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HomeMy WebLinkAbout0604 SCUDDER AVENUE -- -------- - - � - -- •-- -- ��-- -- � ._- _- - - �L� -- !�-32�. �y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 01V4 Parcel 0 Application Health Division Conservation Division Permit# .Tax Collector Date Issued Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village (We r-f- Owner O of 1 t 1 84nbe'_fnr&1 Address Telephone C 7.9 7 /- Permit Request 174crIO r Pmodt — 3) 16eiV-A rnWs - Afew p(, lfXhc") L kimize&- "'o is, o f " xrh c re s ,ab �C�c eas erg �ac�c�`r l Ivew xzsfi s&s/Le S �f S Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation150, ( � Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other (�-f Ca 0. Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing J3 new eier'� Half:existing new Number of Bedrooms: existing_ new _ r;t e� �1 Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: d Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes OKo 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—U- Appeal# - Recorded_❑. _ -Commercial ❑Yes ❑No If//yes, site plan review# Current Use Y (�76(,�� Proposed Use r .�l y,. BUILDER INFORMATION Name e•J•V`C ny r, l r Telephone Number (16W 9 92- #g/1 Address.os4Q Ll dl..e , License# 0031Q, 114-. 6)-01 Home Improvement Contractor# 1 w6Q 9 Worker's Compensation# 61101 02 n06 d ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO M, ar 'S Ski- SIGNATURE DATE q/)- M 5 FOR OFFICIAL USE ONLY S � t , S Y PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER y 't DATE OF INSPECTION: FOUNDATION FRAME INSULATION r , FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT, ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents € Off ce of Investigations ' d 600 Washington Street Boston,M4 02111 , www.mass.gov/dia Workers"Compensation Insurance_Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I ,, ' ,,/, Please Print Legibly Name (Business/Organization/Individual):. E JJ .kY_Pnte —6ut fl(�r, Mc Address: City/State/Zip: Phone.#: � 7�• �9 Are you an employer? Check the appropriate box: Type of project(required):. 1.["rI am a employer with W 4. ET am a general contractor and T . employees(full and/or part;time).* have hired the sub-contractors 6. New construction . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. Weroodeling ship and have no employees These sub-contractors have 8. Demolition � employee's and have workers' � ' workin for me.in an capacity. g � Y P � co insurance.#• 9. Q Building addition [No workers comp. insurance comp. required.] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions 1.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions I rnysel£ [No workers' comp. right of exemption per MGL 12.[]Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' •13.❑ Other comp. insurance required.] . 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. YC6ntractors that check this box must attached an additional sheet sbowing 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. Iam an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: ' ' G Policy#or Self-ins.Lic.#: 5ao a o I OUQ d Expiration Date:/ 6 s Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year impriso�ent, 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 and t pain • id penalties of perjury that the information provided above is ue an'd c rrect~ Sienature: Date: 0 _ Phone# O Official use only. Do not write in this area,'fb be completed by city or town ojjjr71c1a[ 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#: 1 Client#: 2093 2JAXTIM E REJ AGORD- CERTIFICATE OF,LIABILITY INSURANCE. TDATE7107°n"YY' r ,:UODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling &O'Neil Insurance ONLY AND CONFERS-NO RIGHTS'UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 West Main St. PO Box 1990 Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance E.J.Jaxtimer Builder, Inc. INSURER B: Ernest J.