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Home My WebLink About0020 SEA STREET v �./ �/ ��; -- �i �'� '� } TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �VU Parcel 1 A NISTA.0LE F a1 Application # Health Division o, I f' Date Issued 4 _ nn Conservation Division Application Fee fV Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �o Village )0 Owner 4o / /-4z- Address Telephone 2 7-t4— -'7 Z26q'j Permit Request CI® e/)e.% Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ^� ad 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 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 /ghee t^ ��//�Cs/� 4 Telephone Number Ji�SV-.346) Address lcn? �(�rc)lt L-L. License # Home Improvement Contractor# Email Worker's Compensation # CL�`� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO eta' SIGNATURE DATE �� a 7 FOR OFFICIAL USE ONLY ~ APPLICATION# DATE ISSUED MAP/PARCEL NO. Se ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 4 FRAME .q INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. C The Colt2}7L67TtypeaM af?Vfassachm- ys t %ce rr�"�!;<g�iiorrs 600 Wm, wigton,treet a - 1t�Fi'Ni 7f11ISS:� i�IEI ' Workers'CitmpensafiuuInsurzaceA.ffidavit:E-u-ddersf,Cantracturs/BectdcianslPlumbers Applicalat Iufalrmaiian Please hint Li2eill ® 9 a Z- t ryl €a - - 1� Phan� Eire yan znplayer. eclr t��pp[�priafe btsz: � of a"eict :r - 1 am a eanp foyer vrith ❑I am get ct�nfractoar and I 6_ ❑Neva oonsfnx#o employees{full andforpa�f-time}* ha�e'hre�tl��foas. 7_❑ I am a sole propii&ar or parfaer- Iist;ed on the attached sheet 7- ❑Remodeling ship and have no employees These sale-coniractbrs have 8_ ❑Demolifiaa: W forme in Mc employees and have wokkers' �-(�°�� t!- _ 9_ ❑$cildmg addition L 0 Workers' Camp.is,vr=6 comp_msurance Tre -I 5-❑ We are a corporatimand ifs 10-C]Electrical repairs nr aditions 3_❑ 1'am a home mmer doing all wore- of mrs h na a zgexdsed fheir I LIC Plambing repairs or&ddiiions myself- [No wodmers'Comp- rigm.ofeizemption per 11 GL I2_❑Roof repairs i tstuauce gnired_I l c-134 §1(4',and wehwenot Cam,_insurance requirest.j *Any mpx3cmtthateherksboalmnstLlsofli out th°section beIoerch eixtgiheirav&es'rnmQeusatioagvlicy iaffimmxfiom t Hnmeawnes Vrh[3 sabnxit ffiis aftidW t i-Ecstisg they.M doing ff. .c end&6 hire o dsi&c mmY svhafita m��d3rit „�;��*surli tCantmcmrs tint check this burs mast stter-h as addititmA sliest shtraFmy ti>P'asme of �mdstah=uhztLec ce not SnsE eaities 5 zmplayees Iftlte sub-coulmdws hie empIoyees,ffieg mQ I provide their marlin'camp-policy atmbez Iaw arz emplayer th at isptwWd&W workers'comq7gnsafLm ixmzrartce far my engkTess. Heiow is the paUry amijob azts ittfntmalir�t� Instrraut:e t:,ompa�PIams: �� - • - .� FYq)tiratianDate_ Itch Site : c;?o '@ / Ci4 State/Tag: Affich a copy of the workers'compensation palicf de-clarsticm page(show;ng the goScy number and expiration dxte). Failure to as r pfi-edun&x Sectio m MA-of MGL c. 152 can lead to the i nposifien ofcriminal peual>ies of a fine up to SL5010D andlar one yearimpm as wrA- as civil penalties in ihe fbna of a STOP WORK ORDER-and a fine ofup to$250-DO a.day against the violator_ Be advised that a cppp of this stdemu t maybe farwarded to the Office.of Iures rations a the DIA far TMTem-a*+ce coverage verEk an- Fdri hereby Cerii firspaiM nrrrl f per urp tltetf3ae¢rr orntarfrr�a prolddt�/d trhas*e is trxra and currsct� Phoneo 07 . Idol use a.-Ify. Da Kat srritff in frees areas to be cample#ed by cio or taf�n off nkL City or Towa: Perms cetse f t Ensuing A uthntity(tdrele one), L Board of Health 2.BmIffing IDeparttnent Cityff m Clerk 4.Elecft ical Inspector S.Plumbing E ezt—r .6.Other CtrE±act gersonz Phone#: 6 Information and &structions Massachusetts General Laws chapter 152 requires all.employers to provide workers'compensation for their employees. Pursuant-to this statute;an wvloyee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written!' An to er is defined as"an indivi partnership,association,co oration or other le enti or an two or more �p y �P �P, corporation � tY� Y 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 Iocal 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 arty applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfo_naance of public work until acceptable evidence of compliaice with the in m a„ce requirements of this chapter have been presented to the contracting authority_" Applicants Please U our the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their czrdficat(�s)of insurance. Limited.Liability Companies(1-LC) or Limited Liability Partnerships(L LP)with no employees other than the members or partners, are not required to cant'workers' compensation insurance_ Luc an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Departmaimt of Industrial Accidents for corrfrmation of insurance coverage. Also be sure to sign and date the affidavit The affida it should be returned to the city or town that the application for the permit or license is being requested,not the Departinent 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 listzd 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 a out i a the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the pen iUlicense number which will be used as a reference number. In addition-an applicant that must submit multiple permit/license applications in any given year,need only submit one a,5 davit indicating current policy information(if n(-,cessary)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 fiitu m permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidav-_t 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 Commnnwealtiz of M=achusetis Depa-ztn�nt Qf Zndustrial AccxdQzl Q-fxke Of lumestigatiom 600 Washinatoa Sheet Ra ton MA.02111 Tel.A 61 7 727-4 �xt 4-06 or 14 MASSAFE Revised 4-24-07 Fax 9 61 727-7-749 v .ma s&g v1dia . t ► R6�1VC1`I{R.F. s MASS Town of Barnstable Regulatory Services Richard V.ScaIi,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstab le.ma:us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I. ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFaSSIFORMS\building permit forms\EXPRESS.doc Revised 061313 f ' ^� RE-ROOFING/RESIDING/WINDOWS (COMMERCIAL) r ❑ If located in OKH or Hyannis Historic Disttict- Certificate of Appropriateness required unless same color/same materials specified on application ❑ Map/parcel number Approval Sign-offs from: ❑ Tax Collector ❑ Treasurer of squares of shingles or square footage of roof or sidewall to be shingled/sided ❑ Specify stripping old shingles or going over,old roof.' If going over ow many roof layers existing-now what size are rafters? What is span? ❑ Owner's name & address f/v,(�7 Chi,*1 e_ c�?0 ,,•', ❑ Project valuation must be entered Builders Information ` ❑ Signature •t y. ❑ Workman's Compensation Insurance Affidavit State form must be completed and.a copy of Insurance Compliance Certificate must be submitted. ❑ A copy of the Construction Supervisor license is required. Effective March 1,2009 ❑ Check expiration date,no restrictions ❑ Permit fee$160.00 ❑ Property Owner must sign Property Owner Letter of Permission. Projects requiring the use of a-crane must complete the forms issued by the Aeronautics Commission q-forms/bldgpermils/permitchecklist rev.070610 Villani Construction Inc. P.O. Box 692 West Hyannis Port Ma. 02672 \ 508-360-4481 Andi Carole October 4, 2015 20 Sea St. 774-487-1969 Hyannis Ma. Proposal Job Description Install Certainteed architectural 30 yr. roof shingles moire black over existing roof. Total $8,750.00 Massachusetts -Department of Public Safety Board of Building Regulati`o�and Standards Construction Supervisor License: CS-074360 ter.r r.ti RICHARD vu.i.r+ c�� PO BOX 692 Wgst 111yannisporr2 2 02 Expiration Commissioner 06/23/2016 * Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M )of enclosed space. �.. Failure to possess a current dition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS x i Office of CousumerAffairs&Business Regulation License or registration valid for individul use only ( VW ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Igistration; 128fi60 Type: Office of Consumer Affairs and Business Regulation ` piration:.:_ C/2017:', Individual10 Park Plaza-Suite 5170 Boston,MA 02116 RICHARD VILLANI RICHARD VILLANI �j 109 WAGON LANE _ 1 i_ HYANNIS,MA 02601 Undersecretary Not valid without signature 1 A F AC40R& CERTIFICATE OF-LIABILITY INSURANCE FDATE(MM/DD/YYYY) 10/13/2015 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 Iholder 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 - - - NAME: Erica Barrett OLDE CAPE COD INSURANCE AGENCY INC. ' PHONE FAX No Ext: (508)771-3300 C No): E-MAIL erlCab ab@bccia.com @ ccia.com 296 WINTER