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0041 SIXTH AVENUE (HYANNIS)
f / S / x -� tee. r I i i I l NERSAL® UNV-12122 IMF IN USA O&MAJNMLE MIN RECYCLED WIiIATIVE CONTENT 10% cordw fam Sourcing POST-CONSUMER wxaxflpmww—ro s�ma4o ,. Town of Barnstable Building t n Post.This Card So That it is Visible,From:the Street-Approved=Plans Must be Retained on lob and this Card Must be Kept €' 1BIAS& Posted Until Final Inspection Has Been Made. e�n11t W e a Certificate.of Occupancy1s Required,such Buiiding}shall Not be Occupied until,a Final Inspection has been made. 1 1 JhiJl 1 Permit No. 3-18-3926 Applicant Name: ROBERT WALSH DBA HARBORSIDE REMODELING Approvals Date Issued: 12/21/2018- Current Use: Structure :Permit Type: ,Building-Addition/Alteration- Residential Expiration Date: 06/21/2019 Foundation: Location: 41 SIXTH AVENUE(HYANNIS), HYANNIS Map/Lot: 246-143 Zoning District: RB Sheathing: Owner on Record: KUDA, PETER M &WENDY J TRS Contractor Name:' •,ROBERT G WALSH Framing: 1 Address: 6 ESSEX PLACE Contractor License: 'CSFA-057394 2 CHELMSFORD, MA 01824 Est. Project Cost: $26,000.00 Chimney: i Description: 12'X12'SOREENED PORCH N' Permit Fee: $ 182.60 Insulation: Project Review Req: SPECIAL PERMIT 2018-025. FRAMING CONNECTIONS TO Fee Paid: $ 182.60 RESIST WIND AND GRAVITY LOADS ARE REQUIRED. i _ Date: 12/21/2018 Final: - 2 ' � y Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: 'µ 3' Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized,by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the-approved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures 11 shall be in compliance with the local zoning by-laws and codes. 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 Electrical work until the completion of the same. PService: The Certificate of Occupancy will not be issued until all applicable signatures'by the Building and Fire Officials are provided on,this permit. 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) ' Low Voltage Final: .6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).. Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT BUILDING DEFT Application Number...r` I.........( ..................... NOV 2 8 2018 ABM MASS. TOWN OF 13ARNSTAi3 Permit Fee........................................Other Fee........................ 165 TotalFee Paid................................................................ ...... TOWN OF BARNSTABLE Permit Approval by.. ...... .. ............... ............ BUILDING PERMIT .. .. ...... MV........DL4.. ....... .......Pamel-L...............L.Y.%s............ APPLICATION Section 1 — Owner's Information and Project Location Project Address Village� �ejgL j.5e 070_�-- Owners Name V1,1A A01 Owners Legal Address City 1 I-A in k� , State b4 Zip Z. Owners Cell#7Zir e19 9 E-mail Section 2 —Use of Structure Use Group_ ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet R'Single/Two Family Dwelling Section 3 — Type of Permit F-1 New Construction ❑ Move/Relocate [:] Accessory Structure E] Change of use El Demo/(entire structure) 0 Finish Basement El Family/Amnesty El Fire Alarm Rebuild El Deck Apartment Sprinkler System eAddition ❑ Retaining wall ❑ Solar' Renovation, ❑ Pool El Insulation Other—Specify ZY, Section 4 - Work Description 4. Last updated. 11/15/2018 Application Number...................................................... Section 5—Detail Cost of Proposed Construction (AOL crero Square Footage of Project l Y4 5 IC .Age of Structure <, _Dig Safe Number C7 SQ-P� # Of Bedrooms Existing Total# Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method �MA Checklist WFCM Checklist ❑ Design Section 6—Project Specifics Wiring ❑ Oil Tank Storage ❑ Smoke Detectors [] Plumbing ❑ Gas ❑ Fire Suppression • A 1 ElHeating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply 'Public ❑ Private Sewage Disposal ❑ Municipal 2'�n Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: r Gyw ® (y a►9 vtr,s I am using a crane ❑ Yes No r � Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? t Yes ❑ No ❑ l Section 8—Zoning Information Zoning District Proposed Use C Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage # of Dwelling Units (on site) Setbacks Front Yard Required ")Q Proposed t \ Rear Yard Required b Proposed l 0 Side Yard Required Proposed t,G,�1 Has this property had relief from the Zoning Board in the past? Yes ❑ No i Last updated:11/15/2018 a k t P 1 G .. BU'LL.AII'�il , Barnstable Bldg.Dept. - Approved by: 9ZL Nov 28 2010 Permit#: TOWN OF t � s S n , i �e 1 �� 1 a r - r Alm ID / a � a U a Tu V villa 6,o,h RC. 'locus M I v ro ((ff Nantucket Sound A LOCUS MAP SCALE 1"-2000't ry h 1pp.00' io U ASSESSORS MAP 246 PARCEL 143 p N - LOCUS IS WITHIN FEMA FLOOD ZONE X SHED (AREA OF MINIMAL FLOOD HAZARD) AS ZONING-- SHOWN ON COMMUNITY PANEL b25O01C064J SETBACK DATED 7/16/2014 SNR UNE i iy,i S 11 1 a ZONING SUMMARY EXISTING DWELLING TOF-24.9 -) `�T ZONING DISTRICT: RB DISTRICT DECK MIN. LOT SIZE 43,560 S.F. RC g POH MIN. LOT WIDTH 100' i MIN. LOT FRONTAGE 20' MIN. FRONT SETBACK 20'* TL641gF�6Gu6b7'e'''D O MIN. SIDE SETBACK 10' tao PATIO `Es $ MIN. REAR SETBACK 10' 4 MAX. BUILDING HEIGHT 30' a BRB FNO Q�p 1Ss I yf N7gt3'38'E SITE IS LOCATED WITHIN THE AQUIFER 'r B9,00' PROTECTION OVERLAY DISTRICT OWNER OF RECORD D PETER M. KUDA AND WENDY J. KUDA, TRUSTEES E WAY O THE KUDA FAMILY TRUST MAP'- 6 ESSEX_.P,LACE M11 O B 7 I S D I N�CHELM$FORD,°MA 23 - 14 !-7 r REFERENCES DEED BQOK.30918 PAGE 183 NOV2 f;1.A1QJK3o PAGE 23 TOWN OF BAHIy,�) SITE PLAN OF 41 6TH AVENUE WEST HYANNISPORT, MA PREPARED FOR PETER KUDA DATE:JANUARY 10,2018 4W}A or• clDAIE 1f SOB-362-4541 OAA.A'N O fax 508-J92-9880 ONALA N tlowncoPe.com DJALA NnCI 02 jews Na 4 80„ cope engineefing,11 C. 9¢.PPl•G W �9�PF e�°a civil engineers Sc01e:1"=20 \-\0^�Q7 F+PIa Pl Eaa sum ° land surveyors 939 Moin Street (Rte 6A) ACE #17-439 0 0 20 30 M1O 50 FEET DATE DANIEL A.OJALA, P.E., P.L.S. YARAIOUTHPORT MA 02675 17-439 KUOA.OWG The Commonwealth of Massachusetts Department of IndustrialAccidents Off ce of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmization/Individual): 6e,,,� ( ,_,w>A 6 Ins Address: 6 , A-,� -Z 1 City/State/Zip: 4, y ih 02bq g Phone#: '14 2 gs'd Are you an employer?Check the appropriate box: Type of project(required):eq d) 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.K I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for mein any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.ms rrance.t g required.]ed. 1 5. 0 We are a corporation and its 10.ElElectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. tr—ontractors 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 worker;'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the.policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd under the pains and penalties of perjury that the information provided above is true and correct. Sianafore: Date: /I Phone#: GR�� Lf`2—U CT gb Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit drat has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of 1,nvestl igatiow 600 Washington Street _ Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1477-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gvvfdia , Bk 31.305 pg260 #25833 05-31-2018 @ 12 : 11p = ' r Town of Barnstable t_ Zoning Board of Appeals `HELL � 1 Decision and Notice Special Permit No.2018-025-Oda §240-92(B)-Nonconforming structures used as single-or two-tamily residences l To allow for the addition of a screened porch encroaching into front yard setback l i Granted with Conditions summary: peter M.and Wendy J. Kuda,Trustees . Applicant: i b Essex Place,Chelmsford, MA , Property Address: 41 Sixth Avenue,Hyannis (Hyannisport), MA i Assessor's Map/Parcel' 24.6/143 Residence B District i Zoning: April 25,2018 i Hearing Date a 283, tots 446 and Block A Deed Book;30918 Page: Recording information: Plan Book,34 Page:23 Background lied for a Special Permit Peter M. Kuda and Wendy J. Kuda, Trustees of the Kuda Family Trust, applied ; pursuant to Section 240-92(B)-Alteration and Expansion of Nonconforming buildings or structures p e-and two family residences. The Applicants propose to construct a 12X12 screened used a singf ict in which it is porch which encroaches into the required 20 foot set nue H ann s(Hyann for the zoning sipoCrt),MA as shown located. The subject property is located at 41 Sixth Ave , on Assessor's Map 246 as Parcel 143. it is located in the Residence B Zoning District. acre corner lot at Maple Way and Sixth Avenue in Hyannis The subject property is a i 8 iproved with one single family three-bedroom dwelling of , I (Hyannisport). The propertysetback gross square feet(1,084 square feet of living area), constructed in 1951. The dwelling ayhe existing approximately 45 feet from Sixth Avenue from the side yayd lot 1 n 23 terandl herle is an existing deck dwelling is approximately 9 feet set b t ical in the area. The lot is with 0 feet set back from the side yard lot line. Small lots appearyP served by on-site septic and public water. Procedural& Hearing summary special Permit Application No. 2018-025 to construct a 12k2 Greene porch office,which encroaches the Zoning Peats was into the required 20 foot setback was flied at the Town Board of Appeals on March 28, 2018. A public hearing before the Zoning Board of Appeals duly advertised and notice sent to all n April 2018 at which erested time the Board found t grans in accordance with t he Chapter 40A. The hearing was opened on April appeal were Alex Rodolakis, Special Permit subject to conditions. Board Members deciding this Paul Pinard, David Hirsch, Mark Hansen, and Kyle Walantis. Attorney John Kenney represented the Appi icanasb"Seaside torney Kenney reviewed the FPaW' Inefore the Board. 