&Marie T.Jaxtimer INSURER Ci 48 Rosary Lane INSURER D: Hyannis, MA 02601 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING IANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE 1L!MITC SHO1NNI MAY HAVE BEEN REDUCED BY PAD CI AIMS. 1 - - - - POLICY EFFECTIVE POLICY EXPIRATION LTR INSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD!YY) DATE MM/DDM't LIMITS A -GENERAL LIABILITY CPA010264813 01/01/07 O1/01/08 EACH.00CURRENCE $1 OOO 000 nCOM MERCIAL GENERAL LIABILITY - _ _ - DAMAGE TO RENTED PREMISES Ea occurrence $250 OOO CLAIMS MADE 51 OCCUR MED EXP(Any one person) $S 000 - - PERSONAL&ADV INJURY $1 000 000 a GENERAL AGGREGATE $2 000 OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT $ ANY AUTO - - (Ea accident) - - ALL.OWNED AUTOS BODILY INJURY $` SCHEDULED AUTOS (Per person)-• .HIRED AUTOS- BODILY INJURY - - - NON-OWNED AUTOS - - - - - (Per accident) $^ - PROPERTY DAMAGE $ (Per accident). GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUA010264913 01/01/07 01/01/08 1 EACH OCCURRENCE s2,000,000 X` OCCUR CLAIMS MADE AGGREGATE s2,0001000 DEDUCTIBLE ,. .- ,., _ $ - X RETENTION $O- S A WORKERS COMPENSATION AND - WCA02045501 O 01/01/07 01/01/08 _ WC STATU- OTH- .. O Y LIMI ER EMPLOYERS'LIABILITY- - ANY PROPRIETOR/PARTNER/EXECUTIVE `_ E L':EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA,EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 .. :- OTHER_ . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS - Job: Bussmanl. Operations performed by the named insured subject to policy conditions " and exclusions. CERTIFICATE HOLDER CANCELLATION• - - - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI( Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL If) DAYS WRITTEI, 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 - IMPOSE NO OBLIGATION OR LIABILITY OF ANY-KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 6Z ACORD 25(2001/08)1 of 2 #46052 LS1 © ACORD CORPORATION 1' 09/17/2007 01:22 17812356037. FLPUTNAM INV MGMT CO PAGE 02/02 09/14/2007 04:49 5067754909 i ,EJJAXTIMER PAGE 02/02 . , nstable Towti of Bar Regulatory Ser nees r _ is Tpomae F.wer,I ingtor 4 'Building Division Tom Perry, Ruildlq CGOWssfoner 200 s s MA 02601 • taTa�e.me.us , fPFv'pvtv�a]1t. ax# +O ce: sos- �-4038 S. fax: 50�•790-6230 . popettY Owner Must Comojete and Sign Ibis Section if Using A.Builder �a AR j 2� >as Owner of�e subject prOpszty -r he by a o to act on mayb499; charzed by big Parini app3iaatio�a Ate far. in 2n mimes Xel re to*Ork au 1 PM {Adds o Jabs} ,. fad �' V • W Sim of OvMer Date 1 . A � e71T1taL11 Q:i'OF��3S:aWi'�R'PESION • , Board of Building Regula ons and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 ]dome Improvemeri Contractor Registration e Registration: 110609 Type: Private Corporation Expiration: 11/3/2008 Tr# 124739 AXTIMER BUILDER INC ERNEST JAXTIMER _ ° E M1 `� yi_ 48,ROSARY LN - HYANNIS, MA 02601 Update Address and return card. Mark reason for change. LJ Address Renewal Employment Lost Card DPS-CA1 as 50M-05/06-PC8490 0z"G— p U/GL�� c� 5QAJ D �F�UILDII�G� EGI~J POTION r ' `{ 7 it a ',I Lly�sn�e tJS Fi�JGTION 171�E�tVISOF2 . 1956R. . E d1:/14a Tr no: 12839 s7 !r r Film ERNEBT J'JAXTI�VICf fi 48:ROSARY LANE; ! MYANt�11S; MA anofi l.. ;�:- Gv �✓:. I a: COm"`issloner r "'f P�oFtti Town of Barnstable Regulatory Services a I'E g` Thomas F.Geiler,Director q'ArE16�,. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, . -improvement,removal,demolition,or construction of.an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: A�jYI Ott ,MA .1 Estimated Cost Address of Work: 0 U/0 Owner's Name: Join . (� l Date of Application: I hereby certify that; Registration is not required for the following reason(s): Work excluded by law ❑lob Under$1,000 ElBuilding 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: 9 a o q LJJJ. lm�e4 IM60 Date Contractor Name Registration No. OR ` Date Owner's Name Q*nns:homeaff day i�r+k{`1 f�a- rY"°��'tiy j[ABLE Regulatory tom, Town of Barnstable ., Regulatory Services 227 SEP p�.i t: 33 rMASM& Thomas F.Geiler,Director •i679 �0 1639 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 a Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF WITHDRAWAL OF LICENSED CONSTRUCTION SUPERVISOR FROM PROJECT , Construction Supervisor License #e / 0060 ,hereby certify that I am no longer the Construction Supervisor listed on the application for the project under construction as authorized by building permit ��6&-� issued to roe address # o� 1 (property rtY ) on �� , 200 I also certifythat on / � , 200 , I notified the roe owner, that the � property rtY project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building Division. LICENSE HOLDER ATE q/forms/newcontr reference R-5 780 CMR �1HE TOWN OF BARNSTABLE ' ti Bu�ld�ng . Application Ref: 200705497 i BASTABLE, Issue Date: 09/07/07 �` Permt RN 9 MASS 11 $Ark 639. a� Applicant: GLOVER,ROBERT J. Permit Number: B 20072168 ' Proposed Use: SINGLE FAMILY HOME . Expiration Date: 03/06/08 Location 604 SCUDDER AVENUE Zoning District RF-1 Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 287013 Permit Fee$ 328.00 Contractor GLOVER,ROBERT J. Village HYANNIS App Fee$ 50.00 License Num 039868 Est Construction Cost$ 80,000 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND RE-SIDE,REPLACE WINDOWS IN EXISTING OPENINGS,REMODEL THIS CARD MUST BE KEPT POSTED UNTIL FINAL KITCHEN (NEW CABINETS, SHEETROCK AND COUNTERTOPS) INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: CARBERRY,JOHN V&MARY A BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 56 WOODCLIFF RD INSPECTION HAS BEEN MADE. WELLESLEY, MA 02181 Application Entered by: PR Building Permit Issued By: .THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLY FOR SIDEWALK OR ANYTART.THEREOF,EITHER TEMPORARILY OR PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY.THE JURISDICTION. STREET ORALLY GRADES AS WELL AS DEPTH AND LOCATION OF.PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF,TUBLIC 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 CONTSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). form s k BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION• Map ® Parcel Application# 66 -705qq 7 Health Division . Date Issued: Conservation Division Application Fee J� Tax Collector -Permit Fee Treasurer Planning Dept. t. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address ° Village / i�/lf/�//� Owner �/ Q�'U Address 1c/c740 el Telephone 1P�� ` 3 Permit Request Square feet: 1st floor:existing proposed 2nd floor:existing ..:proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type W0012�;, Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 9' Two Family ❑ Multi-Family(#units) Age of Existing Structure Wf Historic House: ❑Yes N No On Old King's Highway: ❑Yes At No Basement Type: W Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) /o2&Z2 Number of Baths: Full:existing new eo Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new 0 First Floor Room Count / Heat Type and Fuel: ❑Gas b Oil ❑Electric ❑Other Central Air: Q Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes S.No Detached garage:1W existing ❑new size 0 Pool:❑existing ❑new size Barn:❑e ' 'ng ❑new size Attached garage:❑existing ❑new size Shed:❑existin ❑new size Other: 9 9 9 � 9 � i Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,,site plan review# —--Current-Use Proposed Use BUILDER INFORMATION Name Telephone Number Address 'Sp License# e-n 3 /94::�g NV9 off Home Improvement Contractor# 1/1T� Worker's Compensation# Wi,*" 06 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �y SIGNATURE � � DATES' FOR OFFICIAL USE ONLY APPLICATION# DATEISSUED MAP PARCEL NO. 