ST. INSURERS AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: TRAVELERS INDEMNITY CO OF AM ERICA 25666 INSURED INSURER B VILLANI CONSTRUCTION INC INSURERC: - - INSURER D PO BOX 692 INSURERE: WEST HYANNISPORT MA 02672 INSURERF: COVERAGES CERTIFICATE NUMBER: 4926 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 -- - - ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD D .POLICY NUMBER MM/DD/YYYYI (MMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ - GEN'L AGGREGATE LIMIT APPLIES PER: _ GENERAL AGGREGATE $, POLICY PRO- - - - - JECT C ❑ OC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED- AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE 'HIRED AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ " EXCESS LIAB CLAIMS-MADE NIA AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N X STATUTE ERH ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6HUB9982A27315 10/02/2015 10/02/2016 (Mandatory in NH) ,. E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 560,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) - Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows.the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 230 South Street AUTHORIZED REPRESENTATIVE 1 � Hyannis MA 02601 ` "F Daniel M.Cro_'ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Hyannis Main Street Waterfront a Historic District Commission , BUM 230 South Street , i639•A� _ Hyannis;Massachusetts 02601 i TEL: 508-862-4665/FAX: 508-862-472522*° ; 51 Application to:. Hyannis Main Street Waterfront Historic District Commission in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, in triplicate, for the issuance of a Certificate of Appropriateness under M. G. L. Chapter 40C, The Historic Districts Act for proposed work as described below and on plans, drawings or photographs accompanying,this application for. PLEASE CHECK ALL CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building, ❑ Addition ❑ Alteration Indicate type of building: ❑ House ❑ Garage ❑ Commercial ❑ Other 2. Exterior Painting: ❑ 3. Signs or Billboards:''New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other 5. Parking Lot: ❑ New Building ❑ Addition ❑ Alteration (Please see the guidelines for explanation and requirements) TYPE OR PRINT LEGIBLY DATE 3- I G 2001 ASSESSOR'S MAP NO. - ASSESSOR'S LOT NO. I of APPLICANT TEL.NO. �I _ a _ APPLICANT MAILING ADDRESS j d d((� �P1 T-a Jo vzj E)fi j ADDRESS OF PROPOSED WORK A 5ea 5 t Awayrs PROPERTY OWNER R � CC1�10 TEL.NO. 91 I - q 6 39 OWNER MAILING ADDRESS QC-) S4C, SA- �1u nnMS FULL NAMES AND MAILING ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. This information is best obtained at the Town Assessor's-Office: (A-ttactradditionaVsheerif necessary). dud aA .fie s&,E � I. N AGENT OR CONTRACTOR TEL.NO. N ADDRESS O O DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done, including detailed data on such architectural features as: foundation,chimney, siding, roofing, roof pitch, sash and doors,window and.door frames, trim, gutters- leaders, roofing and paint color,including materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet,if necessary). 1 (i�, y tx I acid ' 4} At M- �M)Aal ne-�-+ b � d ooy' o& r15h+ Vdc 0--� d&r '�Acl S, n iS WOad ��Y�cQ w t lam'' �} 5 Pain Signed Owner-Contractor-Agent SPACE BELOW LINE FOR COMMISSION USE Received by HMSWHDC. Date Time APR 13 20M This Certificate is hereby By TOWN 07 BARNSTABLE Date 6 Ne -- - — Signed RVIPORTANT: If this Certificate is approved,approval is subject to the 20-da ap al 'od provided i the Ordinance. CONDITIONS OF APPROVAL: AD kuurk � � �, CA HYANNIS MAIN STREET WATERFRONT HISTORIC DISTRICT COMMISSION *** SPECIFICATION SHEET*** ADDRESS OF PROPOSED WORK Q O sea FOUNDATION SIDING TYPE COLOR CHIMNEY TYPE COLOR ROOF MATERIAL COLOR , PITCH WINDOW COLOR TRIM COLOR DOORS. COLOR SHUTTERS DECK GARAGE DOORS COLOR NOTES: Fill out completely, including measurements and materiaWcolors to be used. Three copies of this form are required for submittal of an application,along with three copies each of the plot plan,landscape plan and elevation plans,when applicable. The Plot plan need :-_ :9 not be."Certified",but should show all structures on the lot to scale. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ie Application # r 0 5341 Health Division ~Date Issued oci Conservation Division Application Fee { . Planning Dept. Permit Fee' 4 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 0 E d MEET Village ft YA NAl1,S /l Owner 6 Pld I C. A 2nI Address ,'40 SQ) sr HMVXI15 Telephone 77/_ 75- 3 Permit Request I'/A f- 5XIul,L 9m,94C, Af.Ai4,,-,c �� /IV31/ia 7-)C, TYL&C, 11VSr)11L. /V9 4/ )rVSvL 6, T1o14, Sh ferVLc-C,F, T�_&Jok 7 k/X/ E. 0-0a -S F!rvsh r-t,062)N,r, PA11VT4 bgC6n.J97-�_ Pkv.44bhV& PJ 91ccTA1G-9c. PFAm1►,5 TobTAkfN6of Square feet: 1 st floor: existing 1366 proposed 2nd floor: existing G proposed '0 Total new 4 Zoning District Flood Plain Groundwater Overlay Project Valuatid�,c�v Construction Type ,) Q [Age t Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. welling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No sement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other sement 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 L 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: IZ oning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name W� 19 �C 9� 6 70 r `g"ch Y11 S Telephone Number Address :Z 2 A4 J:61) 6W3e1� \AJjo v License # / Ll C/ a A �/U 11s 1 5M• O 2 Home Improvement Contractor# Worker's Compensation # 2- (5 V a 8 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE � e, 1�; ��t�. DATE , o , 20 -� _2ooF1 ~ FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. p ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION -FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL t GAS: ROUGH FINAL ; FINAL BUILDING Y DATE CLOSED OUT ASSOCIATION PLAN NO. f The Cotnmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 �4 s�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelribly Name(Business/Organization/Individual): Am a L-z N Res /a i now 9 E1-y 1 C e! Address: /9 /KE ft 1 C rl N W A Y City/State/Zip: C, 9£/V ryLS /V 646 Phone.#:�S'O T— 740 -1 J// Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with 1:2,0 — 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors .2_❑ I am a sole proprietor or part�oet-' listed on the-attached sheet 7.. ❑ Remodeling S hip and have no employees These sub-contractors have 8. '❑ Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. Building addition o worker's'.comp. insurance comp. insurance.$ � additions required.] S. ❑ We are a corporation and its 10.� Electncal rep or 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑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 13.�therf'/AC Q� 4 employees. [No workers' 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. tContractors 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. ff the sub-contractors have employees,they must provide their workers'comp.policy number. .lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A DU L 6 P&-D T&C,TI o N Policy#or Self-ins..Lic. #: 701/.310 Lf 88 Expiration Date: 0 Job Site Address:)Q SF4 9 7� City/State/Zip:/7 yA/V1V15, 1*14: 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 cri iiial penalties of a fine tip 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 DL&for insurance coverage verification. I.do hereby certify under the pains and penatties of perjury that the information provided above is true and correct Date: � �Sgnature2,,tk;-- 2Vk-� - A a Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: Information and IPSA �.ct�®�� 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 tiustee 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the tommonwealth 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-contractors)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-insuranGe 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 pe-rmit/license number which null 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"dll 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 tilled out each a license or permit not related fo an business or commercial venture home owner or citizen is obtaining Y ye ar. Where a g P e s is NOT required to complete this affidavit •leaves etc. said person or permit to bum le q mP (i.e. a dog license . p ) P The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate tc give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of lndustri,al Accidents Office of Investigations. 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia 1 z► r Town of Barnstable Regulatory Services . 9ni s �; Thomas F. Geiler,Director kn�a Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 vnmtown.