1t899. He also reviewed the history of the subdivision which was approvedt and structure are legal zoning changes since the lot was created t d and difficult noted is fo the r any alterations to a dwelling to'mee nonconforming. Attorney Kenney noted today's setback requirements whe it is Gated on a corner {at. He also argued that the screened porch is consistent with the neighborhood. The Board asked about the roof style, the septic system, and any future plans to make this porch. year round use. U96:. . .. .Q. - -.- - r r Bk 31305 Pg261 #25833 Town of Barnstable zoning Board of Appeals-Decision and Notice Special Permit No.2018-025-Kuda The Board Chair requested public comment. Ed Morgan, the Applicants builder, spoke about the roof as well as the entire project. The roof will be slightly pitched but not gable. Also, the septic system is sized for three bedrooms and passed a recent inspection. Attorney Kenney stated there is.`no current plan to alter this addition to create year round living space. Findings of Fact At the hearing on April 25, 2018, the Board unanimously made the following findings of fact in Special Permit Application No. 2018-025, a request to construct a 12X12 screened porch which encroaches into the required 20 foot setback: 1. The application falls within a category specifically excepted in the ordinance for a grant of a special permit. Section 240-92 allows for the expansion or alteration of a preexisting nonconforming structure used as a single-family residence with a Special Permit. 2. After an evaluation of all the evidence presented, the proposal fulfills the spirit and intent of the Zoning would not represent a substantial detriment to the public good or the Ordinance and p neighborhood affected. The Board found there will be no negative Impacts from the construction of the addition. 3. The proposed expansion of the dwelling will _nct be substantially more detrimental to the neighborhood than the existing building or-strucure. The Board found that the porch design is consistent with the dwelling design and the design of the surrounding dwellings. I The vote to accept the findings was: AYE: Alex Rodolakis, Paul Pinard,David Hirsch,Mark Hansen,and Kyle Walantis NAY: None Decision -�. Special Permit No, 2018-025 is granted to Peter M. and Wendy J. Kuda, Trustees of The Kuda Family Trust, to allow the construction of a 12 foot by 12 foot screened porch with a front yard setback of 16.7 feet. The property is located at 41 Sixth Avenue,Hyannis(Hyannisport), MA. 2. The proposed alterations will be in substantial conformance with the plan entitled "Site Plan of 41 6 h Avenue West Hyannisport, MA" prepared for Peter Kuda dated January 10, 2018 and drawn and stamped by Down Cape Engineering Inc. 3. This alteration/construction shall represent full build-out of the lot. No additional increase in building coverage or gross square footage shall be permitted without prior approval of this Board. 4. The proposed addition shall remain a seasonal porch. 5. All mechanical equipment associated with the dwelling (air conditioners, electric generators, etc.) shall be located so as to conform to the required setbacks for the district and screened from neighboring homes and the public right-of-way. 6. This decision shall be recorded at the Barnstable County,Registry of Deeds and copies filed with the Zoning Board of Appeals and Building Division. The rights authorized by this special permit must be exercised within two years, unless extended. The vote was: AYE: Alex Rodolakis, Paul Pinard, David Hirsch,Mark Hansen, and Kyle Walantts NAY: None 2 Bk 31305 Pg262 #i25833 Town of Barnstable Zoning Board of Appeals-Decision and Notice Special Permit No.201"25-Kudo Ordered Special Permit Ne setback at 41 i construct h Avenue, Hyann s (Hya nesport)porch h which as been grantedinto subject the required 20 foot setback at 41 Sixth to conditions. This decision must be recorded at the Barnstable Registry f Deeds for The belief e in effect and notice of that recording submitted to the Zoning Board of Appeals authorized by this decision must be exercised within two 40As unless Section 17, wided. Appeals Of th n twenty(20) days decision, if any, shall be made pursuant to MGL Chaptof which must be filed in the office of the after the date of the filing of this decision, a copy Bamptable Town Clerk. 1 % Date Signed Alex Rodolakis,Chair fy 1, Ann Quirk, Clerk of the Town of Barnstable, Barnstable l rd oCounty,i Mass thhs decision a dythat�no that twenty(20)days have elapsed since the Zoning appeal of the decision has been filed in the offfca'f the Town Clerk. ! t' ZAr. under the pains and penalties of Signed and sealed this day of perjury. Ann Quirk,Town Clerk 3 r— Commonwealth of Massachusetts L Division of Professional Linsure c ce Board of Building Regulations and Standards Construction,.So'��e1 60rr1 & 2 Family CSFA-057394 lCpires: 06/02/2019 w' ROBERT G WALSH P.O.BOX 713 ' MARSTONSMILLS:MA ti01f iC Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:individual before the expiration date. If found return to: Registration Exoiration Office of Consumer Affairs and Business Regutafr m 141991 1 03/02/2020 One Ashburton Place-Suite 1301 ROBERT WALSH Boston,MA 02108 D3'BA HARBORSIDE REMODELING ROBERTG.WALSH .- 250 CAPTAIN CROSBYROAD U j e GENTERV{LLE,MA 02632 Not valid without Si nature Undersecretary g F y. r -r. Application Number............................................ Section 9- Construction Supervisor Name l,sa k s"., Telephone Number L&=F) �j aO o 0 Address �n ( �.�0 3 City�;r,r,, State �„ ,�, Zip s 't 7. License Number 171 'y License Type p°0 Expiration Date f z.) a d 19 Contractors Email )D%A c %D 1 ( macro h, Q Cell # R l y a o I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required b 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section 10-Home Improvement'Coritractor Name. Telephone Number Address 6A , City WVVN State W,,-% , Zip Registration Number j y 1 q c 1 \ Expiration Date �'�� Z� is I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required y 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction.inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature Z�d - Date -2- Print Name {be 6'`e Telephone Number s '6 �fD-o— S-6 E-mail permit to: 1p Lkc CO24 4!SL , Last updated: 11/15/2018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ I Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13—Owner's Authorization i I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address job) Signature of Owner date Print Name ' I Last updated. 11/15/2018 ALTERNATIVE . WEATHERIZATIO N Town of Barnstable o v4 200 Main St Hyannis,MA 02601 a H an _ Y Re:Permit# ,o eriiaton;work at `The insulation/weath.,. : ._ . .;: ? has:been cozzipleted:fn accord- ce with.78,OCMR : .'. Regards Timothy Cabral, President CSL-105454 I 58 DICKINSON STREET I FALL RIVER,MA 02721 I (508) 567-4240 1 ALTERNATIVEWEATHERIZATION@GMAIL.COM Town of Barnstable Building Post;This Card 5o Thant�s V�sibleFrom- he5tr.,eet ,A roved Plan Must;beRetamed on 1oband this Card Must;be Kept„ M8T3lTPAEILB. ? „P� ",,. :.'>'r,�� .�, � :- ` � ipp s &c, `� va s;� a� � �i'-a� d �� � �3 ,� '•� M Posted Until:Final Inspection Has Been Made �s y � � ° Where a Certificate of60ccu anc;��s'Re, u�redsuch Bu�[dm shall Not�be Occupiedurttil a Flnal�lnspect�on` h s beer,�,made � Permit .q,. . ..•��wa . �..__ram.;� ._�..k.ago. ���..