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Home My WebLink About0105 PARK STREET i i r h I r , Town of Barnstable Building : Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this.Card Must be Kept Posted . Bmm Lrt. : MAW Until Final Inspection Has Been Made. Permit o Ms+' Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-17-2255 Applicant Name: MOSES M CORDEIRO Approvals Date Issued: 08/17/2017 Current Use: Structure Permit Type: Building-Addition/Alteration:Commercial Expiration Date: 02/17/2018 _ Foundation: Location: 105 PARK STREET,HYANNIS Map/Lot: 327-210 Zoning District: MS Sheathing: ! Owner on Record: DONAHUE,MARK L TR Contractor Name: MOSES M CORDEIRO Framing: 1 Address: 370 MAIN STREET Contractor License: -CS=074674 2 WORCESTER, MA 01608 Est. Project Cost: $347,000.00 Chimney: Description: interior renovation of treatment rooms,drywall,siding,siding removal Permit Fee: $3,332.70 Insulation: Project Review Req: interior renovation.of treatment rooms,drywall,siding,siding fee Paid: $3,332.70 removal Date: 8/17/2017 Final: u� Plumbing/Gas Rough Plumbing: 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 shallconforrn to the approved application and the approved construction.documents for which this'permit has been granted All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. - -- Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are 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: j0e- 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: 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 t p _Tf 2 Project Name:__ ' _(2_c �nb +lk-h�� Address: Px, -�"l`P�-� Permit#• Permit Date:_— MR:__ LARGE ROLLED PLANS ARE IN: BOX: SLOT:__ _ Date entered in MAPS program on:C, r 1 By:-- . I P�oiT"ET°,�y Town of Barnstable BARNSTpBLE. » Building. Department-200 Main Street �c6XIAS& �001 Hyannis, MA 02601 .19 1639. AIEDMAYA Tel. (508) 862-4038 Certificate Of Occupancy Permit Number: B-17-2255 CO Issue Date: 10/25/2017 Parcel ID: 327-210 Zoning Classification: MS Location: 105 PARK STREET, HYANNIS Proposed Use: B: Office, prof. or service-type transactions Name of Tenant: Sprinklers Provided: Gen Contractor: MOSES M CORDEIRO Permit Type: Commercial - Business Type of Construction: VA: Any building material permitted by code Design Occupant Load: 18 T Comments: CAPE COD.HEALTHCARE ` Building Official Date: A Certificate of Occupancy is Required Prior to Occupying Space Building Code: 780 CMR 8th Edition Town of Barnstable Building • an,tr,�i.E, s Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept Posted AEA , Until Final Inspection Has Been Made. M Permit 0 39. Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit NO. B-17-2255 Applicant Name: MOSES M CORDEIRO Approvals Date Issued: 08/17/2017 Current Use: Structure Permit Type: Building-Addition/Alteration-Commercial Expiration Date: 02/17/2018 Foundation: Location: 105 PARK STREET,HYANNIS Map/Lot: 327-210 Zoning District: MS Sheathing: Owner on Record: DONAHUE,MARK L TR Contractor Name: MOSES M CORDEIRO Framing: 1 Address: 370 MAIN STREET Contractor License: CS-074674 2 WORCESTER, MA 01608 Est. Project Cost: $347,000.00 Chimney: Description: interior renovationof treatment rooms, drywall,siding,siding removal Permit Fee: $3,332.70 Insulation: Project Review Req: interior renovation of treatment rooms,drywall,siding,siding Fee Paid: $3,332.70 to removal _ ,. _ ... _ .. r _ Date: _ 8/17/2017 Final:.. .. Plumbing/Gas q�rrL Rough Plumbing: s«= 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 the approved construction documents for which this permit has been granted: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. , Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are 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 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.. Health C Work shall not proceed until the Inspector has approved the various stages of construction. Final: eA l Persons contracting with unregistered contractors do not have access to the guaranty fund".(asset forth in M c GL 142A). Fire Deparwentl �aah>11ro�.� Building plans are to be available on site Final` All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE ►STAB BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY Building permit application number Date 17- 17 Address of structure � _ _�F�` S map/par Area of structure C.O. will be.issued to Name of Tenant (� e y �ea Edition of Building Code'(under which the building permit will beissued) Use and Occupancy Classification' 0,��,.T i,`c �_'RA�r� Type of Construction �sM 0 EIC6,14 ZZ 4Q&C99f,'�� <:SA Design Occupant Load. Is the facility licensed by a State agency? (circle one) Yes No If yes If yes, name of agency Relevant Code of MA RegulationslCMR) that apply ' Sprinklers Sprinklers provided? ' Yes (circle one) Sprinklers required? Yes .(circle one) Building Department Use only Special Conditions: t RR—E.C RTIFICATE QF INSPECTION t In accordance with the requirements of General Laws,Chapter 111,Section S 1,this Fire Certificate of Inspection issued by the head of the local Fire Department certifying compliance with local ordinances is a prerequisite for an original or renewal license. Cape Cod Healthcare Hyannis-105 Park St- Renovations NAME OF CLINIC ADDRESS OF CLINIC t i was inspected on kOt o �1 bysv Date Name of Inspector -�' I HEREBY CERTIFY THAT THIS WSTITUT N COMPLIES WITH THE lACAL ORDINANCES. YES NO If answer is"NO",indicate violations and recommendations. Violations: ; Recommendations: ISSUED BY: Sipature Head of Local Fire Departnat INSTRUCTIONS: FIRE DEPARTMENT TO RETURN TWO COMPLETED,COPIES TO CLINIC CLINIC TO RETURN ONE COPY TO: Division of Health Care Quality 99 Chauncy,2nd Floor Boston,MA 02111 Rev.12.1 31005 DPHCQ117 I 1hT 1 4 rED C 0 M. ARCHITECTS FIELD REPORT ARCHITECTURAL GROUP Date: October 24 2017 To: Hyannis Building Department From: MEDCOM Architectural Group, LLC Project: Cape Cod Healthcare 106 Park Street Hyannis, MA Work in Reviewed: 1. Interior Rough Framing. All work was found.to be in compliance with the Construction Documents and 780 CMR, Massachusetts State Building Code.. Items Noted: 1. Existing ceiling sag within the waiting room and office area was reviewed. It was found that previous renovations had removed bearing walls that were supporting ceiling joists. New longer ceiling joists have been installed. 2. Installation of new HVAC units within the attic were reviewed for weight and support. Additional helper supports have been installed to help with weight distribution. i � •,Yam.,., �` ,. Gregory B. Siroonian 't . President j Ear r-G i Final Construction Control Document To be submitted at completion of construction by a ' Registered Design Professional rep for work per the 8ih edition of the Massachusetts,State Building Code, 780 CMR, Section 107 Project Title:Cape Cod Healthcare Surgical Office Suite Date; 0-18-2017. Property Address: 105 Park Street Project: Check(x)one or both as applicable: New construction X Existing Construction Project description:Renovate area for new office and exam rooms. 1 Gregory B Siroonian MA Registration Number:9748 Expiration date:8731-2018 ,:am a registered design professional, and.I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: X Architectural X Structural X; Mechanical Fire Protection X Electrical Other: Describe for the above named project. 1,or my designee,have performed the necessary professional services,and was present at the construction site on a regular and periodic basis.To the best of my knowledge, information,and belief the work proceeded in accordance with the requirements of 780 CMR-and the design documents approved as part.of the building pennit and that I or-my designee: 1. Have reviewed, for conformance to this code and the design concept, shop drawings,samples.and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar.,with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions-of i80,CMR 107. Jr i . r� Enter in the space to the fight a"wet"or ' s electronic signature and seals I'S` Phone number: 508 759 9828 Email: gbs@M.EDCO1VMarch.com -� Building Official Use Only Building Official Name: Permit No.: Date: 1 Version 06 11 2013 i s ' f CONTRACTOR'S PROJECT COMPLETION I hereby certify to the best of my knowledge and belief;that the installation has been completed as per the following: i 1. All work has been executed`in substantial accordance with the approved. construction documents. 