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-623( Property Owner Must Complete and Sign ` fC s Section. If Using A Builder . as Owner of the subject.property hereby authorize I)WA I[� i �'q�J�i S to act on my behalf, in all matters relative to work authorized by this building permit application for: � Oa &41241 5' (Address of rob) Signature of Owner Date k, Print Name If Propedy Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. Town of Barnstable �apT1iE Tp�y o Regulatory Services Thomas F. Geiler,Director . � Building Division PrED '� Tom Perry, Building Commissioner 200 Mairi.S.treet,__Hyannis, MA.02601 www.town.barnst2ble.ma.us Office: 508-862-403 8 Fax: 508-790-6230 ROMEOW ER LICFNSE EKEWTION Plcare Print DATE: JOB LOCATION: number strcct 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. ' DEFINn-TON OF HOMEOWNER Persons)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 o Y "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" assures responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner" certifies that.be/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/sbe will comply with said procedures and requirements, Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to conVly with the State Building Code Section 127.0 Construction Control. HOMEOPVhTER'S EXET,4MON .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 s 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 responsibilitirs,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the responsrbilitics of a Supervisor. On the last page of this issue ig a.farm currently used by several towns. You may care t amend and adopt such a fonnlccrtification for use in your Community. Q:forms:homcexempt Massachusetts Department of Environmental Protection^ i' �0008od3s Bureau of Waste Prevention • AIr Quality Decal Number BWP AQ 06 Notification Prior to Construction or Demolition Important: A. Applicability - -- When filling out pp forms on the computer.usecommercial, or ng, or only the tab key A Construction or Demolition r operation po e units is indlustriated by the Department of Environmental�onmenal lntlal Protection to move your residential building with 20 of cursor-do not (DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Ns prior tonany use the return ten 10 days key. Construction or Demolition operations is required under 310 CMR 7.09 (2) ( ) Y p work being performed. The following information is required pursuant to 310 CMR 7.09. B. General Project Description ern J 1. a. Is this facility fee exempt-city,town, district: municipal housing authority, owner-occupied T instructions residence of four units or less? ✓!Yes _ No 1.All sections of b.Provide blanket decal number if applicable: Blanket Decal.Numtier ' ' ^ this form must be completed in order Facility Information: to comply with the Department of The Spa. .. . • _. Environmental a Name _ µ - - Protection -~ 20 Sea Street - notification — - requirements of b.Address VA ` ,026O.1 --- 310 CMR 7.09 Hyannis _ -` _ ._ Zi Code------ _ _ _. a d.State _ -e, p` ' 508 778 5143 ._ Address(FPtilonal) -� - f,Telephone Number(area code and extension)_• ,_ one i 300 _ _ ___ r_.�. r .._ __. __ i.Number of Floors hf Size of Facility in Square Feet - . j. Was the facility built prior to 1980? Yes No., f k: Describe the current or prior use of the facility: salon No I_ Is the facility a residential facility? Yes o M. If yes, how many units? Number of units 0 3. Facility Owner: =a Andl Carole �o "t a.Name. _ ». - , 2O_a Street b"Address `u - MA FO2601__ P.... T�yanriis _ d State NEGROSm-cD C..Citv/Town. MOSS t-_508-778- 5143 _.__ umbe — _mail Address(optionall_ -_ f.,Telq hone Nr(area code,and extension) J Q -h.Onsite Manager Name BWP AQ 06•Page 1 of: agO6.doc•10/02 Massachusetts Department of Environmental Protection'.. Bureau of Waste Prevention . Air Quality 1100080439 _ i BWP AQ 06 -Decal Number ~ w Notification Prior to Construction or Demolition General Statement: If B. General Project Description /coat. - �. asbestos is found during a Construction or 4. General Contractor. __ _ ,�, � _,_..._._.... _ _....._...._., Demolition ' Whalen Restoration 1 Servicesf r. operation.all _- responsible parties must comply with 22 American Way 310 CMR 7.00, b.Address 7.09,7.15,and _ Chapter 21E of the South Dennis _ MA _4 s 02660 w General Laws of ty own _ r d State e.ZipCode the Commonwealth. _508 760 1911 x . bwhalen@whalenrestorations.com _ This would include, f.Telephone_ Number area code and extension E Maul Address op tional) but would not be n __ (area_.._ . . _ _� ., �._ _. _ q limited to,filing an Williatr Whalen � r_ asbestos removal h'On-site Manager Name , notification with the Department and/or a notice of release/threat of release of a C. General Construction`or Demolition•Description , hazardous substance to the 1 Construction or demolition contractor: ° Department.if _ _ _ applicable. f Whalen Restoratos Services a Name __ a t 22"American Way. b Address _ - 02660 South Dennis ; Slate- e.Zip Code T„ 508 760 1911 }� bwhalen@whalenrestoratons.com f�Telephone Number(area code and extension) g mail Address Willia?g Whalen r F K.On'sife`Manager'Name 2: On-Site Supervisor. s_William Whalen On-Site Supervisor Name 3. .Is the entire facility to be demolished? �,J Yes xyI No sN �0 4. Describe the area(s)to be demolished: �0 l 5. If this is a construction project, describe the building(s)or addition(s)to be constructed: Two newly constructed bathrooms, sheet rock, insulation, flooring, t0 i painting, electrical, plumbing. - ��o �C �Q ag06.doc• 10/02 BWP AQ 06•Page 2 of 3 i Massachusetts Department of Environmental Protection - j Bureau of Waste Pr2vetl to Quaai 31000804_3_9_�_ IL BWP ACC 06 - Decal Number - Notification Prior to Construction or Demoiifion C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition proiect, were the-sirur:u,e?s' surveyed for the presence of asbestos containing material (ACM)? ❑ Yes No If yes, who conducted the survey? b.Survevor Name c. Division of Occupational Safety Certification:Number . 11/15/09 7. Construction or Demolition, � b. End Date(mmiddi ' y a.Start Date{mmldd/yyyy)' YYYY) 8. a. For demolition and construction, projects, indicate dust suppression techniques to-be used: seeding paving b. if other, please specify: wetting X'shtouding- covering : other-, 9. For Emergency Demolition Operations, who is the nEP official who evaluated the emergency? c. Date(mm/ddNyyyj of Authorization d DEP Waiver Number m D. Certification y) M William Whalen. I certify that I have examined the • �=o above and that to .he best of m knowledge it is true and complete- The signature below subjects the b'Authonzed Si nature _ '�—N signer to the general statutes President O regarding a false and misleading c. Positon/r1fie o �statement(s). Whalen Restoration Services 4d:Representing.. November»2 2009 �r9 e.Date(mm/dd//yYYy) O � ag06.doc•10102 - BWPAQ06•Page 3of3� Date: 10/21/2009 Time: 9:03 AM To: Kathleen @ 9,15087609995 Rogers & Gray Ins. Page: 002 Client#:32193 WHALRES ACORD,� CERTIFICATE OF LIABILITY INSURANCE �0/21MDmrrr) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR P.O.Box 1601 ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED NSURER A: Arbella Protection Co Whalen Restoration Services Inc 22American Way NsuRER6: NSURER C: South Dennis, MA 02660 NSURER D: NSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T-IE 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 AF=GRDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO.ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN NAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE Of INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MWDD, DATE MMlDD LIMITS A GENERAL LIABILITY 8500040398 04/01109 04101/10 EACH OCCURRENCE $1000000 X COPIPAERCIAL GENERAL LIABIL TY DAMAGE TO RENTED PREMIs a occurren $100 000 CLAIMS MADE a CCCUR MED EXP(Ary one person) $5 000 PERSONAL&ADV IIJJURY $1 Q00 OOO GENERAL AGGREGATE s2,000,000 GEN'LA.GGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP!OPACG $2000000 PCLIC"17 JEC-CT El LOG A AUTOMOBILE LIABILITY 7491 T400001 09125/09 09125/1 O COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (For person) X HIREDAUTOS BODILY INJURY $ X NON-0WPIED AUTOS (For accident) - PROPERTYDAMAGE $ " (Fer accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ A EXCESSRIMBRELLA LIABILITY 4600021586 04/01109 04101/1 D EACH OCCURRENCE $1 000 000 X1 CCCUR CLAIMS MADE AGGREGATE $1 00O 000 $ DEDUCTIBLE - $ X RETENTION $10000 $ A WORKERS COMPENSATION AND 9091320408 04/01/09 04/01/10 X WC STATU- OTH- MIT EMPLOYERS'LIAB&JTY .ANYPROPRIETOR/PARTNER+EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? E.L.D SEASE-EA EMPLOYEE $500,000 Ifyes,cesaite under - SPECIAL PROVISIONS below E.L.D SEASE-POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Project location:20 Sea Street,Hyannis,MA 02601 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Andl Carole DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O DAYS WRITTEN 20 Sea 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 ACORD 25(2001/08)1 of 2 #S467051M46219 CBR 0 ACORD CORPORATION 1988 `;assitchusetta Depai-tinent of"Public Safety 4 Bo ard of Building Regulations and Standiwds COnstruction Supervisor-License License: CS 74928 Restricted to.