'Y. ADDRESS VILLAGE OWNER ' DATE OF INSPECTION: k: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING c� t - t DATE CLOSED OUT t; ASSOCIATION PLAN NO. �o� t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers" Compensation Insurance.Affildavit: Builders/Cori.tractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual):. rG ' Address: City/State/Zip: {Y / ,L/��,�C�� Phone.#: Are ou an employer? Check the appropriate box: Type of project(required):. 1. I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub=contrictors 6. ❑New construction . 2.❑,I am.a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp.insurance.$ 10. Electrical repairs or additions required.] 5. ❑ We are a corporaton and its ❑ p '3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myselil [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t C. 152, §1(4),and We have no employees. [No workers' . .13.❑ Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors&ve employees,they must provide their worker;'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ' l ,/�� Insurance Company Name: /+ Z,00►' Policy#or Self-ins.Lic.#:_ qz. �) Q/ExpirationDate: Job Site Address: �City/State/Zip: /4 G • 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 pe ,1des a erjur},that t e information provided above is true and correct Sienature: Date: ...� _ Phone#: <S77d � Official use only. Do not write in this area,'to be completed by city or town o jWaL 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#: E'O''ti Town-of Barnstable yP °� Regulatory Services Thomas F.Geiler,Director MASS 161 BuRdincr Division .eIED MAi� b • Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction, alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. ✓,y`� Type of Work �� Estimated Cost L ✓ ,4ddress of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reas on(s): []Work excluded by law Job Under$1 000 ❑Building not owner-occupied' ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES.OF PERJURY I hereby apply for a permit as the agent of the owner: ate Contractor Name " Registration No. OR Date Owner's Name Q:fo=:h=eafdav tioF- r°�y Town of Barnstable t Regulatory Services 0H CAB '$ Thomas F.Geller,Director $ATF �'1 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,Na 02601 www.town.b arnstable.ma.us Office: 5 06-862-403 8 Fax: 5 08-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder LI, , as Owner of the subject property hereby authonz to act on my behalf, in all matters relative to work authorized bythis building permit application for; . �U 4. 0', (Address of Job) o Signature Owner Dat Nl A-1Z n/W lr 6i(ZR- Print Name QTo1UvIS:0` N'_E tPBRYMSION AUG-14-2007 10:41 From:SANDPIPER INSURANCE 5087903560 7o:15084201963 P.1111 ,. oaTe(MIefDDmllnl ::. AMR& CERTIFICATE OF LIABILITY INSURANCE � A MATTER OF it20INFORMATION THIS CERTIFICATE 19 i5ED PROOUCeR (508} 790-1919 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Sandpiper Ina. Agency, 7AC. HO�p THE THIS AFFO BF-0 CERTIFICATE 8 TNTE POLI�CI� HTL •� 11 a�tarpriae Road INSURERS AFFORDING COVERAdE NAIC 0 ii annia MA 02601- INSURANCE CO, MSURGR a:E88TrX INSURIM INSURER D:LIBERTY XIJTU" Robert Glover Building NWA RC; 8o Sox 703 0 Maratone M,ilie MA 02649- INsuRr�IE. THSTANDING ANY COVERAGES THE POLICIES OTI�0��F L'*ON OF ANY Y ONTRACT IOR 0 ER DOCUMENT MRESPECTTO WHICH THIS ICERTIFICATE MAY BE ISSUEDIOR MAY P R AIM, REGUIREME THE INSURANCE AFFORDED BY THE POI-tGEB DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CON01710►IB OF g�M POuCI AGGREGATE LINTS SHOYiM MAY HAVE BEEN REDUCED BY PAID CLAIMS DATE M TD M nVL ON LBETS OI6R AOW TYPO OP INSURANCE POLICY NUMBER S Le Y I 1000000 02/01/2009 02/01/A008 C OCCURRPNCE 6 I JAIL X ogmMt L UABIUTY 9CN2245 NTL 6 50000 9000 X COMMERCIAL OENeR�AI ABILITY / / / / MDO en TDIP s s CLAIMSMAOC I_^.