.Rain and extreme weather are the most common causes for delay, Notes: 100% Finance, Taxes to be paid in Barnstable: Buyer(s)agrees and understands that this Agreement_constitutes:the entire understandings between the,parties and that there are no verbal . understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyers) and Contractor.Btiyer(s)hereby acknowledges that Buyer(s),1)has;read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including' the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement: NOTICE TO BUYER:Do not sign this contract_if blank.You are entitled to a copy.of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 07/17/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC. dbai Rene�� B .�ersEw Sourhern New England Buyer(s)_ Signature of Sales Person Signature .. Signature Kevin Desmarais :: Robert Guest Print'Name of Sales Person Print Name : Print Name UPDATED:.07/13/18 Page 2 /;9 Office of Consumer Affairs and Business Regslation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 SOUTHERN NEW ENGLAND WINDOWS LL BRIAN DENNISON 26 ALBION RD =. . LINCOLN, RI 02865 Update Address and return card.Mark reason for change. Address —! Renewal —. Employment Last Card -==-..office of Consumer Affairs&Business Regulation Registration valid for individual use only before the -- ` HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: Office of Consumer Affairs and]Business Regulation Registration: 173245 Type: 10 Park Plaza-Suite 5170 Expiration: gM9/2018 Supplement Card Boston,NSA 01-116 OLITHERN NEW ENGLAND WINDOWS LLC. :ENEWAL BY ANDERSON � RIAN DENNISON � 6 ALBION RD _; � INCOLN, RI 02865 l.Undersecreiary Not valid without signature <--- „ �]:d a; �' .":.i J BRIAN D DENNISON � 7 LAMS POND CIRCLE C-HARLTON MA 01507 - The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensatibn Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PE}2MMING AUTHORITY. A licant Info rmation Please Print Le 'bl- Name (Business/Organizationdndividual): ` !✓ e 01 E Address: City/State/Zip: p Phone#: 4n Are you an employer?Check the appropriate box 1.XI am a employer with ZO mployees.(full and/orpart-time)-= Type of project(required): 7".❑New construction 2-f-�I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp-insurance required.] g• []Remodeling 3.F-1 I am a homeowner doing all work myself[No workers'comp.insurance required-]t 9• :E]Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on m 10'[]Building addition y propery- I will � ensure that all contractors either have workers'compensation insurance or are sole i I.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions SM I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.! 1 r 3.F]Roof repairs 6.n We are a corporation and its officers have exercised their right of exemption,per MGL c. 14.Dbther wr r 152,§1(4),and we have no employees.(No workers'comp-insurance required-) ,P�/�i 'Arty applicant that checks-box>Yl 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 jar my employees. Below is the policy and jab site information. Insurance Company Name: `ire pie n$ flis. Policy 4 or Self-ins.Lic.#: C��`SZr7 2-9 — Z.0 Expiration Date: / 1 Job Site Address: City/State/Zip: l-1y/gnn/S l� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation pdriishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator-A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under ih ains andpenalties of perjury that the information provided above is true and correct Simazure: D2te: 7-oZ Phone#: CIO d-2Z g%IT 9ev . 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 I Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector} 6.Other Contact Person: Phone##: r CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) 12/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION 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 CONTACT CoBiz Insurance, Inc.