- 00 _ ti WILLIAM WHALEN 1s22 POND STREET ID BREWSTER, MA 02631 ` Expiration: 8/10/2010 ( onilnissilMeI' Tr4: 1937 ✓s�ie V�anvniareiaea� o��/l�Gaaaczc�ucQed�6 -. _ Office of Consumer Affairs& usioess Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:: "129244 10 Park Plaza-Suite 5170 Expiration 7/30/2011 Tr# 287004 • Boston,MA 02116 Type Pnvate_Corporation Whalen Restoration-Services.-.Inc:', William Whalen - 22 American Way South Dennis,,MA 02660 Undersecretary, Not valid without signature f TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY --- PARCEL ID 308 121 GEOBASE ID 22089 ADDRESS 20 SEA STREET PHONE HYANNIS ZIP _ — LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY as PERMIT 37906 DESCRIPTION ANDI CAROLE CASA VEINTE/RENOVATIONS PMT 33566 PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: .OND , THE .00 CONSTRUCTION COSTS $.00T 753 MISC. NOT CODED ELSEWHERE 1 PRIVATE RAIM' �ti;_ ; t * BARNSTABM * f MASS. { 1639. A�O� ED M1►� BUILDING DIVISI�gN BY ✓✓��.�� DATE ISSUED 04/20/1999 EXPIRATION DATE w WIT.DING PERMIT PARCEEL ID 30B 1,21. cy <' B w;�� ID22c�#3S }, ADDRESS 20 SEA STRP. .T PHONE 1,YANN IS _ ZIP TIOT DBP- DEVEWPMEN1 D I STR,C;.t' hN PERMIT _ 31j565 DE'SUI.PTION REM OD. INTER.& lali YCK 41'E XAf 17.9WT'_ '?,X TE1J0fT PERMIT TYPE bR)gY,01)C 11'[`.LLE WMMI'RCTA.I., Af,T/CONY CONTRACTORE: B0(St CR`1~ THOMAb Department of Health, Safety ARCHITECTS and Environmental Services `LOTAT, F11'FS: $r C6.60 i BOND ,OrJ Qx THE u0NSTRUC''f ON 'LISTS $126,000.00 4', r7 w)NIC13'.S. / N0N1i.*K1- kDD/\-vt.IN : PR AT P -Qi RARNSTABLE, MASS. 1639. BUILDING'DIYISIONBY '� DA`I'HK ISSUED 09/24/1.998 1LXV 1 RI'''."[0N DATE 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 MAYBE 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 ORFOOTINGS 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. BUILDINNGGj INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS lea a Own � %� I c�, 2 3 C^ ,0, TO 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT .._ Axe 4„{ - 2 BOARD OF HEALTH cj OTHER: SITE PLAN REVIEW APPROVAL ' I I 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. TION. R� I I I I I - I i .. I 1r X, it ri - . lM 4, y � � M l r + Qk v +: AW Er 110/15/09 t ... . _ . • a : � • w,. 9 � � .40 r a � o i f � A sJ/ r _ ' ■ Pl Y' - 1 J i a r. 4 20 SEA STREET, HYANN I S /0 . 3 Sign TOWN OF BARNSTABLE Permit * BARMSTABLE. MASS 1639. A� Permit Number. Application Ref: 200701391 20070012 Issue Date: 03/12/07 Applicant: CAROLE, ANDI TR ' Proposed Use: RETAIL & SERVICE STORE SMALL Permit Type: SIGN PERMIT Permit Fee $ 25.00 Location 20 SEA STREET Map Parcel 308121 , Town HYANNIS Zoning District HVB Contractor PROPERTY OWNER Remarks HANG SIGN 5.25 SQ BLK WROUGHT IRON/ GLD LEAFBLK OUTLNE/OVAL THE SPA AT 21 SEA STREET Owner: CAROLE, ANDI TR Address: 20 SEA ST HYANNIS, MA 02601 Issued By: PC POST THIS CARD;SO THAT IS VISIBLE FROM TIE STREET Town of Barnstable �oFt"E'ati Regulatory Services Q` Thomas F.Geiler,Director Building Division ATE 039. p Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Permit# Application for Sign Permit Applicant: � L 0.C0.&s Map &Parcel# ]doing Business As• k �Q!� CL. s-�t'C�-Telephone No.�(- °��.� 4Sign Location e 1 Street/Road: 20 Sew vVre� 1 ww�s Zoning District: Old Kings Highway? Yes/No Hyannis Historic District? Ye" o Property O ner, ` � n Name: [-R36 I �L�t�l Telephone: CJ'op ✓ 9 . Address: CRO Sect- (�—�ek— Village:_ N Q Sign Contractor 1 Name: �� Ln nl 1 V� �- Telephone: `�� U �o Mailing Address:- 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? Yes (Note:If yes, a wiring permit is required) Width of building face ft-x 10= d x.10= � Sq.Ft. of proposed sign c��( 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§240-59 through §240-91 of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authorized Agent: Date: ® 177j w„ Permit Fee: 3 Sign Permit was approved: Disapproved: Signature of Building Official: Date: r" r= In order to process application without delays all sections must be completed. Q:I WPFILESISIGNSISIGNAPP.DOC Rev.9/12/06 [q� 1 � S� ` qr 7F ©UALGIN If MUM is PLANT Mia caPEEr Ye 1 .,.!NC_ *Cusl��WDRf� DER�narc „�� C,�yU t~aacs�-nW,� tV e &MURALS ti WALLS G GLASSWINDOWS custom Hand Painted Signage and Wash Window Painting 55 SPRUCE STREET,HYANNIS,MA 02601 50g-775-6716•FAX 50&790-4547 suzannenowak@mac-com i w-- .ems +�5'. r� .t., f tr,x§ �• ,i r t .0 ,� '�.�: x � �� a.r r 'S,. � .I E .s..i..•.'s�""` 1�r lr a,r� �r ' ,v .�t. - r 1 � " :rr._ "'� �j„�, °' �ii . yrty �6 M•� � ^,yy'9D""`"` y'�+'Aj. .� ry4a ,� .i.i G t `ry r N if �'�. .i `. ,yy;.l..,�wr.h��ir�.`��+.�'M.^"'+ '"'+�" b"1` ' i 4.iY � Y-_,e•, t F. �'? �F` :}^ T • +q y Yi' - .lP" d -.M^'.. w�W}LM� Ww4ry,1 •Y 4 I , J i' Y fi. H. M4 p i^��Y � .� � ,. '.:- .,,r.` +'ar �".... ,!„�,.,,«+--+n?i,;.�r�jxr.. ...res �'�•�" r' y � '} :"'S;,. H 4 ,;�'. Fa r' k•l,.,r '" :�d >' •w._-+.• .s'. . - .� r .t'�`�.,i,�_.,. i. r•wr-» +ti '�% � -x f "+ y; �,F: a.xr Y�`. i iy, �� •, �d,.�*E>=n"vM.��"°�'".r,a,.,�:.a a,_ *^K '*'*'4S'+„T * ":� ��.��• .r .� a R�. ��. '}tj�a � �,� '�,. r �n _ �"5- sr a, � *'+M'r"a'".ry��.. - d � -- ,,�'r.-.L• •«w.F.n+_. 6�Y �.� .,♦ wr. w+� �p - F ... � ' �,1 ', r � i�i If 14- f_ 'r" •,n„„,�,L „„a•--w- «-.*,F. r••r .s wh..a -1 `�U b Y �A�S•,-�`, x * jY � El ` ,r rlfIlia 0 if r it y�AI�� r. *wd` +�e,.. ; r �` "r., s-sa...w.�lr '• �r „�' w r , �; ,'.: LL �.•.:; pry:. y - e �"-.«' - f H '�r�� 77 v / L °s� ,A ! _ gg f ` THE SPA AT SEA STREETS76 3 \;20-A SEA`ST'REET` 1555 ;. s I3Yt1NNI$,MA 02601 = 5s.i3/i to mA PH.�,�508-97 y 5-4407 Date O' 8e436 Pa to the of '' � - f Qrder f 2 � i Dollars r � - b��rikofAmerca r4 ACH�R/f 01100Q138 • �'r OQf1YkeulW _ . ; OUARDIAN®SAFETI/BLUE-URB9L YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which ' you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the.Town Clerk's Office, 1'FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: r `" w Fill in please:. i / nn APPLICANT'S YOUR NAME: � &-OilCC' tZ L-��F�SS L ' BUSINESS YOUR HOME� ADDRESS: 10(0 �c`o Gt o o►_ 08 '195 L4D W , 1(cLr-fw +t , (Y) I- 0A(P 7 r` TELEPHONE # Home Telephone Number ,509 97'7 S NAME OF_NEW BUSINESS a rX TYPE OF BUSINESS IS THIS A HOME OCCUPATIONS Have you been given approval from the b�u,i(ding ivis�on� YES NO ADDRESS OF BUSINESS dO;F} rv-CatrC� a 0.Nn� MAP :PARCEL NUMBER 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. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFIPP This individual has informe- f any permit requirements that pertain to this type of business. Authorized Signature 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: i Assessment Reults Page 1 of 2 0 SEA STREET 1xvicQ map, Map/Parcel / Parcel Extension: Mailing Address: 308/121/ CAROLE, ANDI TR Owner of Record: MOKSHA REALTY TRUST CAROLE, ANDI TR 20 SEA ST Property Location: HYANNIS, MA 02601 20 SEA STREET Parcel ID:308121 Fiscal Year 2001 Assessed Values Building Value: Extra Features: Outbuildings: Land Value: Totals: Appraised Value $ 112,600 $ 0 $0 $ 106,300 $218,900 Assessed Value $ 112,600 $ 0 $0 $ 106,300 $218,900 Sales History Owner: Sale Date: Book/Page: Sale Price: DELIS, SOSSOS TR 4/15/1990 C120298 $ 1 DELIS, SOSSOS 4/15/1990 C120297 $ 177,867 DELIS, SOSSOS C120296 $ 1 DELIS, SOSSOS C38229 $ 1 DELIS, SOSSOS C38229 $ 0 CAROLE, ANDI TR 8/6/1998 C149636 $ 165,000 Land and Building Description Land Building Lot Size (Acres): Year Built: 0.18 1892 Zone: Living Area: RB1 3955 Appraised Value: Replacement Cost: $ 106,300 $244,697 Assessed Value: Depreciation: $ 106,300 15 Building Value: $ 112,600 Construction Details Style: Interior Walls: Store Plastered Model• Ind/Comm Interior Floors: Grade: Carpet Average Grade Stories: Heat Fuel• 1 1/2 Stories Gas Exterior Walls Heat Type: Wood Shingle Hot Air Roof Structure: AC Type: Gable/Hip Central Roof Cover: Bedrooms: Asph/F GIs/Cmp Zero Bedrooms Bathrooms: Zero Bathrms Total Rooms: 2 Rooms http://town.bamstable.ma.us/Information O1/Assessment/results.asp?MAPPAR=308121 4/2/01 Assessment Reults Page 2 of 2 2 Rooms Outbuildings & Extra Features Code Description Units/SQ FT Appraised