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HomeMy WebLinkAbout0304 OAK NECK ROAD �4 CkK NecK. ��G. ,� — 1 Town of Barnstable Regulatory Servieeiry���i OF BARNSTABLE Richard V.Scali,Interim Director „BAMSTABU& Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us --" k 1VI 1 Office: 508-862-4038 Fax: 508-790-6230 PERMIT# Q d/ FEE: $ SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less SoLt 04K NEc-�-, Qt)&y ArNA415 Location of shed(address) Village '7(31-82o-o2..o� Property owner's name Telephone number SS Feel k 10 FCC-r 08 S Size of Shed Map/Parcel# Sign��i� Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) Sim . off"hours.for.0 o serG ion-8 00-9.30_&3:30-430 n - 65 - Hog3 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMNIISSIONS,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-forms-shedreg REV:110413 Town of Barnstable Geographic Information System New Search Home I Help Parcel Viewer Custom Map T Abutters Map Size Qon Zoom Out®�®®O QIn N `� ® )PG Map: 306 Parcel: 085 Full Property 30 7197 3071e7002 Location: 304 OAK NECK ROAD Info 1313 g301 307187004 Owner: MACCALLUM,]ACQUELINE&BLAKE,VIRGINIA 307187003 p279 E: N 289 Mapr^�&Parcel 306085 QW Location 304 OAK NECK ROAD Acreage 0.30 acres Mailing Address MACCALLUM,JACQUELINE✓3c BLAKE, VIRGINIA 12 ,3D4 3DN3 t 3D80 s;X15' 211 SLADE ST 0312 iY E 17G��r` BELMONT,MA 02478 p95 I ' 308088002 SNEg 308 1I. Extra Features $16,500 Out Buildings $3,700 Land $103,700 308084 p Buildings $138,300 ® 9'42 Total Appraised $262,200 3Da 8� 300096 �, .►7+�r rac rs'.R/ _ ()09214 �D32 Extra Features $16,500 24 Out Buildings $3,700 S Land $103,700 — -- Buildings $138,300 Set Scale 1" 457 Aerial Photos V MAP DISCLAIMER Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS BarnstableMA V1.2.5494[Production] hftp://maps.townofbamstable.us/arcims/appgeoapp/map.aspx?propertylD=306085&mapparback=306085 6/26/15,9:24AM Page 1 of 1 Assessor's map and lot number ..........? ..... ................... THE to ((Sewage Permit number ...................... BARNSTABLE, Housenumber ........................................................................ MU& 039. TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...................... .............. .........2e�. ................... TYPE OF CONSTRUCTION .......................Alm 6 ........................ .................................................................. i a .......................................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: �qo q6 Location ... t -�s.............................................................. ................................................................................. 3 ProposedUse .........................................7�' .............................................................................................................. .............................. ..... Fire District .......�I.................................................................. Zoning District ..................T .. 4r PlAq I- -D c4y/v z�4vlb 4, /Name of Owner ... ..............................................4A?gf(..X.Address .................................................................................... Nameof Builder .............. .....................................Address ....................................................................................... ...... . .... Nameof Architect ..................................................................Address .................................................................................... ounaon .........'...mle..................................................... Number of Rooms ..................7..........................................F dti ... .......... GAS Exterior ...61..................................... ...............Roofing ........................................................................... Floors ....el ...............................................................Interior ........................................................................... Heating ..... Z :..................................................Plumbing, .......�< 7Z" ................................................ Fireplace .......................I..........................................................Approximate Cost ............4�.?.9..1....... ...4............................... - / .�.- Definitive Plan Approved by Planning Board -----------—------—----------- Area . e Diagram of Lot and Building with Dimensions Fee ....l ................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH_--T--- OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS t I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...... ......................................................... Construction Supervisor's License .................................... PARREItLA, CYNTHIA & DAVID A. A=3-0m-&5 25613 Build & Remodel Deck No .................. Permit for .................................... Single Family Dwelling ............................................................................... Location A.Q.A...QAk...Ueck..Road.................. ................. yi mi. ............................................ Owner ....CY.11thi.4...&...D.a.Vi-d...A—.Parrel'La Type of Construction .........Framp..................... ......................................................... ...................... Plot ............................ Lot ................................ Permit Granted. .......October....7.1 19 83 Date of Inspection ....................................19 Date Completed .......................................19 dS Assessor's map and lot number ......�.6... .........14 � ,,�j y�F THE Sewage Permit number ....C ,'."„ ................ :l2orU !t�F#rW I ��Q y°►t � r . ..f. C SYSTEM IV ., INS l�B-'c9� LE. �LLE[) House number ......................................................................... IN SsOM c �b H �o eP9 WITH TITLE 5 a`e n 6 TAL CODE �r W TOWN OF BARNS T IMP GULATIONS E•, - BUILDING INS,PECTOR - APPLICATION FOR PERMIT TO ..................... . .. .................: .,......... � ......... �` ................... TYPE OF CONSTRUCTION .......................YVR�. a '� !� ................................................. ....................................... %�� 3 E 6 .......................................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 3� d z6c1C j�..o.4� ,Qiti�✓u�� O, Location .............................��..............................................:...;...............�. ................... .......................................... ProposedUse ....... � ��L .......... /�sL .....:..................................... ............................................................... Zoning District 7 `` Fire District ...... ... ... ............................................................. l ........................... Name of Owner `)!/!�1'!+d!�..�r, iQ!/!/7 4 Pi4!--P---C.'q.Address ....14............' l277!t� Gam..®p:..>`/?Gi.�l��:7� Nameof Builder ............. . 1�.�.....................................Address .................................................................................... Nameof Architect . ..//?rE ....Address. ..................... ....................................... ...............................................::................................... Number of Rooms ..............................................................Foundation .............�� Exterior .............................................�.................................Roofing ..... Floors C ►i2�E/ Interior `ugzzl�t✓A2 ............ ............................................. ..... .. ........................................................... lHeat /l/7C 6 7F/ ing �©/Co .............................................Plumbing/a ...... ............:..... .. . . .. Fireplace ....................411A....................................................Approximate Cost ........... /q. ... ...............:............... Definitive Plan Approved by Planning Board --------------------- -- -�9-----• Area 6� ''x- -� �°(r Diagram of Lot and Building with Dimensions Fee An.061.................