-CO NAME: PHONE 1401 Lawrence St, Ste. 1200 303 988-0446 E-MAIL A/C No:303-988-0804 Denver CO 80202 -ADDRESS: COMaiI cobizinsurance.com INSURERS)AFFORDING COVERAGE NAIL 8 INSURER A:Acadia Insurance Com an 31325 INSURED ESlERCO-01 Southern New England Windows, LLC. INSURER B:Tremens Insurance Company of WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1252851165 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 ADDL SUBR NPOOLLIIpY EFF MOMYDD FXP LIMITS LTR POLICY NUMBER A X. COMMERCIAL GENERAL LIABILITY CPA3158728 1112018' 1/12019 EACH OCCURRENCE $1,000,D00 CLAIMS-MADE FE OCCUR PREMISES occurrence $30D,D00 i MED EXP(Arry one person) $10.000 PERSONAL&ADV INJURY $1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.OD0,000 X POLICY PERC4,T LOC PRODUCTS-COMP/OP AGG $2,000,00D OTHER: $ A AUTOMOBILE LIABILITY N CPA3158728 1112018 1/12019 COMBINED SINGLE LIMIT Ea accident $1 0D0 000 X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS I Per accident $ I $ A X UMBRELLA LIAB X OCCUR CPAS158726 1/12018 1112019 EACH OCCURRENCE $10.000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10.DDD.D00 DED I X IRETENTIONS, $ 8 WORKERS COMPENSATION WCA3158729-2D 1/12018 1/12019 X PER OTH- AND EMPLOYERS•LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNEROMCUTIVE EL EACH ACCIDENT $1,000,OOD OFFICER/MENBER EXCLUDED? ❑ N I A (Mandatory in NH) Ifyes describe under E.L.DISEASE-EA EMPLO $1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000 C Pollution LiablTdy 7930171340001 1/12018 1/12(Y19 Each Occurrence $1,000,13DO Claims-Made Policy Retroactive Date 06202013 Aggregate $1 Deductible $10.00,000 OD0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25.(2014/01) The ACORD name and logo are registered marks of ACORD Town of Barnstable Building g ., ...� s Post;This Card So-That it isUisible From the Street aApproved'Plans Must be Retained on^!ob and then CardrMust be^Kept „�x`, Posted �ntil Fina l Insp ecti on Has:Been M U ade Permit ur' Wy here a; ertificate of Oct,panty is Required;such build rig shall Not berO�cccupied^until a Fnal�ln pe�cNtion.has been made Permit No. B-18-2371 Applicant Name: CAPE COD INSULATION, INC Approvals Date Issued: 07/26/2018 Current Use: Structure Permit Ty e: Building-Insulation-Residential Expiration Date: 01/26/2019 Foundation: P .. Location: 11 MARSH LANE, HYANNIS Map/Lot 324-011 Zoning District: RB Sheathing: Owner on Record: TOBIN,CORINNE F - r .Contractor Name:, CAPE COD INSULATION, INC Framing: 1 Address: 65 SANDERSON AVE L Contractor`.License 153567 2 z' WEYMOUTH MA 02189 r 0.00 Cost:Est.-Pro act 1 $ Chimney: Description: Weatherization PkermitFee: $85.00 =.j Insulation: Project Review Req: Fee Paid: $85.00 s Date . 7/26/2018 Final: � x Plumbing/Gas •� Rough Plumbing: a �, I y Building Official Final Plumbing: 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 fhe�approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and st ructures'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 a,nd shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures Gy the Building and Fire Officials ace provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing „ '. Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: , 6.Insulation a Final:Volta 7.Final Inspection before Occupancy Low�� g Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "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 2 a� TOWN OF D BARNSTa�'EMap Parcel Application # Health Division ?u l Jul 24 Arl 9. 17 Date Issued Conservation Division Application Fee. Planning Dept. Permit Fee US• Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address �/ �t�s'�l L.✓ Village Owner /�6,Ye9 r l J'e-'r e Address S% 14, � Telephoned/2 S"11- '2494 Permit Request 4T1.-, //d T /� '� a 1!g4E t/ ,/2 �-2 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation _3 X6z© ' Construction Type_ 7_7��,ram 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 21q-o On Old King's Highway: ❑Yes 21Ko 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 C � <�� /.�Sv`%/��,xo Telephone Number s7 2 7-5 /5' Address le Z2_2g ZZ License# / f e z /2' ep Home Improvement Contractor# 11f Email,W >c A l/�lAO�Gs / iJG i�,�0���,, Worker's Compensation #W eZ"eQ 5� J G-j ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C_//) eAf'e5 642� SIGNATURE DATE �/ Z �fl FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. t `k ADDRESS VILLAGE 4-. OWNER DATE OF INSPECTION: FOUNDATION FRAME j INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. w ' Permit Authorization tY1> S �V Form 0—ugh en-w Site ID: 3431164 Customer: Robert Guest owner of the property located at: (Owner's Name,printed) 11 Marsh Lane Hyannis, MA 02601 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Date: 000eaoeoea000aeaaooaooaaoeaee00000aa00000eaeeeoaaeooeoaaeeeaoeeoaoaee FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractorto the above referenced project: Participating Contractor Date I Name: RISE Engineering Phone: 401-784-3700 Email: Force Use Only. Rev.102015 The Comjnor�wealth of 1�assaa/IuSetts ' r bepar+tment ofXna'ustr'la6�fooldettits l 1 Congress S''lreet, Sulle 100 13ost091 MA 021142017 