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0099 SEVENTH AVENUE (HYANNIS)
SEVEVT 01/09/1995 07:27 915087906230 r. PAGE 02 " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- Parcei Permit# Health Division � `'� �/ tJ 7,j - Date Issued ���03 Conservation Division hL 03 u Application Fee Tax Collector a Permh Fee � Treasurer I Planning Dept. SEPTIC SYSTEM MUST DE INSTA=D IN COMPLIANCE Date Definitive Plan Approved by Planning Board TITLE S Historic•OKH Preservation/Hyannis ENVIRONMENTAL CODE AND Project Street Address °� "✓ t c1 ?s ec k r`o R �ll eK�r{�� de cl�S• Village yvt,rt r fQ d✓�' /� je— Owner�� ► ►" pit t,A�c�T.�q Jy Address 3-z.,/- lJ/ cr? G,-z,✓� ew t Telephone S� L -7 — vh h�e-o�Q J; fyf�Z) 3 Permit Request ' t v t ;S1', V IV s/ c 4J�a r•— mac . Square feet:.1st floor:existing proposed.2nd floor.existing proposed Total new 71 Zoning District Flood Plain Groundwater Overlay Project Valuation. Construction Type x Lot Size Grandfathered: ❑Yes* ❑No If yes,attach supporting documentation. Dwelling Type: Single Faro' Two Family Q Multi•Famity(#units) Age of Existing Structure Historic House.' D Yes No On Old King's Highway:' ❑Yes Q Ne�� ✓ Basement.Type: ❑Full ❑Crawl ❑Walkout her y Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) bra Number of Baths: Full:existing _new _ Half:existing new . Number of Bedrooms: existing- 3 new Total Room Count(not including baths):existing �° `*. new First Floor Room Count,_� s- Heat Type and Fuel: Pdaa O Oil 0 Electric° ❑Other Central Air: ❑Yes � Fireplaces:Existing Zi;• New Existing wooftoal stove: ❑Yes q Nam= Detached garage t]existing,D new size Pool:❑existing ❑new si - ze Bam:0 existing ❑new size .. Attached garage:❑existing,;O new size• Shed:❑existing D new size Other: ; Zoning Board of Appeals Authorization 0,Appeal# Recorded O s Commercial ❑Yes ❑No if yes,site plan review# '' F LLA Current Use Proposed Use v BUILDER INFORMATION l-q-S/J U L-c` ,S` &/i L•cJ Name_ t.) 0 c-c_. Telephone Number `f 1 3——7 3 2- T—// t r Address 3"2_- LJI License# f A = Home Improvement Contractor# TM . Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO r}'f'i'/t SIGNA DATE Y c7 a r le A a Q1/09/1,995 14:28 915087906230 PAGE 01 • The Town of Barnstable Regulatory Services Thomas F. Geiler, Director Building Division Tom Ferry, Building Comlmissioner 200 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 w w wr Y� u■ HON.[li;OwNER LICENSt]iUMMON Please Print DAT& _ �l i -7, D� ` YOB LOCATION: 9l5 �_ ' O 1— f7 ZG 7 L number tvillage IIHONEOWNEW':._ atj 0'6 A)D LL Y`3 - 5-&7 3 7 3,- name home phone# -work phone M CURRENT MAu. G ADDPMS: 3 Z Z,// /`7f — OIIO4 _— cityhown state zip code The current exemption for"homeowners".was extended to include - ace ' d dweUjugs of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that fhe owner acts as suaervisQi. DERINTTION OF 130raOwNIM ' Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is f intended to be,a one or two-family dwelling,attached or detached structures accessory to such use aud/or form structures. A person who constructs more than oue home in a two-yeaj�period shall not be considered a homeowner, Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work DerfoMd under the buildiul;yeEnit. (Section 109.1.1) The undersigned"`homeowner"assumes responsibility for compliance with the State Building Code and , other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. w. Sig-nature of Homeowner .' Approval of Buildtpg Official Note: Three-fazruily dwellings containing 35,000 cubic feet or larger will be Tequixed to comply with the State Building Code Section 127.0 Construction Control. • H011�OW1V'�R'S MP7•TON The Code states dint: "Any homeowner performing work for which a building purrut is required shall be exempt from the provisions of this section(Section 109.1.1-Licrosing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do ouch work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see y Appendix Q.Rules&Regulations for Licensing Camtruction Supervisara,Section 2.15) This lack of awareness often results in '. k serious problems,particulmlywhen 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 U Supervisor is ultimately respanstble. To ensure that the homeowner is folly aware of hia&cr responsibilities,many conuourities require,as part of the perrtut application,that the homeowner certify that he/she understands the resportsbilities of a Supervisor. en the list page of this issue is a form currently used by several towns. You may care t amend and adopt such a fomdcertification fbr use in your community. o . 'a i. ' ✓`te �a �i a��.�G�asc�2uJe�6 BOARD OF BUILDING REGULATIONS n a art License: CONSTRUCTION SUPERVISOR Number: CS. 049505 Birthdate: 03/04/1947 } ° Expires: 03/04/2004 Tr. no: 19009 ; Restricted: 00 . _ i- DONALD G AGNOLI 32 WILD GROVE LANE LONGMEADOW, MA 01106, Administrator 00 - 35,000 cf enclosed space (MGL C.112 S.60L) ' 1A - Masonry only 1 G - 1 & 2 Family Homes Failure to possess a current edition.of the Massachusetts State Building Code is cause for revocation of this license DIG SAFE CALL CENTER: (888) 344-7233 i `�sf+,"1/ ! .ii.ice ! ,• �e�f.' �4. i J e✓ �tr + v 7,4;z�""f IM fa f �r� rf Y + f � 4 - 2 •__P' ita�a+az •.3-' ---Nlt ' � 't 9`'�i` ,'.�,_. fEjlej � 1 -i t r 11He,p Town of Barnstable Regulatory Services # Thomas F.Geller,Director MAM 9q'ATFo5.�a � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other requirements. Type.of Work: J Z� 1rL ��`'� Estimated Cost Address of Work: �"UC x� A Owner's Name: {�d�L cF �� A C�c Date of Application: AoA-,X 1( I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law []Job Under$1,000 QBuilding not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c,142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name v � „ �' t .� 'may:.•, �` a`�� �" '` ,� ~,y'~ 5 �~ �' °� � � —' � .,• r ,,,�. \W D J � _ �� —_ � i _—_-TT__ � T ,,.rci � . i _. k i �� �� tom✓ r-�� 17 1 C d '�`.. *4,.s.+�lYr. �r +a � '�`� �. �� y�y„.. • fir. � ;. v. is ,a ;;� �_ y i s. .:. �. i� � - - ��' -- ._..ir !, �i - � ,�, I --.. ',�. - z 1 � i�� ;1 .7 � - tea:.' N I i - -- , � �+Y.. '',ti{-V: .:S- LLB ., �r .� �.. r..� �X"M.h-- �.,�. yam. .:. �,. � -..w. '.:. �` ..+ a � ^i .."'i'YSS�..u� '�( a ''"ru� L#q'- ,is'M' � . w �w,+Y .;fit„y i y N , M N Y . - 00 y d m s P (�t�J PINE STREET oo N 87*32'41'Ea , 158' 1 t CA ro t tQ t 72•t O t z O #99 24•': LOTS 582 584 TOTAL AREA 12320 t S.F. C 1 150 •3 t S 87 ,3 41 'w R. THE LOCATION OF THE ORIGINAL DWELLING TOWN OF BARNSTABLE ZONING SHOWN HEREON EITHER WAS IN COMPLIANCE WITH THE LOCAL APPLICABLE ZONING BYLAW ZONE. RB IN EFFECT WHEN CONSTRUCTED (WITH RESPECT TO HOR I ZONAL DIMENSIONAL REQUIREMENTS ONLY) . SETBACKS r OR EXEMPT FROM VIOLATION ENFORCEMENT FRONT - 20' ACTION UNDER T 1 TL E V l I CHAPTER 40A SECTION 7. SIDE - 10• REAR - 10' THE LOT SHOWN HEREON IS IN FLOOD HAZARD ZONES A10 A PROPERTY LINES SHOWN HEREON C AS SHOWN ON MAP 250001 0008 D. DATED JULY 2. 1992. WERE COMPILED FROM AVAILABLE PLANS OF RECORD AND DO NOT REPRESENT AN ACTUAL SURVEY TI sV, - The Commonwealth of Massachusetts - Department of Industrial Accidents Office 811nresti9alioas 600 Washington Street Boston,Mass. 02111 Workers' Compensation.Insurance Affidavit name ce AS ii.ic location: �t�i Cv C`1 Jt —7N �qCJ C ci aL/I S r/L �Q S hone# / 7 3 2 C �] I am a homeowner perfohning all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job f IIn H xb' •s,�, r_'�Y" :"x�,'fir. '�..s16 ..s` .. ale ' T�"i'4 i gr'•L i^-,t � K 3 .:x t��".2•.: 1 _ F f�T. t%,V , N .�Yr.2k.& rw€4 � r. : �, ..ti' v yea. ,:3 s`* aF',' .� -r�a. x,�, ,s c•a a - f€ r- rzx t`a� ,};`"�'.'. ri` x� ''; �° d, Y 4 �" 2sy, .�• i5� g"' c+3, .#'x- 2 �Fr, 3t•3'�^@'�:.ti. coin an knamex � ,� � r �� sJfl ....� .,. .., ,„ �,.s. s r: z, -'x....g � wL:t^ a'x p' ::: s,I> .� �s fi „x �;' t'`- ��`t�'$t`c .Ai .q "_ j r3a� tta P qr a � fi r:7. [•r' s;; Tr s" 2z '-a.,r�,c'Ya s.'a 5 Z Y s�•� .fix s?Y L- a y j .: „Y'"'d @ :dam £;`s' ems* x� 't ' m3fK '� � ..z.x:! � mot^ xr x� x 1 `'`' 4'r) ,'.''� ¢�'�'N�e° `,•�` '�" �-x,: add�reSS � �t -r �� .--t '`,s. � s w s s ::.!f �a .d-z? . .. a,.� xv s s �' Y✓b-� , '.'�"4'`4 ?. ,� ,. >§a. yr-r• �"` Z, ''" ,, :..t..a „ `. :, J'*"a '�s�"'� ,�a 3 g'° y'^' ` a7 x: t( : IMM t'`x.�%� 'i�-q sS *n- ��ro�wr E r sx,"�R ?� ''`"x-�,,,r r •s ��x''��},. r'�K?7�i Q IlOne�# c �� ��`�,'� x'"F"is � „':�`•S^�2'� ��` a F ti'�,, e s'`-�'+"°y.. �•�'�y.�,,.� �'�v;x# �,�� -.} *k'J''S G -vs? h A ';: y""� ,�f sk r x �: ".+3 -:. 7,� 2'Sgt�yr�4'. �# �s�'�'� *�J 3�,�' .x:`?4ei•� ���r...u's�ii�':.zr�a,�a"' �� iz '� -. x .n z t'€. �. `?. z a �. _ �a � u x, �.� fiG'r-*" I am a sole proprietor,general contractor, r homeowner ircle one)and have hired the contractors listed below who have -the following workers' compensation polices: Zil xxkk°90 si g �� _,; ^5`�� x ��eAxx c}y* �#�F.J�,'��,a,� €' �Y': j lu A.y s �& �j `� 3 � r� •�� Z { �°y�,a ��: AI R c» ..,?