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I 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 ...... .. ...... ..... .................................... Construction Supervisor's License � 03�.................................... -PA?ttEa:F,; CYNY!ik_ DAVID A. 25613' Build & Remodels No ..............A. Permit for .................................... y Single Family Dwelling , ...... ..................................................................... Location 304 Oak Neck Road < ................................................................ L ► ' ......... ....Hyannis........................................... Owner ....,Cynth.ia & David A. Parrell a ..... ....... .. Type.of Construction Frame.... ! n ... ...................................................:...... ........ f_, 1' f Plot ............................ Lot .................. .......... .�-�• , October 7, 83 , '► Permit Granted Date of Inspection .................................. :19 { Date Completed ... .... 1 1<1 fell fr , J Eck r A• Assessor's offioe (1st floor): �� CF TN E t0 Assessor's map. and lot number ............................................ Board of Health (3rd floor): Sewage Permit number?.�cs.:.s ��+ �1 '.. .C. sK /98 a Z 339Ed9TAXLE, • Engineering Department (3rd floor): ,o rasa ie39• House number 3 y..... ............... a p ypY APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00*,P.M:'only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..G°�w5''....UC .'J'0 ............................................//U TYPE OF CONSTRUCTION .. .4 p �bl-> f' m ...................................................... ..........1997_ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location D'�' UAk../I��EC, ....!�'oA.v...............`1...*.A, S........1".A............662. 0.1................................................. ProposedUse e�PS�DF!T.... C�......................................................................................................................................... Zoning District p� g ...... .1 ........................................................Fire District .....!tk�A/U/iJ�S.............:.:. �Of/! �rA I OYG!.................Address 3�..�.1 &A /U,�P� RiW-p ...� /U15r�i�, Name of Owner .......5.. !!.. .......................... T.................................... .... . f .. d b...! �...?A.e�e.EctA & Box Name of Builder .......... Address �+ / ^� .....................g....... ...:.. . !rv/ss..:::�YIYI,4.�............... Name of Architect JA.1.�A-a!el. -. ..............................Address/.!.4�.!N*7..6. ~�A/A.0 Number of Rooms .........Foundatil .I.� ............. ........................................................ r s: Exterior ��:�!e...e1/4At.... ....�.N/N....LE......................Roofiin 9 ' /q5 HAriT S1110riG[ f g7' ,v1n r Floors 46'Vekex sus....... ...��.......3/4.7.-T!G•r//ZInterior ...`.. .��1 li,(!/�St//�r...,dit?(i/G�iA ................. ..... >.....o..A3A..L.... .?f! ..........:....�..Plumti ri 111 Heating ... bprou g_.......:.............................................. '. ........... 060,Fire lace .... Approximate Cost ..... ........... �p �^ Definitive Plan Approved by Planning Board ----------------------_._______19__._____ . Area 11.. ..L .`. .... Diagram of `Lot and Building with Dimensions k �4T-IEfiEIS 4F77F Fee�..:' (..�.•.� " SUBJECT TO APPROVAL OF BOARD OF HEALTH PdoT AAA1 R 33 4't OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ,. :Pj I hereby agree to conform to all the Rules and` Regulations of the Town of"Barnstable regarding the above construction. Name ..�.. . ....... .. ..................':�................................ Construction.Supervisor's License A030© STAMOULIS, LOUIS & KATHY A=306-085 30370 Build Addition No ................. Permit for .................................... Single Family Dwelling .......................................................................... Location ....304 Oak Neck Road .......................................... Hyannis ............... ..... ........................... Owner ...Louis. . . .... .... & Kathy. . ....Stamoulis. . . . . . ........ .. . .. . .... .. .... . .. ....... .. . .. . Type of Construction Frame .......................................... ............................................................................... Plot ............................ Lot ................................ Permit Granted ..........January....12.,.19 87 Date of Inspection ....................I...............19 Date Completed ......................................19 R T i' Asseor s,ofioe (1st floor): �� v o — �*TMEtO Assessor's map and lot_number . ................:....................... Board of Health (3rd floor): Sewage Permit number 74i4-,svrre, Baaa9TanLE, Engineering Department (3rd floor): t/ +o r0.°IL House number 3.�...`.................. O 1639- ...... . 0 mxl APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..� T . ODAfj7® 4 ..� TYPE OF, CONSTRUCTION ..0 I,. Y Grab-6..... .E:.............. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following ,information: 664 Location .. ..... ..................................... ............. a. .......................................................... Proposed Use .../���E iD iV?�✓4Cd......................................................................:.................................................................. .......... Zoning District ......Lam. ..............................:..........................Fire District .....L' f�/flN/��.....................................:........... Name of Owner /CDU/S..i. 1.. �L.�S................Address t0! /...,t-ek- R44-gyp..i.../�j¢,�//llls� ,........................ F Name of Builder V/D .. �iQ, ELL .....................Address C%a� E DX $l/.... /�/S� .... �.�.:............. Name of Architect $/. ,R,4.. 0!..�.M ..............................Address ��:...... p Number of Rooms ..................................................................Foundation ...��1..'.YZ 'i�`. . / ✓�0!�1�.....�d,R!� . &A4)e...�1!4P 3a1` '4... Si�1/44`4...................... /�5,.H,9lT....5lie �c L Exterior .... Roofing .. . . G��Floors 1. ey Z3�.... ...... ¢...7% Jnterior ........ �. .` ...Af�� 4' L...............:. G1l l.d.. �114r Heating. .....�...... � ......�... ..�....2L1/✓�...................Plumbing ...........f!!��.�..................................................:........ /�!!/Q/Z/�/4/ ��,E/C/Q8 J �dq, BI E: J�Q Cal? Fireplace Approximate Cost / Definitive Plan Approved by Planning Board --------------------------------19________ , Area • - Ski Diagram of Lot and Building with Dimensions ��6lyC � �7—/,D Fee . . . ............ SUBJECT TO APPROVAL OF BOARD OF HEALTH Plcf Ak4AI NO 3 4'i 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. �. � de Name ... ..... . ...`.................................. Construction Supervisor's License .140300 ........................ pp� STA!',1OU`;-j7*S , LOU'. S & KATHY Build Add-' tAofi .............. ........ Permit for ....... 1 y n Location ....3.Q4...Pa.k...N.ec.k...Road. d.................. .. .. .... .. .. .. .... ............ ........HvRnn.i.s ................... Owner ..-Louis Type of 'Construction .....)�. .*ra.m.e....................... ............................................................................... Plot ............................ Lot ..................:.�........... january 12 ' 87 Permit Granled ............_.I................. .......19 Date of Inspection. ..............y......b..........19 'goP Date Completed ........... .......................1 Qgfofrp EX/STY.VG < �9 EX/ST/,t/G LEACHNG I P/T '�S SE CGA�ER K ¢� CD✓ER t? o � . t EIC � • PROpaSE ..T LOT' 1vt �z- AC�O l/2StOR s � NousE �i PA���L S S N ti oEc /3,835 S.r OF 'y9f STOPHER Z 9 S COSTA ki 31305 � '•`��b1YER' 'O SURVEY )WC 94AZZ ivxa, r6^SE 0z1,e jWShr ONL V RREP �7r D-1 AN . TOWN : OA e*V-frA B[E (MY.4N/V/S) MACS: L OVIS SCAL E : /"-30 � PA i'-E : /- 7 g7 REA :PB. 39W P. TO I HEREBY CERTIFY THAT THE ABOVE DWELLINGS IS LOCATED ON THE GROUND AS SII0HN- AND THAT THIS MORTGAGE INSPFCTICN7VAS PERFORMED IN ACCORDANCE WITH T. E TE,CHNICiAL STANDARDS FOR MORTGAGE LOAN INSPECTIONS AS ADOPTED BY /TM MAS SACHUSETTS ASSOCIATION OF LAND SURVEYOA AND .CIVIL ENGINEERS.IIJPPR d ATED. TH/t LOr 15 "or /At rHE /J - FLOOD PtAIiV. CHRISTOPH R COSTA R. L.S . DATE i17l87 /72 ,67,9.5T GALA feDU AALA,007 /v4A +ram :�'�" 'YT.-�. i o,. i uIy T 15 �i F i TOWN OF BARNSrABLE, MASSACHUSETTS Ulu, LDtNGAPERM1T �85' DATE i1antiaY'V 1 -. 