wwwmass��'ov/�la �1rotkarst Compcnsetlon Insurance Afildavltl;,Builders/Contr.:aotorsl�lectriclens/pl.umbera, TO 8B rC.LBb WITH TIi p RMltrIKO A>r1T nRi"CY Name (gurlHasa/drganlztHoNindlv.idual); 8 Cnd 7r1SU1a11dt1 Address; 18 Reardon Circle Cliy/State/zip; SOUth YarmcUthrMA OM4 phone #1 508�776.1214 An you hn rmployerl' CEeok fhe tpproprltla bort I�I�m e employer with �$ employaas(NI! endiotpert�Urna),r q"Ype o�proJ eot (required); LLD I am 11011 propr elor or ptrtno"hlp and htye no lamployea,workln; for me In ❑ Naw oonstruodon env oepbol� ,No workars oomp, Inourartioe raqulrad,) g, ' ❑ REmOdEl.ing J ❑I am a homaownar doing nil work mysalP CNo workars'oomp In,uranoa raqulrad)I 9, C] DEmollfion �,[]I�a homeowner and will ba hiNng eontraotor,ea conduct all work on my. roe ❑ $ulidlg p addlilon snrun Ute4 U�oontraa►ors flow have workers'aompanadtlon lneunnoe or re soli I vrlll 10 p►oprlcloiswlUt no anployaes, I i,❑ �(ootrloal rcpalrs or adds s,c I vn a pnrral oontreotor and I heya hlred the suboontreolon ila►ad on the aHeohed shoat, 18�o;*§0nvotoiO heye employa-0s and htYe worker$;"znp� 1net1raT1a4,) 2'❑Plumbing repairs or wadi 6[] 13, Roof repay , we ue a aarporedon and Ira ot�ven htve exeraleed their rlgh{ ❑of axampdon per MCA v, 14, ,� 0 W we hive no employees, No workers oomp, Inewnnoeregvlred) C71 ther eatherizatlo 'Any eppl osn{�dl d'heak, x I must nJso AI out. a scot on be ow show n�thelrworker,' oompanastlon polio Into I Homeown►re who rubm(i'�Ji` daYlt Indlaat{n th tConb�as�n Vu4 ohwk th)s Eox mwt att,aohed nrt addl�onal shawl ehowing we nwne oP the sub.vonb�aaWra end � rm6tlon are oing all work and then hire ovwide oona�osora must submit a Haw alndeYlt lndloating euor smployeer, Itthe ru�eona'doton Iuve efi to lee they m roYlde their workara ooni , llo number, to whether or no►►hole lolaa ; ys ;U lam" employer AV tr pravedl.�g workers' oompen,ralton j�suranee,for ray empte e¢s ,,,,;' „ trttorrnattorG y 8¢tow tr the p0oy and yob sir lnsuraaoa Company Name; At,lant i.c Charter " Polloy�or SelP�lr,s, �lo, #I WCEDO�� 1902 .:!`, �xplration bate 08/30/201� Job SItE AddresslJl ryr A,�I.sti / ,.,� Attach'; copyofthe wor�cersf oo�pensatlob pollay declaratlob page sbow OltyySiate/zipl .9 az Fallure to seoura oovarage as required under MOL o, ( 1q, the policy n bar and explra hors d, arjdlor,one�year Imprlsonmont, as well as olYil ponaltles2� §29A Is a criminal Yiolailon punlshablE b a day agalnsl fhs Ylolator, A copy of this stat,Em�nt may bs forwarded 10 the 0 0 y >�nE up to SI,S00, " ooyerage Yerl>�oatJon, � O��R and a fine of up to S2S0, Of CnYes igatlons of the DLA for Insurer do iar¢by,a¢r un r lh Ns and peMallles o er u 7,. ra ! ap vdeda hove ! t ndeorregG �, 4 home 5 12 OfJiclal usa oily, Do riot write trs flits nreo, to ba Completed by airyow or f n o,/y'IofaG City or Townl Csstiing Authority (olrola ono)I C'ormltlC,loense # I,l3oard of>-Cealth 2, Buiidirig bepartment 3, Cltytrown Cler4t 4� �Ceotrloal , .6, Oiher Cnspeator' Si plumbin5 Cns,pecto Coniaef person; ----- ----------- CAPECOD-27 AIMAHLER A`oRo• CERTIFICATE OF LIABILITY INSURANCE D 06/06/DD/Yl/2018 06/05 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 endorsements , PRODUCER ME Rogers&Gray Insurance Agency,Inc. PHONE FAXNo:(877)816.2156 434 Rte 134 A/c No,E,t South Dennis,MA 02660 AI mail ro ers ra .com INSURER S AFFORDING C VERAGE NAIC# INSURER A:West American Insurance Company 44393 INSURED INSURER 13:Saf8ly Inderrint Insurance Company 33618 Cape Cod Insulation,Inc. INSURER c;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atiantic Charter Insu rance Comp any Yarmouth,MA 02664 44326 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE X OCCUR EACH OCCURRENCE _ 11000,000 ❑ BKW(19)63328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,000 —EREMISES(Fa occurrence) MED EXP(Any one erson 5,000 PERSONAL&ADV INJURY 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE 2,000,000 X POLICY❑JECT ❑LOGS X OTHER:see holder descrip of operations PRODUCTS-COMP/OP AGG 21000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO 6232707 di entl OWNED SCHEDULED 04/01/2018 04/01/2019 BODILY INJURY Per PersonL AUTOS ONLY X AUUTNOOSWNEp X AURTOS ONLY X AUTOS ONLY BODILY INJURY Per accident P�20.ERdY AMAGE er ecu ant C UMBRELLA LIAR X OCCUR EACH OCCURRENCE 2,000,000 X EXCESS LIAR CLAIMS-MADE EXC10006635003 04/01/2018 04/01/2019 2,000,000 AGGREGATE DED RETENTION$ D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY PER OTH• ANY PROPRIETOR/PARTNERIEXECU I IVE YIN WCE00431903 