��. .,. �;�.. Permit NO. B-18-2858 Applicant Name: ALTERNATIVE WEATHERIZATION INC. Approvals Date Issued: 09/04/2018 Current Use: structure Permit Type: Building-Insulation:Residential Expiration Date: 03/04/2019 Foundation: Location: 41 SIXTH AVENUE(HYANNIS), HYANNIS Map/Lot. 246 143 Zoning District: RB Sheathing: Owner on Record: KUDA, PETER M&WENDY J TRS Contractor Name ALTERNATIVE WEATHERIZATION Framing: 1 INC. Address: 6 ESSEX PLACE # 2 ( z° �- - -. Contractor License 175683 CHELMSFORD, MA 01824 �, Chimney: Description: weatherization 'Est Protect Cost: $4,080.00 �� Permrt'Fee: $85.00 Insulation: Project Review Req: Final: Fee Paid $85.00 .,: sr Z � Da a 9/4/2018 Plumbing/Gas z � M � y � Rough Plumbing: 4 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 amend thetapproved construction documents f rIwh�ich this permit has been granted. g All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by lawstand codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or r ad�and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. � � a � Electrical The Certificate of Occupancy will not be issued until all applicable signatures by t�he�6 ild ng and Fire Officials are provided on this_permit. Service: Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or Footing ( y. Rough: 2.Sheathing Inspection �• ', - .,w 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:. 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health 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:' t All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT O� Application number ......... ,� Date Issued.. ....................................................... n sKAM ° r Building Inspectors Initials..... ..................... . UG 3 0 2010 Map/Porc .. .`.�. .. ...`t! ............. TOWN OF BARNSTABLE- s EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION c' - Address of Project: V �' 1 &, .P- S Njrvm STREET VILL AGE _ Owner's Name: Phone Number 91lp- � - 7791 Email Address: lY►1'CA Cell Phone-Number�-6YY\ Project cost$ 0, � Check one Residential ✓ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 dMR Owner Signature: Date: 029 TYPE OF WORK Siding ❑ Windows(no headerchange)':#, g Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector'sareview ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name e `2�ah4 Home Improvement Contractors Registration(if applicable)# / _ 4_ \ R (attach copy) Construction Supervisors License# / (attach copy) Email of Contractor OfPhone number 5 / Im�'J ALL PROPERTIES THAT. VE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATIONNUMBER............................................................. *For Tents Only* Date Tent(s) will be`erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X , X Additional tent dimensions can be attached on a separate piece of paper. K Check one:,this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am--9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date -AP)-] IC T'S SIGNATURE Date Signature �h/ All permit applications are subject to a building official's approval prior to issuance. L Permit Authorization .ass save Form Site ID: 3439090 Customer: Peter Kuda I, ,owner of the property located at: (Owner's Flame,printed). 41 Sixth Avenue West Hyannisport, MA 02672 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Date: sees 689*06 D66*4Q0*0 660106021; 26069606 0*01 060 060019i'0/0 G a 0010 0 trio 0000.G we%�oa i FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: A wtro -V e- Participating Contractor D to Name: RISE Engineering Phone: 401-784-3700 Email: !�,-r 0fti a use only The Commonwealth of Massachusetts Department of Industrial Accidents I 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 Lesibly Name (Business/Organization/Individual): ALTERNATIVE WEATHERIZATION, INC. Address: 2 LARK STREET City/State/Zip: FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 16 employees(full and/or part-time).* 7. ❑New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.a I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition 10❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance. 13.[]Roof repairs 6.F�We are a corporation and its officers have exercised their right of exemption per MGL c. 14. EOther INSULATION 152,§1(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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#: XWO(19)58867158 Expiration Date:6/8/19 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 S250.00 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 u d ain a p lti s f perjury that the information provided above is true and correct. Signature: Date: Phone#:508-567-4240 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC�® DATE(MM/DDIYYYY) A� CERTIFICATE OF LIABILITY INSURANCE 06/11118 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 endorsement(s). PRODUCER I : Anthony F.Cordeiro Insurance Agency N Ext: 508-677-0407 ac No; 508-677-0409 Fal Pleasant Street ESS: HSouza@Cordeirolnsurance.com Fall River,MA 02721INSURER(S)AFFORDING COVERAGE NAIC# ERA: Liberty Mutual INSURED INSURERB: Ohio Security Alternative Weatherization INSURERC: Ohio Casualty 2 Lark St INSURER D: Fall River,MA 02721 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 UULr POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurrence) ccurrence S 300,000 MED EXP(Any one person) S 15,000 A Y Y BKS58867158 06/08/18 06/08/19 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY ECOM aBINEDISINGLE LIMIT S 1,000,000 ANYAUTO BODILY INJURY(Per person) S B OWNED AUTOS ONLY X AUTODULED Y BAS58867158 06/08/18 06/08/19 BODILY INJURY(Per accident) S X HIRED �/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident S X UMBRELLA.LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/08/18 06/08/19 AGGREGATE $ 1,000,000 DED I I RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? n I NIA XWO58867158 06/08/18 06/08/19 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Action Inc and NGRID,USA its direct and indirect parents,subsidiaries and affiliates is added as an Additional Insured for General Liability on a Primary&Noncontributory basis per the terms and conditions of form CG2001 (04/13),for Ongoing Operations per the terms and conditions of form CG2010(04/13),for Completed Operations per the terms and conditions of form CG2037(04/13)and Waiver of Subrogation applies per the terms and conditions of form MEGL0241-01 (04-11) Additional Insured for Automobile Liability applies per the terms and conditions of form SCA005(02/16) Excess Liabilitv is a following form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESENT / 1 ©19$P-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD if`t i ti � iltstir 'Sfid 5 f' ' iU'I�1�'/Cam:• ,,�-� €y; ��12�, r`ti112•'1??iCt��2.1,1.�"�C�i���LZ� f�/;���/I��i.�,�t",f�i�'l�!/ i;.ri. Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Ma: chusetts 02116 Home Improverneit��:� tractor Registration ,s Type: Corporation ALTERNATIVE WEATHERIZATION, INC Registration; 1756$3 2 LARK ST ..,,R„. r=._. : Expiry on: 05/28/2019 y FALL RIVER,MA 02721 ji..w 4� Update Address and return card. Mark reason for change, ."_ _ L� n. {�IG'3�.. "L3`.£N�C1L.. l .J 1JtriY±nt n j Qc+-Core_ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Cofixratl before the expiration date, if found velum to: ` Figgioration Expwaiion Office of Consumer Affairs and Business Regulation =175i 83 05128/2019 10 Park Plaza-Suite 8170 ALTERNATIVE WEATi-IER1ZATION,INC. n,MA 02115 TIMOTHY CABRAL 2 LARK 5T �;r"x FALL RIVER,MA 02721 Undersecretary ti OUi; � BtUre r Town of Barnstable I ed Building t fPost`ThisLard SoThatrt isVis�ble.From;the Street :A rovedPlans'Mustbe°Retani d on3Job an this Card.=Must be-Ke t'> nnitN'ASS. fi �,' �i ?a ��,� � . �, �, .gip � •1d b 'Po oted Until F,inalInspection�Ha�sBeen IVlade 1 � � Permit r +° Where aCertificateofOccupancy�s Requiredsuch Buildmgahall Not be Occup�ed�until a Final inspection has been made Permit No. B-18-127 Applicant Name: FRANCIS E MOGAN Approvals Date Issued: 01/19/2018 Current Use: Structure Permit Type: Building-Addition/Alteration,-Residential Expiration Date: 07/19/2018 Foundation: Location: 41 SIXTH AVENUE(HYANNIS), HYANNIS Map/Lot 246-143 Zoning District: RB Sheathing: Owner on Record: KUDA, PETER M &WENDY J TRS 'nCantractor Name FRANCIS E MOGAN Framing: 1 Z :. S . �� `Contractor License CS-02-6071 Address: 6 ESSEX PLACE 2 CHELMSFORD, MA 01824. Est Project Cost: $63,000.00 Chimney: Description: Replace all Window-Relocate Windows Remodel Kitchen Remodel Permit'Fee: $371.30 Full Bath-Turn 1/2 bath to full, relocate closet for laundr new Insulation: �� Z �` Y Fee Paid: $371.30 paint in and out. Relocate Rear Entrance. Date 1/19/2018 Final: Project Review Req: SMOKE DETECTOR UPGRADE-NO STRUCTURAL CHANGES 14 - - z : / Plumbing/Gas .