� sF,t �.:+Y'k f}N rs --+ 3x°�y � �"� W� ,, udy�• v � � �s'.'t ¢ a L, I"� " F 6 a -- L3 � ei4x3ts IrJ+�'•a�' ,�,-r{ •cs J` aClareSS �c u-, �e,�s,���s�x`rs'�•�-��z 'a��� i � '� 3"^� � 4 I 1 rati s z xs .k+'v ' S ,x"'T ; s x.?� �. FI+ c�'��• ,�z" � �• ;a 5 �S r�x� :. v�. s� �,,�" a �, z,'.. s �a r xk s+ �?n�n��, �•=' A,�'`'�"� �t �:CItV 1c`��" t.5„ta ya �"'�5 trr34�>,`�'�5,.y; � e �' R )� im'�' y .'(�QIIOn@ Yf .rC iJ,. 1..^+n a 'r.•t��.54 � f`'�x a4«mS'si 1 A x`�he G'�n�xS,�.�d 'air,--'� r ru..��.r'+ ,a��X^u��. r'{�,x, y k .r xy �-z��"� €7: �:i h'' .Ys-"� �`a.+ ? .`-`,' •r J".>., � fix �'�� k "� �s €InSUranCe C04�tr -§^".�.�at�z z .�' �-•i�a .,x..Y s A r"$,dy x � r OIICy'•# x.; sy _c a:`axY x:.s',� :,`F»a- :�x:�ri�- ": ".�_x=.�`%.ea � fi'� rla ,�.� : ; :>^. 'a'oir.'"F =� . . 5 t r '? ., COm an name n�3 �� ��� _ t x �k, �a rara- ^sa';r.: �" "�'�' a° �tit• �"' � x r-p^-• ». 'T'"" '�'°S�v '� `x 3 'R _,� :' E : t� xrs 4.T��„;+ka'�'�t.:u�'�`sk`�R3 3 sx <ti�.+r"'>�'��.•saec .. ,x.,��.c:*'� <"'r-�e�m-�``"�'s�'� .. ,v..rr- eta x�... >t�"na.���` �e�� �"^� '...�".ate �,'t 7�°°�,,.: "'r'� ate- a .-Ev,�t�'s'���.�za'" �; '� x�sxk'h��s.•,�'`max }•"'�,-�€�4S3yx�„ , .�§���` f�"�'3-��r�r '� fkz� s. '.`T:S:T�' a -FS„�� a J<z�r,�Z�`�t�zx'^.x�" gx-fi � s ;�,..�� .� m� �s �,„n 5��. �s k:,.�' '�':•`^^»�e„t„ �' s, ' 3 r #.T-r c r - t 5 fx -» € t n sx,x� .. ,'`x. .Fk � -•v F' �,an�.d�t'€�,f '�� as �.� � "'�`` '�`�x'� t v "s � ,h r�w��L,�i� �, 'X;£� 7 'mr��`--s •a t§J Y� � ,L�"�f�Yr;i� s� �`�YTy a,°» �,ra?�'[��i�� � y? .liisuranc �CO�"a ays.�"5, � .��,d,� c r � a x s � f g r s -.rF- � 1 d POIICrV.#. .:z#.a�e.:�s.�. .z. t."'�,,,.•,�a.a� Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/ar one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Signature Date Print name I Phone# t� —7 3`Z official use only do not write in this area to be completed by city or town official city or town: permit/license# nBuilding Department ❑Licensing Board check if immediate response is required [)Selectmen's Office []Health Department contact person: phone#; nOther (revised 9/95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out.in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the i Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. iggging: gm! i INNER,, _. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406 SAGiFAX 4 11 103 10:41AM JAN4ESWI3UWNaMIk 3NS AUIVJI PAGE 1 ,, CERTIFICATE OF LIABILITY INSURANCE 04;;,iQ3°`"n PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION James J.Dowd&Sons Ins ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 14 Bobala Rogd HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O.Box 10300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Holyoke,MA o1041 INSURERS AFFORDING COVERAGE INSURED - INSURER A:Travelers Agnoli Sign Co.,Inc. INSUR ER R:Safety Insurance Company 722 Worthington Street INSUR ER C:RLI Insurance Company P.O.Box 1013 MINSURER D:A,I,M,Mutual Insurance Company Springfield,MA 01101 NSURER.E COVERAGES THE POLICIES OF INSURANCE LISTED BELMIV 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 AFFORCED 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. INSRI j IPOLICYEFFEGTIVE-POUCYEXPIRATION LTR TYPE OF INSURANCEPOLICYNUMBER DATE(MM DD DATE MM DD LIMITS A GENERAL LIABILITY Y630298X2220TILD2 06/21/02 06/21/03 .EACH000URRENCE $1000000 IX E--DI,UIERCALGENEHAL!IABILITY FIRED iAMAGI(Anyonefire) $100000 CLAIMSMADEaOCCUR� - IEXP[Anyonepersonj $5000 _ PERSONAL&ADVINJUR $Y 1d00,000 J �GENERALAGGREGA?E T$2 000 000 -_ GEN'LAGGREG ATE IIMITAPPLIESPER!II (PRO DUCTS-CO MPJOPASGi$2,000,000 POLICY PRO- LOC - r JECT B AUTOMOBILE LIABILITY 11601163 06/21/02 06/21/03 OMSIdNeED SINGLE LIN41T $1,000,000 ANYAUTO ALLOWNEDAUTOS ?ODILYINJURY $ X SCHEDULED AUTOS ( erperson) X HIREDAUTOS - ' I - � 90 DiLYINJURY X NON-OWNEDAUTOS (Peraccideri $ — X Drive Other Car PROPERTY DAMAGE $ (Per accident) GARAGE LIA811 AUTO ONLY-EAACCIDENT $ - ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ C EXCESS LIABILITY ER00006354 06/21/02 i06/21/03 EACH OCCURRENCE $5000,000 X OCCUR CLAIMS MADE Umbrella Form I AGGREGATE $S 000,000 $ DEDUCTIBLE $ X RETENTION $10,000 - IS D WORKERS COMPENSATION AND 8003518012002 06f21/02 O6/21/03 X IVI TOFYS�-MITs °Fa EMPLOYERS'LIABILITY E.L.EACHACCIDENT $1000000 4-A.DiS-EA3E-EA EMPLOYEE $1,000,000 -__ E.L.DISEASE-PDLICYLIMIT $1,000,000 OTHER - - DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BYENDORSEINENTJSPECIALPROVISIONS - - RE: Job by James Denman CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: CANCELLATION SHOU LDANYOFTHEABOVE DESCRIBEDPOLICIESBECANCELLED BEFORETHE EXPIRATION Town of Barnstable DATETHEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAILID—DAYS WRITTEN 200 Main Streel NOTICETOTHE CERTIFICATE HOLDERNAM EDTO THE LEFT,BUT FAILURE TO DOSOSHALL Hyannis,MA MPOSENOOBLIGATIONOR LIABILITY OFANYKIND UPON THE iNSURER,ITSAGENTSOR ; REPRESENTATIVES. AU-HORIZED REPRESENTATIVE ACORD 25•S(7�97)1 of 2 #S39179/M36097 CJS 0 ACORD CORPORATION 1988 SAGIFAX 411103 10:41AM JAMES J.DOWD&SONS INS PAGE 2 4 . 1 cr � IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded bythe policies iisted thereon. ACORD25•S(7/97)2 of 2 #S39179/M35097 Assessor's offioe (1st floor): Assessor's map and lot number` ......a MUST BE `pFTNETOE. �lC EYSITEA� Board of Health (3rd floor): 3 ��' y - �4TALL.ED IN COilAPL1AQ°'D . Sewage Permit number ............:......'...... ...1..�. ....,... : BasasTsnts WLgN an 5 t Engineering Department (3rd floor): g C) s , �E `'►o E AND, soo rnsa House number. ................................................�,.. .,.............. _ V1RC �Fp ORh�eO� EGULAT APPLICATIONS PROCESSED '8:30-9:30 A.M. and,1:00-2:00'`P.M.+onnlyy;.TOWN f1__ IQ�S A P P R 0 V N lOF "-BARNSTABLE B rnst ble Conservatfon'eom ssYbn UILDIHG INSPECTOR S fined Date _ ll APPLICATION FOR PERMIT TO ......: .... ............................ %Z.............. TYPE OF CONSTRUCTION r .... ........... / ..'.. .....19.'c5.6 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......�0:l......`J�� ,fps .-?........ . . ..............c .,...:..1� ,r ww.f �..�z.. Proposed Use •...... /..: },/ N.1. .` )..k�.l .../........ .. t� .!>1............. "ZoningDistrict ......Fire District (10.:..... j j Name of Owner -?.f.�.l. !. Q � �c��N..........Address �j/�. 7%.... L1�1�/�i. ........ y. .. .. �.t�... v;i ?.. 7.r...G....../..t.�............. Name of Builder 'RL......m:.11.1V.C�.tq.&.e.09..4)...........Address ....�r..�J.:.....Wf..f...n!1!9l/v.`.... ........!//119 ftiJ Nome_of Architect ........:...... .. . .....���/i k)k)—? 1i441/9 cldress A..f..%m.t....��.��7.�t�/�1�9.��Q.��...!Y..r//IC73Z Number of Rooms ....... .......................................................Foundation ...... . . .. . ...... ....:r....:Aj/ .'..... Exlerio �`a. . �'� J _ . � r ...t(,'.. .� �..� .��........cS.h.F.!t).44.iv�..s............Roofing ......A.�:.�1-�.��. / _ Floors .......V..l.{�y..L...............................................A........:....Interior ........�,-S. '1 k Heating .... ....................................................Plumbing .... i.G. ,S �2 ...:..� L. �; , R Fireplace ......r... . .. ......�.I�G....r�1.�..� ?�,1� .�..)�..Approximate Cost .............. ... �. Definitive Plan Approved by Planning Board---------------------------------19 Area �. ... . .. r......... .. Diagram of Lot and Building with Dimensions Fee ".:,.,! c.............................. SUBJECT TO lAPPROVAL OF BOARD OF HEALTH 1 5 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS4 4 I hereby agree to'conform to all the Rules and Regulations of the Town 0 Barnstable regarding the above t construction. 17 Name .. ...fCr7 � ... Construction Supervisor's License .. .(,}�,/.�/!.�..... J y JORGENSON, WILLIAM � ��?,•_ gar n � � � 30347 AID D DORMER - E No .............:... Permit font'........ "t Single 'Fami1 D ding - ,} ..............................Lot, #f82-58.4�, .9.9...,7rh Avenue 4 LocationI. ... ................. r , West' Hy;innisprt `Y +... '.f......... ..... ...... .. ......,.......... Owner .Wil'liazn `Jorn�on` ♦ L a '�^ j `J e of Construction Fume c T £ YP uc on : .:,>,......... ............ x,. . 1 ...................... ............ r.................. Plot .. ..... ........... Lot ............ .......... r - -P_ermit.Granted ....... .......-19 87 sT Date ofrhspecfion'/G f!L. ' . .. ...�19�7 Date Completed .... ............—L")...............19 - ` 4'f � .+ •^ `� { .{�• Jam,,.. - - � r . Assessor's offioe (1st floor): oFTNEro Assessor's map and lot number ..... ....)_:7. .-+�s7...(L,./� Q� �♦ W o Board of Health Ord floor): 3 8 R' Sewage Permit number ......... - ! BAMSTLMLE, S Engineering Department (3rd floor): 1639, 0� House number ........................ y 't0 MAI y� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00'P.M. only tea TOWN. OF BARNSTABLE.� ,,/�UILDIHG INSPECTOR APPLICATION FOR PERMIT TO \ .............. TYPE OF CONSTRUCTION .............. C.�1.?�.(.).... ejF9.,d9M,155 .................................................................. fa _ T ............ ....