06/30/2018 06/30/2019 %ICER/M Mg EXCLUDED? NIA E.L.EACH ACCIDENT 1,000,000 (Mandatory In NH If yes,describe under E.L.DISEASE•EA EMPLOYEE 1,000,000 DES RIPTIONOFOPERATIONSbelow 1,000,000 E.L.DISEASE-POLICY LIMIT i I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers Compensation Includes Officers or Proprietors. / Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess Liability is follow form. CERTIFICATE H LDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2016 ACORD CORPORATION. All rlahts reservefi. ,7 c' Commonwealtli of Massachusetts Division of Professlon'al Licensure ,Boa rd Of Building Regulations and Standa rds Constrt�;C4il�r{'Itb �.rvis,or CS-10,0988 Fires: 11/11/2019 HENRY E CA�gSID.y,'; i- `t�f 8SHEDROW: WEST YA RMOGT�i ' Commissioner cil 4-1 -- Office of Consumer Affairs and Business Regulation ;� 10 Park Plaza - Suite 5170 Boston, Ma ��usettS 02116 Home Improveme.;: � ,o tractor Registration eInc �•� �:,. f;::;;i;^r:._ }. ) Type; Corporation Cap Cod Insulation, Inc ':1.1I/' Registration: 1535 87 18 Reardon-Clrcle `...1'~-'��f:=;;'':` 'u Expiration: 12/14/2018 So, Yarmouth, MA 02664 --------------- --------------- iaoa4<, 20M•05n: — t•• Update Address and return card, Mark reason for change, '207,o�anYnca�atuurr��u�C�/G�aaJu�ude�lJ _ ;11_n��;"!O'/. , Office of Consumer Affairs&Business Regulatlan HOME IMPROVEMENT CONTRACTOR .�; T-,ype: Corporation Registration valid for Individual use only before the expiration data, If tun10)urn to: EXpI Office of Consumer Affairs and $i as Regulation "•.i ;J:.:fr;t:1: 5367f 12/14/2018 10 Park Plaza. e 5170 q p Boston M Cape Cod insulatl"'n��l•'�o�i'�`"+1 Bc A. 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B,.7-t l 01 « W 1 841_ !- , att )0 r iLM � (. i 1 f NAC . ..L..., O.n A�R, ei 01 K 1i17 ` 9t i 1 033 K • = s ` ._---_-� °'r�inwou�seacuz a����GczJaacricate�s� t j L DEPARTMENT OF PUBLIC SAFETY f CONSTRUC 4OW SUPERVISOR LICENSE ' Nuelaer Expires: — _ •Res Err ted Ta 1G VIC114F VIlLkAI PO BOX 21g4'" CENTERVILLE, MA 02632 z+ w , • Tllc• Currr»runmc01111 (if Afassachusctti ,",� `i.�: •`' ' Dcpartrrrcrr!of Industrial.4ccidcnts 1�= office 012W,V tlgatlons 61111 !i<a0zi igro r Street y„��+•. ��_; Busturr..1luss. (12111 i ' Workers' Compensation Insurance AiTdavit i li •in inf rm inn• _. __ _ _. -- -- — V ' Q I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity - ...... . I am an employer providing worikers' compensation for my employees working on this jod. cnm tanv namc� - 9dtlrecc• , hnnc#• niiev 0 [� I am a sole proprietor. ;cneral contractor, or homeowner(circle atte) and have hired the contractors listed beio�� u the following workers' compensation polices: ennIrlinv Milne* ldllrece• hnnc a• cit••• inc�iranrc rn. .z._. - - -_.--.:r=-•._;�•••.-+-r-s:- - —"•'-. cnm an.• Mctmc, •tddrecc• hnnc#• eirv• Attach additional sheet if neeesiary•• •c"'-•" " r'�•-""""�� Failure to--cure coy-rage as required antler�eetton r..A of�1IGL IS3 can iead to the lmposttion of crtmtnal penalties of a line op to S1S0U.U� unc can impri,onm-nt as�c'-it as civil penaitics in the form 0172 STOP WORK ORDER and a fine of slo0.00 a day against me. Y uaderstan Copy of this,tatement ma% be furwarded to the Ofric of It»estit:ations of the DIA for.coverage verification. I do hercht•crrtif•t cr t •parr nd penalties pc ' tha informarion prodded above is true and cat•rect. / " Date si__natunP/ V'T• ran. - Phone# C V j4`-U ^ G>- .& D Print nameAle- use''o(iicial univ do nut write in this atea to be compicted by cite or town oRciai n-rmidticcnse i# rltlaiidintt Department city_ or tMwn: J=Uccnsinr Huard OSeieetmen',URcc • dfr tMe - . The Town of Barnstable 9 � Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph CrosserBuilding Comm Fax: 508-790-6230 For office use only 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 contractors, with certain exceptions,along with other requirements. / �T a of Work: JL`�- `' Est.CosX( yp �© Address of Work: zzi� Owner's Name ,/ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner puffing own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WTTIi UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL r—142A SIGNED UNDER PENALTIES OF PERJURY I hereb apply for a permit as the ent of the owner. Dat Con or Name Registration No. .� •,k J L.:.Dl.�.�.....�aa /La:..`.LJ3.O,Y.. - 1 • ' � i ✓� U/Ol)7/r/7,O�jZCl/POUfL �vU(.CWc1�lZCCJe�Lp # � i DEPARTMENT OF PUBLIC SAFETY 1 CONSTRUETJON'SUPERVISOR LICENSE Nuaber 'w Expires: — Restrrcted To 1G MICHAEL UILLANI F41-o X�� PO BOX 2144 u. , CENTERVILLE, MA 02632 ` n r. tOM P Og ENT CONTRACTOR" Hotuta of>ratt" � F t,�ARSTOH MILL 2C6 r , r ri • :. , � � III �rR.