Value. Assessed Value No records returned. r http://town.bamstable.ma.us/Information Ol/Assessment/results.asp?MAPPAR=308121 4/2/01 •=< 'TOWN OF BARNSTABLE BUILDING PERMIT.APPLICATION Map O Parcel ` -Application# DO Ttl e� Health Division _ Lt,5 Date Issued g) ,1 C .. r , Conservation Division Application Fee L Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address .20 SE A CS'T Y19/y N I S 60/ Village A Y /V/YIS Owner 19 NC)/ CI P o 4 t Address 2 a J"]�F-i1 5 f Hy'l il'os IW Telephone a 8 77i' 7 S L3 q Permit Request E/A C 06 lif A C C- 89 51,101tC: 0AnACr_ 1t��v v� � ,�.1✓P1.14 C-L A 0&All T S T✓ds I? P19 e Ele T/o i A- S,064 I: //ySTO I.i Yye,t,", 4 SV96T A&CI- rVE w P9/111T 0 LA&Pe_r PEel,096L_ Sk)C w4,4LL5_hj�vC LES Square feet: 1st floor:existing G G proposed U 2nd floor:existing Cod (5" proposed Total new C). Zoning District Flood Plain Groundwater Overlay Project Valuation S 0 o® Construction Type 6-8 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: U'Full ❑Crawl ❑Walkout ❑Other � 1. J cam Basement Finished Area(sq.ft.) C) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing ' new Total Room Count(not includingbaths):existing � new First Floor Room Count Heat Type and Fuel: L Gas ❑Oil ❑Electric ❑Other Central Air: U' es ❑No Fireplaces: Existing 0. New 0 Existing wood/coal stove: ❑Yes Flo Detached garage:❑existing ❑new size Pool:❑existing ❑new size J Barn:❑existing ❑new size 0 Attached garage:❑existing ❑new size C) Shed:❑existing ❑new size L9 Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Nave it/)/}J E A/ AF_S lopt,gTt o rV SE�Vl C elephone Number S 0 C/ Address Z tl t C/P ov W 4' License# D 7 A �r S ` g N A I S X1 0 A G 6 1 Home Improvement Contractor# Worker's Compensation# 9®`� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Yi9 f1 M0 y-r/f 2 c C`f L l>'v& SIGNATURE DATE C> 0 d 7 FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER • DATE OF INSPECTION: FOUNDATION FRAME D 'ZT '7 INSULATION FIREPLACE . ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH r FINAL FINAL BUILDING IR` DATE CLOSED OUT ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts Department of Industrial Accidents 42) E Office of Investigations d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers" Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): .W b i?),E N Address: 2 Z WA City/State/Zip:$, Q&v/LjS M d a;z e4 t Phone.#: 1 �o Are ou an employer? Check the appropriate box: Type of project(required):. 1. I am a employer with �d 4. I am a general contractor and I . employees(full and/or part;time)." have hired the sub-contractors 6. ❑New construction . 2.❑ I am a•sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance.$' 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 employees. [No workers' . •13.❑ Other comp.insurance required.] , "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must providb 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: a2 b F_t LA iY V 7_h I.. �}L I/yS Policy#or Self-ins.Lic.#: 9-S-00 o Z, 4 S Expiration Date: 0 y 1 O f Job Site Address: .® 61/1 rS T !RYA A/A/i S /,f 0 City/State/Zip:&'4/r N aS IyR p 7, a C 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: SiEnature: Date: b S� 06 O / - Phone#: Official use only. Do not write in this area,to be completed by city ar town o IciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: . Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two.or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee-of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the' dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to*operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract fox the performance of public work until acceptable evidence of compliance with the inrance requirements of this chapter have been presented'to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)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 Pl ease be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all-locations in (city-or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Deparhnent's address, telephone-and fax number:. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.rmass.go-v/dia °FZHE, Town of Barnstable. Regulatory Services teeMAM '$ Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 50.8-790-62.30 Property Owner Must Complete and Sign. This Section If Using A Builder I, Akl'rf. 6APL� ,as Owner of the subject property hereby authorize W44A'Ue2q , rlo� to act on my behalf, in all matters relative to work authorized by this building permit application for. . �o _44AWm,--;, MA l (Address of Job) Signature of Owner Date Print Name } Q10P MS:O ddNE-UEP-MISSION rv�rr�mcoa,aa BOARD OF BUILDING REGULATIONS / License: CONSTRUCTION SUPERVISOR Number: CS 074928 Bittttdate 0&'10/1961 Expires: 08/10/2008 Tr.no: 1273.0 Restricted: 00 WILLIAM WHALEN 122 POND STREET �j BREWSTER, MA 02631 Commissioner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:. 129244 Expirations 7/30/2009 Tr# 132276 Type:,Private Corporation Whalen Restoration Servicesdric. William Whalen 22 American Ways South Dennis, MA 02660 Administrator AUG-06-2007 12:43 ROGERS & GRAY—Dennis 15083941393 P.01/04 A • CERTIFICATE OF LIABILITY INSURANCE $I6T/0(7M/DDlrVYv) n PRODUCER THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.$a.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O.Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A: Arbella Protection CO Whalen Restoration Services Inc INSURER s; Arbella Mutual Insurance Company 22 American Way INSURER c; South Dennis, MA 02680 INSURER D. INSURER E: COVERAGES 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 1$$UED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADD1I GTIVE POLICY EXPIRATION LTR INSRCTYPE OF INSURANCE POLICY NUMBER M DIYY DATE MMIDONY LIMITS A GENERAL LIABILITY 8500024585 04/01107 04/01/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SES(Ea n $1(IO 00O l.�J CLAIMS MADE OCCUR MED EXP(Any one pesos) $5 000 PERSONAL 4,ADVINJURV $1000000 GENERAL AGGREGATE S2,000,000 GFJV'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000 000 POLICY PRO.JECT LOC A AUTOMOBILE LIABILITY 74917400001 09/25/06 09/25107 ANY AUTO COMBINED accident)SINGLE LIMIT $1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS COOLLY INJURY $ X NON-OWNED AUTOS (PeraWdent) PROPERTY DAMAGE $ (Per acddent) GARAGE LIABILITY AUTO ONLY.EA ACCIDENT $ ANY AUTO EA ace $ OTHER THAN AUTO ONLY: AGG $ A EXCE$SIUMORELLA LIABILITY 4600021596 04/01/07 04101/08 EACH OCCURRENCE $1 000 000 X I OCCUR ED CLAIMS MADE AGGREGATE $1 000 SSO $ DEDUCTIBLE g X RETENTION $10000 g g WORKERS COMPENSATION AND 9091320406 04/01/07 04101/08 X wC ST.A OTH- EMPLOYERS UABILITY im- ANY PROPRIETOWPARTNER/EXECUTIVE E.L.EACH ACCIDENT S500 00Q OFFICER/MEMBER EXCLUDED? EL.DISEASE-EA EMPLOYEE S500 OOO Ifyms doscrN under SPECIAL PROVISIONS below E.L.DISEASE.POLICY LIMIT 1$500,000 OTHER . DESCRIPTION OF OPERATIONS I LOCATION$I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Project location,20 Sea Street Hyanis,MA 02601 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE YHE WiRAY10N And[Carole a Casa Viante DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL —JI)— DAYS WRITTEN 20 Sea 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. AUTHORLEED REPRESENTATIVE ACORD 25(2001108)1 of 2 #S30266/M28098 CSR 0 ACORD CORPORATION 1988 of Preliminary Report € � u �➢ IIIIIIII IIII-IIIII IIIII IIIII IIIII IIIII IIIII IIII III Assignment Details Customer/ Insurance SAFETY INSURANCE Company <<Type Address Here>> QUINCY Ind Adj Firm Name PATRICK J. DONOVAN &ASSOCIATES MICHAEL DONOVAN 508 580-1475 71 LEGION PARKWAY SUITE 25 BROCKTON 02301 Broker/Agent DOWLING &O'NEILL KAREN ANDERSON 508 775-1620 P.O. Box 1990 HYANNIS 02601 Policy Number IBP00000242 Reported By Homeowner Customer Claim Number Referred By A ent Job Number 07-1805-E Contractor Name Whalen Restorations Services Inc. Estimator William Whalen Estimator Phone 508 760-1911 Policyholder Andi Carole a Casa Viente Address 20 Sea Street, Hyannis, MA, 02601 . Cell Phone 774 487-1969 Business Phone Home Phone 508 778-5143 Tem ora Phone 508 771-7539 Loss Address to 20 Sea Street, Hyannis, MA, 02601 Name of Cont kcftV Andi Carole 508 778-5143 Cell Phone 774 487-1969 Preliminafv Report Date AReceived '` Saturda Au ust 04, 2007 Date of Loss Saturday, August 04, 2007 Time Received f4 10:24 AM Time of Loss Insured Contacted ; Time Insured Contacted Date Inspected Type of Loss Fire Secondary Type Deductible 1$500.00 Rough Estimate Amount 1$0.00. Loss Description Cigarette in mulch ignited &damaged wall, rug, pad, clothing Loss Directions P.13, 11 R South Street Detailed Findings i f .a... - I . 