---------------19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information:-- r' Location ...... C� ,,-� Z./� � �..T`t.....�� ��..................(1.9....../� .1.:S..u�-��./Z...�............ Proposed Use .��r. `%:f //�\.( 1.A) z.).1.. ....... za.n... ........... ............................................. - Zoning District ..... ...............Fire District ...�.A�.r.....�!.. / !�)i��./... ..I[✓�.�.1.......:. ..........-....................................... '+ Name of Owner W.(41.1.0.m...T10.17 ..e AA ..S.01.U...........Address',?o... ....../2/)...... Q. fsf�lL/�rl/N Name of Builder .RL.......R,). .O.A.)C.. L.9.4)............Address 3......(.o. ...�.�!(C)...���.......�/ = '-''Name of Architect s`�9�"'���1 5/OA�..I..'!.%,1.`1.1.9,5Address ��.X..�. m.e.....���.�.��Fryl�.d11��QR�y../l`�'�/ICJJ�z < ,. Number of Rooms A Foundation .,.. .. _ ........,.. .... ........................M/ ..... Exierior ..(1.. . .!7�z....cer�� �.<4......� Roofing ......!���..It N9.�:�:..':.................. .. . J c / Floors ...... 00././..............................................................Interior ....... .......................................... Heating ....................... ........................Plu Bing:.... . .;,.�5: .....`��1 �-"`. ...................._. _ - Fireplace ...............,;:....._.........�7+5....('�1J�. �1 >�E�l..:i�...Approximate Cost ........._. Definitive Plan Approved by Planning Board --------------------------------19-------- , Area 'p.-Cre. `..� Diagram of Lot and Building with Dimensions Fee . ✓.!.. ........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH X= OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name2.. ..... .� ....... ,... ar..............: ...... Construction Supervisor's License .!!.n.�z,G�../............ JORGENSON, WILLIAM A=245-057 S i 30347 ADD DORMER No ................. Permit for .................................... Single Family Dwelling .......................................................................... Location ..,Lot 582-584 99 7th Ave. ......................................... .................... HXannis�ort .......................... _ Owner ...William Jorgenson ............................................................... Type of Construction ...Frame ............................................................................... Plot ............................ Lot ................................ January 5 , 87 Permit.Granted ........................................19 Date of Inspection ....................................19 Date Completed ......................................19 i Town of Barnstable REcEiPT ' KASSsec 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit ' Application No: TB-18-2450 Date Recieved: 7/30/2018 Job Location: 99 SEVENTH AVENUE(HYANNIS),HYANNIS \� Permit For: Building-Siding/Windows/Roof/Doors f Contractor's Name: STEPHEN T DICKINSON State Lic. No: CS-081843 Address: Plymouth, MA 02360 Applicant Phone: (508) 676-6820 (Home)Owner's Name: DURCAN,JOHN J& MARTHA L Phone: (781)438-5471 (Home)Owner's Address: 14211 HELMSLEY ROAD, MIDLOTHIAN VA 23113 Work Description: 5 replacement windows no structural Changes U.factor 0.27 10 a Total Value Of Work To Be Performed: $10,271.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. i Signed: Stephen Dickinson 7/30/2018 (508)676-6820 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost: $10,271.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $52.38 ' VW2018 $52.38 roc-XXXX- -_,, Credit Card 1 7597 ........ ......... :.. Total Permit Fee Paid: $52.38 r E x THIS I NDY"A PER ITv 4 /c7 �ME Town of Barnstable '°Permit# �—1 Expires 6 monthsfront issue date 'Regulatory Services Fee + IiARNSTABLE, • \,pn�o' �'ebp 1M"� Richard V.Scali,Interim Director p 9 TO nn �� Building Division �6\4om Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 = \� www.town.bamstable.ma.us Office:. Sfl8 862-4038 Fax: 508-790-6230 ' EXPRESS PERMIT APPLICATION - RESWENTUL ONLY 2 �0`� Not Valid without Red X-Press Imprint Map/parcel Number_ Property=Address zeUPi1�t� A e-- ( Residential Value of Work S ._ y��. Minimum fee of 535.00 for work under$6000.00 Owner's Name&Address T pr C- b 1 ,&A-N Contractor's Nam eT E 6T pwRl o- Tele hone Number 711.6.3 f - p l Home Improvement Contractor License f(if applicable) %o/z 7 _ Email: Construction Supervisor's License#(if applicable) d 7 / Zy 7 a T Workmtin's Compensation Insurance dd \\ Check one: ' ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name I�/�T�/f/i� �/Vlo Ili Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each p mit. y Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side . = Replacement Windows/doors/sliders.U Value (maximum 35),if of win T of doo _ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Wheie required: Issuance of this permit does not exempt compliance with other town department reeulations,i.e.Historic,Conservation,etc.. `'Note: 4' WMRES'S.d0C er must sigh Property Owner Letter of Permission. Home Improvement Contractors License&Construction Supervisors License is SIGNATURE: Q:IWPFILESTORMSIbuild _ Revised 0613131 The Commonwealth of Massachusetts A Depai tment of IndustrialAccidents Office of Investkations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information l Please Print LeVjbly Name (Business/Organization/Individual): Address: City/State/Zip: kA o 30;?'s Phone#: � - Are you an employer?Check the appropriate box: Type of project(required): 1.El am a employer with 4- El am a general contractor and I employees(full and/or rt-time). have hired the sub-contractors 6: New construction pa 2 I am a sole proprietor or partner- listed on the attached sheet i 7. ❑Remodeling ship and have no employees These sub-contractors have g• 0 Demolition Working for me in any capacity.. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. EJ Building addition required.] 5. We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall 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' 13.0 Other comp. insurance required.] Any applicant that checks box#1 must also Lill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all.work and then hire outside contractors must submit a new affidavit indicating such. + #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees;they must provide their workers'comp.policy number. . I am an employer that is providing workers'compensation'irisurance for my employees. Below.is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.-#: ` Expiration Date: .t Job Site Address: City/State/Zip At a copy of the Workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder 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 fof insurance coverage verification. I do hereby cg under the pains and penalties of perjury that the information provided ab ve is true and correct Signature. Date:... . 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SPECIAL SERVICES CUSTOMER,INVOICE Page 1 of 15 NO. H2612-67254 Store 2612 HYANNIS Phone:(508)778-8948 65 INDEPENDENCE DRIVE Salesperson. RHP4LE HYANNIS.MA 02601 Reviewer,VXG1123 Name _ Phme I - REPRINT DURCAN JACK {781)439-5471 Ad'— 99 SEVENTH AVE WEST HYANNISPORT MA 02672 Camyary Name W N Cty HYANNIS Jcb DwApraa patio door install CT) 2018-03-02 09:08 �...............-. ap— .g��.. ....�..,,.�.�.�«.,. :02672—..,...co-,oy,......BARNSTA6LE..... ..-.r....�,....,..._...,..,. m MA m N - N We reserve the right to limil the quart5[ies ot merchandss m MERCHANDISE AND._�, 4 , -_ SERVICE SUMMARY smiocustemers _: � z _ .�;t. co °"'#' ' REF# W33 SKI#0000-615-664 Customer Pickup!Will can S.0.-MERCHANDISE TO BE PICKED UP: 510 ANDERSEN REF# S21 ESTIMATED ARRIVAL DATE: 03126/2018 19224 w Ld LOGISTICS _ H ._._•�'-_;. �.:. .:-gym-:-:.. _ ... :._ _ _ .-._` ..LU :`�S',x`..`.=z'•. a5`..:_>:^i - --c. nY,ris:_. _- _ "' - .yA�•r�+'.'` .Y_ _ -seer-- O:..C'-'�'r-.r'�:._v-._ _'s _i_;�-a'.. LU 52121——1i700=0t2`-869 2-0 EA NA7 200 S£RiES-PS PATIO DOORS 2 PA111ESTAT t 200 SERIES-PS A42:98 $685:56 PATIO DOORS 2 PANEL#1 S2122 1000-012-809 2,00 EA NA I(CONTINUED)/200 SERIES PS PATIO DOORS 2 PANEL(CONTINUE Y $O.OD K=TRIBECA-WHtT ALOOKUPEXTERIORTRIMSET- 2=NONEALOOKUPINTERIORTRIMSET-2=NONEALOOKUP DP UPGRADE=YES^LOOKUP GLASS TINT=NO TINTALOOK TYPE=NO GRILLE(S)ALOOKUP GRILLE PATTERN= UP GRILLE BAR WID S2123 1000-012-809 2.00 EA NAJ(CONTINUED)t 200 SERIES PS PAT PANEL(CONTINUED) A Y $100 625^ LAB HEIGHT=76.219A$WQ$- YESA$SU$=RIGHT _... . GLASS$$1A$WPROP$�WDIM PAAME-WIDTH—OACOMMON - .... ... _. _..,.. _ . FRAME HEIGHT=0AFRAME E=DAGLASS WIDTH=31.SADISPLAY TH=31,501GLASS HEIGHT=72ADISPL S2124 1000-012-809 2.00 EA NA J TRIM SET 1 P ATIONARY-SIGHT TRIBE 1200 SERIES PS A Y $46.05 $02-10 PATIO DO LATT TO #1 :S2125 1000-012-809 2.00 EA NA!PA FT SLAB PS51168 STATIONARY-J 200 SERIES,PS A Y $316:20 $�636.40 D RS 2 PANELATT TO f#1 .►Ci�NtDI?k111 E:**" t.�-(iAlt.r1�E{�t�it P -- - Will-Call items.