2. Execution and control of all methods of-construction.has been in a safe and satisfactory manner in accordance with all applicable local, state and federal statutes and regulations. # 3. Functional and integrity testing has been performed confirming system operation in l accordance with specified tests and the required operational sequences'. Project: Cae (W �kaiAe yz )65` p6liyk t Permit No:: Location: Construction Documents: [=��e�� iW%V% S FU.® e/ 2 D t I Date on Plans and Specifications submitted for approval and issuance of the Building Permit: Addendum(a)/Revisions Date(s); Signature I i ' Date. Company License Number License Expiration Date l ll 1 . i CONTRACTOR'S PROJECT COMPLETION i I hereby certify to the best of my knowledge and belief,that the installation has been completed i as per the following: li f 1. All work has been executed in substantial accordance with the approved construction i documents. I 2. Execution and control of all methods of construction has been in a safe and satisfactory manner in accordance with all applicable local,state and federal statutes and regulations. i 3. Functional and integrity testing has been performed confirming system operation in accordance with specified tests and the required operational sequences. f I 1 Project: CCH Park St Permit No.: P-17-1106, P-17-1247 i Location: 105 Park St,Hyannis, MA Construction Documents: A0.01,D1.01,D1.02,A1.01,A1.02,A1.03,A1.11,A1.121.A2.01, A2.02 3 , Date on Plans and Specifications submitted for approval and issuance of the 6/26/17 Building Permit: Addendum(a)/Revisions Date(s): Signature a - A? Date v / , Comiihy 2128 5/01/2018 License Number License Expiratfon Date i MEDCOM ARCHITECTS FIELD REPORT ARCHITECTURAL GROUP Date: October 2, 2017 To: Hyannis Building Department From: MEDCOM Architectural Group, LLC w/LD/VG®gyp • 1: Project: Cape Cod Healthcare 0er 04 105 Park Street' . T 2017 Hyannis, MA owNO�ggpNSTA SSE Work in Reviewed: 1. Interior Rough Framing. All work was found to be in compliance with the Construction Documents and 780 CMR, Massachusetts State Building Code. Items Noted: 1. Existing ceiling sag within the waiting room and office area was reviewed. It was found that previous renovations had removed bearing walls that were supporting ceiling joists. New longer ceiling joists have been installed. 2. Installation of new°HVAC units within the attic were reviewed for weight and support. Additional helper supports have been installed to help with weight distribution. a o.3748 erli M Gregory B. Siroonian �� President d TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION n 1 Map: . � Parcel DD Application Health Division -" Date Issued -7 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board r)L Historic - OKH Gar- ' `Preservation/ Hyannis Project Street Address 10 5- ��1� • 5Z'�� e- T Village 0 1 14a-'Vv E Owner V A. 4- u YN% LL �-- Address Telephone d `K Sfl 70 -7 (O Permit Request Roo 1� I Y\ °I �-V°�,l bve�' y � S� �✓� 'n-�5 ,Square feet: 1 st floor: existing proposed 2nd floor: existing `proposed Total new Zoning District Flood Plain Groundwater Overlay ,3 Project V�uation �-. o 0 �e Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup orting c ff umgation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure - S Historic House: ❑Yes ❑ No On Old King's ighway::b Yet ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 5d Telephone Number Address a �G«ti 13 3J 4 °2� License # C 5 053 [ 3 0©rc-es"Z e A 5 S Home Improvement Contractor# 1 Email M A•CoeCT 91�`J cK(- LO- AO [ ice® .-►-�- Worker's Compensation # ALL CONSTRUCTION DEBRIS RESU C lNG FROM THIS PROJECT WILL BE TAKEN TO 0\)Cv-, f- LA" SIGNATURE DATE I FOR OFFICIAL USE ONLY OPLICATION# DATE ISSUED MAP/PARCELNO. F: r. ADDRESS VILLAGE OWNER k DATE OF INSPECTION: FOUNDATION FRAME i r INSULATION RREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING L , DATE-,CLOSED OUT ' AWO AATION PLAN NO. The.Commonwealth of Massachusetts _ Department of IndustrialAccidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeZibly Name(Business/Organization/Individual): 1q (0ATirCe f—Tfl t2� Address: , 2'5 6 c e- e n b v s (4 V"✓D City/ tate/Zip: 06r-c- wt-(4t Phone#: U LP ' Are on an employer?Check the appropriate box: Type of project(required): l. I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New constriction 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; 0 Demolition workingfor me in an capacity. employees and have workers' Y aP tY• 9. ❑Building addition [No workers'comp. insurance Comp.ins,uranee.l required.] 5.,� We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no c employees.[No workers' 13.❑Other_�,A� O� comp.insurance required.] *Any.applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: 410 Job Site Address:�d S City/State/Zip: �`Il fw" . Attach a copy of the workers'compensation policy declaration page(showing.the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: f I Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitiLicense# 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#: j Information and Instructions _ y Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance.or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C( )states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call.the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license nunnber which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of lavesiigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASgAFE Fax#617-727-7749. Revised 4-24-07 www.mass.gov/dia I CERTIFICATE OF LIABILITY INSURANCE DATE(MINf001YYYQ �...� I 4/1t2014 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 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 endorsements. PRODUCER UNIVERSAL INSURANCE AGENCY INC NCON AME: 374 BELMONT ST PUONE FAX WORCESTER, MA 01604 la A/c No): ADDRESS: DISURER S AFFOROING COVERAGE NAIC 9 INSURERA: Liberty Mutual Fire Insurance 23035 UNSURE INSURERS: M &ACONTRACTING SERVICES INC 25 GREENBUSH ROAD INSURERc: WORCESTER MA 01604 INSURERD: INSURERS: INSURER IF: COVERAGES CERTIFICATE NUMBER: 196§2362 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 SUER OL L'Y EFF POLICY 1JCP LTR INSD VJ1I0 POLICY NUMBER MIDD1MMIDDIYnT) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMACLAIMS•4ADE OCCUR 1 O D $ MEDE*(Anyone person) $ PERSONAL&ADV INJURY $ GENLAGGREGATELIMITAPPLIESPER GENERALAGGREGATE $ POLICY D!EMED LOC PRODUCTS-COMPIOPAGO S OTHER - $ AUTOMOBILE LIABILITY comamm-d0M tR LIMI $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per academy $ AUTOS AUTOS NON-OWNED PROPER DAMAG $ HIRED AUTOS AUTOS er. nt $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR I I CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION WC2-31S-372464-033 11N712013 11117t2014 SER OTH- ANDEMPLOYERS'LIABILTY YIN ATUTE _ER ANY PR0PRIErO1LPARTNERFXECUTNE � E.L.EACH ACCIDENT S 1000000 OFFICERIMEMBEREXCLUDm7 l.::J NIA (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE S 1000000 U pss,dewrbe under 0 SCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICYLIMIT S 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD ID7;Addlgonal Remarks Schedule,maybe atlachedlfmorespaeeleregWred) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION CHAEL BURKE pt�, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MI MI GURNET ROAD p� •}1 THE EXPIRATION DATE THEREOF, NOMCE WILL BE DELIVERED IN DUXBURYMA 02332 M�j`1LE� �•' ACCORDANCE WITH THE POLICY PROVISIONS. • �+ - AUTHORIZED REPRESENTATIVE Liberty Mutual Fire Insurance �4ttW 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CERT NO.: 19692362 CLIENT c00E1 1391037 Lucy Garfield 4/1/2014 9.57141 AN Page 1 of 1 Town of Barnstable ' Regulatory Services Richard V.Scali,Interim Director Building Division Tom Perry,Building Commissioner 200 Main Street;Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must 'Complete.and Sign This Section If Using A Builder #L 1h`l 6 L— ro as Ownet of the subject — - • � l P - pettY hereby authorize to.act on mp behalf, in all matters relative to work.authorized by this building pe=dt ta (Address of Job) **Pool fences and'alanns are the responsibility of the applicant. Pools are not to be filled or.utilized before fence is installed and all final inspections are performed'and accepted. At, Signature of et Signs of Applicant Print Name Print Name Date �t ,.V 1 � 0 � ro � � '�� > � � � �+ � � � C ��•; �. � � � \. - �. � � � � � M .,. � � � C ,� � ;� � . �: _ Mass. Corporations, external master page Page 1 of 1 v t b s. • • i • . S ` 9r'j 16 Corporations Division Business Entity Summary ID Number: 461527105Request certificate New search Summary for: JIYA & AUM LLC The exact name of the Domestic Limited Liability Company (LLC): JIYA & AUM LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 461527105 Old ID Number: Date of Organization in.Massachusetts: 12-08-2012 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): Address: 105 PARK STREET City or town, State, Zip code, HYANNIS, MA 02601 USA Country: The name and address of the Resident Agent: Name: JOHN E. NORTON, ESQ. Address: 540 MAIN STREET City or town, State, Zip code, HYANNIS MA 02601, MA 02601 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER VIMAL PATEL 105 PARK STREET HYANNIS, MA 02601 USA In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title Individual name Address SOC SIGNATORY PINA PATEL 105 PARK STREET HYANNIS, MA 02601 USA The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: Title Individual name Address REAL PROPERTY VIMAL PATEL 105 PARK STREET HYANNIS, MA 02601 USA http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.... 