� v�L Rough Plumbing: _ - h - Building Official Final Plumbing: P ,�� i Rough Gas: This permit shall be deemed abandoned and invalid unless the work authonzedsby this permit is commenced within six,!months�after issuance. All work authorized by this permit shall conform to the approved application a_nd the4approved 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 permitshall be displayed in a location clearly visible from access street or.road and shall be maintained open for public tnspectio"n for the entire duration of the x 3 work until the completion of the same. - Electrical Service: at The Certificate of Occupancy will not be issued until all applicable signures.by"the Building and Fire Offlcialsare provided on this permit. Minimum of Five Call Inspections Required for All Construction Work v Rough: A 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 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 �Post�This-Card:S'o�Ttiat rt is�V�s�bleFromY.the Street�A "roved�Plans Must�beRetalned,o.n:Jgb�and;thisCardMustbe".Kept� ,� BA1tDTB['ABS.IS, " s�� ",'�Ns„c - .�•..: 2 a� ��:_ s X "':a � � ������a "� ,�� "��„"�� �i Permit �""� Posted Until-Final�lnspection Has I3een�Made � r> � z '�'ebr�° Wher�"e a Certificate of"Occupancy��s Required,such Buildmg shalljNot-be®ccupied until,�a Final Inspection�haspbeen made ,� �i ,�<""�^-z,:.��'...z,.:,✓..,s�.,a;;.. ..,.,,>�-.�,s: '.�";:: o..aab%� .:c ".....Xk;.s __.�., ...«wP.„r::. z�d..�:_ o„�':. c'. r��,...� �..�.�." :;'< ,......P�.._. �-., s„ .. :: Permit No. B-18-132 Applicant Name: Craig Bishop Approvals Date Issued: 01/19/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 07/19/2018 foundation: Location: 353 MITCHELL'S WAY, HYANNIS Map/Lot: 291-012 Zoning District: RB Sheathing: s Owner on.Record: FERGUSON,JAY M&HEATHER A �� Contractor Name Craig P Bishop Framing: 1 Address: 385 DAWSON ST 4 � Contractor L�censeCS 109777 2 PHILADELPHIA, PA 19128 Est Prolect Cost: $2,444.00 Chimney: Description: Air Sealing&Weatherization 4 'Permit Fee: $85:00 r >� Insulation: Project Review Req: Fee Paid: $85.00 � Date ° 1/19/2018 Final: Plumbing/Gas z1A Rough Plumbing: r Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authoriz-414this permit is commenced within six months after issuance. g All work authorized by this permit shall conform to the approved application a°d theapproved construction documents for whicH this permit has been granted. All construction,alterations and changes of use of any building and structures"shallbe incompliance with the local zo in ng,by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access Streator tih"road and shall be maintained open forpuc inspection f or the entire duration of the work until the completion of the same. f Electrical P: i The Certificate of Occupancy will not be issued until all applicable signatu es 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 Low Voltage final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work-5hall 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 r Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ONNr� o�1HE r� Application Nlumb� ..... .........0. n.MINST.131 + P=MkFee...... . ................01herFee.. ..... XAss Total Fee Paid................. l,./................... TOWN OF BARNSTA13LE P .................... 8 .. BUILDING PERMIT Y r APPLICATION '' v'°° ""' `` " 'r Section 1— Owners Information and Project Location Project Address '-i 1 S'; x 4'--• Aix Village fl�4K h co K LvDr,OwnersName `- � z C—, C ,nCO Z o Owners Legal Address (. t X <P L, C\n L I ms Q fD M4 > cn " z �J City CvIv,"s At State yn a Zip 0 2-cp_ M w 1 -° Owners Cell# 9-7 & C,/ 9��� E-mail �7 ��rev' ,rl , C&V', Section 2—Structural Use Single/Two Family Dwelling ❑ Commercial Stricture over 35,000 cubic feet r ❑ Commercial Structure under 35,000 cubic feet Section 3—Type of Permit ❑ New Construction ❑ . Move/Relocate ❑ Accessory Structure ❑ Change of use M ❑ Demo/(enre stractm-e) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑Addition ❑ Retaining wall ❑ Solar L� Renovation ❑ Pool ❑ Insulation Other—Specify Section 4—Detail Cost of Proposed Construction cV f 3 cov o Square Footage of Project gy 2 b Age of Structure !; Dig Safe Number #Of Bedrooms Existing 3 Total#Of Bedrooms (proposed) ,3 110 MPH Wmd Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist a Design Last updated:l ln/2017 Section 5 -Work Description 7 2 dv -e� ��,� - I Section 6—Project Specifics aVrning [] Oil Tank Storage . ❑ Smoke Detectors [2-Plumbing Gas ❑ Fire Suppression ❑.Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply El Public ❑ Private Sewage Disposal ❑ Municipal [On Site Historic District ❑ Hyannis 11istoric District ❑ Old Kings Highway Debris Disposal Facility-. I am using a crane C Yes ED-Ro Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No [ i Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) Setbacks Front Yard Required Qy Proposed a.v Rear Yard Required /Q Proposed c2 Side Yard Required i o Proposed j c) Has this property had relief from the Zoning Board in the past? ❑ Yes . Er No r erupdab:&IIn2oi7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street - Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Lep-ibly Name(Business/Organization/Individual): MEk,0L-t 4--(?o JvA-L. Address: City/Sta-te/Zip: V,VJ- Phone#: ED E,) 7 3 G Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a empl.o * with with 4., 0 I am a general contractor and I y 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. g9emodelmg ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' inctrrance,# 9• Building addition [No workers' CO comp.insurance comp. required.] 5. U] VJe are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repair insurance required]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other camp.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 anew affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state%ybctber or not those entities have employees. Tf the sub-contractors have employees,they must provide their workers'comp,policy number. . I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correc4 Signature: „Ar Date: Phone#: 71 1. U D Official use only. Do not write in this area,to be completed by city or town official City or Town' Permit/License# IssuinLILBoard Authority(circle one): of Health 2.Buiding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plurmbing Inspectorerson: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is deemed 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 house dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced'acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if s names address es and phone numbers)along with their certiificate(s)of contractor' address(es)necessary,supply sub () () insurance. Limited Liability Companies(LI.C)or Limited Liability Partnerships(L,LP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below, Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit(license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e,a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Depariment's address,telephone and fax number. The COMMOn vealth of MassacchuseW Department of Tndu.stdal Aeddents Oface of Inve4tigatim 600 Washiltgtan.met Roston,MA 0211.1 Tel, 617-727-4900 ext 406 or 1-977-1�WSAFR Fax# 617-727-7749 Revised 4-24-07 w,m=,gov/din 1 '� ^~�118 (OOJ7f.19G(YJLG1rgfGll�Of C%��C�Jf/C�CIJG' _ Office of'Consumei�Affairs&'Business Regulation; _ HOME IMPROVEMENT CONTRACTOR t• � TVW Corporation i 'Registration Expiration;' <w1.8b l-82 10/19/2018 Mogan and Company Inc Francis Mogan Jr 63 Joyce Ann Rd Center.yl e,MA:02v32 .. f.. { Undersecretary Commonwealth of Massachusetts f Division of Professional Licensure Board of Building Regulations and Standards Constr4jt06K Sbpgrvisor CS-026071 i res: 10/03/2019 } L f FRANCIS E MOGAN �, 63 JOYCE ANN=RD A 'CENTERVILLE MA 02632 �` Commissioner i � I S��s _,ems µ_ - ._ S��� ��,,,,,� �UCJ!''lit- ��.�✓� �c,!�✓��s-.i iJ �� � � S_�vtt�.�_ �+ i_��_o k � J 1 e t r • r r � ., a ._ .� ._... __ -- - -...r a.....�._- - _._._.�.....-_ �._ - - - —.._...,.� c -_._.._... - - .._ i _ -+�/T�� --�+�.� _ r PAULWSA-01 DBRIGGS DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE F01/09/2018 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 endorsement(s). PRODUCER C NEACT Diane Briggs Almeida&Carlson Insurance Agency,Inc PHONE FAX PO Box 719 (A/C,No,Ext):(508)888-0207122 AIC,No:(508)888-0550 Sandwich,MA 02563 Eo AiL .dbriggs almeidacarlson.