__ n me�to�for 7 aayg oniyW.:� --' Check your current order status ionline at - www.homedepot.corn/orderstatus '? -Aft. A rt C)isltm 1o.7ri� Page 1 of 15 No. H2612-67254 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE•Continued Name: DURCAN " Page 6 of 15 No. H261 -6724 AU WANT 0 .1.1 REF#102 f.. v .,. DURCANJACK INSTALL LABOR CHARGE. 135.Oi .. ~�-1I1�? - ADDRESS: 99 SEVENTH AVE WEST HYANNI SPORT MA 02672 TRIP CHARGE: $0.00 CITY: HYANNIS STATE: MA 21P: 02672 CREDIT FOR DEPOSITIMEASURE: $0.00 N B COUNTY: BARNSTABLE SALES TAX RATE: 6.250 TAX: Merchandise-Y LAOR- N 135.U1 a; PHONE: 781 4395471 ALTERNATE PHONE: 81 4395471 BASICINSTALLATIO>1t L''ABQR`INCLUDES�._-..........._,-y..,.—...�......,.,_.....�....,.�...,.w.w,.,..�.._ -...�.,,. .._�.�..,M,.....,�..,�.,w... �..,................: ARRIVE AT JOBSITE OM DAY OF INSTALL AND LEAVE WITH CUSTOMER. POSTAGE AND ADMINISTRATIVE). N OR INSTALLER.IF DELIVERED TO INSTALLER,THE INSTALLER WILL FEES,ENGINEERING,WIND LOAD CALCULATIONS,RECORDING. mPICK UP FROM THAT MUNICIPALITY AND DELIVER TO EITHER JOBSITE •ALL FEES ASSOCIATED WITH OBTAINING PERMrT(MUNICIPALITY m 'DELIVER COMPLETED PERMrT PACKAGE TO PROPER MUNICIPALITY, m SPECIAL NOTES: Iq •CUSTOMER IS RESPONSIBLE FOR PAYMENT OFTHE PERMrT.ONCE IN FULL.NO REFUNDS ON PERMIT FEES AFTER 72 HR5.OF PAYMENT. > THE PERMIT IS PAID FOR,WORK ON THE PERM IT ASSEMBLY BEGI NS W IMiAEGIATELY.CANCELLATIONS WITHIN 72 HRS.WILL BE REFUNDED _ _= Isla--�'a-.r TOTAL CHARGES OF ALL MERCHANDISE & SERVICES Policy Id(PI): $6,194.16 A:90 DAYS DEFAULT POLICY; SALES TAX $274.01 TOTAL $6 468.17 BALANCE DUE 4 403,56 • PAYMENT TERMS Refier to the Horne Improvement Agreement for _., _._._ ..... _...__- _ p Ag payment terms 'The Home Uepnt resetws Me right to limit/deny netums Please seethe refum policy sign in stores for details' :::.:•`.t- i,�iF. -�71�I ` L�i� .�2 Co k 4-y-cL�v- e PU-c Page 6 of 15 No. H2612-67254 Customer Conv - k - fi0i s b;_ _�t a•: CS-074247 PAUL M DOWNING .'t90 KESWICK GOAD BROCKTON AAA 02302 t y�y j Ey / Commissioner : '. �0,�& I (i.E 3(' l( sC�'C12-.{}.Q' ti Office of Consumer Affairs and Business Regulation =s 10 Park Plaza - Suite 5170 -- Boston. Massachusetts 0211 Home Improvement Contractor Registration -;ype: Suppiernerlt Cart Registmtion: ,12-85 Expiration: 04122,'2012 HOME DEPOT USA INC 2455 FACES FERRY RD C-1 y HSC A.TLANTA,GA 30338 Update Address and return card. Mark reason for chance. E] Address ` Renewal a Employment ❑ Lost Care _ pT{,ce of consumer Affairs&Business Regulation Registration valid for individual use only ` before the exPiratwn date• p fount return to: HOME IMPROVENENT CONTRACTOR TYPE:SUDDlement Card pfFiee pf Consumer Affairs and Busness Regulation Resoisirabon gyp'--=at'—n ' ?0 Park plaza.SurtE E17G _ _?g 04i22'20?P Boston,NSA 02116 40ME DEPOT USA 1NC i \ d .,thou signature ANDAEAti'-FEARy.RD C-1ET I HSC 2455 PACE. UndersecretaN ATLANTF. GA 30339 I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a et, Suite 100 1 Congress Stre I=! Boston,M4,02114-2017 � >` www mass.gov/dia Builders/Contractors/Ele umbers Workers' Compensation Insurance Affida�it: Please Print Legibly A, licant Information Name (Business/Organization/Individual): The Home Depot At-Home Services Address: 908 BOSTON TPK Citv/State/Zip: SHREWSBURY: MA 01545 Phone.#: (508) 942-6942 Are,you an employer? Check the appropriat b x: Type of project(required): 200+ 4. 1 am a general contractor and 1 6 []New construction [1-2. _l am a employer with have hired the sub-contractorsemployees (full and/or part-time).* 7. Remodeling listed on the attached sheet. ❑❑ 1 am a sole proprietor or partner- These sub-contractors have 8. ❑Demolition ship and have no employees employees and have workers' 9 ❑ Building addition working for me in any capacity. comp. insurances [No workers' comp. insurance 5 ❑ We are a corporation and its 10-❑ Electrical repairs or additions required.] officers have exercised their 11.❑Plumbing repairs or additions .El am a home o�mer doing all work right of exemption per MGL 12_❑ Roof repa s myself. [No workers` comp. c. 152; §1(4),and we have no 13Other r insurance required.] + employees. No workers' comp. insurance required.] *Any applicam that checks box i l must also fill out the section below showing their workers`compensation 4policyf ation. t Homeowners who submit affidavit hed an additional sh et showing the name of the sub oing all work,and then hire outside contracton and state whether eor note those�entitie have Contractors that check this box mP. olicy number. employees. if the sub-contractors have emplovees,they must provide their workers con p rance for mh employees. Below is the policy and job site I am an emplover that is providing workers'compensation insu information. — NATIONAL UNION FIRE INSURANCE COMPANY insurance Company Name: Expiration Date: 03/01/2018 Police# or Self-ins-Lic.#: XWC 65831 45 (OSI) _JW__ ExP �'/ D City/State/Zip:1V`q#nnl Sr yr+t '" Job Site Address: Attach a copy of the workers' compensation policy declaration pag c. e(showing ead to theoimpositionot criminal penalties of a Failure to secure coverage as.required under Section s w ofM fine up to$1,500.00 and/or one-year imprisonment as ised that a coell as py ofthiil nstatement may be forwarded ttes in the form of a STOP o tthh O�ceoff a fine of up to S250jerft:ft e violatoce r. Bye verification. p Investigation e�ef perjury that the information provided abo a is tr a and correct I do hereby cins a d Date: Sia-rtature: " Phone#: official use only. Do not write in this area,to be completed by city or town official. Permit/License# Cite or Town: Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PlumbiEng ] 6.Other Phone#: Contact Person: DATE(MMIODNYYY) ACO II CERTIFICATE OF LIABILITY INSURANCE FZ1712017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemer i. CONTACT PRODUCER NAME: MARSH USA,INC. PHONE Exth FAX ac No "NO ALLIANCE CENTER EMAIL 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC 0 100492-HomeD•GAW-17.18 INSURER A:Old Republic Insurance Co 24147 INSURED INSURERS:A9n General Insurance COmDany 42757 THE HOME DEPOT,INC. New Hampshire Ins Cc 123041 HOME DEPOT U.S.A.,INC. INSURER C 2455 PACES FERRY ROAD INSURER o BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: I COVERAGES CERTIFICATE NUMBER: ATL-003746387-14 REVISION NUMBER:2 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. ILS�R POLICY EFF POLICY XP TYPE OF INSURANCE 1 POLICY NUMBER MMIDO MMIODIYYYY LIMITS A X COMMERCIAL GENERAL UABIUTY MWZY 310022 0310112017 . 03/0112018 EACH OCCURRENCE s 9,000,000 CLAIMS-MADE X OCCUR _ aREMI5ES1Ea occurrence) S 1,000,OOD LIMITS OF POLICY XS MED EXP(Any one person) s EXCLUDED OF SIR:81 M PER OCC PERSONAL&ADV INJURY s 9,000,000 �GENL AGGREGATE LIMIT APPLIES PER: I I �GENERAL AGGREGATE s 9,000.000 X POLICY PE O LOC I PRODUCTS-COMPIOP AGG I S 9,00D,000 S OTHER COMBIN D SINGLE LIMIT I S 1 000 000 MWTB310021 0310112017 0310112018 A � AUTOMOBILE LIABILITY I Ea acudenl X ANY AUTO BODILY INJURY(Per person) S LLOWNED SCHEDULED SELF INSURED AUTO PHY OMG BODILY INJURY(Per accident) S AUTOS NON-O`NtJED i PROPP}2TY'DAMAGE S HIRED AUTOS I AUTOS fPer acatlent I S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS L1AB CLAIMS-MADE AGGREGATE s DED RETENTIONS I S B I WORKERS COMPENSATION WLR C49112300(TN) 031012017 0310112018 X I STA TE ERH C AND EMPLOYERS'LIABILITY YIN INC 023102423(AK,NH,NJ,VT) 0310112017 0310112018 E.L.EACH ACCIDENT s 1,000,000 ANY PROPRIETORIPARTNERIEXECUfIVE N N 1 A C OFFICERIMEMBER EXCLUDED? ❑ WC 023102424(WQ 03/0112017 0310112018 E.L.DISEASE-EA EMPLOYE S 1,000,000 (Mandatory In NH) 1,000,000 It yes,tlesaribe wider Continued on Additional Page 1 E L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i AGENCY CUSTOMER ID: 100492 LOC#: Atlanta AC`ORE) ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY - NAMEDINSURED . MARSH USA,INC. HOME DEPOT U.S.A.,INC. OIBIA THE HOME DEPOT POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA.GA 30339 CARRIER NAIC CODE EFFECTIVE DATE ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensalion Continued: --Carver:I�mnily Insurance Company ofNor�4r7trnenca -- Policy Number.WLR C49112294(ALAR,FL,ID,IA,KS,KY,LA,MS,MO,NE,NM,ND,OK,SC,SD,WV,WY) Effective Date:0310112017 Expiration Date:03/01/2018 (EL)Limit:S1,000,000 Carries.New Hampshire Insurance Company Policy Number.WC 023102422(DC,DE,HI,IN,MD,MN,MT,NY,RI) Effective Date:03/0112017 Expiration Date:03101/2018 (EL)Umit S1,000,000 Cartier.ACE American Insurance Company Policy Number.WCU C49112282(OSI)(AZ,CA,IL NC,OR,VA,WA) Elective Date:03101 P1017 Expiration Date:0310112018 (EL)Limit$1,000,000 SIR:$1,000,000 SIR for the states of AZ,CA,IL NC,OR,VA,WA Cartier:National Union Fire Insurance Company Policy Number.XWC 6583144(OSI)(CO,CT,GA,ME,MI,NV,OH,PA,UT) Effective Date:0310112017 Expiration Date:0 310112 01 8 (EL)Limit:$1,000.000 S1,000,000 SIR for the states of CO,ME,NV,MI,OH,PA,UT S750,000 SIR for the state of GA $350,000 SIR for the state of CT Cartier.National Union Fire Insurance Company Policy Number.XWC 6583145(OSI)(MA) Effective Date:0310112017 Expiration Date:0310t11018 (EL)Limit S1,000,000 SIR:$5M,DD0 TX Employers XS Indemnity: Carrier.loinlos Union Insurance Company Policy Number.TNS C48613202(TX) Effective Date:03/0112017 Expiration Date:03/0112018 (EL)Limit.S10,000,000 SIR:S1,000,01)o ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD rTy �� Town of Barnstablei in � 11 Post This Card So That it is Visible From the Street-App'roved Plans Must be Retained on Job and this Card Must be Kept Posted Until Final Inspection Has Been Made. ti°off ta39 ate® o r+ Where a Certificate of occupancy is Required;such Building shall Not:be Occupied until a Final Inspection has been made., Pernift Permit No. B-17-3566 Applicant Name: RETROFIT INSULATION, INC. Approvals Date Issued: 11/06/2017 Current Use: Structure Permit Type: Building- Insulation- Residential Expiration Date: 05/06/2018 Foundation: Location: 99 SEVENTH AVENUE(HYANNIS), HYANNIS Map/Lot: .245-057. Zoning District: RB Sheathing: Owner on Record: `FOX, MICHAEL M & MELISSA A TRS Contractor Name: RETROFIT INSULATION, INC. Framing: 1 Address: 14211 HELMSLEY.ROAD Contractor.License: 160461 2 MID LOTH IAN,VA 23113 Est. Project.Cost: $8,671.00 Chimney: Description: Weatherization Permit Fee: $94.22 Insulation: Project Review Req: Fee Paid`. $94.22 Date: 1 Final: 1/6/2017 ... Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from.access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call inspections Required for All Construction Work: Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to'iovering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the Various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Lis Parcel_057 111' ? r. 1-1 A � T��� Application # Health Division { Date Issued I I 17 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board i fN1 Historic - OKH _Preservation/ Hyannis Project Street Address Q Qq /VJ-� Z P9,� U.), \Lk- A NNl p1I C,o Village Owner Address �Q,J n Telephone /_l -2�( � y.� 9 `�`' / w. (-S-4 AA)N ti V- ��f Permit Request C_U r Si l , ry c CZ-) Door SL. ►c—a 103 � r`1 6 -� # cZ �s') 2 2 r y; V 3 a.40 —_J� I PR e ,vk r C t c� v,,, e .,� t - )-1 C 5 cz-3r.�-_6 Cc n r,�-x PO 0 � It- Square feet: 1 t floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuati (�'7 oConstruction 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 C'Icl Cj Telephone Number Ci — C y� Address O 3� License # 7 ) J A GA 7 7 I Home Improvement Contractor# L U y 6/ Email C►�M�1.. ��orker's Compensation # V ! 2 U ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C � f SIGNATURE DATE 4 _ i FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED s MAP/ PARCEL NO. _ I ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE 1 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t, The Commonwealth of Massachusetts = W Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 :- �, www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):RetroFit Insulation Address:PO Box 105 City/State/Zip:Seekonk, MA 02771 Phone#:508-989-6436 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 10 employees(full and/or part-time).* 7. ❑New construction 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.O I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.[:]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.D We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[E]Other Weatherization 152,§l(4),and we have no 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Star Ins. Policy#or Self-ins.Lic.#:V9WC802160 Expiration Date:8-2-18 Job Site Address:99 Seventh Ave City/State/Zip:W• Hyannisport, MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t s and penaltiiels of perjury that the information provided above is true and correct. Signature: Date: Phone#:508-989-6436 Official use only..Do not wrz ' ' area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: s � t sk too TOW" erry'Wl,ldstx c prnrn s on r ` _ '�vtr�v 1pvun ba bte. n� WIN .' ., s xr aRetrofit Insulations 3 � xi rk au or d.b t As nie t a p3ic� wfar:: too ntz r � r } y ''f; F _a e, cry cl ,f f ass Opmta'k _ sa.. Y WE 7271, WS W5, yj , cow, Y ' • ' ��I Y./ � ,V�/fir/��`i.!I/jlI�/�/,�l/r^P//�1/��D�L.V W�/ Office of Consumer Affairs and Business Regulation 10 Park Plaza:Suite 5170 Boston,Mas efts 02116 Home i1proYment Reestratjon Registration:lk" 16046� I ,.,1 =: Type: Private CorpwMan jti i = ;` "" yf 6spirmen: Trmo16, T1 2691e4 RETROFIT INSULATIO "` = JOSEPH REILLY P.O. BOX 106 SEEKONK, MA 02771 UpdZte Addrm send rat=card_Ms�rk rossson for change. Ad&m ❑Renewal p raopwymnt p Lost Card -- Qmo%-WlwulvdeAa o am�«aslls � �n valid for WWI"W IM4 { O ice of Coaamner A3airt �nd,oea�EeRalafion Wwj tho a 0A date. if t oread rdurn tos `+ M011E Re& e, `y6o481 t'AN7RI1CT0 o�of cmwumw A�and Bo b=Reguiadon 8 Private cosgosatlon 10 Park Phan-8atee s]90 Borbo4 MA 02116 REf'RIDFR •N �'y _ - JO=EPH RE ILLY e44 RODMAN Or FALLRIVER MA 0272� i" uadmeeretm Not Tau withoat ai�ratbare a 1 i 1 f !ss Commonwealth of PAassachusetts °... Division of Professional Licensure Board of Building Regulations and Standards Constru i 'U.d6t i¢ pr Speciaity CSSL-102771 Expires 06/05/2019 y JOSEPH J R kt-i PO BOX 105 � SEEKONK MA Commissioner cjI RETRINS-01 ACORN" CERTIFICATE OF LIABILITY INSURANCE DATE/27/2017Y) �-� o7i27no17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER License#1780862 C TACT Diane Carvalho HUB International New England PHONE FAX 222 Milliken Boulevard A/C,No,Ext: A/C,No): Fall River,MA 02721 Eb AI ,diane.carvalho@hubinternational.com INSURERS AFFORDING COVERAGE NAIC fi INSURER A:Selective Insurance Company of South Carolina 19259 INSURED INSURER B:National Liability&Fire Insurance Company 20052 RetroFit Insulation,Inc. INSURER C: PO BOX 105 INSURERD: Seekonk,MA 02771 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMBS A X COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE 1,000,000 CLAIMS-MADE ❑X OCCUR S 2187653 08I15/2017 08/15/2018 DAMAGE TO RENTEDEMISES(Ea occurrence) $ 100,000 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 POLICY MPT El IOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO A 9100182 08/11/2017 08/11/2018 BODILY INJURY Per personL OWNED LXX SCHEDULED AURTEO�S ONLY AAUUT�OSWN p BODILY INJURY Per accidentX AUTOS ONLY AUTO O&Y PeOac Aent AGE A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE 1,000,000 EXCESS LIAB CLAIMS-MADE S 2187653 08/15/2017 08/15/2018 AGGREGATE 11000,000 DIED I I RETENTION$ B WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY ANY PROR�PREIETgOERR/PARTNERIEXECUTIVE YIN V9WC802160 0810212017 08102/2018 E.L.EACH ACCIDENT 1,000,000 R.F'Il rM In NH)EXCLUDED? N/A (M E.L.DISEASE-EA EMPLOYE 1,000,000 If es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached H more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN National Grid Sylion an Road ACCORDANCE WITH THE POLICY PROVISIONS. 02451 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD u-2017 12:01 Blue Selenium Solar 5088339501 PA Blue ...-k .. . (.* ...... \,a._-------- \�a.'...\...\.m..... ith Fax.Tra1nsnitttall From: Carolyn V{les, Office & Permitting Manager Blue Selenium Solar- LLC 17 Jan Sebastian Drive,Ste. 12 Sandwich, MA 02563 Tel 508-833-9500 x '102 Pax: 508.-833-9501Sal Email 1'ri: Hobert McKechnie, Building Inspector 0 cp - Town of Barnstable Regulatory Services Building Division t . 200 Main St. - Hyannis, MA 02601 -= Tel: 508-862-403.8 Fax: 508-790.6230 Ernail: rob ert.mckp.chn ie ,Ito,�,n.barnst able.mi)mis Date: Nov. 17, 2017 RE:Time-Sensitive Request to Town of Barnstable to Correct Total Solar System Size on already approved online Building Permit#B-17-3816 for solar customers-t John 1.._& Martha L. Durcan, 99 r Seventh Ave. Hyannis., MA; Number of Pages: 2 pages total (1 page plus fax cover page) TUIESSAG E: Per our conversation earlier this morning,we have received through the Town of Barnstable Online Permitting System our customers approved Building Permit. However.,we mistakenly put'12 kWh DC" total system size on the online Building Permit Application, but it should have:said "3 kWh DC . total system size..Wearied to make this request within the online permitting system,:buff we did not find a way to do so..So we Would appreciate it if you could mare this correction as soon as possible in the online system &.confirm back once you have done so via email to both me at cviles;�l,bltil,c�li�? & my co-worker Joe Brady at tl;s; 1�, so that we.can go into the online permitting system to print out the corrected online Building Permit, as we.have scheduled this installation in the near future. Thank you Very much for your Delp &your prompt attention to this matter. Please let us know if you have any questions or need for clarification. 17 1an Se+I'asti an Drive,Suite 12 Tel 5,08 833 9 560 --- ........... -- .......................... . . — 7-Mov-2017 12:02 Blue Selenium Solar' 5088339501 p.2 Pormilt Forn., t .1` 51 r;+•�rv� \y� '\1.•:\\ v:% MR vv: ,y�:, i•,�: :m•. ...��•;'y'- ♦n\r^ .2s`: �NN VN .. 3, 4.`,...'".fii - `:v:.a,;'�''•\ >„i, ,.aH +k 2,4�. y.ti ,(,..";\\.v'...