4/14/2014 eaarvnaooau eaLC/o�C�/�cr�accc/c.�eCla License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: — OME IMPROVEMENT CONTRACTOR OME IMPROVEMENT ,EMENT Type: Office of Consumer Affairs and Business Regulationegist i xpiration 4/3/2016 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 M&A CONTRACTING,ISERVICES 'INC. STEVEN O'CONNOR 25 GREENBUSH RD WORCESTER,MA 01604 Undersecretary qt valid without signature i Massachusetts Department of public Safety Board of Building.Regulations and Standards I Construction Supervisor r L i License: CS-053137 f STEVEN J OCONOR 25 GREENBUSHIWj WORCESTER AfA O) 07�4 Expiration Commissioner 10/28/2015 j m; I TOWN OF BARNSTABLE SIGN PERMIT PARCEL ID 327 210 GEOBASE ID 24312 I� ADDRESS 105 PARK STREET PHONE HYANNIS ZIP - LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY i PERMIT 61259 DESCRIPTION DUFFY HEALTH CENTER/6 Sty j PERMIT TYPE B SIGNN- TITLE SIGN PERMIT CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $25.00 BOND .00 CONSTRUCTION COSTS $:00 753 MISC_ NOT CODED ELSEWHERE * il1RNSTABLE, • MASS. i639. A�O� i i R' ILDING DIVISION BY � D DATE ISSUED .05/22/2002 EXPIRATION DATE `, 1 Town of Barnstable �OpTHE rqi, Regulatory Services Thomas F.Geiler,Director 9 STABLE,g Building Division i639. aim i0tp0 r�.� Peter.F.DiMatteo, Building Commissioner .200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Tax Collector v 3— o v-- Treasurer Application for Sign Permit Applicant: (//U6/ ��7y C ��+� : �'t G Z� Assessors No. J °� 149 Doing Business As: :Da-!e /V arc/ ! G'�yl Y Telephone Sign Location ! Street/Road: �� r Zoning District: Old Kings Highway? Yes/No Hyannis Historic District? Yes/No Property Owner —� Name: 9, �'. �� .5��t� / ��-5 t Telephone: Address:" 512 r,40.cL 14W Z�zn Village: e/y�e v✓l !)e— Sign Contractor t Name: v/lj__ 4 t% M 1 75 r�Telephone.`3 - so ' _ Address: 'r' ✓� = Village: Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions,location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? Ye [No (Note:If yes, a wiring permit is required) I hereby certify that I am the owner or that I have the authority of the owner to.make this application,that the information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authorized A ate: 3 � Size: Permit Fee: d7S �J Sign Permit was approved: Disapproved: Signature of Building 0 ' l: -A Date: f Signl.doc rev.122801 SEE M 001 IMMME.��C�= �PNW � am law=, M_ M W Niffimmommommul . MINN Mom mmommommomm Immoomm an Ono Ina an a mmummosommon main MEMO, man an on a on moon ommommmomm INNER 0 0 loan MOMW 0 Moon man ONO Moon MEN a NOON nommommumimmmon mom noon Room man a moon MM , MM no oom NN .. No .... . . ... ... ..... ..:::: :...:::�::in=:?:.C�C:: :C:: �:::::_:::ONO mmomm"Mmin an mom ONO ', a mom a in ENRON a an MEMO mommummommummmm NOON MMM , MMM MEN MEMO on OREM= a muman MEN _ mmom a mKommum amommal 0 Oman mom mmomm a a NOON mmmmmomml goommumn Room mmummin 0 Moon an umm Woman mom Mom mom mom an a mmummom mmmmom on no ME lummolon"MIN nomomms mmonammmum Milan 0 main ROME a UNIMMINUMMMUN man a no mom . a WMANSOMMUMN mom , in ROME maxommommain mmoms ommoommom an Was am in MKOW a Rangoon mom a No mono No a a a an no No ENRON noon a a an Malmo 0 RXIMM no ME noon a a an an an 0 a MR MIN 0 Milo a a an a a M , mono a al 101 on a a a a a an No a . . a an .. ....... .. ... . . .. .. .. am . Nunn a no ..�►�.�..�.�.....C�...0 �....� �imam..: - :�.: . . .. .. . ... ... ... .. . TO ALL NEW BUSINESS OWNERS Fill in please: n". M 'e APPLICANT'S , � YOUR NAME: ea,? n BUSINESS �`� '3 YOUR HOME ADDRESS: a-/ V -- S"D S'-9J/- TELEPHONE Telephone dumber Home o 5-- 7.7 8= ,!6Z2� NAME OF NEW BUSINESSdW, TYPE OF BUSINESS IS THIS A HOME OCCUPATION? ADDRESS OF BUSINESS /05 Pa-r k 6f . HYaY, 7 is MAP/PARCEL NUMBER %3 o2 7 72/0 When starting a. new business there are-several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is.intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed below, you_may apply for a business certificate at the Town Clerk's Office (Ist floor- Town Hall) or if you get the business certificate first you MUST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St. —(c9rner of Yarmouth Rd. & Main Street) and you will find the following offices: 1. BUILDING^ PECTOR'S FFICE This individual a een-i rm of any permit requirements that pertain to this type of business. A i ed S atu e COMMENTS: ' 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature COMMENTS: Business certificates (cost$20.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. - it does not give you permission to operate -you must get that through completion of the processes from the various departments involved. Wlineering Dept.(3rd floor) Map t Parcel //) Permit#" House# ��,�� Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:36 Fee ©c� 'eonserv-at!aff1)ffrc—e(4th floor 8:30- 9:30/1:00-2:00 APPLICANT MUSE OBTAIN A SEWER P1ftfWAftg Def-4 CONNECTION P(1st floor/School Admin. Bldg.) M THE .� ENGINEERING R TO d y Planning oard r 19 CONSTRUCTIO . P�(��\'\� , 1 t ,( BARNSTABLE. V, t6yq• WN OF BA S A E. ` 01 Building Permit Application Vtreet 05— R,2 k Village Alv6e ni It/ S Owner D Address C1 s Telephone , Permit Renquest ^/?�'jCa,� ��/Z7///o�✓ C {yc��S ,1 4 / r / —, ,` :� First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ `(�� ,G 0 C, Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes &No T On Old King's Highway ❑Yes U-90 Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half-'E ix sting .New No.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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial U' eS ❑No If yes, site plan review# Current Use Proposed Use /� Builder Information T Name c J50/v l� �lcL'2tr,� Telephone Number &C,$) ` S— ' ` ? T f Address 1&1,✓ _5'7, License# C S O 6 a 79 F70 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 CONSTRU ION EBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO com S � SIGNATURE DATE E/ BUILDING PERMIT DENIED FOR THE OLLOWING REASON(S) n - FOR OFFICIAL USE ONLY _ PERMIT NO. DATE ISSUED - MAP/PARCEL NO. #` 4 r ADDRESS # VILLAGE OWNER DATE OF INSPECTION: - 1 FOUNDATION- FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH ' FINAL t PLUMBING- 4 ROUGH FINAL y , GAS:' zQ�(,ROUGH FINAL ' 1 FINAL BUILDING- DATE CLOSED"OUT ASSOCIATION"rPLAN NO. The Commonwealth of Massachusetts _-.._ ..L Department of Industriit!Accidents �� OffICE 011/IYBS11gSONS � , - - l� 600 Washington Street Boston,Mass.. 02111 Workers' Compensation Insurance Affidavit rr��i�rr�rr/O r///4i AM!iaiao�i�� /rrge'�,'',,,, , name: U S O�✓ �� l location: Q a Zc city &` V1 hone I am a hom owner performing all work myself ❑ I am a sole proprietor and have no one working in anvcapacity ❑ I am an emplover providing workers' compensation for my employees working on this job. com anv name: address: City: phone#: insurance co. Unlicy# lZE////i/////Di//// ❑ I am a sole prop eneral contractor r homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: . ... company name /OZ!! rp L/ ` N co ` address CU•�� d . : rcenz hone#: / insurnnce ca. nlicv# Sly com anv name: address: City- .phone#: olicv# insurance co. / // ,l/%%%%/ Failure to secure coverage as required under Section 25A of 11GL 152 can lead to the imposition of criminal penalties of a One 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 S100.00 a day against me. I understand that a copy of thfa statement ma a forwarded to the Office f Investigations of the DIA for coverage verification !do hereby certify r the p and pen es of perjury that the information provided above is truce d cGrreet Signature Date 3 Print name S l.'