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Travelers Indemnit y Company of Connecticut 25682 INSURED INSURERS: Paul Sandborg INSURER C: P 0 BOX 19 INSURER D: Sandwich,MA 02563 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. ILT R TYPE OF INSURANCE AODL SUBR MPO�ICY EFF PO DDY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY N D POLICY NUMBER TY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR 68051866015 11l15/2017 11/15/2018 DAMAGE TO R NT D $ 300,000 MED EXP(Any one erson $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYEl JE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO OWNED BODILY INJURY Per person) $ AUTOS ONLY AUTOSULED W1� - BODILY INJURY Per accident $ AUTOS ONLY AUOTOS ONLDY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N AF SIAT ER FICEWMEMBE R EXCLUDED?ECUTiVE ❑ N/A E.L.EA H ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATION&I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mogan&Company THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 63 Joyce Anne Road ACCORDANCE WITH THE POLICY PROVISIONS. Centerville,MA 02632 AUTHORIZED PRESENTATIVE ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I` A6� CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDD"YYYJ lsk-� 01/09/2018 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(les)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 endorsement(s). PRODUCER TACT DAVE JARRY Neill&Neill Insurance Agency Inc NAME: 662 Riverdale Street PHONE 413-732-4137 FAX No:413-731-6629 West Springfield,MA 01089 EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC p INSURER A: Patrons Mutual Insurance 30937 INSURED Doug Askew Electric INSURER B: PO BOX 1714 COtuit,MA 02635 INSURER C: INSURER D: 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. ILT ADDL SUER POLICY EFF POLICY EXP R TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MM/DD/YYYY LIMITS A COMMERCIAL GENERALLIA61UTY BOP273247403 04/13/2017 4/13/2018 EACH OCCURRENCE S 1,000,000 CLAIMS-MADE 2 OCCUR DAMA E TO RifNTED 300,000 PREMISES(Ea occurrence) S MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO• JECT LOC PRODUCTS-COMPlOPAGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accidenn ANY AUTO .BODILY INJURY(Per person) S AUTOS ONLY AUTOS OWNED SCHEDULED BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Par acc dent S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION S S WORKERS COMPENSATION I PER OT AND EMPLOYERS'LIABILITY YIN STAT H- UTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEM8ER EXCLUDED? N/A (Mandatory In NH)If E.L.DISEASE•EA EMPLOYEE S yes,describe under 0 SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Addlilonal Remarks Schedule,may be attached If more space Is reclulmd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ed Mogan THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 63 Joyce Anne Road ACCORDANCE WITH THE POLICY PROVISIONS. Centerville,MA 02632 AUTHORIZED REPRE TATNE /�) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD CERTIFICATE DATE(MM/DD^,YYY) OF LIABILITY INSURANCE page 1 of 1 09/19/2017 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 endorsement(s). PRODUCER CONTACT Willis of Tennessee, Inc. UA PHONE FAX c/o 26 Century Blvd. • 877-945-7378 914-801-4450 TN P.O. Box 30 E-MAIL certificates@willis.com Nashville, TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Zurich American Insurance Company 16535-005 MAP Installed Building Products of Sagamore,LLC INSURERB:American Guarantee & Liability Insurance 26247-004 165 State Rd (02562-2415) INSURERC: Ironshore Specialty Insurance Company I25445-002 9agamore Beach, MA �02562-1309-_______ -tNSURERD:-'-- ------------_--.-�---._ _. ____.._ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:25711213 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. TNSLTE TYPE OF INSURANCE qn SUB POLICY EXP POLICY NUMBER POLICY EFF LIMITS A X COMMERCIAL GENERAL LIABILITY y Y GLO 9139527-11 10/1/2017 10/1/2018 DEAnCnnHpp��OFFCTCURRENCE $ 2,006,000 CLAIMS-MADE OCCUR PREMISES?,?occTErence) $ 1,000,00 000 00 0 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY JET LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: A AUTOMOBILE LIABILITY $ Y Y BAP 0156620-01 10/1/2017 10/1/2018 COMBINEDSINGLELIMIT X ANYAUTO (Ea accident) $ 2,000,000 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Peraccident) $ X HIRED X NON-OWNED PROPERTY AMAGE AUTOS ONLY AUTOS ONLY (Peraccident) $ $ B X UMBRELLALIAB X OCCUR y Y AUC 9314206-06 10/1/2017 10/1/2018 EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10 000 000 DED I RETENTIONS Retention $0 S A WORKERS COMPENSATION Y WC 9139526-11 10/1/2017 10/1/2018 X P R AND EMPLOYERS'LIABILITY N _-- A ANYPROPRIMBER ARTRER/EXECUTIVE' N N/A -Y.-.WC-91"39"5"28=1'1--"- 30/1�2017-10/'1�2018 E:L-EACH ACCIDENT- $-—1,--000-,-OOU-- - OFFICER/MEMBER EXCLUDEDT Mandatory In NH) fyes,describeunder E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Excess Auto Liab y Y 002907301 10/1/2017 10/1/2018 $3,000,000 Occurrence (Excess of underlying $3,000,000 Aggregate $2,000,000 Auto Liab) DESCRIPTION ERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if 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 ACCORDANCE WITH THE POLICY PROVISIONS. Mogan & Co. Inc. AUTHORIZED REPRESENTATIVE 63 Joyce-Anne Road Centerville, MA 02632 Coll:5125789 Tpl:2167964 Cert:257 213 ©1988-2015 ORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Client#: 15228 2BRANNDR ACOP& CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/10/2018 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil Insurance Agy A/C E><c:508 775-1620 ac No: 5087781218 9731yannough Road E-MA P.O.BOX 1990 ADDREIL SS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:NGN Insurance Company 14788 INSURED INSURER B:Hartford Casualty Insurance Company 29424 Richard Brann D/B/A Brann Drywall 3701 Falmouth Road INSURER C: Marstons Mills,MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR tNVD POLICY NUMBER MM/DD MM/DD LIMITS A. GENERAL LIABILITY MPB1438S 12/31/2017 12/31/2018.EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea NTU D occurrence) $500 000 CLAIMS-MADE 0 �OCCUR MED EXP(Any one person) $1 O 000 X PD Ded:25O PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO X $ LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNEDAUT PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION 08WEGLD8356 2/13/2018 02/13/201 X WC STATU- OTH- $ AND EMPLOYERB'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y IN E.L.EACH ACCIDENT $50O 000 OFFICERIMEMBER EXCLUDED? a N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Ed Mogan SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 68 Joyce-Anne Road ACCORDANCE WITH THE POLICY PROVISIONS. Centerville,MA 02632 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S204633/M204632 RPJZ1 ' llk I- CERTIFICATE OF LIABILITY INSURANCE °A�`"°" /10/' �-� � � 1/lo/la THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C NTACT NAME: JIM HINDMAN Schlegel & Schlegel Ins Broker PHONE(Aia Na Exit. 508 771-8381 Fax N ; (508) 771-0663 34 Main Street West Yarmouth, MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:PHOENIX MUTUAL INSURED INSURERS:TRAVELERS RICHARD H GARDNER 92 PARK PLACE WAY INSURER c MASHPEE, MA 02649-2725 INSURER D:INSURERE. 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 AODL SUBR POLICY EFF POLICY EXP - --LTR TYPEOFINSURANCE POLICY NUMBER M/DD/Y MM/DDIYYYY LIMITS A GENERALLIABIUTY CPP0709341 8/20/17 8/20/18 EACH OCCURRENCE $ 1 00,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 5O OOO CLAIMS-MADEa OCCUR PREMISES(Ea occuffencelME EXP(Anyone prim) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE UABIUTY I COMBINED SINGLE LIMIT Ea accideri $ ANY AUTO ALLOWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS _ NON-OWNED PROPEFTY-DAMAGE Peraccident $ $ UMBRELLA LIAB OCCUR EXCESSLIAB CLAIMS-MADE EACH OCCU RRENCE $ I AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC-017.9798 6/3/17 6/3/18 WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPR IETOR/PARTNER/E XECUTIVE OFFICER/MEMBER EXCLLDED? N/A E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $ 100,000 Ityes describe under DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICYLIMrr $ 500 OQ0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attarh ACORD 101,Additional Remarks Schedule,If more space Is requi reel) RICHARD GARDNER HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMP POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MOGAN AND COMPANY ACCORDANCE WITH THE POLICY PROVISIONS. 