<A:"Y >:x:^:h \ ` •,'"„\ > \. '�5lt , a; •,:.f.a\,,tee..•, rn<„ \�.:.. ..\' ��g<2: ;;:�:;\` \;:4,\:' ever`.. `> "::mot`' - „a,•. .;; ,.. s,.?k....._,•:Z.,. ,., w.ti IN 9•}C�� !�to \ -',\ \. \ \ \.. 3 v y t `w:7! d e€F<aizi A,F ii. £sir� t�,�c �sf72aSEi� �i'#t�> � � . 1 al�moste�rz hitlesel.coir+(corltid�sr) �gy�p�pp •i:;'ii. 1.oc._: ;gat . .., .E J1�4 t��,.. �.1 �;�sr��,' ��..#� �-��sr�.N:N-31S SiAtczs: 1 u.,.d G—UPeney Type Sui{dil 1�pe hate Submitted Date Issued P®¢:iit For Residential single fah"lly 11i11Y017. 11:18i2017 Building-Solar Panel F?esidenlial Projec't.Cost Petl-AU Fee, Additional Fen Tdtal Feu Total Pald ' 1151:; aQ $58.73 $50.0L- $408..73 Flog<73 �J Work Descriptiwr to install d 2 aSJ be mnf-trourrte.d.solar photovoftar system,ut{)g".2 soiar PV panels 3t 250 klrl+h DC pe{panel,with 12 micro-{nvelters A OWNER . �ia3'i�;�i5.;st 5 " f':y L�'� �1/�1 C_.. 4� t�1,>��•j�Y{ F CJ DURGAN,JGM1FiN'J t NARTHA.L Abraham.Lemotle c' 1'4 0 .. U'P--5' P.O.'Box 48-3 P.O.Box 1792 �, G-• S s`v 6Y� �J 5 f ZSZS' West Hyenn{spori AAA 02672 Onset MA 02558 U I:.Y�1 ` ABRAHAM LEMOTTE Onset CS-1G9986' 08131/2019 Attach C ..................................................:........._......,...._.;., ........:.......,....,......;........,...... . - R - U,,SV i_?!:GCi#to q S S 1.1_C t,Q!tw.1 Durmat+J.i3sMs i itc Otfr.;<'sr,Wet i;wrs Abrairzini I—emotte €tsttt3§cs3 F3 r-:a9t+We. t'_rs:ri r..f t3arnsfe bLa ioi'?rat i t)k;tiii Cutisp dsrs>uaancz Alf Ew 11 Eic;.Mar P-0 14,t'O pA.1-a'}li1 ri.f'£IF Ordor SIC:i�iEi t,Fitz4 SIGNED z01'7111 i (q1+tL`'i�J;iris 27,pr?F • .1h Fri Naw 17.2017 1=r1 Now 17 2017 Fri N,ov 17 2017 Fri Nov 17 2017 Fri Nov 17 2017 +APPLICATION REVIEW STATUS +i•.:E',R.Y3'r''ICKrir OP OCCUPANCY CY REVIEW TA't'U5 vittps:!?pot al.viewpermii<coni)SecuredIPermiivie,,.aspx?enc=-FIG00KJTIw oouCVtNZ04lz;3DtOoYHz041ii8vFBfhit8gF-+`YINOcxY i<g)ch•/rMrYPb2h 112 Town of BarnstableBuilding l l anxrneLc) Post This Card So That it is Visible From the Street=Approved Plans Must be Retained on Job and this Card Must be Kept $1° Posted Until Final Inspection Has Been Made: oo� ,use/,g A y� Where a Certificate-of`Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit Permit No. B-17-3816 Applicant Name: Abraham Lemotte Approvals Date Issued: 11/08/2017 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 05/08/2018 Foundation: Location: 99 SEVENTH AVENUE(HYANNIS), HYANNIS Map/Lot: 245-057 Zoning District: RB Sheathing: Owner on Record: DURCAN,JOHN J &'MARTHA L Contractor Name: ABRAHAM LEMOTTE Framing: 1 Address: P. O. Box 463 Contractor License: CS-109986 2 West Hyannisport, MA 02672 Est. Project Cost: $ 11,516.00 Chimney: Description: to install a 12 kWh DC roof-mounted solar photovoltaic system, Permit Fee: $ 108.73 using 12 solar PV panels at 250 kWh DC per panel,with 12 micro- Insulation: inverters Fee Paid:fx $ 108.73 Date: 11/8/2017 Final a Lill��� Project Review Req: Plumbing/Gas " Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street.or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit.Cards are the property of the APPLICANT-ISSUED RECIPIENT ���� J Town of Barnstable *Permit C;bz Regulatory.:Services ee 6 m the from issue date � 1ARN8TABLE, � MAss. Richard V.Scali,Director s63y. i* . Building Division Paul Roma,Building Commissioner JUL I a 2016 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us ^ Office 5,%%--8C2-40,83, SLE Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 6 Property Address Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �^^���5 5� :2 sa Contractor's Name G � C G, L Telephone Number. !fZ-7 3 Home Improvement Contractor License#(if applicable) 1 y3 (o Email: 61Cf ; i /+r�cl Construction Supervisor's License#(if applicable) [�Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [ I have Worker's Compensation Insurance ,, II 4 Insurance Company Name 21 Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑R of(hurricane nailed)(not stripping. Going over existing layers of roof) M"Re-side = ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prope Owner must sign Property Owner Letter of Permission. c of the ome Improvement Contractors License&Construction Supervisors License is e ui ed. SIGNATURE: QAWPFILESTORMS1bu'ding permit o s�EXPRESS.doc 06/20/16 x Massachusetts-Department of Public Safety 3oard'of Building Reguiatioris and Standards ^ =- %,u„a-- u ucuui,Sup'e,—vsor License: CS-074660. JOSHUA X KOUR,#` /% x PO BOX 210 : CENTERVH.LE 1VIA Expiration Commissioner 02/12/2017 Vfieom�inzonul o�U��adaac�erae Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR , Registration.'.`-165936— Type. Expiratior� Private Corporation CAPE&ISLAND CO, ; A 3, OINC. JOSHUA-KOURI 55 ELM AVE. HYANNIS,MA 02601 -� Undersecretary , a s ♦ 4 J , I f 5/11/2016 9:16:14 PM PST (GMT-8) FROM: 100005-TO: 15087756688 Page: 2 of 7 ACO CERTIFICATE OF LIABILITY INSURANCE 75')11/2016 MM/DDA-Y" `-� THIS CERTIFICATE IS ISSUED AS.A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.' If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER FRANK L HORGAN INSURANCE AGENCY INC rCO TACT 44 BARNSTABLE ROAD PHONE a No PO BOX 250 EMAIL HYANNIS, MA 02601 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC a INSURERA: LM Insurance Corporation 33600 INSURED - INSURER B CAPE& ISLANDS CONSTRUCTION COMPANY INC PO BOX 210 INSURER C CENTERVILLE MA 02632 iNSURERD: INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: 29878745 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICYNUMBER MM/DDM'YY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DA A CLAIMS-MADE ElOCCUR PREMISES Ea occurrence $ MED EXP(Any one parson) $ PERSONAL&ADV INJURY" $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY -- COMBI ED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR • EACH OCCURRENCE $ HD'ED CESS LIAB CLAIMS-MADE AGGREGATE $ RETENTION $ A WORKERS COMPENSATION WC5-31 S-377540-016 5/7/2016 5/7/2017 STATUTE ER AND EMPLOYERS'UABIL ITY Y/N c ANYPROPRIETOR/PARTNER/EEXECUrIVE + - E.L.EACH ACCIDENT $ 1 OOOOO OFFICER/MEMBEREXCWDED7 �N NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 D•ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) _ WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. this certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. " CERTIFICATE HOLDER CANCELLATION OWN O BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T F MAIN T THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HYANN IS20 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r' LM Insurance Corporation ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 29878745 1-377540 16-17 WC yogesh.patil@libertymutual.com 5/11/2016 9:13:58 PM (PDT) Page 1 of 1 ' i i3oardao h Regulations of Public Safety Building n d " g g cations and Standards. . a.u7air'iic iuL q p 13JI ° License: CS-074660 JOSHUA X KOLV r PO BOX 210 - % (F CENTERVILLE VIA Expiration Commis�sionne�r' 02/1212017 r, 1 ate'. • � ,. Cj m� `Ave- . :,,eve � � �o.�'/(//•�� a- Zs\a�as Cov,s �-� vac-�`�� .w'�\\ °� � r�\ae:v\.� _• . . n F n ` •y '� w1 � •a'�� `" . fin. ' : a . • . • 1" w r! i The Commo7nreafth ofMassesdtrtsetts Departure ut afraifastriatAccidie7zts 600 Washfivion&keet Boston,MA 02111 mom— masmgmIn7a Wkwkers' CumpemsafianEmn-ante Af Edavit BmldeISdCuntraCt6r--JEl &,kia.II�hmbers . App'kan#Inflation Please Print Nm=(B rC � C Phone Am yqu an employer?Cfteckthe appropriate born Tyke of project.(required}_ I. I am a employes with_ 4. ❑I am a general contractor and I 6. ❑New eomsliuction employee,;(fib andfor part-time)-* have luredthe sob-cogs 2.❑ I am a sale proprietor orgartaer- listed on the attached shmtti ?_ ❑Rernodeliag s*and have no employees These sub-contractors have 9- ❑Demolitioa wod3ng forme in any rapacity_ employees andhmve wod=' 9..❑Build addiiic.a [No wow comp.fi-=UM,re comp_msura c l r -I 7 5. ❑ W_e are a corporatmn and its III[]Electrical repairs or ad&ions officers have exercised tlu±ir 1L Phmbin r ai s or additions 3.❑ I am.a homeowner doing all worlc ❑ � eP . myselo workers' _ right of ennption per 1'�GI. insurance, €��,,,r,&]T C.�,§I{4},arldtive have no l.w❑Roof repairs employees.ENaworkrrs' 13_❑Other cam msursae-required_] � YHPPff��stcbeclsbasislmastalsoMoutthesediaabd wslsaRiag&&vMko 'comPenMdDapeTicginffi=Sff a 415 Who salAIIFi iC is dWY RM tlaM�alf VFak sad d=biM auW&rantXC9 reffi snit�t a DEW sffidaVftCmdieiias ICc tLd cbedctids boot must attached m aaa;t;nn2l shEd sbmxfng +e n� of the s¢b-r� snd state arhethet as not fuse hwm employees.7ftbemib-t�t�ctaeshaveemplgw-%&ey=xrtp=vide*ek madceW=Zp.pGi y=nbm lam au erripIaFar float ispreauiiriirrg�vr�rkers'canrpertsrdz�rn utsriraacevr earpFg}�ee� $etouv is ii�tepvficp aid job site trz�ormafr'ars LL Insumce Company Name: i Policy or Self-ins.Iie f'1/�G I�`� SC�- gxpiration.Date: Job Site Address: 1 f •'l CitglStafel�ag. j/`. /`/�/Lill mil.�5 /.