- Phone# ` Ed. o not write in this area to be completed by city or town ofIIdal permit/license# ❑Building Department ❑Licensing Board response b required. ❑Selecnnen'a Office ❑Health Department phone#; ❑Other (Mww 9/9S PIA) s } �b Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their an employee is defined as every person in the service of another under any contaac employees. As quoted from the "law", . of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver . owner of a trustee of an individual , partnership, association or other legal entity, emploving employees. However the dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of anotherwh:,employs--rcr%nc to tin maintenance , construction or repair work on such dwelling house or on the grounds o: building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew business or to construct buildings in the commonwealth for any applicant who h of a license or permit to operate a a not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and ipplying 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. MEN 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 maybe rationed to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions• please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Invesduadona y�yrs 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 eat. 406, 409 or 375 a �, 0:�1Y'�o�a+�YA�G ima6s�.wrCYY1 p, w II finish • F j I dire. I I II T-2"— i FEY TdWHIFI F ROOM Md or to be used new shelfs j j door r I s HALLWAY � I I jNlE�� j NEW CLO. II IFEWCE i1! I I _._ (40 I r,e II I -, � Ijl�• NEW i J a CJ1 t gm ,1•� vo `� \ '" x r, ,gyp v.C3 i C•Q W y ineering Dept.(3rd floor) Map 3,2 7 Parcel_ (Q F'U T Permit# A 3 to Hou e# _ Date Issued —� 7 Board o Health�3rd floor '( :15 -69:'30/1.00-4:3 :Fee Conservation Office (4th floor)(8:30.-9:30/1:00- 2:00) AV,rS.F'Lt� Planning Dept.(1st floor/School Admin. Bldg.) - APPLICANT ASEWER 'CONNECTIO OM THE im ' Plan Approved by Planning Board 19 ENGINEER OR TO CONSTRU 9 RNSTARLE. - ' E MAS& �FD lAfd�� TOWN OF BARNSTABLE Building Permit Application Project Street Address Village Owner _ 2i Address Telephone Permit Request L_ T IP &ZZ:�(7 7- First Floor d square feet Second Floor ' fh 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-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl' ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing I New Half: Existing New No. 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 - Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) " ❑Other(size) t Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Build Information Name phone Number �2 Address j l MMAll r-heC -C License# �y/ Home Improvement Contractor# � � / Worker's Compensation#Zoij,�� (��a3 Y=_9( 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 0&r/75-A" A SIGNATUR DATE I� , 17 BUILDIN RMIT DENIED F THE LLOWING RE 01 °' • k^ r; s - * FOR OFFICIAL USE ONLY ` PERMIT NO. y ZX DATE ISSUED' MAP/PARCEL NO ADDRESS VILLAGE` OWNER r sii C r. , .. .} . t .. r`y ,,. F _ � -fly �� • �r�. t DATE OF INSPECTION: _4q r;♦ .. 4 , t cif.{lt FOUNDATION FRAME INSULATION= FIREPLACE ELECTRICAL:, ROUGH FINAL PLUMBING: }-t ROUGH FINAL" GAS: ROUGH 'FINAL' '* FINAL BUILDING' •' a DATE CLOSED OUT . ASSOCIATION PLAN-NO. 1 " f, F t SEE MULTI-FAMILY FILE IN RALPH' S OFFICE. THANK YOU The Commonwealth of Afassachusctts •fill ;�:=1•: Department of Industrial Accidents r INC9fif10 st/92MRs 61111 1111Y11in,;ton Street �� = :+' Boston.Man. (12111 Workers' Compensation Insurance Affidavit hniic tot information•• Plc-tse ebi�@ Al 12 z. �' brio•tt 1 am a h eowner performing all wort: myself. I am a sole proprietor and have no one working in any capacity I am an entpiover providing workers' compensation for my emp71es workingg on this job. nnf t•tm• na e: t •tdtlrccs: I 'h•- ( brio t!• incnr•tncc cn ` �I C�.0� nolicv t! /o/� j ztE -,.............. _..- Q I am a sole proprietor. general contractor. or homeowner(circle one) and have hired the contractors listed below who h.- the following workers compensation polices: mmn•tm• n•fmc• •ftitlrccc• cih•• nhnnc±t• nniicv inciirnnrr rn cnm rim' name: atldrecc- rite nhnnc i!• insur•tncc co _ _ noiic�•tt Attach additional sheet if neccs_ia_ry =••.�:.� -- * --+%'...._;:L''''= -= •r' -~��• "'vs ..::wr- �•..r•�• Failure to secure cttvernec as required under Section 35A of DIGL 152 can lead to the imposition of criminal penalties of a line up to SISOU.UU andiu one+ears• imprisonment as well as civil penalties in the form 0172 STOP WORK ORDER and a rifle of 5100.00 a dad•against me. I understand that copy of this,tateafcnt may be furnvarded to the O1rce of Investigations of the DIA for coverage verification. 1 do herchr c f tinder the pains and penalties of perjun•that the information prodded above is true ai d co ct. Si__natur Date 0 1 7 Print name D Phone>* '5�_-)-o z o 112 �oRc tai use Holy da not write in this area to be completed by cin•or tOWn oRciai permitilicense it f nuifding Department cin or town: C jucensing hoard check if immediate response is required 0Seicetmen•s Ufti <] m cc F' -. attcatth Department contact person: phone#: rjUther c. Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers compensation for their employees. As quoted from the "la��". an emplgree is defined as every person in the service of another under any contract of hire, express or implied. oral or written. An entpl( rer is defined as an individual. partnership, association. corporation or other legal entity. or any two or more . the forc�_oin;; cngaged in a Joint enterprise. and including the legal representatives of a deceased employer, or the receiver or tntstee of an individual . partnership. association or other legal entity, employing employees. Ho%%,ever tltc rnvner of a dwelling-hottse having not more than three apartments and who resides therein. or the occupant of the d%%�cliim_ house of another a-Ito employs persons to do maintenance , construction or repair work on such dwelling hous or oil the urcunds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL cha.ptcr 152 section 25 also states that even'state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commomvealth for any applicant who itas not produced acceptable evidence of compliance with the in coverage required. Uditionall��. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the -)erformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ita -seen presented to the contracting authority. 1pp icants 'lease fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and upplying company names. address and phone numbers as all affidavits may be submitted to the Department of idustrial Accidents for• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The ffidavit should be returned to the city or town that the application for the permit or license is being requested. of the Department of Industrial Accidents. Should you have any questions regarding the "law- or if you are required D obtain a .vorkers' compensation policy. please call the Department at the number listed below. Itv or Towns ease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of e affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas sure to fill in the permit/license number which will be used.as a reference number. The affidavits may be returned to Department by mail or FAX unless other arrangements have been made. ie Office of Investi=ations would like to thank you in advance for you cooperation and should you have any questions. =ase do not hesitate to aiye us a c--ll. ie Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 ' phone ': (617) 7274900 ext. 406, 409 or 375 : . The Town of Barnstable f 9� Department of Health Safety and Environmental Services Eo r Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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. Type of Work: Est.Cost Address of Work: Owner's Name U d -ez L&aLrz4i 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 IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: 112300 Date Contractor N Registration No. OR Date Owner's Name t 1. -.:;._..%cam'•. ... � -_' - - .. 7 `.. t - Y.P-`�',r-•.c�,r,� --•.,P 3,a',t,G�.w-� ter�rsrt+-�` :.r-•,....-,.. ' ;�1, _". :Tine�a�xvwo�eu�ev/.l�i e�..F •.oe[!a � . HOME IMPROVEMENT CONTRACTOR Registration 119300 type - 08A - Expiration 06/19/97 ISLAND SIDING go L. TAYLOR J: ADMINISTRATOR 31 HANK CACLE -- CENTERVILLE MA 02632 « 5 Home lmprovemcnt wiiLiaL;Lvi ,r r �a Assessor's_Office(1st-floor) Map ,:�a � - = Parcel Permit#' ✓ w Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) Date Issued 9 `77 Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) r Fee Engineering Depi.