19 APPLICANT a' D�� d _ ADDRESS s ��� ST (CONT- LIE 5 1` NUMBER OF. PERMIT TO ( 1' STORY WELLING`UNI900biV�A, El .TS ZONING, I TR I T LOCATI, D S C( ON) �$ NO TREE: I BETWEEN 4 AND (CROSS SIRE ET)-�, '" •(CROSS-:'STREET)' s LQqT I SUBDIVISION'' S LOT: BLOCK S17E ;t BUILDING IS`TO BE FT: WIDE BY FT. LONG BY FT. IN HE,IG'HT.AND SHALL CONFORM-:IN"CONSTRUCT.ION TO'TYPE USE GROUP I� BASEMENT WALLS OR"FOUNDA710N (TYPE): REMARKS .. AREA OR VOLUME x ESTIMATED.COST $ �Tnnnn FEEMIT ►C/S . FEET) - - OWNER Ti6� Tr_> �3 C•1- T •7h - -' Y-¢z� e �=�"-- . .. .-BUILDING':DEPT ADDRESS ��7 Y--r✓C c R`m id 'RR d $ BY i OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. ' - MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON, JOBAND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIREDFOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERSIREADY TO LATH). FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION. BEFORE OCCUPANCY.., - POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 3 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT I 1 i r V OTHER Z. BC ��s""�� 'a1jS%�'�l WORK SHALL NOT PROCEED UNTIL THE INSPEC- RERMIT W!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED 0 IS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELE HONE OR WRITTEN CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. 'NOTIFICATION. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # �f q6(J�(2� Health Division Date Issued Conservation Division Application Fee Planning Dept. ; ' Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address �vOL� L)CL� Q,e fL. Village. �kldlnp i S Owner &)0&1 taals%wahs Address &MIg 11 &ffit'Oed1QA Telephone �g4(e c�1/�-� + m►4 61 S3Z ,Permit Request a L-1 T/o/U r1 9r?L19C,_CMJ,:W AF >OJ514141 y- OA) I/W,,92-L 1,c ro W19-,tr4 .'Mm1Me Y ER14>4 .:Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation! v � Construction Type Lot Size -3 nAjS Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 9" Two Family ❑ Multi-Family (# units) Age of Existing Structure Nq VrS 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) `KI Number of Baths: Full: existing new Half: existing new b Number of Bedrooms: 3 existing D new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Ly Oil ❑ Electric J16ther aA.4 . r Central Air: ❑Yes 2"No Fireplaces: Existing 10 New Existing wood/coal stove: ❑Yes Ulo Detached garag e t' g ❑ new size_Pool: ❑ existing ew size _ Barn: ❑exis 'n new size_ Attached ara e is in ❑ new size Shed: ❑ exisf' ew size Other: 9 9 9 — � — Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ �= Commercial ❑Yes YNo If yes, site plan review# Current Use �nJ� ` �... yu.�c� Proposed Use - .: APPLICANT INFORMATION - - - _ - - (BUILDER OR HOMEOWNER) Name ( , (hC / P&V 1,9 atk. Telephone Number" Address CN►CrtTt� Yi aLicense# CS FEU IS l� LUC I Home Improvement Contractor# toot A 211 Q5OJLAV�C 'TNmjfsd),�tle HI 6VVSZ_ Worker's Compensation # CP gC6CdtihyS'lie 41 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 2QX(KA (CLA6T—i 1 �S GNO—AT URE ..DATE._. / / e FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED t MAP/PARCEL NO. t ADDRESS VILLAGE r i OWNER DATE OF INSPECTION: LL� FOUNDATION " FRAME INSULATION FIREPLACE 'k ELECTRICAL: ROUGH FINAL F= PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. F f w r t , � ` i r ! k i _' 1 4 � ! i. �Z� •D+��L�1�LL � 1�. -`)� )NSULr9Ti��N t ; a c S ' I i r k .ff k I , The Commonwealth of Massachusetts Department of Industrial Accidents 4t� Office Investigations ff of 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): O p1'`-c->, 'ICA Q, =hc t, Address: a 1 City/State/Zip: �--k ann i J Phone#: 2 Are you an employer?Check the appropriate box: Type of project(required): 1.© I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees 'These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance.1 ❑ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 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.❑ 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: w ck�-(C')ry-d ..5._.N11 SU IF_a c)C'_C _Q 1'Y1 tP" Policy#or Self-ins.Lic.