►OCCUR 6 1000000 P A DYI RY Q000000 Gr�NERA "ooRE°"Tc � iD00000 ROD TS- OEWL AGGREGATE LIMIT APPLEII PCIL POLICY MP ' LOC / / / I COMBINCO SINGLE UNIT AUrLe LIAIKUTY 0 emdo„1 AUTO / / / / Dwe v INJURY 6 ALL OWNED AUTOS (Per permal ec"COULBDAVTOS / / / / BODILY INJURY 6 NIRCD AUTOS (Per moment) NON.0WNEOAUT06 / / / / PRoPERTYOAMAOC $ (Per eeddem) AUTO ONLY•LEA ACCIOG 4 GARAGe LIABILITY / / / / OTHGR THAN AG 6 ANY AUTO AUTO ONLY• AGO 6 gXCIS rUMBRM.LA LIABILITY AGGREGAT• s OCCUR a CLANG MAN s OrOUCYIBLE 6 RUTENTION 4 04/19/2007 04/1,9/2009 X B ,.�..� $ WORIM"COMPBNSATICNAND NC5�718�720866-017 E CH ACC IT 5 100000 EMPLoYIRW uADIUTY / e 100000 o� �RM TNE� UTNE� bo000o If vm.dMMw wider R L,DISWA•POLICYLIMIT 4 BppCIAL PROVISIOM-- DeECRIPTN)N Or OPL'MTIONIILOCATNNISNE1RCLe8►m(CLUDIONB ADDED DY tNDOR66MENTj5pWA4 PROWS= CANCELLATIO CERTIFICATE HOLDER ItI _ (508) 062-4717 SHOULD ANY or THe ABove DeECRleeo PoucIPA ee CANCELLED oeFoNe T CMPIRATION DAYS TNBREOP, The ISSUING INSURAN WILL ENDEAVOR TO MAIL 10 DAVIS WRITTCN NOTICR To TNe CgRTIWCATE MOLDER NAMED TO THO LIFT,BUT TOWN OF gAiIN8TA8I18 FAILURE TO 00 EO ALL IMAM NO OBLIGATION OR LUIDILITY Or ANY RIND UPON INS 367 DSAIN BTABST INOURER ITD oRReFREeaNr TIV AUTNORae HXAWIS MA 02601- 0 ACORD CORPORATION 1988 AjCORD 26(1001M) FORMS.INC.ELECT I .r INS0161Btoel.o6 ELECTRONIC LASER •p00g27.0616 I'', j i 1 1 awt. Ve ist�at�oa {oaoastb e of Yeg i�atioo d�iat�p°S �' {8°Ja��4iaeeRm o, theri SO exQ • R g 13 8`�l'tie p a�4t. R 4kJ N ES��K�, Results Page 1 of 1 Licensed Contractor Look Up Select the search method: 1_Name Maximum number of matches: 25 ;= Enter Search terms separated by spaces. IGLOVER Select Search type: tea AND (7, OR �wSearch; Search Results City/Town Name ,Type Lic. # Restriction Expiration Street State Zip ❑� MARSTONS MILLS GLOVER, ROB ERT J CS 39868 00 5/24/2008 PO BOX 703 ®02648 TOWNSEND GLOVER, PAUL S 176 BAYBERRY HILL RD ®01474 ROXBURY GLOVER, ROBERT C 1 28 SAVIN ST JW02119 DAVID M CS 64680 00 7/9/2008 119 DRUM 2 MA RD # 01824 CHELMSFORD GLOVER, �❑� BOLTON GLOVER,TEPHAN CS 92045 1G 4/6/2009 24 HUDSON RD MA 01740 _ ❑� FRAMINGHAM GLOVER, SEAN P CS 93683 00 10/11/2009 55 PINCUSHION RD ®01702 Total of 6 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.ma.us/bbrs/contract.pl 8/31/2007 9Y Town Of Barnstable *Permit# P Expires 6 mouths from issue date Regulatory Services � Fee Thomas F.Geiler,Director PPR 1 �sI BV Building Division OF 6P�N Tom Perry,CBO, Building Commissioner 1 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number CJ t Property Address io d A N C A V-e Residential Value of Work ti:1,c�`,� .L` Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address J b 11 A CA e C'l Contractor's Name i�1v 1-�eN 5 t Telephone Number Gd7 Ll A6 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 2-1 have Worker's Compensation Insurance Insurance Company Name Y�A_AsRA-' Workman's Comp.Policy# o 1 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) i Re-roof(stripping old shingles) All construction debris will be taken to C-A!;f.1 d ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Ownerkrast s' Property Owner Letter of Permission. Home rove ent n ctors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 f 4. Board of Building Regulations and Standards lugHOME IMPROVEMENT CONTRACTOR Registration _126480 Eacgratr�oo $181j 006 � t idual 117, 1 i MARK HERBST' y MARK HERBST !35•.PEEP TOAD Administrator CENTERVILLE,MA 02632 i II i . r 9 r , ''1:- - •��`'. } {/«�4. F J�.�1�K V.�:-��`G 7 -�,� 'a'F{. � Y f7,.� '��` �"Y.I�i� 4e� i� T �'��aY �' �������3�„� � 2 � r � J �,,s`t of a i w '�,r- —k•f ��K `` MARK HERBST s. Peep Toad Rd,'. Centerville MA 02632 (508),420-6216 - ' cell phone 774-238 208 n ` hWPROPOSAL SUBMITTED TO WORKFERFtORME�AT �' � 3 John carbery p K q fl, x - '✓" Y e; 56 Woocicl�R l a q¢ 3 k r n fD4,Scudder le Cif FF N�.