� Bch a--opf of the workers'comapensationpolicg declaration page(shawing the policy number and expiration.date). Failure to secure coverage as required.under Section 25A o€MGL m 15 can lead to the imposition of criminal penaUiees of a fine up to$1,5t}D 00 aadfor one-yeacimgrisonme ,as well as ritad penalties in the fog of$STOOP FTC}Ri ORDER and ri me of up-to 0_00 a day againd the violator. Be whised ibat a copy of this zbh=Pnt maybe forwarded to tine Offlce cd Investigations ofthe DIAfes' covetaSe v o� T do Jferetry ca tyy and nabs offF ly thatthe in,farmagmprm�d abm�s i�tMw :d tarred AI,0"0" ,V Phone Offal use a 4n Do r►at write in 66 area,to be carapreted by nip artewn er f j4cid City or Town: PermitUcense 9 Issuing Anflorety(dude one): 11 L Board of Health IF Bwffirmg Department 3.Cit}YTawit Clem 4`Fiectric d hapeetor S.Phuabing Inspector b.Other Contact Person: Phone#' 6 laformation and Instructions Mf ss � ctf3 CTCb=Mt Laws chapter 152 regna=all Moyers to pravide•wark0as'=nPeSion fcs tbeg employees. Pn¢•sa�this sfa#[zfe,an��3'�is defined as_=e:vezy pearsan is tee service of another under any contract ofI�, •; express or implied,oral or W itb=f AnMMp&yer is defied as-an inffiyja ,part==�,assoCiEion,corporation or other legal entity,or any two or mote of the:foregoing=gagedis a joint else,and inclndmg fhe Legal=esenfafives of a deceased employer,or the receiver or trastee of as ink paw,association or other legal entity,employing employees. However fhe house not more tbm jhree apartments and who resides therein,or the occupant of file - owner of a.dweIInag having . dweMag house of another who employs persons to do maw,consLmz;on or repair work on such dwelling house or on the grounds or bmZdmg appmt=--&tiiereto shannDtbe cause of such a aplaymea the deemed to be an=3ployex." MGL`chapter 152,§25C(6)also states that¢every siafe or local licensing agency shall withhoId ffie issuance or renewal of a ficease or permit to operate a Imssm.ess or to construct buildings in the commonwealth for any applicant Who has not prodnced acceptable evidence of complian.m with the insurance coverageregnired-" Additionally,MGL chapter 152,§25CM ghats fiNeiihe:r the co®onwealth nor any ofits political subdivisions shall MI d into any c ant rad for the per5n an ce ofpubho work u a iI acceptable e-ideate of compH4ace With the insurance. requammenFs of this chaptcr have been presented to the cont�M3fa03ity." A.pp4c=-ts , Please fill out the wozkeas' compensation affidavit completely,by the a g ihe boxes-ff�apply to your sifnation and,if necessary,supply sob-cant or(s)name(s), addresses)and phone nnmber(s) along wiihtheir certcicate(s) of msurance_ Lmnted Liabffity,Companies(LLC)or LimitedIaabrZityPm-tacships(LI.P)Wier no employ=otter than the members or parrneas are not regrm.-rd to cant'workers'compensation inset-anm If an LLC or LLP dDes have employees,apolicyisregaired_ Be advisedthattbisaffidayitmaybesobmhiedtotheDepaitmentofIudasftW Accidents for conEm ation of msuraace coverage. Also Be sure to sign and date the aj=daQit The affidavit should be rctome d to the city or town that the application for the pemiit or license is being request not the Department of ; Isdosfrial 14 t-r i marts Mumld you have any gnestians regzrdmg the law or ifyon ai a regrffied-to obtain a wormers' compensation policy,please call the:Department at the numbed hsind below. Self-insured companies should ends their self-i seta ce license number on the appropriate line. City or Town OMdals Please be srn-e that the affidavit is complete and pradedlegibly. The Derma tcarmt has provided a space at the botbom of the affidavit for you to fM out in the event the Office ofInvestigatiDns has bo co�ac#you regarding the applicant Please be sure to fill in the pemn license number which will be used as a reference number. In-addition,an applicant that mast submit multlple permitlIicensa applications in any given year,need only submit one affidavit indicating cosent policy infomation(if necessary)and under'Uob She Address"the applicant should write"all locations i a (may or town)-"A copy of the-affidavit that has been,officially stamped or mar$ed by the city or town maybe provided to the applicant as prooythat a valid affidavit is Dn.file for futm-e peonits or licenses A new affidavitmust be filled out each year. 'Where a home owned or citizen is obtaining a license or permit no#related to any business or commercial (i.e_a dog license orpe¢aitto bum leaves et�,_)said pm-son is NOTrvjahed#o c amp le a Ibis affidavit The Office of inyestigadons would Izilm to thank you in advance for your cooperation and should you have any question's please do not hesitate to prom us a caIL The Department's address,-telephone and fax rsdmber_ Tha CoMMQUWeetbE a G - ' hem of ludo AmUenta �tce Qf�tio� ' � I�fA E�IIF Ta#617-727-49CO Cat 406 Qr 1-977 IIA 2,4F Fag#617'27 7749 Revised 4-24--07 -9MIrAU& WE Town of Barnstable *Permit# ' -eZ q , p Expires 6 months from issue e Regulatory Services Fee q, ilk * SAIUMABLE, • 1 Richard V. Scali,Director Building Division : [� Tom Perry,CBO,Building Commissioner ,.. APR 052016 - n 200 Main Street,Hyannis,MA 02601 nl www.town.barnstable.ma.us TOWN Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint r Map/parcel Number Property Address �Kesidential Value of Work$ �vo Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name_ c%U�� f� L< Telephone Number �Z�Sc9 C� Home Improvement Contractor License#(if applicable) �34, _ Email: jo1�k Construction Supervisor's License X(if applicable) (5:7T orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner - t_ have Worker's Compensation Insurance Insurance Company Name L,Lal ± Workman's Comp. Policy# Copy of Insurance.Compliance Certificate must accompany each permit: Permit Request(check box) r Ze-roof(hurricane nailed)(stripping old shingles) All construction debris will be to s k--L.V. ❑Re-roof(hurricane nailed)(not stripping. Poing over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/slidersU-Value. (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance'with other town department regulations,i.e.Historic,Conservation,etc. <� ***Note: Prope O must sign Property Owner Letter of Perulission. ` A/q3� of, he ome I provement Contractors License&Construction Supervisors License is rd:.SIGNATURE: 4 Q:\WPFILES\FORMS\buildin+ rmit XPRESS.doc t . d't• ' Revised 040215 n ..t a ?Ise Commornwealth�qf_ aysachusetfs ` Department of Indmtrzal Acciderrtr Offike of invmtfgafions �y 600 Washington Street . n , Boston,M4 02111 impm nasmgovIdia Warimrs' Campensafian Insurance Affidavit:B.uilders/Cflntra dursJEIeclricianslPhunbers AppEcant.Infmrmafran Please Frinf LeQibIy Name(BussiraEess,'�ganr�onflnduidua4� Address- U CifylStatefip_ Phan G,� �719- 3 c9 J(:5) Aa7,an euaployer?Check the appropriate box: Type of project(requu ed}: I. m a employer Withl 4_ ❑I am a general contractor and I employees(full andlor part-ime). * have hired the sub contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodelkg ship and have no eanplayees These sub-conEractars have 8. ❑Demolition wonting for ssie in any capacity. employees aiidhave workers' [No tu-orScers'comp.insurance camp.insurance-1 g- ❑Building addition. required.] 5. ❑ We area corporation and its 10_❑Electrical repair or additions 3_❑ F am a homeowner doing all work officers haveexercised their 11.❑Plumbingrepairs or additions myself[No workers'camp. right of egensptiosr per MGL' 12.❑Roofrepairs �T+� nce reguiiiu3d]i c.I52,§1(4�andwe have sari employees.[No workers' 13.❑Other camp.insurance required.] 'Any applicantdut cbeddsbox OR tun;I also f0loutthe secBoabelowshotdng their workere compensafmapaUcy information. N #liameoamerswho subraft this di idatqu inkrating they am doing all pro.$=4 dieahim aUM&cont mctnamast submit anema�davit iodicaba�sacb IComraciors that dbea this boric must attached as addidanal sheat shown g the names of the sub-conwmt r s and state whether or not(hose eadties have e 3playees.If the sub-contamishave employees,dteynnuCpmr-de their workers'comp.polity number. I aua an¢rrapIoyYrr tieatispra�ddiru��a�nrkers'coaralr¢rasatiara insalrarace fur Rr}•¢nipl gees Boo is f7re�palicy ar�d job;Site irnforma on. Insurance Company,Xame: . Policy or pelf-in s.I ic_ L %7 �/5' 7 �—;�liapiratioa Date: Job Site Address: CitylStatelzip:�jrj�� Attach a copy of the workers'compensation policy declaration page-(showing the policy number and respiration bate). Failure to secu-e coverage as requiredunder Section 25A of MGL c.15 can lead to the imposition of criminal penalties of a fine up to$1,50D OD anchor me-year imprisonra—f as well as civil penalties.in.the form of a STOP WORK ORDER and a time of up to$250.0O a day against t447iolator. Be adtased that a copy of this statement may be forwarded to the Office of Investigations of the DIA far' ce co get ca Lion Ida hereby cRrtFfj�atr t R 'as and tames ofgedury thatthe iafOrmati npm i&da 'e is and correct Sitoature= Date: (o Phone 3F l `7 ' lr� Official use warily. Da nat write in this-area,to be comp7eted by city artolm gfjiciat City or Tanis• PermitUcense AE Issuing:tiuthor€ty€drcIe