#: C F Ll It)CC) U 0' 15-1' Expiration Date: ( 1 Job Site Address: City/State/Zip: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Bert.. u er1h a and penalties ofperjury that the information provided above is true and correet. Signature, ' Date: Phone#: 4 < 1 Official use only. Do not;wIte in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of I3ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: y � Client#:586925 20CEANSIDEIN ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MMMDIYYYY) 01106/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certiflcate holder in lieu of such endorsement(s). PRODUCER CONTACT Dowling&O'Neil PHONE F Insurance Agency (Al aNe Ext:508 775-1620 Arc No): 5087781218 IL ADDRESS: 97$lyannough Rd., PO Box 1990 INSURER(S)AFFORDING COVERAGE NAIC 0 Hyannis,MA 02601 INSURER A:Arbella Insurance Company INSURED INS URERB:Everest National Insurance Comp Oceanside,Inc. INSURERC:Safety Insurance Company 217 Thornton Drive Hyannis,MA 02601 INSURER 0: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MMID�lYYFF MMIDDIYYYY LIMITS A GENERAL LIABILITY BINDER369532 1/0112014 0110112015 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREM�SES Eaocarrence $100 000 CLAIMS-MADE ®OCCUR MED EXP Anytne person $5 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE $2 000 000 GEM AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY 7JE PR0. MLOC $ C AUTOMOBILE LIABILITY BINDER369536 1/0112014 01101/201 eB eDtSINGLELIMIT 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALLOWNED BODILY INJURY(Par accident) $ AUTOS AUTOS HIRED AUTOS NSCHEDULED NON-OWNED PROPERTYDAMAGE $ AUTOS Per accident $ A X UMBRELLA LIAB X OCCUR BINDER369537 1/01/2014 01/01/201 EACH OCCURRENCE s2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE s2,000,000 DED FX1 RETENTION$O $ B WORKERS COMPENSATION . BINDER369533 1/01/2014 01/011201 X T TATu- 0,- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L EACH ACCIDENT $1 1000,000 OFFICERIMEMBER EXCLUDED? a N I A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. 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. • ZED REPRESENTATIVE AUTHORIZED E,�R�P T NE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1227721M122770 KKM THE RIGHT,CHOICE '` — - — �_ ' ceUse only Since 1971 .. f " • �s JOB NUMBER � � 0 Restoration— - -- 217 Thornton Drive,Hyannis,Mass.02601 508-771-3110 800-464-3318(MA.Only),774-470-2211 Fax MASS.HOME IMPROVEMENT CONTRACTOR REG.#100121 MASS.CONSTRUCTION SUPERVISOR REG,0000043 ASSIGNMENT AND AUTH ORIZATION TO PAY The undersigned, herein called claimant, has authorized and ordered from Oceanside, Inc. , the materials and/or services requested. Undersigned hereby assigns to Oceanside, Inc. any unpaid proceeds due or to become due, under the claimant' s policy with he insurance company to pay direct to Oceanside, Inc. or to include its name on a check or draft, for all requested work. In the event that Oceanside' s claim herein is not covered by, or paid by, an insurance company, claimant agrees to pay Oceanside,, Inc. within sixty (60) days after work has been completed. C-laimant understands that Oceanside, Inc. is working for them and not the insurance company or the. adjuster. Payments remaining due and payable after the claimant has received payment from the insurance company shall bear interest at one and one- half (1-1/2a) percent per month. In the event that there is a breach by the claimant of any of the conditions of this agreement, Oceanside, Inc. shall be entitled to recover, as additional damages, attorneys' fees, costs and any other collection expenses reasonable and attributable to said breach. If payment is not received within 60 days, collection action will commence without further notice to the claimant. DATE I PHONE: . �j '3b -J/ --- / (�j� PR(IN(T NAME.JI 44 04 at 41 MAILING ADDRESS (BILLING) CITY STATE ZIP 30`( 0aLk Ne r.4 ( 414( f, LOSS ADDRESS 1 r S INSURANCE ADJUSTER' S NAME/CO. INS RANCE GG/ENNCY NA2T ME N \\OCEANSERV\Customer\documents\ASSIGNMENT 2011.doc -1 Z J 1 - i 1 Massacliusetts Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-073097 PETER A LAROCE 18 CEDRIC ROAD ' Centerville MA 0632 ; r txmration Co-mir, ssicner. 11/03/2014 . 1 ' \ Juice of Coniumer' Affairs` c Business Regulation ME`IIVIPROVIJIVT CONTRACTOR' eglstrat10.. Type,. Expiratt' SUPP.lement I OCEANS IDE,:INC PETER LAROGHE 217 Thornton Dr Hyannis MA 02601 . Undersecretary. License or re on valld`for mdividul nse only before the expiration;date: If:found.ret4rnto:. Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 rani Boston,.MA 02116 Notvalid without signature