` i � � �� � ur� H Cznna s n.Yfi,_, C' z 781 235-6437 F } ' herby propose to furnish the materials and perform`the labor,necessary for the a fir' f Completion of the following, }} ` New Roo rr j, ' .� Remove one la of exzstzngXshzn rt , } Install 8"drzp'edge around "perimeter r . u �V� r Install rce &water shield at edke &zn valley areas - �> = Install ISIb felt paper Install Certaznteed Algae Resistant shingles of choice } ud, Eut ride &install cobra vent r s � six w IZ debris ctearzed da'il `� 50vr AYchztect �ilfetlrile' r �1 720 44(� } Y44�Y re Kry Y9 �. Garage, " # t TK *Pleasecheck&znztarl chazce(s) above :Thak�'ou ��All mmntei iid is guaranteed f be as specified ansl above'work to performed+in g fi� k4 accordance with specifications submitted fog above, and completed m a substantial 3 r 3t } F workmanlike?manaer�for tl a`sum of,as"i,s,,&q gd-Qp�ove;, i� zfied w49ur 011, C44 Dollars fb �7$ o 1 with Da ments a fblto r Y start with.balance due in full>upOl-, ly} zxr } completion vE h � J* Any alteratibn(s)fro b*o my�l Ong extra costs will Abe adidedundrr�tten ; y ' agreement and co an tr rge overand above gnedestimate/a greement tiEx, . h jrsr4}sS,r' RESPECTFU Signature 03 3 i 06 � �4" a r � ,� �> :u- kv h STANCE O,,F FRUP`1 S X r, >;W � t� • I The sl ave P rites :e if anon J condrtian�,s are sates ac ory,wet herby accept k l .�, { f you areauthorize t d S he rk andpayments will b , sKspecified a�o�e x -. {s Date 0:,� 4 �" < f +�fir,f, `'+� Zr .r E^-- °F,r� ,.. 4*4his;proposal may be withdrawn by_said company if hot accepted withYn 30 days f . t a a,� �<��� �-y � 4k�`r��x��r�,��`r3, �`� a x•�at'p' n «'x� '� a��`��+ a,qr r= �'� � �r1 y�xkrgt'-Y.a - �� f4�����.'�+�" ,F�4� y. �y�•,. a, �� fgy r�� 't�� ta. � ."; r'. .s 3 i .r s En*ineering Dept. (3rd floor) Map 7-- Parcel Permit# ,��y House# 0 Date Issued Board of Health(3rd floor)(8:15 -9:30/ 1:00-4:30 . 01 lf� Conservation Office(4th floor)(8:30-9:30/1:00- 2:00) pUht, SE=_ 4TEM MUST BE kist oor coo m - Ili TALLED IN C N-C.E VIVIT H 3i ���, .,:�� A L �. ID F', TOWN OF BARNSTABLE Building Pe it Application Prol treet Address 442� 1"bli- Village T-- Owner AzsewAyAddress �� Telephone ZZI —ZE,1547 Permit Request �NS'-791G 3 �9 �*✓�� j drU'i�;✓ /�o/ G�Q,�/!y 'First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes UWo On Old King's Highway ❑Yes G�Woo Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not 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) M ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name 0�� n��_2r Telephone Number �2 g--9o/S Address .y/12 r4/i,! 4�1 lg_ License# !C_�7_2z AXE�119 Home Improvement Contractor# /60 740"� Worker's Compensation# 0 -W 91 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) J-1 ¢ • 7 % + FOR OFFICIAL USE ONLY PERMIT NO. t " DATE ISSUED, MAP/PARCEL NO. �. ADDRESS I 1 VILLAGE • , i OWNER t r x t DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING:? ROUGH FINAL GAS: ROUGH FINAL FINAL Btfi- DING . E1 DATE CLO- OUP ASSOCIATION PLAN NO. ✓lee Z�7 I I I. I , iOME .IMPROVEMENT CONTRACTORS REGISTRATION �. _!' Board of Building Regulations and Standards i One Ashburton Place - Room 1301 i Boston, flassachusetts 02108 - j HOME IMPROVEMENT CONTRACTOR L---------------------------------- Rec:stration 100740 Expiration 06/23/98 ��Jt Type — PRIVATE CORPORATION HOME IMPROVEMENT CONTRACTOR N Registration 100740 CAPIZZI HOME IMPROVEMENT., INC. I Type - PRIVATE CORPCRATION Thomas Capizzi , Sr . kzv Expiration 06/23/98 1645 Newton Rd . I Cotuit MA 02635 CAPIZZI HOME IMPROVEMENT, INC Tiaras Capiz , Sr. EX, 4TI Newtort Rd. AOMIN1STWj0R Cotuit MA 02635 I DEPARTMENT ONC A31iDURl i DOSTUN, jAUG_TION`SUPERVISOR LICENSE s� � rExpires: . a: r is{ad. l.ti. UU i� t Y .! Z ;� }try t r rn .t {ALL C Yr: S•. , � ' �S�X �GA�IZ�IaJR:�..: ?tr c VAGb ��' ' ��Flu•'��:�i..