63 JOYCE ANN ROAD CENTERVILLE AM 02632 AUTHORIZED REPRESEN A IN HAND, ©1 8 2 10 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered markk of ACORD Phone: Fax: E-Mail: Client#:.762395 2TAVANOME ACOPD. CERTIFICATE OF LIABILITY INSURANCE °ATE`MM>o°"Y""' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOL 8/07/2017 DER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Dowling&O'Neil Insurance Agency a orEie Dowling&O'Neil 973 lyannough Road A/c No Ext:508 775-1620 FAX,No:5087781218 E-MAIL coi@doins.com P.O.BOX 1990 ADDRESS: @ olns.com Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:safety Insurance Company INSURED f 39454 Tavano Mechanical Systems LLC INSURER AsaocatedEmpleyersl"'araneecempany 11104 270 Communications Way,Unit 1-B INSURERC: Hyannis,MA 02601 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR LTR TYPE OF INSURANCE POLICY EFF POLICY EXP INSR WVD POLICY NUMBER MM/DD MM/ODW LIMITS A GENERAL LIABILITY. BMA0024O03 8/14/2017 08/14/2010E $1 OOO 000 X COMMERCIAL GENERAL LIABILITY TEDcurrence $500000CLed:5 0 OCCUR e person) $1O000 X PD Ded:500L&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRODUCTS-COMP/OP AGG $2,000,000 JECO T- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident $ ANY AUTO BODILY INJURY(Per $ ALL OWNED SCHEDULED person) AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ _ Per accident UMBRELLA U $AB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION WCC50050149582017A 8/14/2017 08/14/201 X wC STATU- OTH- $ AND�EMPLOYERS'UABIUTY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE YN OFFICER/MEMBER EXCLUDED? N/A E.L EACH ACCIDENT $SOQ OOQ (Mandatory in NH) If yes,describe under E.L DISEASE-EA EMPLOYEE s500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing Contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage,provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Mogan and Company Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 63 Joyce Anne Road ACCORDANCE WITH THE POLICY PROVISIONS. Centerville,MA 02632 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S196004/M195727 CBD 1 Section 9—Construction Supervisor Name 71 Telephone Number Address G.' f c>Ncc_ AV, c_ City C`►,4e,-,o t U State M A Zip License Number CS 2 4 b -71 License Type C.s Expiration Date Contractors Email MoG( _- + �J cy G[yw�Ca 5 ,v�� ell# SOy-?7L- �c)-76 I understand my responsibilities under the roles and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documientation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date /15_/u Section 10-Home Improvement Contractor Name c:-. L9 PL e4e 4- Telephone Number Address_ 63 JA4e, City_ C,•,,.(eoA-A- State IM, , Zip 0aL3z 6 Registration Number/`Pio / z. Expiration Date I understand my responsibilities under the rules and regulation for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature �! Dar /5� Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number 5 I understand my responsibilities under the rules and regulations for Licensed Canstraction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the contraction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature �; Date APPLICANT SIGNATURE Signature s /I Date l� PrintName �s �.-� N��� �� Telephone Number sorP,-?-7L ;zo7o E-mail permit to: ,N,0 C,\C,--%, hc)vvx c.5 (1, .vim Last updated:I ln/2017 Section 12—Department Sign-Offs Health Department ❑ Zoning Board(ifrequired) Historic District ❑ Site PIan Review(if required) ❑ Fire Department ❑ Conservation For commercial work,please take your plans directly to the fire department for approval i Section-13— Owner's Authorization as Owner of the subject property hereby authorize i;_L9 1MS?qc. to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name { Last updat r&l l/72017 ' NOTES. I. ) CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS &DIMENSIONS IN THE FIELD 2.) CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, DETAILS,&FINISHES IN THE FIELD WITH OWNER 3.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETTS STATE BUILDING CODE,9TH EDITION AMENDEMENT&IRC2015 ' 4.) 110 MPH EXPOSURE B WIND ZONE EXISTING 5.) VERIFY ALL PLUMBING&ELECTRICAL DETAILS W1 OWNERS ON THE SITE DECK DURING FRAMING CONSTRUCTION 6.) TIMBER FRAMING TO BE SPRUCE/PINE/FIR NO.2 GRADE 7.) FOLLOW ALL REQUIREMENTS OF THE IECC2015"RESIDENTIAL.ENERGY EFFICIENCY REQUIREMENTS&VERIFY ALL DETAILS WITH THE INSULATION INSTALLER/CONTRACTOR. IECC2015 RESIDENTIAL ENERGY EFFICIENCY DETAILS -- -REF ° � CLIMATE LONE S(USE EITHER PRESCRIPTIVE VALUES OR RESCHECK CALWLATION �3�.5' TABLE 402.1.2(MINIMUM PRESCRIPTIVE INSULATION&FENESTRATION REQUIREMENTS) --T,— REMOD. \o BATH CLOS. KITCHEN 3 m EXISTING EXISTING /\ g o NOr s. _ 1 R VALUES AFF MINIMUMS e U FACTORS ARE MAXIMUMS BEDROOM .D BEDROOM _ _ 2 16119 MEANS R=I5 CONTINUOUS INSULATED SHEATHING ON THE INTERIOR OR EXTERIOR ANDERSEN j DW j 1 ww N OF THE HOME OR R=19 INSULATION CAVITY Al'THE INTERIOR OF THE BASEIVENT WAIL(. CW235 L---J I 3.REFER TO IECC 2015 CHAPTER 4 FOR ALL INSULATION B ENERGY REQUIREMENTS CASEMENT 3'3 J 3'-4" 4.'13 15 MEANS AS CONTINUOUS INSULATED SHEATHING ON THE.NALI.EXTERIOR -I R R13 CAVITY INSULATION I REMQD � § SINK j �� ANDERSEN BED v E Doon OOM Ak251 (VERIFY KI CHEN J0 t �j AWNING LAYOUT W OWNER( •. 1'6'DdOR . CLOS. - CLOS. '•' W10 BOOR A CENTER i SMOKE DETECTORS REVIEWED ANDERSEN ARZSi f O A`vYNING I RANGE C �O _ EW 2�2x6 HOR.ABOVE P -- -� LE BUIL ING DEPT. DATE 21<.2J ANDERSEN 2K.2J EXISTING FEENCH L LIVING FRDOO SLIDING ING DOOR FIRE DEPARTMENT D E DOTH SIONAtURES ARE REQUIRED FOR PERMITTING NEW 2-:x 6 HDR.ABOVE NEW 2-2 x 6 HER.ABOVE , ANDERSEN ANDERSEN TW30310-2 7W30310-2 OOUBLEHUNG DOUBLEHUNG MULLED MULLED 12 B 26.0.' - 12 0" - FIRST FLOOR PLAN QS SMOKE DETECTOR - LEGEND. ©CARBON MONOXIDE DETECTOR � )C Z. ✓� �� � EXISTING WALLS CONSTRUCTION TO BE REMOVED NEW CONSTRUCTION I COTUIT BAY DESIGN, LLC NEW ADDITION/REMODELING FOR: SCALE: DRAWING N o. - 43 BREWSTER ROAD 1/4"= 1'-0" -_ _ MASHPEE MA. 02649 KUDA RESIDENCE PH.(508))274-1166 DATE FAX(508)539-9402 41 SIXTH AVENUE WEST HYANNISPORT, MA w..., ,"Q'. 1/8/2018 Al r4,l :' iti ❑❑ O[Ell ❑❑ ❑ ❑4� � Y; IIIul iM 1 NEW IYT x 8'8' FREN""I DOOR FUl URE AOUITION FRONT ELEVATION _ WI RAILING FOR _ 4 Ln� Il I NL }�Al � - ri� I I?ll'1`t LEFT ELEVATION I 1i�'iiri�'� AF - ' �� RIGHT ELEVATION COTUIT BAY DESIGN, LLC NEW ADDITION/REMODELING FOR: SCALE DRAWING NO. 43 BREWSTER ROAD MASHPEE MA. 02649 KUDA RESIDENCE PH. (508))274-1166 DATEA3 FAX(508)539-9402 41 SIXTH AVENUE WEST HYANNISPORT, MA 1/8/2018 T Town of Barnstable Buildin o -T,h!s.Ca�ir,l".vtFifini{c, e z'� ®s�cec,u:, iedn,until a"z,Final Ins ect�onhb as:be eny magde` Permiet PWostedUnt Cmns& st hee;ae of Occupancy;is Required,such Building shall Not be p p . Permit NO. B-17-4389 Applicant Name: FRANCIS E MOGAN Approvals Date Issued: 12/21/2017 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 06/21/2018 Foundation: Location: 41 SIXTH AVENUE(HYANNIS),HYANNIS Map/Lot 246-143 Zoning District: RB Sheathing: Owner.on Record: SMITH CHARLES A&ANN G Contractor Narne RAN CIS E MOGAN Framing: 1 Contractor License£ CS 026071 Address:. P O BOX 704 2 WEST.HYANNISPORT,MA 02672 k Est Project Cost: : $3,500.00 Chimney: Description. 30 u-value 3 windows . Permit Fee: $35.00 ' Insulation: A"ItFee Paid $35.00 Project Review Req: f 12 21 2017 Date / / Final: e c S t`L Plumbing/Gas Rough Plumbing: Y .. ,Building Official 7. 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 wh Ch this permit has-been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zornng by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street o rd and shall be maintained open for publ inspection for the entire duration of the work until the completion of the same. V ,, � r, Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Bwldmg and�Fire Officals are,providgg �ed�on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work. �, g 1.Foundation or Footing m m� mM Rou h: F 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 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 Inspectorhas approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGLc.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 Post This Card So That rt�s Visible From�the Street. A 'roved Plans;Must beRetamed on Job and,thlsCad;Must be Ke: t -}, tARNfTI'ABl ,. " s: z .�.xr r s' rr.:�� z ,.pp` " a,.