one): 1.Board of Health 2.Building Department 3.C itylTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Oth-er Contact Person: Phone#: luformation and Instructions M L,zs rrsetfs General Laws chapfiE 152 requims all employers'fa provide wo=keas'compensation fm tbeir empldyeesl E p=SUMt-to ibis statrrla,an..minploy w is defined as. .every Person in the service of another under aay comb act of hie, express or implied,oral or wrest." An errT&YEr is defined as"a a i acrividual,partnership,association,corporation or other legal entity,or MY two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trmstee of an individnal,partnership,association or otherlegal entity,employing employers- However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwPTTing house of another who employs persons to do maibaan ce,construction or repaa'work on such dwelling house or on the grotmds or building appudon mit themto shall not because of such employment be deemed to be an employes." MGL chapter 152,§25C(6)also sfajes that"every state or local licensing agency shO withhold the issuance or renewal of a license or permit to operate a business or to construct buildings is the comet onwealth for any applicant who leas notproduced acceptable evidence of cdmpliance with time insurance.coverage required_" Additionally,MGL chapter 152, §25C(7)states¢Neither the comm®.wealthnor;ry of its political subdivisions shall enter intD any contact for the perfi maace ofpubho work until.acceptable evidence of compliance with the ius rran ce.. r ems of tizis chapter have Been presented to the contracting authority_" Applicants Please ELI out the workers'compensation affidavit completely,by checId g ine boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), addresses)andphonenumber(s) alongwiththeff certificates)of ins=nce. Limited Lia � omPb Companies(LLC)or Limited Liablidty Parfnershrps(LLP)withno employees other than the . members or P artaers,are no iu t recpmed to carry workers' compensation s=ce- If an LLC or L LP does have . employees, a policy is requied. Be advised that this af�dayt maybe submi�d to the Departmentof Industrial nf=ation of insm-,mce coverage. Also be sure to sign and date the affidavit The affidavit should Accideniv for co be retraned to the city or town that the application for the permit or license is being requested,not the Dapatnent 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,lime number on the appropriate line. City or Town Officials t . Please be sra e that the affidavit is complete and primed legibly. 'Ihe 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 condact you regarding the applicant Please be store to fill in the peunit/license number which will be used as a reference number. In addition, an applicant that must sabmt mul tip Ie permWlicense applications in any given year,need only submit one affidavit mdicatilg rnrrPnt p olicy fin:Eb.ation(if necessary)and under"Job Site Adress"the applicant shoud 'aII locations ilt (city or town)-"A copy of ffie-affidavit that has been officially stamped or maimed by tht city or town may be provided to the applicant as proof that a valid affidavit is on file for 5.tra'e 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 bran leaves etc.)said person is NOT regnied to complete this affidavit The Office of Investiga ions would like to thank you in a brace for your cooperation and should you have any questions, please do not hesitate to give us a call. The Departmenf's address,telephone and fax number. Thy Camp -fit of Massachus�tks Department C&ILkstdal Accident~ its of f ves�dgatio---= 600,Vlashi zG1,Street Boston=MA G�I I I T(,-I< '617-727-4900 Qx- 4-06 or 1-977-MA.SSAFF. Fax 9 617-727-7M Revised 4-24-07 �Qg�dia AIS CERTIFICATE"IS'ISSUED"As•q-nn;a�-r - - ": ;,�„� �,. � � CERTIFICATE DOES NOT AFFIRMATIVELY oR rrEGiaTIveL,r:E.,.� y ` r �M BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE Pc'corrrRper BET,,,; - , REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pplicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to,Z- the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to'the certificate holder in lieu of such endorsements . CONTACT PRODUCER FRANK L HORGAN INSURANCE AGENCY INC . NAME: 44:BARNSTABLE ROAD PHONE FAX PO BOX 250 C o (A/C No .. `- E-MAIL § t HYANNIS, MA 02601 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 wsURERA: LM Insurance Corporation 33600 INSURED NSURERB: CAPE& ISLANDS CONSTRUCTION COMPANY INC, PO BOX 210 wsuRERc: CENTERVILLE MA 02632 INSURERD:` ' . INSURER E: - j - INSURER F: COVERAGES CERTIFICATE NUMBER: 24610723 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE,INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS., INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP. LIMITS LTR INSD WVID POLICY NUMBER - MM/DD MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR _ -� PREMISES occurrence) $ MED EXP(Any one person) $ �. ,. ' PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- JET LOC PRODUCTS-COMP/OP AGG $ OTHER: t $ AUTOMOBILE LIABILITY 6.`, COMBINED SINGLE LIMIT $ , Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ i AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR - - ) -. EACH OCCURRENCE `' $ -HCLAIMSMADE AGGREGATE $ EXCESS LIAR ' RRED RETENTION $ A WORKERS COMPENSATION WC5-31 S-377540-015 5/7/2015 S/7/2016 / STATUTE ER AND EMPLOYERS'LIABILITY Y/N - 'F ANY PROPRIETOR/PARTNER/EXECUTIVE •- e - E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED?. - � N/A - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If es,describe under 500000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage CERTIFICATE HOLDER - CANCELLATION s SHOULD ANY OF THE ABOVE DESCRIBE_D POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE LM Insurance Corporation 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 24610723 Anne Chandler 5/8/2015 1:54:54 PM (EDT) Page 1 of 1 �, ���„ �. {�'•j,+r�,9 t � -k� ... ......e..vxtr.. _ .-x. .. s....�,.-' _�'x+.�.,,-��.».,-.�-,.- �-_, ,.,� -a...._.»�.�_,-s_...x..d...x,.,vx ��t..,-..,-:w r,>...m.z`->-��•.,.. - '�. - µ :, ,- 3, �",-3 '`'" wCF'y.4 -,+ 'l r..�k' r'ZC- =.,.a a` �q`' '+`s`.*TY», `x` �+^ara�" � F .rJt� at ✓' .w�.-x '11If) _ Cape & ylslandsConstructionCo. PQ -•, f � Po BOXf21 Q »-Centerville Ma.tf2632 t�. � � � � eBerns �f� =SQ8 775 7663 - s hlyyd�r P Wt ISJ1l1'W Melissa Fox 99 7th Ave. W. Hayannisport, Ma. CERTAINTEED Certainteed Shingle Roof 7,840.00 Strip existing shingles from roof. Secure any loose sheathing. Install Hicks brand vented aluminum drip edge. Install Wip brand Ice&Water.Shield to all eves, rakes,valleys and all protrusions. Install Rhino brand Synthetic Felt Underlayment. Install Certainteed Quick Start starter shingles to all rakes&eves. Install Certainteed LIFETIME-Landmark architectural shingles. Storm nail all shingles. (State building code requires 4 nails,we use 6) Re-flash all vent pipes with new boots. Install Rigid Vent 11 ridge venting. Remove and dispose of all job related waste. leave your property.looking like we were never there! Provide all manufactures warranties and. LIFETIME warranty on our labor, if it ever fails due to our workmanship we fix it,forever! It's The Best In The Business. Please note our wind warranty is also the best And longest available ANYWHERE! am Ni+`� '�- N l A " 110, - -- sk r 1` � - �? �` fir.= ��-� - ��€�: ..":�'£ �' H'4 f'i�-��'w��'yam.,-.t �.'`," "`R..;�,� ,.s. r€ ^�-y`''�'�,� [� -**''���gc..�/•�U ��,..� q �.��.: ���`.`"= '3. �;.'` 9 'a�*�,'n x" �.,�' a�r^s��r��:�. �, ,� �-r �#r�`,.� ^�� w g r;.=.;.-�,,.F�j'6.'.:'1G�hC��✓��7�':'U `` . 41, WX �.:� s - �.r=:-; `€-mot -'* '�e,r,��� ,� +�� .. '+sss, r'���: `�� ��,rr� s«�-�`�.�`��, � ,.����ro4��r� �,.. �• z Massachusetts -Department of Public Safety Board of Building Regulations and Standards wua"--'`Lr'u cLlon Supervisor License: CS-074660 JOSEWA X KOMRk PO BOX210 CENTERVHdLE VIA Expiration Commissioner 02112/2017 Unrestricted-Buildings of any use group which z contain less than 35,000 cubic feet(99,M )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS licensing information visit: www.Mass.Gov/DPS i` License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation a 10 Park Plaza-Suite 5170 i. Boston,MA 02116 of all without signature ' Office of Consumer Affairs&Business Regulation i HOME IMPROV,-MENT�TRACTOR `i Registration:`,"-165936 Type: ' ExpirationJ— -W2— Private Corporatidri 41 CAPE ISLAND COr � Z JNC. - ` I JO$HUA--KOURI 55 ELM AVE.. HYANNIS,MA 02601 Undersecretary a U P To ....,-r M�2 e. �T p* , A:��c�rc o—c7 cad O-o r,.t.. t i "� �jTC R r CC t¢ c a ICE LO 7 ° 4 y tmV G i s + Dili 4 Cl Ll ' 1 44 .�.. .""1-"' ..+........mot P 1€ ! NV- 4A1►'� t , ! a r a 1 e m r� ar: ^ t. . .N. c- - 1../N1./ f c f tu Oow e r io ? � 'TIL t`ZL F^� t r1J r'��} `�._� I•-�-'� Ce nG�'�f�..�� ?.'e+ � ..._.._w -.� � � fi �4,� 4� � Y � } P ,r..�.r..ee ._.�M,•„ .++.ors. .... wp:wwwWrrr'F+:+i•+•+, �r � ��., � w� «� �( �Y! feL.rvi� .1..��r��� ; a`f �� r _ s» •K •aaro .