4 TOWN OF BARNSTABLE - ' SIGN PERMIT i PARCEL ID 308 121 GEOBASE ID 22089 I ADDRESS 20 SEA STREET u PHONE HYANNIS ZIP i i LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 37382 DESCRIPTION ANDI CAROLE A CASA VEINTE (48 X 28) PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $25.Op 1ME BOND $_00 Ox CONSTRUCTION COSTS $.00 753 MISC. NOT CODED ELSEWHERE * BARNS'1'ABI.E, *' MASS. 039. BU DIN, IVI$'IIO - BY DATE ISSUED 03/26/1999 EXPIRATION DATE f i IJL ,,,�,�,, • : Department of Health, Safety and Environmental Services ., il i639• Building Division _ `0� 'OtFp�•l� 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Tax Collector - Treasurer ,5 a 9 7 Application for Sign Permit Applicant: CA k 0 IE— Assessors No. Doing Business As:_ A i2n SA ye/fW E Telephone No. Sign Location Street/Road: d S(5 S! �� 6 a Zoning District:__ Old Kings Highway? Yes/No Hyannis Historic District? Yes o Property Owner Name: A IT 1) l C9 12,eQ IF; Telephone: J - S�.3 9 Address:_ oa S Village: /� VAIVV S r A� G �a/ Sign Contractor Name: Cosy ec�`S osv— Telephone: Address:-( ?o 1 Rom. Village: � ,c,t, '►„ p G�� 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*k�k' e o (Note.Ifyes, a mnngpermitisrequired) 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 Agent:. Date; j`02 Size: �o x�� Permit Fee:— '? �r : G Sign Permit was approved: rN Disapproved: Signature of Building Offici �iw C l � Date: e ` Signl.doc rev.8/31/98 l'4i� . i r t wt c y Mr f r Ca-s:a el e Y'�-i C:£M Al ,Ilg evL 00 t �ST CvT Map Parcel Permit# �� House# RA'h _ Date Issued In Board of Health(3r oor)(8:15 -9:30/1:00 fqp Conservation Office(4th floor)(8:30- 9:30/1:00=2:00) z Planning Dept.(1st floor/School Admin. Bldg.) Definit' e P pproved by Planning Board 19 APPUCA CO ARM TOWN OF BARNSTABLE Nsvc�'ro , o$� Building Permit Application roje t t Address o Village Cf/N/yt t,f3 Owner �,�. ( i4�j-C�_ Address s ?'l�� Telephone s3 Permit Request dn i First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ . Q/X) Zoning District A 8 1, 4( B Flood Plain Water Protection Lot Size ./9 I�Cu4 Grandfathered/IdYes El No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure r 16 Historic House ❑Yes ❑No On Old King's Highway ❑Yes �Basement Type: Full 4 Crawl Walkout ❑Other >(No Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) J 4W . Number of Baths: Full: Existing —� New Half: Existing Ne No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count y Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other N ' Central Air ❑Yes,.-,'Q No Fireplaces: Existing •—-- New Existing wood/coal stove ❑Yes >kNo AGarage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) - ❑Other(size) -- Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial Yes ❑No If yes, site plan review# Current Use / Ey IL SO'1 Proposed Use Builder Information Name / /��r��S /0/161£,,Q% Telephone Number 5J08. Address ✓ GffU / S f License# 001 g 10 Home Improvement Contractor# ' Worker's Compensation# UgA 0 �Y, 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 F OWING REASONS-7— 0 �/ C-P FOR OFFICIAL USE ONLY PERMIT NO..��- DATE ISSUED p � -_ `l� - MAP/rPARCEL NO. ADDRESS ' VILLAGE OWNER DATE O?;INSPECTION: FOUNDATION i t FRAME INSULATION_ �' ` a' 1 FIREPLACE +, . - ' �`i �� . -• � • - d ELECTRICAL: ROUGH 'FINAL' PLUMBING: ROUGH FINAL, GAS: ,.• ROUGH`' FINAL+ FINAL BUILDING 1 DATE;CLOSED OUT .r�;; 8. ASSOCIATION PLAN NO' . �v' - '—i->'___' l'�fie Uomv�rto'ruueaccr� o�✓UCa.J��acf t�Je�J tr' DEPARTMENT OF PUBLIC SAFETY CONSTRUCTt9H SUPERVISOR LICENSE Numbei . Expires: 3ir�h,j,_te; H CS � 001310 .61�31;2008 B1,311SSA T,NOMRS R_SOI9VERT 15 CNERRY'ST / HYANNIS, MA 12oOI r n MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL . APPLICATION FOR WORKERS'COMPENSATION INSURANCE MAIL TO: The Workers'Compensation Rating&Inspection Bureau of Massachusetts P.O.Box 9006 Boston, MA 02206 (617) 439-9030 IMPORTANT This application must be typed or printed and filed in duplicate with the Bureau. An original bl-fold form must be used. A separate application must be filed for each legal entity. Enclose check made payable to: The Massachusetts Workers'Compensation Assigned Risk Pool (MWCARP). Coverage will be tentatively bound provided that,upon review,Bureau Staff finds that the application was satisfactorily completed. The earliest date coverage can be bound is at 12:01 A.M.the day after the application and deposit premium are received in the office of the Bureau. Under no circumstance will coverage be bound if:payment or deposit premium does not accompany the application;the declination requirements are not met;there is a record of coverage in force for the entity making application;or,the applicant is in default of premium for prior workers'compensation coverage. The undersigned employer is unable to purchase workers'compensation and employers'liability insurance in the voluntary market and hereby applies for such insurance in the Massachusetts Assigned Risk Pool and expressly represents that such insurance is sought in good faith. Requested I. GENERA INFORMATIO Eff a Date: 1• �09 (,t NAME OF EMPLOYER (Name of sole proprietor,general partner(s)or Istee(s)must be given with the trade name of the business.) 2. 7 �� ❑ PENDING FEDERAL EMP OYERS IDENTIFICATIO NUMBER (If pe ding,attach a copy of the IRS a lication.) 3. �� v M ILING DRESS Number Street City State Zip Phone 4. 5 ��A HUSETTS LOCATION Number Street City State Zip Phone OTHER MASS.LOCATIONS Number Street City State Zip Phone (Attach separate sheet if necessary.) 6. LOCATION OF RECORV DS Number Street City State Zip Phone 7. LEGAL STATUS Sole Proprietor ❑ Partnership ❑ Trust ❑ Limited Partnership ❑ Corporation ❑ Other(explain) II. CORPORATE INFORMATION List the Name,Duties,Percentage of Ownership and Annual Salary of each officer listed in the Corporate Articles of Organization. NAME DUTIES %OWNERSHIP SALARY President Treasurer Clerk NOTE: Corporate officers cannot elect to be excluded from coverage in Massachusetts. See the Massachusetts Rate Pages for corporate officer maximum/ minimum payroll limitations. Sole proprietors and partners cannot elect to be covered in Massachusetts. �1. III. INSURANCE COMPANIES WHO REFUSED TO WRITE VOLUNTARY COVERAGE According to Massachusetts General Law,Chapter 152,Section 65A,an employer may obtain workers'compensation coverage through the Massachusetts Workers'Compensation Assigned Risk Pool if they have been rejected by two companies licensed to write workers' compensation insurance in the Commonwealth of Massachusetts. 1. Attach two letters of declination from insurance companies who have declined to write voluntary coverage. The letters must be submitted on original letterhead; they must not be dated more than sixty(60)days prior to submission; they must have original signatures; and,they must be signed by carrier personnel authorized to bind coverage. NOTE: if you are currently insured in the voluntary market,one of the declinations must be from your present carrier. A copy of the cancellation or nonrenewal must be attached to the application. ,;, 2. Have you received any offers of voluntary coverage? (Include mufti-line or retrospective rating terms.) El YES LWNO I ' IV. '� INSURANCE RECORD 1. Has the applicant previously had Massachusetts workers'compensation insurance? YES NO 2. If YES,complete the following for the most recent three years: LLI INSURANCE COMPANY POLICY NUMBER POLICY PERIOD PREMIUM /0 9 4k�f,2 3. If NO,complete: ❑ New Business ❑Self insured ❑Other(explain): 4. Former Self Insurers are subject to the Premium Determination Endorsement-Former Self Insurers-1.An audit must be completed before coverage can be bound. Refer to the Procedures Manual for details. If self insured within the last twelve months,provide the termination date: 5. Is there any unpaid workers'compensation premium due from you or any other commonly owned or managed enterprise? If YES,provide the entity name,balance and policy number(s)below. If the premium is being disputed,attach an explanation for Bureau consideration. / If an arrangement for payment has been made,attach a copy of the signed agreement. v 6. Is the employer in bankruptcy? If YES,attach a copy of the approved bankruptcy filing. \/ 7. Does this entity or any commonly managed or owned entity have operations in states other than Mass.? If YES,attach a list of employer names,states,carriers and interstate or intrastate ID numbers. 1 . Has there been a name change within the last five years? 9. Has there been a merger or consolidation within the last five years? 10. Has there been a sale,transfer or conveyance of ownership interest within the last five years? 11. Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last five years? 000 12. Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? COMPLETE AN ERM FORM AND ATTACH TO THIS APPLICATION IF THE ANSWER TO 7,8,9, 10, 11 OR 12 IS YES. V. BUSINESS OF EMPLOYER 1. Does the applicant supply employees to other businesses? If YES,complete and attach the supplemental YES NO application,Side A,and refer to the Procedures Manual for instructions. 2. Does the applicant regularly have employees supplied to them from other businesses? If YES,complete and attach the supplemental application,Side B, and refer to the Procedures Manual for instructions. 3. Mass.law provides that you,the employer,are liable for injury of employees of uninsured subcontractors. Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated I subcontract labor will be utilized during the policy term? If YES,estimate payrolls made to subcontractors without certificates of insurance. $ Transfer this amount to Section VI and identify by classification of work performed. 4. Do you use independent contractors? If YES,you must maintain documentation which supports that they are,in fact,independent contractors. If such documentation is not available,or if the designated carrier finds evidence of an employment relationship, then premium may be charged as if the individuals were employees. f , V. BUSINESS OF EMPLOYER (continued) S. Completely describe all operations of the employer by location. Also,completely describe any changes that have taken place concerning the business of the employer or the nature of the operation. Attach a separate sheet if necessary. VI. MASSACHUSETTS CLASSIFICATIONS, PAYROLLS, AND PREMIUM CALCULATIONS Payrolls of corporate officers must be included. Attach the four most recently filed Form 941's or DET Form Vs. Payrolls and classifications on the application will be com ared to prior audit and PaVroll records submitted. Describe the Duties of the Employees by Location Class Number of Total Rate Premium Code Employees Remuneration 18- nt14 S,_, Clerical NOC 8810 Outside Sales 8742 Drivers,NOC 7380 Employers'Liability TOTAL PREMIUM " Experience Rating( )or Merit Rating( ) " Massachusetts Construction Credit( ) Loss Constant STANDARD PREMIUM Deductible Credit( ) VII. DEPOSIT REQUIRED : " ARAP( ) 1. Installment Options •** Insurance Charge( 10% ) Estimated Installment Minimum Additional Expense Constant Premium Basis Deposit Payments Under Annually 100% none TOTAL ESTIMATED ANNUAL PREMIUM $5,000 At least Semi- 75% one DIA Assessment( %)of Standard Premium $5,000 Annually At least Quarterly 50% three TOTAL EST.ANNUAL PREMIUM AND DIA ASSESSMENT $10,000 At least Monthly 25% nine DEPOSIT PREMIUM $25,000 -! C 2. Enclosed is check number / in the amount of s4,5 made to the Massachusetts payable Workers'Compensation Assigned Risk Pool(MWCARP). A single check must be submitted. Any binding of coverage is based on the assumption that the check is negotiable. If the check is non-negotiable,the assignment will be rescinded. 3. Is the premium being financed? ❑ YES O If YES,then 100%of the Total Estimated Annual Premium a Massachusetts DIA Assessment must be sent with the application along with a signed copy of the finance agreement. If applicable. Refer to the Was. of the Basic Manual for Workers'Compensation and Employers' pages pe p Dyers'Liability Insurance for details. ** Applies only to Former Self Insurers. Refer to the Procedures Manual for details. i Vill. APPLICANT'S STATEMENT The undersigned hereby certifies that he/she has read and understands the statement in this application. Furthermore,in consideration of the issuance of the policy of insurance,he/she also certifies that the statements made in this application are true and agrees: 1. To maintain a complete record of all policy transactions in such form as the insurance company may reasonably require and that all such records will be available to the company at the designated address. 2. To comply substantially with all laws,orders,rules and regulations in force and effect made by the public authorities relating to the welfare,health and safety of employees. 3. To comply with all reasonable recommendations made by the insurance company relating to the welfare, health and safety of employees. This insurance is being provided through the MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL,and not through the voluntary market. NOTICE: MASSACHUSETTS GENERAL LAW,CHAPTER 162,SECTION 14(3)PROVIDES: "Notwithstanding any provision of section one hundred and eleven A of chapter two hundred and sixty-six to the contrary,any person who knowingly makes any false or misleading statement, representation or submission or knowingly assists, abets, solicits or conspires in the making of any false or misleading statement,representation or submission,or knowingly conceals or fails to disclose knowledge of the occurrence of any event affecting the payment,coverage or other benefit for the purpose of obtaining or denying any payment, coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...shall be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars, or by both such fine and i prisonment." t B`siness Name of Employer) Date Signature and Title(Sole Proprietor,General Partner,Corporate Officer or Trustee) IX. AGENCY INFORMATION AND PRODUCER STATEMENT The producer hereby certifies that the information provided,including premium information,is true to the best of his/her knowledge and belief. _ AGENCY MYCOCK INSURANCE AGENCY fj y--�5 3�S Name(Printed) P.O. Box 437 Agency F eral Identification Number ,� COTUIT SSA,.USETA 02635 _ ADDRESS U ' Str State C� Zip C e Telephone PRODUCER / "- Name(Printed) Signature Datd Agency 0cen§e h4ber MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL RULES AND PROCEDURES PLEASE READ CAREFULLY 1. Applications will not be accepted by FAX machine. 2. An additional or replacement entity cannot be endorsed onto an existing assigned risk policy as a named insured unless an application and check are submitted and coverage is assigned by the Bureau. Refer to the Procedures Manual for instructions. 3. The Pool is able to provide coverage only for Massachusetts employees. If an employer has operations in any state other than - Massachusetts,or commences operations in such state after policy inception,application for coverage for those operations must be made to the appropriate Bureau or other agency administering the Residual Market in that state,if voluntary coverage is not available. 4. If voluntary coverage has been cancelled or nonrenewed at the insured's request,the insured is not eligible for assigned risk coverage. The insured-or their agent must replace coverage in the voluntary market. 5. When a Pool policy has been cancelled twice for non-payment of premium or at the request of the finance company,the employer must reapply to the Pool for subsequent coverage after all outstanding balances have been paid. 6. Applications for joint ventures must include a copy of the joint venture agreement. 7. Payrolls and classifications are subject to review by Bureau Staff and may be changed. 8. The Waiver of Our Rights to Recover from Others Endorsement,WC000313,is available to employers who require the endorsement by contract. Refer to the Procedures Manual for details. 9. Agents are not agents of the Mass.Workers'Compensation Assigned Risk Pool and cannot issue Certificates of Insurance. 10. If you have any questions about the rules governing the Massachusetts Workers'Compensation Assigned Risk Pool,refer to the Procedures Manual. If additional information is required,contact the Workers'Compensation Rating&Inspection Bureau of Mass. at(617)439-9030 or write to either P.O.Box 9005,Boston,MA 02205 or 101 Arch Street,Boston,MA 02110. EOMON 11-95 COMMERCIAL ADDITION/ALTERATION �] Letter of Approval from Site Plan Review(if necessary) If located in OKH or Hyannis Historic District- Certificate of Appropriateness required Plot Plan Map& Parcel number Sign-Offs from: Health Tax Collector Fj Conservation Treasurer Street address of project Correct square footage Estimated Cost Owner's name & address Contractor's name, address &telephone number Contractor's signature Full sized plans, stamped plans (1 full size and 1 reduced) Workman's Comp. form Construction Super's License Check expiration date on license(00 next to restrictions) Fee q-forms-PERMITS I Rev 6/2/98 f oFIME t° The Town of Barnstable Department of Health Safety and Environmental Services MRNSTABLE,A"M Building Division 1639. A�0 367 Main Street,Hyannis MA 02601 TED MA'S Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Building Permit Procedure for Commercial Additions zoning-compliance._,. 