£ Y. '`t 3``r ,' s. s sr`°. ". ,,p O arm Posted Until Final�tn`spectionHas Been MadefS fi y ,:k n °3m{� - 6}Q aw s; RWhere a CePermi rtificatof,,pccu anc..is%Re aired suchBuild�n shall Not,.be�®ccu led,unt�l a Final ins ectio,n;has been<made , � Permit No. B-17-4389 Applicant Name: FRANCIS E MOGAN Approvals, Date Issued: 12/21/2017 Current Use:: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 06/21/2018 foundation: Location: 41 SIXTH AVENUE(HYANNIS), HYANNIS Map/Lot 246-143 Zoning District: RB Sheathing: Owner on Record: SMITH,CHARLES A&ANN G. F` Contractor~Name .FRANCIS E MOGAN Framing: 1 Address: P O BOX 704 Contractor License CS-026071 2 WEST HYANNISPORT,MA 02672 Est Project Cost: $3,500.00 Chimney: .Description: .30 u-value 3 windows . yPermrt Fee: $35.00 Insulation: 7 Fee Paid_I $35.00 Project Review Req: Final: Date. 12/21/2017 s y Plumbing/Gas 44 Rough Plumbing: ; h Building Official r Final Plumbing: ,rzy This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved appl ation and thefapproved construction documents�for which this permit has been granted. All construction,alterations and changes of use of any building and struures shall be in compliance with the local zornrig$by-lawsand codes. Final Gas: ct This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for publkc 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'.,thhe Building and Fire Offic I�s'are pr�vlded on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:. - 1.Foundationorfooting , Rough: 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 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 i oFt ,q j, Town of Barnstable *Permit# ,9-t 7 Y pExpires 6 mom hs from issue e Building Departments®lvices r�eeS • aAMBrAst,s, • Brian Florence,CBO m Ar 1639. �� Building Commissioner 0 FD p�21 200 Main Street,Hyannis,MA 026Q Jp www.town.barnstab11W.us Office: 508-8624038 /�j� 1 ��°� Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDEN kl a NLY e �Z—r— Not Valid without Red X-Press Imprint Map/parcel Number gP y/6 / L3 I Property Address L-( ( S.,J-, 04 t ❑Residential Value of Work$ ` eg i 00 nn Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ���/ �•tJ4� Contractor's Name D. oc,i„� �. Telephone Number ��cX) 77 av?0 Home Improvement Contractor License#(if applicable) Gj l 02— Email: w_t4 1+\ov%-- C, C.-.?,4^ Construction Supervisor's License#(if applicable) C S 0,1t, C)-71 ❑Workman's Compensation Insurance Check one: ["I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Lj G i cJ 7ci �w�✓u✓ � 5+ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Plieplacement Windows/doors/sliders.U-Value , 3 D (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is re uired. SIGNATURE: QAWPFILES\FORMS\building permit forms\EXPRESS.doe 08/16/17 G ' 27m C'ommarnr'eafilt of -Mas achuset& Deparklieut a'radrfsvid Acciderd#s _ 600 Wasfiingiou&hi wt Bastrin,CIA 02111 u Fvmmam%gapMa Workers' Ca mpensaf an Insm-anceAffidavit:$wlderslCantractaErsMe c dcians/Phm3hers ApplicantIufc;rrmafinlu Please Print LeQr 1iy NaP17CRIP �j Address- Crfyf�fatel�ig= Ph�omti�' Are you an employer?Cfteckthe appropriate bo= ' T of project r L❑ lama eau 1 With 4 21 am a gerreaal confractor and I YPe e 1 ( ictim employees(Rd an&or park-lime * 1 ave hired1he sub-confrat-�ors 6. ❑lde�consi� iag 2.❑I am a sole proprietor orpartner- Usted an the.attached sheet. i. ❑Remadeding s4rfp and have no employees These sub-contractors have & ❑Demoli6ort addng for=e,in any capacity. emFloyees and have�FO&ETS' - � 9. ❑Building addition [NO fig,' camp_isaauanCO camp_%ncaxaa 5. ❑ We are a cmpozafiou and ifs 10-❑E eetxinl repairs or addifious officersh dd have exmse � 1 L❑Mm3bsa airs or addi hans 3_❑ lama bQmeov�er doing a1I v�oriCre� P Myself No V'Okk='t0mF_ 69ILLof exemption per M(M 1?,[:1 Roafrepairs i astir a.ce re�+'ed}1 a 1.5Z§I(4k and we have no n . employees-[NO Wosiresa' a El Other coasp_insurance requhiAj •guyapp dsstcbedcsbosiRmastalsoMattiesed=bffbwsllwrong&e"awaaeecvmp—ssati�aupe&cyiaiilamas`]aa_ t T,H=aamner swho salt�lis xTuk s inducting tisr_y axe�daieg RUWCA and t6 M MM nut ade Con 3Cft=— SnFrmit s aew>�3 t m� 5ac5_ ZCbvmiCfp6iff=trbeatIYF.SbmEm=rftr1v DL 9dd �D915 +I 5bOlC3Rl�,tlleL�4E'Of IIIE Sn�7-CO ZS�dStJ�E SIClYEIIlEL OiLoL•�5E Pdtt'C[PSl1a'i@ -%dayeas.Iftbesabtantxctu 1wn emp1c7ee%rlrey I pma&dim warke&camp.palm.'nu mben I am all empinpr that is prauir b warkers'coarirerrsrdian inmirowe jor my entpkwem Bdbiv is Aepv&y and job s e informrritiarz ` //.�' • lasutanceGompany1fame: -Pooficy 41 or Self-m,s_I ic. C; f 75 7 9/ 9-' Job Site-Addre= Li t (<" � -�� CifyJS#afe�T.sp: Attach a!copy of the u;orlmre compensationpolicy'declaration page(showing khe policy der and expiration date). Failure to secure coverage as required.nudes Section 25A of MM.a 157-can lead tD the imposition of criminal penalises of a fare up to$UDD OU and+'or one-year impdsn--nt a's well as civil penalties im fiie farm of a STOP WORK OBDEltand a$ne of up to$250.00 a dap against fhe violator_ Be advised 9mt a copy of this state +¢nt.shay be forwarded fn the Office of Irrvestrgatiom of the DIA far ihsmnce coverage sdfrcatim 'Ida hengby cert5,under tha pabis w dr psruffi s af'pe thatthe arf ar za&u pm-rW abmv A liars ar:,d cwect Sit�ature Date: "02 Z l l Phone ik '�� of jtciaL use arr£}: Da rrat avrite itt fig 1rreQ,tir be cortrgleted b�cafp ar ton�ri of j`rcirrt My or Town: Per—Wr ieeuse:9 bsmingAufho•r€t5*(d de erne): L Sward of Head RurTding Pquntn:eut 3.City1rown,Clerk 4 Electrical Laspector rr.Phunbiag Inspector 6.Other Conact Person: Phone#: — -- - --- 6 Information and 11astructiOUS Ty rime meEtts Ge�:u l Laws c 152 regan-e-s all=ipIoy=to prUVIE WOII s,comps fur flies employee- tills s� an. Inyeeis defnedas. _.evPaypeasonm..Elieservice of anafher uader aaY canfraot of hs PmsaMju � empress or implied,oral or written: An mzpIay�is defined as"air maid A partner,assocj rn,cc m n or other legal may,or any two or more of flie foregob g=pgrd fu a Joint ,and i=kcilug the legal=2=senf&es of a deceased employer,or the receiver or trustee of an inavidaA patIMMbip,amociation or other Iegal ent$y,employmg employ- However fhe owner of a dweIIIng hose bavmg not ma a tba a three arhnenis and wlzo resides fli�eu►,or tine occ ofthe- dw Mag house of anofher who employs persons to do ,conefrrrr li a"or repair work on such dwelling house or on.the grounds or buffidmg agp Himeto sballnotbecanse of such employmedbe de medto be an ezrrployta" MGL d apter 152,§ C(6) a sib nr Ioral l;sea g agency shall itbhoId ffie issuance ar 7S also sues fin'¢ eveary renewal of a Ncen e,or permit to opm ate a lduskes's or to construct bm7rLmgs in the commna4Peali3l for any a-pPhcantw•b.o has not prodnced acceptable evidence of coraplii=m with the hisurance.coverage raquired-" Additionally,M TH-chapttx 152,§25dM stains-Teifb=the cc= aweahli nor try of its political subdivisions shah eater into any contact for the performance ofpnbIic v u acceptable evidence of complian cewito e;,, -an ce. regvir==fS ofthais clisptesbavebempresenfsdin the conf�.auf =ty:, A-ppHcants- Please fill out t$e woI',compensation affidavit compleinty,by g the boxt s tint apply to your IL and,if necessary,supply� r(s)name(s), (es)and phonenumber(s)alongwiththcir certda afe(s)of Inso rance. L Cone ( L ) rIzt ibi-i • enehipsLI )`T ompyeoriwe dLab� no the tb members or pMtueas,are not rbq>mnd to CMXY W(ni ,compensation fus¢r m If an LLC or iL P does have employees,apolicyisretjaia4 Beadvise-dEnt this aflidayit maybe mbmfitedtotli-,Depa-imentOfEa&stial Aeeide t for confirmation of ias>n�ce coverage- Also ba sure to sign and date the ai=dxdt The•affidavit should berefnmed to the city or town that the application for the permit or license is being regaesEed,not the Depaemeaf of Tmuldyou have any question regmtag the law or f fyou am required to obtain a workers, =npensationpoHcyY plmsecaatheDepadmerfatthennmbe Hst!:dbelow- Self-msvredcompanies shoulder$heir self-;�,crn•-an ce license number�tiie agpropziai�Ime- City or Town Officials - r Please be some that fire affidavit is complete and punted Iegi6ly. The Departineat has provided a space at tiie bottom oftiie affidavit for youto fib out m.toe event the Office ofInv o s has to con ac,-tyon*�mg tho applicant Please be sure to f M in the pent liicense umnber which wM be used as a re:E s=ce number. a addition,an applicant t at must submit multiple pezmitlIicense applications m any givenyear that ,need only submit one affidavit indicating ton�nt policy i nforaatian-[if necessmy)and under"Job�e Q��s�fie applicant should write Or "sII locations m ( Y town)--A copy of tie-a$davitt3iathas be=officianY stamped ar mmkrdbythe city cur t'°wn m ay be provided to t3ie applicant as prooftizat a valid affidavit is on Elc fur futore'pemits or licenses Anew affidavit n n'A be filled out each • year.V7Iieae a home owner or tin is obtamfag a IicemGe or pe�.it not rela•[�.d:fn airy business or�mmescial vie - Cie. a dog license orpatmit to bum leaves e#�-)saidperson is 1�TOTredta complete this affidavit The Office of Juycsfig -o _ would3ce in fhank you m a&mm for your cooperation and should you have any qtn ons, - please do nothesiiste to give us a call. M5 I?eparim eufa amass,telephone and fax numbea: 600 bb$m Stcet B oil II T '617-727-4900 Qxt 4-06 Qc Fax#617 727 7M Rmised•424-07 W.Tn 4 � Town of Barnstable Building Department Services ` DUM ` Brian Florence, CBO w`� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section - If Using A Builder I �`e-�-o�! �` as Owner of the subject property hereby authorize 1 '�DG .. et �'` `" =ct on my b eh4 I in all matters relative to work authorized by this building permit application for: e-// G fa (4-v t— (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature o Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:09/16/17 4 Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 snaxsr�e. : . KAM ,p. www.town.barnstable.maus �1639. A1�° Ep Mla Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: L// a 4L, 4, G.w� number street village "HOMEOWNER": �Z. ✓ ►/��..