-� �. �� l,/V ! �� � �� � w� v y , , �� � � � ��„ � � �- c -� � � •'`" Tlrc• C11111111U11H'Caltlr Uf Massachusetts u Dc�parttrtrt of Iftdirstrial.4ccidents =• � 1" -•!� p�cEallayestlgallons 61111 ahiu;;tnn Streetff Buxtatt. Muss. (12111 ' Y- �'orkcrs Compensation lnsurancc Affidavit i li in inf rnt ion• ca • n• : 1 hnn la a homeowner performing all work myself. m I am a sole proprietor and have no one working in any capaciry ,••-,�.�........_- -- .._. .�L.�----- M I am an employer providing workers' compensation for my employees working on this lob. cnm utnv name: •ttltlrccs• , Phone Of [� Tam--a-sole proprietor. ;cneral contractor, or homeowner(circle atte) and have hired the contractors listed beio« A the following workers' compensation polices: cnm am name, atitirccr • hone a• cin•� Con in• nntoe, atltlrc�c� hone rf• cite- nil •� ._-„! in�urtncc co .. Attach additional sheet if neccsia_cv •`' _ '1�' �"'� ' '""' Failure to secure cttycracr as required under�eetton 3A of AIGL lsz can lead to the imposition of criminal penalties of a tiae up to 51.SOU.UU unc sears' imprisonmenins well as ciyii penalties in the form 0172 STOP WORK ORDER and a fine of SJ00.00 a dad•against me. 1 uaderstanc cope�►f this statentrttt may be furnardcd to the Ofrcc of Investigations of the DIA for coverage verification. 1 tlo hereht•ccrrift•t err •pant ud penalties pr ' ilia information prorided above is true au .comet. / Date Sianattl Phone � ' 4`� Print name '��`�" completed by city or town official '�n(iicial use unh do nut pyrite in this area to 6r permit/license it rltluilding Department City nr town: aucensing hoard QSciectmen's OIGcC iv uircd ___ nttcaith l)cnartme:rt "ram assachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation F01, td't:;1 nPirnyees. As quoted from the "la�ti", an einplitree is defined as every person in the service of another undc,an\, ` )ntract of hire:express or implied. oral or written. _ :) cl»lpinrcr i.;'`dcf incd as an individual. partnership. association. corporation or other Icgal entity•, or an\, two or morn. = forcuoin�_ enuaged in a,joint enterprise. and including the legal representatives of a deceased employer, or the :eiver or trustee of an individual , partnership. association or other legal entity. employing employees. However ttic .•ner of a dwelling_ house having not more than three apartments and who resides therein. or the occupant of the -cllin" !souse of another who employs persons to do maintenance , construction or repair work on such dwelling hou ott the _­rcunds or building appurtenant thereto shall not because of such employment be deemed to be an employer. :;L chapter 152 section 25 also states that every state or local licensing agency shall tvithliold the issuance or )civil of a license or permit to operate n business or to construct buiidin-s in the commonvealth for snv ilicant who Icas not produced acceptable evidence of compliance with the in coverage required. Jitionali•,. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the iormanec of public work until acceptable evidence of compliance with the insurance requirements of this chapter Ita n presented to the contracting authority. )iicants se fill in the workers' compensation affidavit completely, by checking the box that applies to your situz—.:on and dying_ company names. address and phone numbers as all affidavits may be submitted to the Department of strial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The ovit should be returned to the city or town that the application for the permit or license is being requested. lie Department of Industrial Accidents. Should you have any questions regarding the "law- or if you are required :a in a wcrkers' compensation polic%'. please call the Department at the number listed below. . or Towns be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of Tidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas -e to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to _partment by mail or FAX unless other arrangements have been made. )ffice of Investigations would like to thank you in advance for you cooperation and should you have any Questions. do not liesitate to give us eparttnent.s address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents r i Office of Investigations 600 Washinbton Street Boston Ma. 02111 fax #: (6I7) 727-7749 phone 'r: (6I7) 7274900 cxt. 406, 409 or 375 THE . The Towne of Barnstable 9 9. Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 ' Ralph Crossen Office: 508-790-6227 Building Commi: Fax: 508-790-623,0 ` ' For office use only 4 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 contractors, with certain exceptions,along with other requirements. c LL Est.Cosh Type of Work: Address of Work: I zz Zxbwner's Name ® `~ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME awROW3= WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereb apply for a permit as the ent of the owner• Dat0 Con or Name Rego tratton No. Engineering Dept. (3rd floor) Map 3 Z 4. Parcel d G ` rP it# o� I �J q a House# I to Issued ( �9 Board of Health(3rd Boor)(8:15 -•9:30/1:00-4:30) 7-74 ZV e5�WFee 4*'�lo •�; Conservation Office.(4th floor)(8:30-9:30/1:00-2:00) o SEPTIC SYSTEM BUST BE Planning Dept.(1st floor/School Admin. Bldg.) INSTALLED IANCE a Definitive Plan Approved by Planning Board 19 WIT . ENVIRONME AND ' TOWN OF BARNSTABLE Tow" ..`: 3 � Building Perm't plication Project Strge dress Village Owner Address Telephone 7 - Z 9 Pe mit equest l 3 First Floor square feet Second-Floor square feet Construction Type Estimated Project Cost $ Zoning,District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Fam:OiZ Age of Existing Structur Historic House ❑Yesn Old King's Highway ❑Yes L<O Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing /?/New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not inclu 'ng baths): Existing_ New First Floor Room Count Heat Type and Fuel: as Oil ❑Electric ❑Other Central Air ❑Yes Fireplaces: Existing / New Existing wood/coal stove ❑Yes 0No Garage: ❑Det bed(size) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information ame iCh f� / Telephone Number �S 6) 'Ied O -00 5'O Ad ress_�. a c , 0/41 4 License# CS Q S'7�,_D d 01 G�� Home Improvement Contractor# Worker's Compensation# l ?� NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ' DATE =/ (�� o BUILDING PERMIT D I DL4 R OLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED , _4 -MAP/PARCEL NO. ADDRESS VILLAGE w. OWNER. DATE OF INSPECTION: �} FOUNDATION FRAME U (.--, INSULATION / _ ) FIREPLACE ELECTRICAL: 40Ugv FINAL _ PLUMBING: �OU FINAL: 1 "N. ~ ` ~ GAS: ', FINAL FINAL BUILDil DATE CLOSE6-04 ASSOCIATION-11 N Nam. �a , tt.�,►.Il{t tvty ItrOtrA0 ol t IRtK. `OIt� \ Iliu L % 11t J4 116 ', •( (: Or+b�rlj' i.J'�0�1aV1�( ,� + � t�K1. rl1e�,'h LMs1.M/•1.1 FAAtJ Jr1 io I.snt.a " tlOT.1p �6A66 rLCIL I%Y •TAe►� ND;iA:li(gltl' aau+t f 1a1♦vet a al�►n w.: rhell.not aae,atad Yla 4�►tltf �r�C.rto�� L. n1:A /1I, rrnnar}lt/{ va Wr •to a 1 4"I tal: wrap, ve parts /aa1. aa11A 1h► t fOn a1a aet• 1113 thaA II f0 M ta r . ro than 11 w•lltvra y wlllu., coalet NA 1,f l /tI,ni Ihatt 6e ettran t1wlaWltl la . ►Owe at 1+ ( tlaa/ d1►Vlnvlpfuti#aftof o,,.til. s1 1 ollcrl star C1fiL A alt ppr4@01t Ihlil bf 11 pot on N:1 lu►. dllk vhlrl 100 (fill, of 11/1 1l IN11 Is u/al, to 1a 1ACMINlyd `1 1 rtl to( Ide1 10tlt:lo�►1 I'?"' lux to nfplif I�anotIt fha l 1'4 l•1 1 lnctll. Mat1r rtupun Ihfl: 11 /t ltaab.if �,It Ibtvr alp �� J= pxlllYtd aC !IN na1111. ' NMI t `l ta1 0 M �Arr�� -14fi��.:U1QL + 6i Not1t. sp1 `srao pha11 b1 b:r.l fv f ge.an01'.t eh. uclo to\art.v IC Q.G •! ►it u.t aebavN. (I)Wy vLt.a oh►t: ►a tnrtito I �r �µ, Ylllr 1 it Ivclt ♦ ►tann•t lhat IIMy a00tlnrMir1/0tltnt II tr �►R k TT 4.d oli'old `Iyai'1 rrt(ta y tJlf+ 1 ft`IT n11i. ltntula/ oust..• ae lr/laa p p �Yp�Lt,L Q�;1'Vr �rrlQl` trY Gheap. Qrd.r. Uri "all W k"01t'td .t lr►.rv► tuflltllnr to 111wra prof al"Ch1ekMR1,. rlrr th+l: i6N:La'h.�lvd y1 Itt `4h•d titltl anll Shill nOV be 4Inorlt frtor `1 a/��Ia►ttaa •t 1tn1111WA o•a.:. a+dUNLYII Ail ►Ot%&Cvg rnall to i1aflplHod 010•a ppl•1c►teen ►nd a♦t/rl►. ohall not `o trpttl�l to a tvrlaty an rtllh. San Iti nl 44 / Aiw nslfn,l bll' vh ch trot vlldt ,1111t1. JWeft•ta11 Lt{I I rabev,ldr I {t 1 �t Aoll nel lass oloAt If the very 11i111 11 Itovol. opylr Io 1'l4 t �f k" IDa(�4.�taa 11r101 1 doLevhd oltnll no. b/ vlod to taY_ v.:tlen.ot the M/ A111n1 l.eaxtll,b •asset 1/1 1n 11111101111 ►re/It. 1'.! o:l/rrll 1 tee`t xlnrll N /• If iyRlt Any Mxtivo It to /Stet r„l,flOWV11tib 1410 111 fr n••d tt•twl:•tJ Y itrrNl(d Ti oonn 1 Aa Hntalnd lapplt pp4rkvt.•1 tr th4W d.rhO! +v O"'If o[ ► t t r.v,.