2. Historic District Commission approval required prior to construction/demolition for any properties located in a Historic District: • Old Kings Highway Historic District(north of the Mid Cape Highway) • Hyannis Main Street Waterfront Historic District(See map for boundaries) •_ --Historic Preservation(if applicable). 3. Construction plans -one complete set of full sized plans,and on p p ed p e complete set reduced to 8:5" x 11" or 8.5"x 14"must be submitted with the building permit application. Note: The applicant must also submit a set of plans to the appropriate Fire Department for review 4. Approval from the following departments must be obtained: Health Department(3rd floor Town Hall - 8:30-- 9:30 a.m. & 1:00 -2:00 p.m.) Tax Collector(1st floor Town Hall) Conservation Department(4th floor Town Hall) (8:30-9:30 a.m. & 1:00-2:00 p.m.) Treasurer-3rd floor- School Administration Building Workers Compensation Insurance Affidavit form must be submitted for any workers hired. In the event the homeowner takes out the permit, subcontractors hired must supply his.. 6. A copy of the Construction Supervisor license is required. 7. Fee must be paid prior to issuance of permit. Note: No wall is to be covered before wiring, plumbing and frame inspections. PERMIT Rev 8/12//98 I ' I � '. '. . I �� " .- I I1. '� I I p: , . . : . . i . I I I ! ; I i t'jR . q . I I . fit,: I.. . : � d . �'% 1 .I �� 1 i � [ J� � � : . I C / N 1 ,. I .,_.I. ....I , ' i , ' i I' ;. ;... .. .J . }. I _ ' :.. , : i I i i , ( ' : 777 I :.. . , ' J , 1_: : t . 4. , .. , ...I I ., `.. . 1 I I ... f 4... : 1 l I I ; ..., : I..: . I. . �. : ' , , f : : , : , .. ... I _,_..,._.�._l_:.. > i � I J I I , ! j'_' _� _I ,�, I+ + J..; I /� . i I .. I 1 ... I -. ; i 1. I. I ' I GLl i 1 i . I I : . � ,. I i - ,. 1 : F _ S , ( .i..i ,_I : ; ... . ? ' i I i i. ,.I ;, T 0 . i , , . ..._,.... " i I i , co . , . . „ 1.11: I. . . :-.....: ,. :. i. ,.. . .. ,. .� ,.... tt ...t I .I. , I ' l I I I i. I �. 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I _ ,. ; , ► 11 ► I I t � 4if ! ! . i i � I :.ii . ..lt. 11 L..I � ' ...II : �:: ! i , . { I � ! it I i ► f f.` , ; � Ir i , I ! I 1 ' ; ! ., L. ' - . . . . . L - 7 i j I -A i Ia , I � 1 Af , 4-6 _ _ f !F FS f 1 llf 1 - - �� - � : _ �� _ -- - ._ _ ._ ._ ___ _ ___,_ _...__ _._ __ _ __ �__ _� _____._ __._ _ _ �j _ _ _ _ .w - � � .� � ��.r�,ter. �r v ��. .. �. _ �..� ..-� .s.. � +rnl...a....� t � __ �_ .. __ � �.. .� �. -� -� _ -_ {1j r .� _ � �.�+-�— .tip_�� , __ -��.� _ �.�-`- � e �� .� _. �� . _.�....� s-�_ �ll � .. .� _..�..`.. �� _ _ _ _ _ _ _ _ _ j� _ _ �� e_ �. ---._.�.._ _ � -- - - -__._.__ _+__.Y.� . _�. _ �.__ __._ �. _.. _ - ._ — — ----'— -- __ _ i�. ,. _ __._ �� is � �;' _� The Commonwealth of Massachusetts Department of Industrial Accidents "�`� '=�� Office otlnyestigatians 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit MINNIE name: 1/11�10cation: city [D I am a h vner performing all work myself. I am a sole proprietor and have no one working in amp capacity ❑ I am an employer providing workers compensauon for my employees worlung on this job. comounv name: address: ---- --- -- - city phone#- insurance cn. olicv# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compcnsation policcs: cons anv name• address: ohone#� Mr. ;> .. . insurnnce cm cam anv name, address city phone#• .. .... insurance co. Failure to secure coverage as required under Section 25A of 11GL 152 can lead to the imposition of criminal penalties of a fine up to S1.So0.o0 and/or one years'imprisonment as wen=civil penalties in the form of a STOP NVORK ORDER and a fine of 3100.00 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. 1 do hereby certify un a pains and penalties of perjury that the information provided above is true an correct signature Date Print name Phone# official use only do not write in this area to be completed by city or town official dty or town• peemtillcense# �❑Building Department ❑Licensing Board ❑checkif immediate response is required Mel Office(:]Healthfilth lth Depegartmeat contact person: phone#• ❑Other (arum 9/93 P1A) 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 cork 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 d,,e foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the receiv . rrrstee 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 ...s.e-...s,..,......t.,.n,.P�n"c rn do maintenance , construction or repair work on such dwelling house or on the grounds o: building appurten thereto shall not because of such employment be deemed to be an employer. T ant _ MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha 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 contractiaQ authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to ou davits mac be and supplying company names, address and phone numbers along with a certificate of insurance as allsubmitted 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bc=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 io not hesitate to give us a call. The Depwzunent's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Ottice of 11vesugadons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 r oiTaetp�y� TOWN OF BARNSTABLE Z 89HHSTADLE, i Mb 9 BUILDING INSPECTOR APPLICATION FOR PERMIT TO ... .4.!P?!t� .. . ........ !. ..T..l.: . . kj.gl... ...S.J.�'r': r•. �`C TYPEOF CONSTRUCTION ..................................................................................................................................... TO THE INSPECTOR OF BUILDINGS: Y The undersigned hereby applies for a permit according to the following information: Location ..rr�.�...., �c ......... .T.P�.....: ..i.. i4 E �...... .� ✓tiN..!..5....../fll:�Fes....C1 .6�. ........................................... ProposedUse ....... ./.. .sr/ .1 1 .............................................................................................................................. Zoning District ..... 95. .Fr..-Al,;—A......tq:...�9A F�.09'...Fire District .................................:............................................ 50 s 5o S C-- Li S 13 Erik"N4vovD iyr-- . ffy/f�v^iil,�yl�9SS o�Ge Name of Owner.. M,lkt.B.N.II .....5"4l.Y.. 7. 5.............Address .... SC //Y,IA'NIS 4Tg Name of Builder .,/V/.. .K........SWA.V..T Address Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ....... ................................................. Foundation aQ./.V.CAk 7.4C: .... ..... ... : .. ........................................ . Exierior ...... .�...............................................Roofing .... .5. / /QL. ................................................ Floors ....../W.0.49..Z).............................................................Interior ....i. �QD. ..., �/✓��.5 Heating l'.D G. ...1�i .sue.. i�..TFl ............Plumbing .... '..I?PAEr.Ij.. /.y.�.T. ............................... Fireplace ........Ab0..A .L:.....................................................Approximate Cost .............. Pp Y 9 ��Y---�`--.r--------19 ?l /' ,I e 'C a t.�.-4,o�•"/� e— Difinitive Plan Approved b Planning Board ___ Diagram of Lot and Buildin?, lth. Dimensions SANITARY WATER SUPPLY, SEWA�:E D�.�t(��i AND DRAIN GE 15 HEREBY APPR .'v E_D TOWN OF BARNSTABLE, BOARD OF HEALTH A LICENSED INSTALLER MUST OBTAIN SEWAGE .PERMIT, AND INSTALL SYSTEM. I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........ �� .... C�� ............................... s, Sossos, & Emmanuel Santis r r , No ....l z7S:. Permit for .......convert existing .................. 2nd floor to 2 apartments ......................................7....................................... Location ..........20..Sea Street ............................................ I!� .......................HYanni s........................................ Owner ..:........Sossos De.lis.. .. ... & Emmanuel Santis t .. .... ...... ... ................. .. I Type of Construction .............game.................. ................................................................................ Plot ............................. lot ................................ + a 4 Permit Granted 'September 28 19 72D Date of Inspection ..... 8.............19 i Date Completed ......................................19 ' A JIW�T=z PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................... . ......................... � x ............................................................................... ............................................................................... t Approved .................................................. 19 ............................................................................... ............................................................................... 00 oG a n � a a . � a Y 'n,E3E•�' T k N � T 1/i c r-oR hen Jr z = '