(3rd floor) House# IKE � BARNSI'ABLE. -- ' '. MABB 19 . t639•►�0g TOWN OF BARNSTABLE Building Permit Application e 7OwnerW. dress' ��J ?Cart ' Q ' Addresst at'/TY SI-Arl Telephone J02�0?8' /� Permit Request First Floor square feet Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use ��. S d•• 6ee Proposed Use p Construction Type Commercial 11� Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure 0?0 J' kS ' Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other �^ Builder Information Name / Telephone Number Address an License# Home Improvement Contractor# /'93b Worker's Compensation# 4A&&v 1 ,e2&5:V4 5ef,5- NEW CONSTRUCTION OR ADDITIONS REQUIRE ASITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1 I2• Za - 1 SIGNATURE DI DATE /0 Aft BUILDING PERMIT DENI R T E FOLLOWING REASON(S) FOR OFFICIAL USE ONLY 1 , PERMIT NO. 1 , DATE ISSUED MAP/PARCEL NO. ADDRESS j VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION - FIREPLACE . . i � - - r• `- ' ELECTRICAL: ! ROUGH FINAL PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT , ASSOCIATION PLAN NO. , -,� j` The Conrnu,t wealth of:AfassachuscrIv Department of Inditstrial Accidents ONC9811A Sfigal/ons ;x 600 Washington Street Boston.Mass. 02111 ' Workers'Compensation Insurance Affidavit @Rnhcant tntormatiom- " Please PRiNT;Ie y �.. h ® �� LZ I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity VM I am an employer providing workers' compensation for my employees working on this job. address, cit2: — phone#• /' /� /�� y�•-y`(� C� insurance co policy N /(�Y/6 1 am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comijany name: - address: Sim: phone fit: ' _ r insurance co policy N I` ..- -r - +C/[rJ-T..:r�va-��"" '.�•fil�Fr!i)F:se FFS�J�S1f'�i?his'•,-R .SF�?�-!"tT!!_'9!!°�h�'�4!if� ''�••�?�S companv name- address: city phone#• incur•tnce co policy# :Attac_h additional'shcet if aeeessa nz -...y s ;:f *' .:�` • =•°�r',:" :w 7..`; Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one Fears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy'of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cend •tt der the pains and penalties,ojperjuly that tite information provided above is true and correc% ` Si-nature .� Date 161-0- Prinrname )` U Phone# 4ZW�6�LQ 522(3 M - oMcial use on1v do not write in this area to be completed by city or town official city or town: permit/license q r iBuilding Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office 011calth Department contact person: phone#; nOther _ s Iraned 3105 PJA) HOME IMPROVEMENT CONTRACTORS REGISTRATION. Board of Building Regulations and;5tandard; . One Ashburton Place - Room 1301 Boston, Massachusetts 02108 HOME IMPROVEMENT `CONTRACTOR, Registration 11930'0 Expiration 06/19/97 Type - DBA ISLAND SIDING RONNIE L . TAYLOR 31, MANNI CIRCLE 02632 CENTERVILLE MA , r Assessor's Office.(1st floor) Map Parcel P rmit#' Conservation Office(4th floor)(830-9:30/1:00-2:00) rW CONNECTION FROM THE Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) ENGINEERING MUM 10 0..7 O - O- w Engineering Dept:(3rd floor) House# !ems Planning Dept. (1st floor/School Admin. Bldg.) Defin- ' e Pla �,proved by Planning Board 19 ""Af s63q. TOWN OF BARNSTABLE Building Permit Application ` P ect Street Ad ess Village ry( nj,& 0 pp �� Owner A bf (2, Address 0 5'k�ELQ ME ;Telephone ' ::Permit Request rl'1 {� t I -First Floor 3 y 7� square feet Second Floor r) 14 square feet G Estimated Project Cost $ U1 (SOU Zoning District Flood Plain r1 Water Protection n I Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Oo cz( S p Proposed Use DO L7 C S O-q-- ICE Construction Type U,�OOU Commercial �4e Residential n I Dwelling Type: Single Family 0 l4 Two Family Multi-Family -Age of Existing Structure Basement Type: Finished Historic House JA Unfinished ✓ Criq L,3\ cb2,q(r, Old King's Highway r) 1 ,4 Number of Baths `-1 No.of Bedrooms d1 � Total Room Count(not including baths) First Floor Heat Type and Fuel Pt Central Air f Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name ` Telephone Number �� 31 57) Address License# G 1 Home Improvement Contractor# U 3 r) Worker's Compensation# n J� NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTR \ON DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 5 el Cp BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED - MAP/PARCEL NO. ADDRESS - VILLAGE - - OWNER o- i , 1 DATE OF INSPECTION: FOUNDATION - - FRAME'. - . t ,. .,. f _. INSULATION FIRE .�P C cs .. =• _ . ram` ELECTtICL: ROUGH FINAL FINAL - - PLUMB�fNCrt' ROUGH _ - GAS: _ ROUGH FINAL j • f '+ r ! -' , FINAL BUILDING r _ DATE CLOSED OUT ASSOCIATION PLAN NO. i . WA11!l 11NG AlL EA FOYER � H/C Railings fastened to building Existing door r ised H/C ramp 1/12 max. slope 5' Wide and provided / 4'-0" clear width Landing VESTMULIIE H/C Har are <istingg floor raised to meet terio�-flo-ar level 5'Wide Landing OH/Cing fasten to PT 4x posts concrete se bbmshn a DVTUUWUUV4D Existing Landing ]PLAN for HANDICAPM RAW RISER 105 PARK STREET HYANNIS MA scale 1/4"=l'-0" January 23, 1996 Existing Ramp removed and New Landing Built The Commonwealth of Alassachusetty Department of Industrial Accidents :� ;� _ � OJffceoJlalvesllgaUons 600 fi'aslrinrtott Street Boston.Mass. 02111 Workers' Compensation Insurance AMdavit rnse _ — -- - - name city '�'� ' �=-u`V\�� 1 \ nhnne# 1 am a homeowner performing all work:myself. II�.am a sole proprietor and have no one working in any capacity I am an emplover providing workers' compensation for my employees working on this job. comenny name- --- address: - city: nhnne#• insurance co ,.. .�. ..............3yf..+-�-�,Pia----^�!""'2""„-►n^•* - - �: _ �: - I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: cominay name: address: - C*tx. phone#: inourance co policy# Meir; s :ae`,'p^�':..r, '_ "�'m��o -- -'•T.TsfFv!Jrel�f6'�Oi�:.R:+r►�f,�°.�ce?F�^ "�!_:�R43=!'s'+^ —' . company name.- address: city phone#: insurance co police# :attach additio her, if iiie air 2a=:.plrF- a+��1`c JY CSa erg'-r.:. :•rtr4. l�tr. .w awYiaa. Failure to sec re cn rare as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'i prison ent as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this s ate n may be forw tied to the Once of investigations of the DIA for coverage verification. I do hereAr rJ•r f}}•u de file in apenalties of pei juq•that the infornwtion provided above is true and correct T) Si�nature� L2,z Print name i Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# r9Building Department oucensing Board check if immediate response is required ❑Selectmen°s Office (311eaith Department contact person: phone#; riOther r (revised 3•4J5 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. An empint+er is defined as an individual, partnership,association, corporation or other icgal entity, or any two or more of the fore=oin engaged in a.joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1.52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any , applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. I:•�.*r-.�+-r+� {`. +•r2., e s ..{ tie. 7777777F.7 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 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 tite 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. t- .. 7 .. - st,:.' n -d :. v ,r -�_,�, A•�ry;�:riw ! Cy�:`,iY ':+i-�,,.�"ir. , ..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 returned to 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. 7.r.t..i. 7 7 -. .- is .a y...•.. J+• , ♦.t�yt.Nd: . ".-.� • .. .:Y `Kq.,. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents i Office of Investigations 600 Washington Street -- Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 cat. 406, 409 or 375 f ic.... � R.,�,,. ......., : Q,..�r, - - -w�•e+••.. ,i,-my, -.-v! 5,-*s+cxe-n^P�y#�y r ' � +.`fir+--�-aPir-+`---".,c.+,.r* .++,+�'.,,+,,..�•-`.'-.._...-.... 74a'a.si '6k`k'r ,�I1i`'. µ. ici^. +�\ ,Y.r h�� . '* ,,"�' .i �'. .� �q;'�. 3..hS5:1> d -:p a�Y�.,� 'Ar�{"� �'�s�•t .} 5 r �� h .ri ��-- HOME IMPROVEMENT _CONTRACTORS REGISTRATION„ �_ � Board of Building Regulations a _d+' t a�nd ace Room 1301 `One Plhburton ag t k Boston, Massachusetts 02108 f x SOME IMPROVEMENT CONTRACTOR Registration 103928 x r � F Expiration 07/10/96 { ; Type — INDIVIDUAL w z ✓iEe TOornvnonu ude[ jj,,r -�"� 7 HOME IMPROVEMENT CONTRACTOI s "!,-,Registration ' 103928. I :.TYPe INDIVIDUAL Pet er E.- Kell y Y P , ,:.� -Ex it t'a ion 07/10/96 93 Pheasant Way Centerville MA 02632 Peter E. Kelly 93 Pheasant Way enterville MA 02632 ADMINISTRATOR DEPARTMENT OF PUBLIC SAFETY 13824 ONE ASHBURTON PLACE, RM 1301 BOSTON, MA 02108-1618 CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Restricted To: 00 PETER E KELLY Detach bottom, fold sign on 93 PHEASANT WAY back, and laminate license card. CENTERVILL, MA 02632 Keep top for receipt and change of address notification. Restricted To: 00 _ ` - DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 00 - None Rusher: Expires: 1G - 1 & 2 Faaily Hozes Restricted,To: 00 Failure to possess a current edition of the Massachusetts State Buiilding Code PETER E KELLY is cause for revocation of this license. 