�6tnrS v th Al1 lu1,( t xrt I Ir r Sal M(letivl ollall be +Iwd Sod rrplileA vl',b na, %4% I.d./. No i,lttvi nIf,1t �I�l <orllr It prk/...wf ♦1 chdlrl,. ljl �t or IpAwl vlt►. to lh:lott� oi[�Lti4u. Ir the 0�1t a t/11 1}1d Y 11p urf� U tsfutl IIv1 ti!alorccnlnt i11 In1f/ I lx yoglud� Id Nteun an Il.tnt. 1n / 0yAjtC r111 be Nll ted is, 14Y4rl•:.to-1 Vr lnsvr A11 1�1t9r1, t h1�, elxrll/tlat har,yo !o' `.he WAt thiakrr►fr fDr-Ain1A yl. Ir�ce_+rlrr pl•ev�f bt ti•:fd by Xrf, Wit f yp to 1 1nOto• wo two-rml.Mlea to ltado for bF.6va1h1n/ Aste61t/h dltinite ,tvinnal of choPl:lnl %fit thlot:la+, • by attua o/ a ir►eh rri!. All 1Yrtlin bo ndllt•rvrlal. .. cons it II a I art llae taut. s{�y a .�,a/�ative Its nrglOt tiro\ •f SLi jlaeil t►nfra►t The �lrtnolan 't` •n dravNtl Senate/ ILA- IOhft t yy! tltroo a/aCLnanr (At►111'1 rl;]•' Of ll:rw turf .n o[ tha► ojla p1 11�v1r•d. fho bafto TAii1��11u1nAatre oneiJltlitt�ieeAyittiI'diYe., one rtl.n[.•rr.•nss vll.. Se ra u ttd u. v113 al rr tot► • at:1,l►1n1 .L►ll bf at{laln•/.tar;'.fKI1 1nr1 tt)ot'afo/111r111v♦ rattV2tltianbl It waY Item net If, parlrn. .:I+ rvrt1l11a 1d1t1•na1 tatvsn liars, sM a.111Y1Ir w/ac�ty my have to 11I tronad ItN•�J,,, alu, rt•yylllnf 1ltlavn•:►1 a shop♦ ou1.Ll11lh.py la ltal LY ens• �rfvlvl vlrfa , trill to (it c• tnall'be:rrSor/ !(I to A1.1 /tp^ 1•hntvl.l It ba fvc xfwta•lo er Woulhtqyvl rtotyropr Srdd-lbyt111aoGijid4;tb on'll IL: I r9V�1r/span.. to1411a1• ThI suffm 1hAl: be bt0o!a 'lklthol IS 1• ♦ Vnitern 1nr(o4c tvSlyy{{1• M1apglr>q'.oul Vora'+\ }t. voel Neat .ball be ho14 to a nlainwt.' AoboU14 of acrtttV:dlol 1011) Will ,ifum Ia..rv+►+vrd tla►oofl of by wit t a11t'nftor. »tl a rLA 8 Dp Fllp(1G.JS.t ntTA roil ►1 �t t,1 A . ` PooL5 13Y art , ► R o. 0X, Cs fm(2 tl,cE, ✓� A , � ''j ✓lam �'��Y,� �Paltl ✓ letla #' BOARD OF BUILDI G REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 077875 Expires- 05/08/2004 Tr.no: 77875 Restricted To: 00 ROBERT C SMITH _ 1547 SERVICE ROAD W BARNSTABLE, MA 02668 Administrator. ZMO Y c�r_-�V Board of Building Regulations and Standards , One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 133121 Type:, Individual Expiration;-' 05/10/2003 ROBERT C SMITH ROBERT SMITH 1547 SERVICES RD. W.BARNSTABLE, MA 02668 Update Address and return card.Mark reason for change Ac.dre..sc Rnna.aJj F. _Jnvrnppt --' i.Art C'Irrl //2P U�O�YI7/YYL(1'YLllIP.0000/!• dL i�(��1L10CJ.CdG[CO�tCo ___. �_. __. ._. . r 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: 133121 Board of Building Regulations and Standards Expiration: One Ashburton Place Rm 1301 P 05/10/2003 Boston,Ma.02108 — --Type:—Individual ROBERT C SMITH ROBERT SMITH 1547 SERVICES RD. W.BARNSTABLE,MA 02668 A + ;,;c rnr Not valid with-wit civp�..hire 6 N N T w N o a s r a G s a o u CD CD �_ w o w o W ad o d a a= po po V)o LI '' II 1 IN O I Q LA rl CN O — m N _ -_ 2 E Noll 6 y� N z y N _ -o ,M � — �o bL - \ n _ E 00 a� = �O N M a E o * 1 * i i r The Commonwealth of Massachusetts f<� — - Department of Industrial Accidents ' Office 91/nYe599atioos - G 600 Washington Street Boston,Mass. 02111 xxxxxxom Workers Compensation Insurance Affidavit name: location 0 dtv •t✓ (/�V y V L AE!_ phone# ❑ I am a homeowner performing all work myself. ❑ I sole r rietor and have no one workin in anv capacity to er rovidin workers' compensation for my employees workin on this 'ob. ::: I am an emp Y ... g J c phone.# .N: oU insurance co. � - ❑ I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have workers compensation the following w polices: p P coin an name: X. address: ;. h >< ci ..one# ::::...... .............. :::::::::..........:v::::.:.................... ............................:�......:::::::�.�:::::::::.:�ii.�}iii:�iii:�:�:�iY.:^::;: _i':.;.,:��:.�:::��::�:::.�:............:::.:.........-�:�::::.iii:�iii:::::iii:v::::v::::.v/ •n• :.:•.:::iii:::: ::i?:::i::::?:':iii::::}"::i:::::::::::::i:!.::.iii Inaniaiice co:;::; c an na address ci iaturance co:.:> �/ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to Offlce of Investigations of the DIA for coverage verification. I do hereby c the pains and p es of perjury that the information provided above i�s-tt rrw,and coned signature Date ' Priest name �� �� "' \ S w\ , i Phone# official use oply do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board is required ❑Selectmen's Offlce ❑check if immediate responseq ❑Health Department contact person: phone#; - ❑Other (}mud 9/95 PJA) 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 contract of hire, express or implied, oral or written. 