�.••' • • - -. k� °FVE The Town of Barnstable mmma Department of Health Safety and Environmental Services �. Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Building Commissioner Fax: 508-790-6230 For office use only Permit no.-'-.--. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: GtA�4Z%,'� Est.Cost Z 0&& Address of Work: doe �co� Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law _Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that:OWNERS POLLING T _ THEIR APPLICABLE HOME IlViPRO MENT WORK D OR DEALING WITH ORNOT HAVE EGISTERED CONTRACTORS FOR 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. r- -- on ctor N me Registration No. Date OR Owner's Name 35 604 SCUDDgER AVENUE YANNISP tt ANONYMOUS All ion SIDEWALLING WITHOUT A PERMIT ll,F A-1/1? 1-2 A�l a r �vah SO how jQ ..vy' - ..... T _ $w a za T� NOW ASS � f x � � r a # t 4 r MAY >wt ink 77 5�r.':. _ � �' I:I i�I r• II� IIIIy„h II.II i, j r� ��: - � � - i s - �, r __l _.� __....�,-•-'-----" .-. ._.. _�.-,_._ _-_.. V .--_ate____-_...__.�..r ..._ .. ..-.___._'_ r � \� a L; _ _ _ 41 4 cills .' ..-+. ...-. --'I..�v.. M. .. tea•✓ ._ }ter r r Fdi' Z hot Kh Ivy I Q SO got". ; I I I ( � I I 1 i I I tom„ -•it- y s; ,. I I .I�'�'i I,I I'I .I. III I.IILI Ilh �I'�•II I� ,I u.l I I .I IIJ..: - fL WOW 1 Iz .I�, L5/A-PION ...yw..n_....r...R,. E - _ IT TOT cc i .. .'3e VIA--- 0 w .n ,.✓a t.+M�+., re x M" 5. a e 9 V t $ 4 Y _ .1 r - { p PLALI i 1 HOME IMPROVEMENT CONTRACTORS RE13I STRAT I ON ' Beard of Building- Regulations and Standards One Ashburton Place — F,'1_om 1301 B�Est c In, . Massachusetts 02108 HOME I MPROVEMENI" i:ONTRAC TOR Registration 100134 Expiration 06/09/94 — Type — PRIVATE CORPORATION _ HOME IMPROVEMENT CONTRACTOR Registration 101134 Rogers & Marney, Inc . ENV Type - PRIVATE CORPORATION i_har l es Rogers s Expiration 06/09/94 445 W. Barnstable Rd Ost er vi l 1 e MA 02655 Rogers & Marney, Inc. Charles Rogers 445 W. Barnstable Rd Osterville MA 02655 i ADMINISTRATOR I? I COMMONWEALTH OF IvL SSA.CHUS D F-1'A 1—MEN1T O F rl-D USTRIAL„ACCI DENTS _ 600 W/61-11-NGTON STTZ- I- James liOSTON, MASSACHUS=S 02111 NVORIER.S' COMPENSATION INSURANCE AFFIDAVIT I, ROGERS & MARNEY, INC . (licensee/permiacc) with a principal place of business/res1dcncc2v 445 OSTERVILLE-WEST BARNSTABLE ROAD , P 0 BOX 310 , OSTERVILLE MA 02655 (Gry/Sta(c/Zip) do hereby certify, under the pains and pcnalries of perjur)-, that: 1g I am an cmplovcr providing zhc following workcrs' compensation coverage for my employees working on this job. AETNA LIFE & CASUALTY 06' CO23252923 CAA Insurance Company Policy Numbcr j ) I am 2 sole proprictor and havc no onc working for mc. (J I am a sole prop rictor,gcncr-zl conmaor or homeowner(cirdc onc) and havc hired the conimaors listed below who havc the following workcrs'compensation insurance politics: I I=mc of Contmaor Insurance CompanylPolicy Numbcr ?�Zmc of Contractor Insurance CompanylPolicy Numbcr N-amc of Contmaor Insmricc Company/Policy Number Q I am a homeowner performing all the work myself NOTE_ Plcasc 6c zwzsc tbatwbilc I;orocowacrs wbo cruploypersons to cro raaiatca2mcc.0009truc600 or rcpairw+orl<on a 1.Mclling of not roorc tbaa tbrcc units in wUa the borocowacr also resides or oa the trounds appuruaant tbcrcto arc Dot CcocraU)• I cons&-d to be ccaploycrs tmdcr tb<'1or':cri Compensation ha(GL C 152.aca. 1(5)),appliutioo by s bomcowacr for a Iiccnsc or pernit r::y cvidcocc the lcFJ st;tus or:=cr_floycr undcr the Workcrs'C.Omp•cosation Act i unccrstanc tisat a copy of tius st_tcm<ns wiL oc for,ardcd to the Dcpr:mcnt of Industrial Acodcnu'Ofncc of Insurancc for.covcratc ---crificz6on:nd that failure to secure covcr�c s rc9uircd undcr Scction 25A of MGL 152 can Icad to the imposition olS mi—J per aJucs consisting of a fine of vp to S1500.00 zndJor