93 PHEASANT NAY CENTERVILL, MA 02632 , . I C1= IFS r x 1= x Ti= CGS 3 1,4_,:E3UF-,�j:4t @C D�1"fE: 1 1/02/95 -------------------—---------------------------------------------------------------- I PRODUCER -----------—----------- I I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS I I NO RIGHT UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, i 1 Horgan-James Ins. Agency, Inc. 1 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 1 44 Barnstable Road i I------------------------------------------- 1 I P.O. BOX 250 ------------------ I Hyannis , MA 02601 I COMPANIES AFFORDING COVERAGE I I—-----—-----—---—--------- ---------------------- 1 (.,08) 7h-5830 1 COMPANY A Northern Assurance Company of America - - I 1 LETTER i I ______ ________________ I---------------------------------------------------------- __ -----------1 I INSURED — -- — — -I COMPANY B Lumberman's Mutual Casualty i I LETTER I i Peter Kelly d b a I---------------------------------------------------------- 1 I Centerville Construction I COMPANY C —I 1 93 Pheasant Way I LETTER 1 i Centerville, MA 02632 I------------------------------------------------------------------------i 1 COMPANY D I i I LETTER i---—-----—--------------------------------- i I COMPANY E 1 COVERAGES I LETTER I===== ==______=____________=_____-=__________________________=_=___= 1 THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I 1 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 1 1 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, i I EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY CLAIMS MADE I---------------------------------------------- I—---—----------------------------------------- 1 I I POLICY I POLICY i 1CO I I (EFFECTIVE IEXP'IRATIONI 1 ILTRI TYPE OF INSURANCE I POLICY NUMBER I DATE 1 DATE I ALL LIMITS IN THOUSANDS i---I------------------------------------I--------------------I----------1---------I------------------------------------------I i I GENERAL LIABILITY I I 1 I GENERAL AGGREGATE 1 A 1 [XI COMMERCIAL GENERAL LIABILITY I NBF822710 1 02/25/95 1 02/25/96 1 PRODUCTS-COMP/OPS AGGREGATE $ 600 1 1 I L ] [ 1 CLAIMS MADE [X] OCCURRENCE I i I i PERSONAL & ADVERTISING INJURY $ 300 1 1 1 [ 1 OWNER'S & CONTRACTORS PROTECTIVE' i I 1 EACH OCCURRENCE $ 300 I I I t ] I i FIRE DAMAGE (ANY ONE FIRE) s i00 1 I MEDICAL EXPENSE(ANY ONE PERSON)$ 5 1 1---I-------------------------------------1---------------------I----------I----------I---------------- I i ---------------------------I 1 AUTOMOBILE LIABILITY I 1 i 1 1 i 1 i I I [ ] ANY AUTO j i I CSL i $ I I [ ] ALL OWNED AUTOS i 1 1 ------------i--------------i i I I [ I SCHEDULED AUTOS I I i I BODILY INJURY 1 I I 1 I L ] HIRED AUTOS i I I (PER PERSON) I f I I I I I NON-OWNED AUTOS i 1 i -------------i-------------i I I I I I GARAGE LIABILITY I I 1 1 BODILY INJURY I I I i I [ ] i � I i (PER ACCIDENT) I i 1 I I i I I PROPERTY j1 I I I I 1 I DAMAGE 1 $ j I I---------------- -------------- 1 i I---1-------------------------------------I--------------------1----------I----------1------------- ---------- - --------------- I i EXCESS LIABILITY - - I I 1 EACH OCCURRENCE I AGGREGATE I I I [ ] UMBRELLA FORM i i---------------- 1 I [ I OTHER THAN UMBRELLA I i-'------------1 i---I------------------------------------- ------------- 1 i I I I I I STATUTORY i 1 i B I WORKERS' COMPENSATION 13BY 001408-00 101/12/95 1 01/12/96 1------------ 1 ------------------------------ I I AND I I I I ► f 100 (EACH ACCIDENT) I i I EMPLOYERS' LIABILITY i f i I i $ 500 (DISEASE-POLICY LIMIT) 1 I1 i I i $ 100 (DISEASE-EACH EMPLOYEE)I ---1------------------------------------I---------------------1----------1----------1--------------------------------------------i OTHER I I I 1 I I I 1 I 1 ► i i t I I I I 1 1 I I 1 1------------------------------------------ ----------------------------------------------- I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS 1 I 1 I i I 1 CERTIFICATE HOLDER =________=__-----------------------= i -------- ---- - - CANCELLATION I I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX- 1 I Cape Cod Brew House, Inc. I PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL I I Main Street 1 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 1 1 Hyannis, MA 02601 1 LEFT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR I 1 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. I i--------------------------- ---------------------------------------1 I AUTHORIZED REPRESENTAT 'E i 1 1 I I --------------------------------—--------------------------------------------- — -- -- -------- ---- ------------------- TOWN OF BARNSTABLE BUILDING PERMIT I'ARCFI, I D 827 210 GEOBASE. ?D . 24312 ADDRESS 105. PARI STRE T PHONE Flyann is ZIP o LOT BLOCS LOT SIZE DI3A DEVELOPMENT DISTRICT HY .. PERMIT 112.88 DESCRIPTION RESHINGLE OFFICE COMP14EX I PERMIT TYPE BROOF TITLE . BUILDING PERMIT IWO Y°"ment of Health, Safety CONTRACTORS: RONNIE. L. TAYLO z °., and Environmental Services j ARCHITECT.S r TOTAL FEES: . $100.00 �T11E BOND $.00 , CONSTRUCTION COSTS $2,000.00 C 750 ROOFING AND. SIDING A PRIVATE P:(*,> sTABLK OWNER CHABRA, .RIITTA A. TRS EC ADDRESS 284 STARBOARD :LANE OSTERV I LLE MA BUILD4NG DIV N DATE ISSUED 10/27/1995 EXPIRATION DATE B � THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,-ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN-, CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED.ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. POST THIS , . D s IT IS VISIBLE FROM BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 2 BOARD OF HEALTH " OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT.WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. q TION. 508-790-6227 I I i I I I I I I I I i I I I I I I I I i I I I I I I I I I I I I O I TOWN OF BARNSTABLE PARCEL ID 327 210 GEOBASE ID 24312 ADDRESS 105 PARK STREET PHONE Hyannis ZIP - I LOT BLOCK LOT SIZE DBA DEVELOPMENT ' DISTRICT MY PERMIT 12150 DESCRIPTION SOUTHEASTERN SURGICAL ASSOCIATES JI PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $50.00 tHE BOND .00 CONSTRUCTION COSTS $.00 753 MISC. NOT CODED ELSEWHERE * BARN3TABLE MAS& 014NER CHABRA, RI ITTA A TRS �FC 39. A� ADDRESS 284 STARBOARD LANE BUILDING DIVISION OSTERVILLE MA DATE ISSUED 12/07/1995 EXPIRATION DATE 'aK � � .. ' ,f .. � r • .'E � , . � .. ; i 1 i �+ � 1 � _ - �. �— � # � �. .. ry .• � �"� � . � a ` � 1 � � � , L-_ _- -- - v The Town of Barnstable =;tt /A�Q no. Department of Health, Safety and Environmental Services NAM Building Division awe 367 Main Sheet,Hyannis MA 02601 Application for Sign Permit Applicant: 1P0 q c�Rk NA-D Assessor's no. D Doing Business As: fob-1 4 6-P STL-r2tJ ��P-q (� A-<Sz)cr A-%Telephone 77 - '7 7 11 , Sign Location p streettroad: 10 �;- PAR k, (?,T P-c T t--YPTAJ rJ 1,� a 2,6 o Zoning District 2 Old King's Highway District? yes no . Property Owner Name: Paz c 1 '3 2 R Telephone Address: f r�2r�� r' 0 L IN G Village Q S-&R-01 L t 67 Sign Contractor Name: Gef J Telephone 7y0-31 X- Address: 1'-) ahaa 64J _Village Description Diagram of lot showing location of buildings and existing signs with dimensions, location and size of the new to be drawn on the reverse side of this application. Is the sign to be electrified? yes no � (Note: if yes, a wiring permit is required T hereby:....uy ta�'.at i a?n ilia owner or`he I hwia hha, attioruy rii1F�C owner to II1ilKC.�Pilcailon, iilat me information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of Barnstable Zoning Ordinances. ( 67eT . Date Signature of Owner/Authorized Agent Size (sq. ft. D Permit Fee �So- , 0-e Si Permit was roved: -disapproved: Sign approved:_ /,2- -7 Date Signature of ceding Official FecwT of 6u L4�) ov(o 10C) x fo nQ I o (� I I su I i i . VV � A T K S S la ®AVID P-. W I Lt lAt,4 S N D f CP'rr2 LvS A . F®"T—S- Y � A 1 IROPERTY ADDRESS • I ZONING IDISTRICT.CODE SP-DISTS.I DATE PRINTED CSTATE ACEL IDENTIFICATION NUMBER LASS I PCS I NBHD KEY NO. 24-4173 0105, PARK STREET' - 07 PRO 400 07HY 7 9 LAND/OTHER FEATURES DESCRIPTION = ADJUSTMENT FACTORS I Y UNIT. 