1 r 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. e state or local licensing agency shall withhold the issuance or renewal MGL chapter 152 section 25 also states,that every g g Y in 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 commo nwealth nor'any of its political subdivisions shall enter into any contract for the performance df 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. I 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 number. The affidavits may be rerenmEd t^ 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. 110/11 The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of lmles"98"Ons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 Ftrte • The Town of Barnstable BARNSrABLL • MASS. g t. Regulatory Services 1659. A.` Thomas F. Geiler, Director QED MA'S Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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 contractors,with certain exceptions,along with other requirements. I Type of Work: Estimated Cost 0D� �41 �1 vh �/-/ (o � C7 Address of Work: C /� Owner's Name: Date of Application: — I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law []Job Under$1,000 []Building not owner-occupied ❑Owner 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 PENALT F PERJURY I hereby apply for a permit as the agent of thq owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION J 4 Map Parcel Permit# J 57 Health Division 1/1,01 Date Issued l Conservation.Division C'io � ©� FeeIP Tax Collector �Z/44 Treasurer b I AYPI,ICM MUST OBT=A MEWER Planning Dept. caY-ECTION PERMIT FROM TEFL i NUINZERING DIVISION PRIOR TO Date Definitive Plan Approved by Planning Board s , Historic-OKH Preservation/Hyannis Project Street Address Led�— Village }W A n n f Owner Address s� Telephone - Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation ��s 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) V 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 2 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 -21 Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:0 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 C9 �� ' f 1 Telephone Number Sdi_ Address S L�7 S V-4 ig License# 7 7S 0)ter(-S L"e-- Home Improvement Contractor# Worker's Compensation# O rtALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 00 1''i Qs 1 e � SIGNATURE DATE 1 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS ; VILLAGE. OWNER' - . 1 fir,^ . - • . DATE OF INSPECTION::, ; FOUNDATION Zco FRAME .. INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL _ GAS: ROUGH FINAL FINAL BUILDING -- DATE CLOSED OUT ' ASSOCIATION PLAN NO. - "- Cce ar ke h ex c.t.-) C ek- I AO Cell , I Engineering'Dept:(3rd floor) Map Parcel . . Permit# 5 Off - s---t House# ate Issued 'Board of Health 3rd floor)�(8:15 -930/1:00-4:30Y Conservation Office.(4th'floor)(8:30-9:30/1:00-2:00)' 0 t 11N9' A 81MR PlanningDe t: 1st floor/School Admin. Bldg.) , g) [ Old 0. i'8R FM to Definit' e Plan A proved by Planning Board 19 EN4 i ABLE. MASS. TOWN OF BARNSTABLE P Building Permit Application Proje tree ddress ° (� S Village 4Ny' Owner . /1/ /S r� 4 Address ZZ Telephone Permit Request u1 02o Ax, � ® e i C_7C1 ty First Floor _ square feet Second Floor square feet Construction Type Estimated Project Cost $ 5" , �) Zoning,District �f a . i Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family p/�Two Family ❑ Multi-Family(#units) Age of Existing Structure 13 ® 5< Historic House ❑Yes U-Ncr' On Old King's Highway ❑Yes UNer— Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing=� New Half- Existing New No.of Bedrooms: Existing New Total Room Count(not includm at hs): Existing New First Floor Room Count Heat Type and Fuel: as .i-1 ❑Electric ❑Other Central Air ❑Ye o Fireplaces: ExistingNew Existing wood/coal stove ❑Yes p � g s Garage: etache size) Other Detached Structures: ❑Pool(size) L&Afrached(size) l -,�t,. ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ 'Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name / C��=, r ,p Telephone Number `ld 0 - s Address Z,4 License# 77 o d 0- G- Home Improvement Contractor# /� - Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTIONDEBRIS RESPL JING FROM ^THIS PROJECT WILL BE TAKEN TO GJ� SIGNATURE I DATE UILDING PERMIT NI D FO HE FOLLOWING REASON(S) R , R E f sy FOR OFFICIA12USE ONLY ;,-> PERMIT NO - DATE ISSUED' t ! � k. f�' - `' ♦ ` .f` • ..� T . , .! fi°"y maw--- MAP/PARCEUNO. ,. ADDRESS s • °_ .VILLAGE' r { 4 rt ,f , OWNER DATE OF-INSPECTION: m FOUNDATION FRAME INSULATIOi N FIREPLACE —• -I ,r — �+ ELECTRICAL: ' ROUGH - FINAL "' PLUMBING: ROUGH 4 f ,?FINAL'. GAS: H FINAL FINAL BUILDINIOgt i DATE CLOSED CRAB ASSOCIATION Pf O. j is i