imprisonment of up to onc year and civil penalties in the form of:Seop Vork Order and a I fine of S100.00 a day against mc. Sin this_ _ d2yof cnscJ crmi cc Li nsor/Pcrmiaor t t a Assessor's office(1st Floor): pq a� i�e� J tlet J�E..,i Assessor's map and lot number 1 oC 13 s a �. of THE TO al Board of Health(3rd floor): n � d Sewage Permit number 1 l �� -� ° P Engineering )Department(3rd floor r ENVIRONMENTAL CODE t iNA213TAXE House number. �n tGJ. TOWN REGULATIONS 'moo t�6 V. Definitive Plan Approved by Planning Board 19 APPLICATIONS C SE 8,30-9:30 A.M.and 1:00-2:00 P.M.only tmN OF BARNSTABLE UJLDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 6,Q z,Ff- g,� Proposed Use Zoning District Fire District e "/Avsr Name of Owner �� er' r'. Address C006rf-44FE/2 Name of Builderf311'�i —��i�7� /J�r _ Address ' Cz- Name of Architect �r Address Number of Rooms _ Foundation Exterior /�7 Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost � �� Area. 300 b� Diagram of Lot and Building with Dimensions Fee .� y x '°s/ 7 % -- OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstab ardin g the above construction. T Nam i Con's ction Supervisor's License CARBERRY 31 L n' EMODEL DECK. r; No Permi or Single Fami D llin , 604 S de Location Road , 5 Hyan por Owner, Carbe .• Type of Construction Frame -� ,' • Plot Lot `� r . T Permit Granted April -5 , 19 94 Date of Inspection 19 Date Completed 19 rF.• a • sF The Ca111t11a11'wealth of Afassac•husetts De artnient of Industrial Accidents 600 INis'hinrtan Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit 5lican in r6 i•m a tion urn : location' r91i' /L/�LtJTl/GG�iI/' cin �r1-��% ��/T d Ze5l nhonc V 0 1 am a homeowner performing all work myself. CD I am a sole proprietor and have no one working In any capacity p•,•R.:..-rsz'?.r^!� nes. _ - - <- *'�T'•"v�re�-:::�.�...-.�-.r—..�xz.. E.•1'Lii ..a..]:(e.K�ti� W�tr.iia�=�RCC�'� .a� ,' _ _ :'�I•..•L.'+'.i:i:.��..vri t<,r`�a:..-:..cam_ _ .S I am an employer providing workers' compensation for my employees working on this job. comPan�'name: address: city: Phone#: insurance co.� `��' �J�� 7�f��1� policy# 109 AJ1679GLI' [ ...• ,.a .:'',', �_�_ i-'e-+r..,y-._<„-•.»...-•- verfr---r'^!-r;s.<. -,f-.�..+e^!..u..,_ ._"�S��� �'"""�""'•'..��-.._.��::..... ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and hav:hired the contractors listed below who have the followin-workers' compensation polices: P company name: address: city 12hone#: insurance co. nolicv# �--a-__.........-. _:Ll--.... :JA".u�tu.1'1� -_ ^L:CL'-.rilrf�i:Liv 1ir6!�,11d..a.��.i•T~�- •acli-t...iirr^:�-,•� company name: address: city phone#• insurance co. colic•# _ --., r,..—err f"'--..-c.a Q.,�---.ram-£•T-=�••.•.-•-•--7�^-qc----;t-•-T'--r`R -- Attach additional shc+et if riccessa c:.—rc-;T'.r:c a _�4t'rYm�r �:� v [��- wp n'�+-.r�.,�te:•,e.:r<.S".•x•<•'�.�w+ ;d�r.,c`"Y'"~`"`r' t t_ ,.___. __.. _.._�-' - -�:c3.i.ia+.c:er:�Jfail�'Y YiiPl.:L:Sa r./1R� TYS'lf.AtLS"�i`TM�'1-al• .Y1�.11L.Yuw(.S�' Failure to secure coverage as required under Sectionr25A of iNICL 152 can lead to the imposition(.`criminal Penalties of a fine up to Sl 500.00 and/or oneyears'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fire of S100.00 a day against me. I understand that a cope of this statement may be forwarded to the Office of Investigations of the DIA for coverage ve_fication. I do h creb r certidcr pains and pe hies njperjun That theinforntrrtiort provider!¢sore is true turd correct. Sisnaturc t Date Print name /'C ��— :_ Gee 27— Fr-hone •official use only do not write in this area to he completed by eih or town official `. city or town: permit/license# r113uildinr Department k, Licensing Huard i•: Q chuck if immediate response is required 0Sclectmen's Officc 0I1calth Department �cLtntact person: �.-- m •..,. Phone#; — nOthcr = (res isc: VIA) I .