'ADJ'D.UNIT- CHABRAI RIITTAA TRS Lana By,Date Sne D.mens�on ACRES/UNITS VALUE Dexapron MAP- CD, FFDemlAnes LOC.lYR.SPEC.CLASS ADJ. COND. PE PRICE PRICE #LAND 3 45.30D CARDS IN ACCOUNT - L 30 3SITE 1 X: .2i =10 242 71999,9 174239.9 .26 45300 #3LDG(S)-CARD-1 3 170,600 01 OF 01 A MEDICAL BLD U 1 X' #OTHER FEATURE 3 2.700 COST 100 *266636.0 266636.0 1.00 266600 B #PL 105 .PARK ST MARKET D PV1 .PAVING S . X' C=- 100 .4 .45 6000 2100 F #RR 1208 0117 0886 0104 INCOME 290000 A I I #SR LEWIS. BAY ROAD USE D I APPRAISED VALUE A i I I A. 218.600 PARCEL SUMMARY r U I AND 45300 S = I ( BLDGS - 170600 T i O-IMPS 2700 F Ei i TOTAL: 218600 N N CNST I - I I I DEED REFERENCE Type DATE R�tle, R I O R' Y E A R VALUE T ' _ I I i I I I Book ge Inst. MO. Yr.ID Rico AND - 4 5 3 0 C Si I I I i 4782/25PaT 1,10/85 A 1 SLOGS 173300 ,J 4782/250: 1:10/8.5 A 110000 TOTAL 21860C 4782/247: 1�10/85 A 1 - BUILDING PERMIT AND ADJ F O R J Number Dale Type Amount S E/L O C LAND LAND-ADJ INC ME I SE' SP-BLDS 'FEATURES BLD-ADDS UNITS 45300 270D 266600 B17485 12/74 AC Class Con- Total r Built Norm. Obsv. Units Units Base Rale Adj.Pate A e I Age Dep,. Co_ntl. CND I Loc %R G REpI Cost New Ad, Rep, Value Stories 1-.101 1 Rooms Rma Bathe I Fla. PW".Il Fec. 41B 001 000. 001i 53 75 19 84 80 64 266600 170600 1.0 1 : 1t 14.0 Descnp,ion Rate Square Feet Repl.Cost MKT.INDEX: 1.DD IMP.BY/DATE. / SCALE: 1/00.30 ELEMENTS CODE CONSTRUCTION DETAIL 3 BAS 100 .00 3477; CNST GP:01 T *-----47--�--* TYLE 31 FFICE BLDG 0.0 E$IGN AOJMT 00 ----- ------ --- 0.0 EXTER. A WLLS-- -01 D 06 FRAME - ----0.0 ! EATlAt 'TYPE 20 fAIR & AIR C0 0.0 f * ! NTER.FINISH 04 RTYALL 0.0 J 10 INrER.LAYOUT 1-2 VEft.TNORMAI-----0.0 *-* ! INTER.QUALTY 02 AM_E AS EXTER. 0.0 ! ! LOOR_STRUCT_ _02 D JOIST_I_.0E_A_M_ -__ 0.0 D W 30 BASE85 E LOOR COVER 04. ARPET 0.0 E TOIa,A,eas Aux. ease= 3477 ! + ' OOF `TYPE 00 . -- 0.0 .r BUILDING DIMENSIONS ' ! ! L_E C f R 1 CAL 00 0 D SAS W27, N26 W08 N30 W07 N10. W05 *8-* ! F0LfW6ATI6N -00 ------------------K6 A N27. BAS E47.SO2 E06 S06 W06'S85• -------------- - ---------------------- L -- 26 ! -----PRDF-ESSIO ALl ZONE----------------- ! LAND TOTAL MARKET ! ! PARCEL 45300 218600 *r=27--X AREA ' VARIANCE +0 +0 _ ._ _ STANDARD 50 'r �&ru1+v7Tk' c`�('�, ,h� FEW, n 1.4 r r� MASS TOW N�. OF .. BAR�NSTABLE, #. ., •,,_ °� �,��,�� pl,�'_ THIS IS`TO CERTIFY THAT A PER 'IS HEREBY GRANTED"TO : c P Frances �IL�Itiai�ab�a ry _..._................ ......... ..:.... ....... .._......_ �... .._..�_. _._........r _.� ., f r 5 IPROPERT OWNERI (ADDRESS) - TO L'rs _.-._-' ,.." r,' .-•r ( ITYP6'. 1 INO "�7t ar+ ." T6'1._..; -_».. IAPPROXIMAT6 81ZB1� FT, r ltit}p�q:n S, {Fit 1'0 k NY _ •�1�i� :1 ._ ...... (SVIO OCATION ...... ._. _Me RI f NAME OF BUILDER ONTRA T.OR r' EBY'rAGREE'T CO FOR ITO ALTHE:'RULES'AND:"REGULATIONS OF THE TOW_ N�� ih.- '.irY �c,-. 1 w .Y.•,� OF ,BARNSTrAB E�, ,REGARD NG �HE A'BO E 'CONSTRUCTION ' �2 r ,aT��Q�. -I_ _ - ri5'•,l r:� _ kr _-. (CONTRACTORI IOWN ERT ,_ _ UILDINld+�NSPBCTOR tt1 �i 4'01 Subject_fo Approval'of Board of Health- - '.. }ir4. tuf fR + r'vS ...d., ll +Sk..1+`�S'nik.4P�C}bice -u` d ,.:bl 'aH,?i4(-w�.:r'��rdiA,tl3ieuid�ai'ida .i'' W.�fiBy4!'e.�,3.tam' ..' 14rt/nk�i:'��F.4�� SS..c�` s)"rz ;+.i: l'SA�_ tiva�b. �`�?�� !�f/ � �„ �pv1,,OL r� lc�i ,,t �'X2E/� ia.0 (�<�C..- �rL /� �TN' ��gLY��5 LTfT•C�i . • TO1,11N OF BARNSTABLE BULK RATE COUNCIL ON AGING U.S. POSTAGE PAID 198 SOUTH STREET NON-PROFIT ORG, HYANNIS, PIA 02601 PEPJ.IIT NO. 2 v I 1 •-w l 3 Assessors map and lot number ......... ......... ......... Sewage Permit number �A+ n��✓ !� j ^�*:lYr. ° QuJ y�FTHE_ TOWN N ®F. BARNSTABLE Z EAWS AMLE, i 9 BUILDING INSPECTOR CEO MPY a'' APPLICATION FOR PERMIT TO .��',t�; ,lan' ►- ......\.O O .................................................... TYPE OF CONSTRUCTION ............................................................................................. h ................................ ..............1.9 . TO THE INSPECTOR OF BUILDINGS: i of t. The undersigned hereby applies for a permit according to the following information: Location .. ra Q.... ? ' .:..��. ? Cam' F........:..................................................................................................... Proposed Use ....t?11' C7�C da.. ��' ��-.............................. ��. ....................... t ZoningDistrict ......�".. ................................................... Fire District ..............,............................................................... Name of Owner .. .fir . . 5..... �, Q,r ,,\ { Address .. 'f Name of Builder �L-L� t� Address ��'�'`p `� ti' �'�� ......................................................... ........................................................ Name of Architect ..................................................................Address Number of r-- Rooms , . �O-aL• c a 'r ..: .................................................... .......................................................................... V .Foundation .... r Exterior .. ... .... :�.,a��. :`?......Roofing ...........�?. .....�...... ................................................. 11 1 Floors ........................................................................Interior ................ f Heating,-r, S. .::t. .... �,o?rt ? ?Plumbing ... ::?.. .! 'ui u.................. Fireplace ............ .............................................................*Approximate. Cost .i ............= Definitive Plan Approved by Planning Board __________________________ :.� '�'� ?-"`�!�.:! i --____19______--. Area . Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH i� IAJ-41 �uV0WIN 0QVI r) s. Y I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...FML " N -............. �-.....!-, .........' Garran, Frances 17485 permit for remodel to medical No ...........a. .................................... offices Location �.. park Square Hyannis Owner Frances Garran Type of Construction frame .......................................... f 1 I Plot ............................ Lot ................................ Permit Granted Decemb r 10 74 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... 4 Approved ................................................ 19 ............................................................................... I ..................... ...... .......................................... t k 1 �T"..`ti+../'itiY�..�.r..�rY'�.._�,v4. �,�.�.,.i r�V..Y'`+�.+•Y.r...,Vr.....� �+ti'`rv...•-�.+'+n.'�T4+^.r�n�.�I'+^tirYr..�.-+-�tiY�.+-�..-r.-n.1+Y'+r.��r..,Aw.'�..r!✓�.+^•-..r avp Assessor's map and lot number .. ... ................................... crPTIC .rywT :...� �;► T BE Sewage Permit number .nij .. . . ....... °... . TO PyoFtNEro�o TOWrN OF . BA t FABLE Z BARNSTABLE,VAS i r6 9 0 M OUILDING INSPECTOR 'EPY a' APPLICATION FOR PERMIT TO .Q�.nvvv.-.......w.d....Qat ,!.tA7 TYPE OF CONSTRUCTION 007...... 4 ........................................:..................................................... .......Z..........N.a. .............19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ' Location ........ .... ....GAO -A�-`A-... ....... `. ..q.............................................................................. ProposedUse ....Wa \C,-dt,......®t- �.............................................................................................................. ZoningDistrict .......T....P.,......................................................Fire District .................................................................... Name of Owner ..... ��4 �'-rl ...:.........Address 1:!?..... �'..........�) �?- `.�� :�.. ............. Name of Builder .. .Gf LLD \1oC............................Address ... �3— �',`.�'C'i ` .............. p5........................... Nameof Architect ..................................................................Address .................................................................................... o , Number of Rooms .......,.. �-a:.:.................................................Foundation ... ....G...............�?........5-. ........................... Exterior .... . ? �1� ..........................�T►C .V�--�`.?.......Roofing ... .G'. .. �..... .... . .. .. ................................................................ Floors t]c7 Interior ... ..................................................................... ................h........................................................ `� d Heating -'Wr�...��.�.... .. ............:.Plumbing ..l�S?.: .. -e..........' ... `'... .. ....................... Fireplace. ...........�1. ...............................................................Approximate Cost :' i. ©� ..... d............. A— Definitive Plan Approved by Planning Board ________________________________19________. Area '�C'�:— "--5 Diagram of Lot and Building with Dimensions Fee 't SUBJECT TO APPROVAL OF BOARD OF HEALTH (OW-OE2 �r-x«UoI w jV043t-, 0OV-) i t I hereby agree to conform to all the Rules and Regulations o the I of Barnstable egarding the abo e construction. l�Vl Name ...t-EL- ...... ..N.C'.............r,a- ..i ....4. ', Garran, Frances No 17485 remodel to .... Permit for ............................. medical offices ............................................................................... Location ...........Park..S.quape............................ Hxannis ..................................... Owner ................Frances Garran....... .................. .................................................. Type of Construction frame...................... ................... ................................................................................ 410 Plot ............................ Lot ............... ............ At Permit Granted ......December...1.0, 74 .. . ...... . .... . .- ..........19 Date of Inspection ........ ................ 7 19 LL Date Completed". '19 ............. PERMIT REFUSED ............ ......................... ............. 19 ............................................................................... .................................................. ................ ............... i w _ ...................................................I............................ Approved ................................................ 19 Y 'R /y _`� t ;} ............................................................................... f. ............................................................................... 1 Corporate office. g6 Howard Ireland Dnve 6 �Attleboro,;MA 02703 4612'; a 508.226.6006 F 508 222.1344 ,, Environmental systems,Inc. rn ESI No Mechanical Contractors Engineers 15 Fletcher,Street #6. F !Chelmsford;MA 01824 a r P 978 513.0070,% s, F 978513.0071v1r info@envsys.net E`I So e; �x^ ESI South. P:508.226.6006 2980 West Shore Roads#4, 6 W ariwck'R1 02886T F:508.222.1344 ��P aor73z:1soo }F401 732 434 ` www.envsys.net °` _ mA . Commonwealth of Massachusetts Sheet Metal Permit �• Ma�� / tercel �� Date. 9/6/2017 0 •t# gqj(� Estimated job Cost:$ 20,000.00 Permit Fee: hot 0 111 o Plans Submitted: YES X NO TO Mips viewe 'YES NO ��99 'Jr Business License# 436 Applicant Li. A.HJV' , _Q, Business Information: Property Owner/Job Location Information: Name: Environmental Systems.Inc. Name: CCH 105 Park Street n Street: 6 Howard Ireland Drive Street: 105 Park Street City/Town: Attleboro City/Town: Hyannis Telephone: 508-226-6006. Telephone: Photo I.D.required/Copy of Photo I.D.attached: YES NO Staff MORI J 1/M-1-unrestricted license J-2/.M 2-resdricted to dwellings 3-stories or less and commercial up to 10,000 sq.ft./2-stories or less Residential: 1-2#hmily Multi-family Condo/Townhouses Other Commercial: Office X Re Industrial Educational f - w1i'�I !Institutional_ Other Square Footage: under 10,000 sq,lt. '- over 10,000 sq.ft. X Number of Stories: 1 Sheet metal work to be completed: New Work: Renovation: X HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents LX Air Balancing X Provide detailed description of work to be done: This is to do'selectiye demo of the existing diirt wnrk and the existiraqunits_ We are to replace these with 3 new split systems with new flues and condensers. We will also be providing 4 new electric exhaust ceiling fans, RGUs for the supply and return systems. We will have stand along controls and will doAk balancing at the end of the r—o'ect. INSURANCE COVERAGE: have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes® No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ® Other type of indemnity 0 Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box®,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments f ' : t+ Final Inspection Date Comments Type of License: By ©Master Title El Master-Restricted A4 city/Town ❑Journeyperson Signature of Licensee. Permit# - " ❑Journeyperson=Restricted: License Number 436 3 L 789 Fee$ Check at www.mass.gov/dpl Inspector Signature of Permit Approval Town of Barnstable Building Department services -- s�axsr�+ah$, sAO& Brian Florence,CBO 16,I Building Commissioner FD Mfd R 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax 508-790-6230 Property Owner Must Complete and Sign This Section - - If Using A Builder go5 ,as Owner of the subject property hereby authorize_ f'N Jt c o N th f yska,5 -T iu c to act on my behalf; in all matters relative to work authorized by this building permit application for: wT P4�k d ' M�9 Y9NN, $; (Address'of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. er Signature of Applicant IaN �6P►+tn►g�S Print Name Print Name `irZ� /�� I Date Q:FORMS:OWNERPERMISSIONPOOLS RCV 0&/16117 7 •' Eyyer,'s.«his ti'YrtF.:P+9 s„nr+s+1S, Town of Barnstable Building Department Services Brian Florence,CBO e ; Building Commissioner °- 200 Main Street, Hyannis,MA 02601 BARNSTAEM MAW www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print • DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone#. CURRENT MAILING ADDRESS: „ > city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner roval of Buildin Official APP g Note: Three-family..dwellings containing"35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q-.\WPFILES\FORMS\building permit formsUMRESS.doc 08/16/17 Client#: 10383 ENVIRSYS M/DD/Y ACORD,. CERTIFICATE (MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 9/07 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 Sandy Benigno Starkweather 8r Shepley PHONE N E.t:401 435-3600 a No, 401-431-9678 PO Box 549 E-MAIL sbeni no starshe com ADDRESS: g p• Providence,RI 02901-0549 4O1 435-3600 INSURERS.AFFORDING COVERAGE NAIC# INSURER A:HDI-Gerling America Insurance C 41343 INSURED INSURER B:Travelers Insurance Company 25674 Environmental Systems, Inc. Houston Casualt Co 6 Howard Ireland Drive INSURER C: Y Attleboro,MA 02703-0037 INSURER D INSURER E: INSURER F: _ w 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 SHCWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IN SR WVD POLICY NUMBER, MMIDD/YYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY EGGCC000163516 12/31/2016 12/31/2017 EACHOCCURRE14CE $1000000 CLAIMS-MADE �X OCCUR PREMISES Ea occu r nce $100 000 MED EXP(Any one person) s5,000 PERSONAL&ADS^INJURY $1 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - _ GENERAL AGGREGATE $2,000,000 POLICY F_X]ECT LOC - PRODUCTS-COMP/OPAGG $2,000,000 - OTHER: A AUTOMOBILE LIABILITY EAGCC000163516 12/31/2016 12/31/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED, AUTOS AUTOS BODILY INJURY(Per accident) $ - X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ - AUTOS Per accident $ B X UMBRELLA LIAB X OCCUR - ZUP15T7008116NF 12131.12016 12/31/2017 EACH OCCURRENCE $10 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1 O 000 000 DED I X RETENTION$1O 000 $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY EWGCC000163517 1/01/2017 01/01/201 X PSTATUIE ER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVEr E.L.EACH ACCIDENT $1 000 000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 j000,000 If yes,describe under _ - DESCRIPTION OF OPERATIONS below P E.L.DISEASE-POLICY LIMIT $1,000,000 C Professional LiiaO ICC1722368.' :, 1101/?.0 17 01/;II20!8 $?,^00,40C► ' 0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #S999545/M972739 PAT4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 sr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Environmental Systems Inc. Address: 6 Howard Ireland Drive City/State/Zip: Attleboro, MA 02703-4612 Phone #: 508-226-6006 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 142 4. El am a general contractor and I * have hired the sub-contractors 6. El New construction employees(full and/or part-time). $ '7, ❑ Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8..'❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right.of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[Z'Other HVAC + Controls 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. HDI-Gerling America Insurance Company Policy#or Self-ins.Lic.#: EWGCC000163517 Expiration Date: 1/1/2018 Job Site Address: 1 U S l City/State/Zip: U I Attach a copy of the workers'-compensation policy declaration page(Showing the policy number and expiration' date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde thepains and lties of erjury hat the information providedQa ove its true and correct. Si nature: Date: ` Phone#: 508-226-6006 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#: Please visit our web site at http://www.mass.govidpl/boards/SM JAMES S BALDASARO ENVIRONMENTAL SYSTEMS ING (SM) 6.HOWARD IRELAND DR ATTLEBORO,MA 02703 Fold,Then Detach Along All Perforations :COMMON. OF�M. SHEE MI±1"AR WORKERS, f }5 :£t ISSUES THE FOLLOWING I�ENSE� BUSINESS JAM ES S BALDASARCl f '' ENVIRONMENTAl, SYSTEMS INC zf n 6 HOW-9 IRELAND DRIVE ATTLE1�010,.MA 0210 436 t = A512612019 291354. u : G 1 .t � ..ram---=•'^'�"•'��1 �� Ate. �` �w�,`,.�1►__�__._��-�- r m _ •