(Q� �� y fo 125 c�7 95 name home phone# �+ n work phone# CURRENT MAILING ADDRESS: to L S S z k �L a c C_�.ti��+c h!✓cY vvlAr 2-4 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- f unily dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules andregulations. Y The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro ps and rp ' ements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFU-ES\FORMS\building permit fosms\EXPRESS.doc 09/16/17 J r AC®R CERTIFICATE Q = LIABILITY INSURANCE DATE(MM/DONYY ) THIS CE RTIFICATE IS ISSUED AS 7/26 17 A MATTER OF INFORMATION ONLY AND I CERTIFICATE DOES NOT AFFIRMATIVELY CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD ER.DER OR NEGATIVELY AMEND THIS BELOW.. THIS C , EXTEND OR ALTER THE COVER AGE RAGE CERTIFICATE OF INSURANCE NG INS R (S THE POLICIES RANCE 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 endorsemenf(s). PRODUCER Schlegel. & Schlegel Ins Broker NAME: JIM HINDMAN PHONE 34 Main Street 508 771AIL -8381 1(AI Nc: (508) 771-0663 West Yarmouth, MA 02673 aDDRESS- schlaiinsuranc9@gmai1.com INSURE S AFFORDING COVERAGE I NAIC 1: _ INSURED- ------- -----"- ------- - - - INSURER A:PHEONIX MUTUAL _ RICHARD H INSURER B:TRAVELERS ! — GARDNER. -- MARA. GARDNER lNsuRERc: 92 PARK PLACE WAY INSURERD. MASHPEE, MA 02649-2725 INSUReRE: — ( — COVERAGES INsuRER F CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIF INDICATED. THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ED. 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. )NSR -. - - --------._ ADDLISUBR ------..-_ ---- - - - - - - - - LTR TYPEOFINSURANCE POLICYEFF i POLICYl7(P I - - - - - N i POLICY NUMBER ( MMIDDNYYY I MM/DDIYYYY i LIMITS A , GENERALLIABILITY { ; ICPP0709341 ! 8/20/161 s/20/171 �� i 1 EACH OCCURRENCE is 1,000,000 Xi COMMERCIALGENERALLIABIUTY I I DAMAGE TO RENTED �! CLAIMS-MADE u OCCUR i PR Mtn c r a own ram—s s 50.000_ uI j ME ow(Anyone person) is 5,000 I { I i PERSONAL&ADVINJURY is 1,000,000 { I GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER I — POLICY PRO- I I I I i j PRODUCTS-COMP/OPAGG ,'s 2,000,000 . LOC J AUTOMOBILE LIABIU STY I I COA'BINEDSINGLELIMIT ! i I(Ea acciders) 5 ANYAUTO I { 90DtLYINJURY(Perp-----i g ALLOWNED SCHEDULED AUTOS AUTOSNON-OWN BODILY INJURY(Per accident)1 S HIRED AUTOS AUTOS EO I PROPERiYDAMAGE 5 --- 1 { { �PeraccidenU j j is UNIIRELLAUAB OCCUR IXCESS UAB ; f I EACH OCCURRENCE S CLAIMS-MADE I i AGGREGATE I I I s DED RETENTION S -- B WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY YIN TO �WC-0179798 I 6/3/17+ 6/3/18{ i WCSTATU- 10TH-1 • 1 IMITS 1 ANY PROPRIETOR/PARTNER/EXECUTNE OFFICEWMEMBEREXCLIAED? NIAj , j + E.L-EACHACGDENT S 100,000 (Mandatory In NH) { E EL.DISEASE-EA EMPLOYEE!S 100,000 If yyes desaibeunder I j DESG�RIPTIONOFOPERATIONSbelow ( i I i iE.L.DIS EASE-POLICY LIMIT�S 500,000 f I l f i i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (AttaUt ACORD 101,Additional Remarks Schedule,if more space is reglired) RICHARD GARDNER HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMP POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES-BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N WILL BE DELIVERED IN TOWN OF BARNSTABLE ACCOR CE WITH THE POLICY P ISIONS. IN HAND, , AU TH RIZ SENTATIVE if I r l 01 8.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: t r 1; Commonwealth,of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Con st`.gri t116�1§Spervisor CS-026071 E4pires: 10/03/2019 r FRANCIS E MOGAN y='*1 63 JOYCE ANN RD ` t' CENTERVILLE MA 02632 �� � Commissioner 1 • i . , �," �clfze•�rrauu��ioarcGeall�o�C�/l�rc:Jtic�i�rieCtt Office of Consumer Affairs&'Business Regulation HOME IMPROVEMENT CONTRACTOR Type. Corporation - ` Registration Exoiratiofy` x' t80182 10/19/2018 Mogan and.ComP 9 F.ransis Mo an Jr 63 Joyce Ann Rd r ` .Q Center dle,;MA &dd 1 Undersecretary OFtr�e. Town of Barnstable *Permit Expires 6 months from issue date Regulatory Services Fee AMMSTABLE, t MASS. , 1 �' Richard V.Scali,Interim Director �ATi63q.f 2.2019gg] FD N1p'� Building Div ision f T®►A,� ® Tom Perry,CBO,Building Commissioner. v►/ ARNS . STA® 200 Main Street Hyannis,MA 02601 LE y , www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION = RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number E Property Address 141 i i► 1 [Residential Value of Work$ 'li' :I Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address PC) b3y, .-J,�q �fij myq,0(Sf Contractor's Name v UL Telephone Number `TO � o i � �n� Home Improvement Contractor License#(if applicable) Email: C C,u�'"f�e� �� 1'1 Construction Supervisor's License#(if applicable) l ❑Workman's.Compensation Insurance ` { C h ecklone: I am a sole proprietor. ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp:Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Req st(check box) [ Re-roof(hurricane nailed)(stripping.old shingles) All construction debris will be taken to i ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.,'U-Value (maximum.35)#of windows 1' #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: Property Owner must sign Property Owner Letter of Permission. A y o he provement Contractors License&Construction Supervisors License is quired. SIGNATURE: 0AIATFILESTORI C5VW11ding permit forms\EXP� do c Revised 0613,13 r _ , 1 _ l a o V iHie Cornrtt't7ityrealth of assachus � _P hiz& afIYulrvsftial Accidents ,,�1 r ( r; [lt ofTIVeStZlOY�S- r r l' 600 Y[SSIFCri /O ri S�reet " I ( j I Bostong�A 0411 ���� " ii'f •Fm ," 1• ,#;, r{r` f,' YVFL'i1P.7t2[LS�gOi�dYa .� Workers' Compensatirlailn�nc� Affiidavit:Bmd&rsf ntractorAlectricians(Plum�iers Applicant information . Please Printb!y r. Name(Bustiness/oganizafionaadividuai) Address: ; P}o x r C tyfState/Z p_ V�I U`1�,K l 1 ► �0 one I� Are you an employe ? eck the appropriate boa: 1 s l Tape of project(xNuired}_ 1.Ail ayetnd I to eep yea with 'p- )'I* 1 4'.:0 Iam hired.tlretlre*suntrac or anrs ti F 0 New oonsEiucfirsn s full and or art�me. _ 2_ a sole proprietor orpartner; �.i irk listed on the attached sheet . 7_ ❑Remodeling s and have nra to ees. k t. These sub-contractors have . Y S_ Demolition. wording"for me in any capacity. ! employees and have Workers'.; [No woiir�s' camp_inwtra=e. 1{ ,comp_insurance.$ t 9_ ❑Building addition required_] t 1 3"4 . ❑ VtTe aiz a corporation and its 1U..0 Electrical repairs or additions 3-[] I am a homeowner doing all wont officers have exercised their, 11_Q P96bing repairs or additions. myself [No workers comp_ 1 .1 :. iight.of exemption per MGL' 1 of repairsinsurance requued j F, c. 152, 1(4},and we have no employees_.[No workers' 13_.❑Other 3 t ,comp_insurance required_]; #AryapPtictvtfiat checks box#1 mast also Sll out the,sectionbelowshnwing their wocdcets'compe atioatpalicginfflr ram Homecrwaers who submit this afiidac"it indicating d-y are doing all wok and then hire outa&contractors must submit a new afdasit indicating snrii Contactors that check this bax must attached as additional sheet shoa�g the name of the s t ors and sude whether or not those entities have loy 'sub employees. Ifthe -contractors have employs,[he}most ptuvide their wti&—'comp.policy number. I am an ernplayer that is prof iding xr orkeis''comperrsafi¢n insurance for rrr,J,en¢pinyeees. Beloty is the policy and job site Insurance C omP: Y au Name , Policy 9 or Self-ins_Uc_4. . f Expiration Date. Job Site Address ! + C tyOStafe]Zip Attach a copy of fhe,isorkers'compensattubn policy declaration'page(shoNving th+ policy number and expiration date). Failure to secure co.�;erage as required uuder�Seetiori 125A of MGL c_ 152 can lead to the imposition oferimitnaI penalties of a fine u to S1.500.00 andlor one- ear' ' _t s as P well as c Y ,izal penalties in the form of• �i p a STOP RTiJRRg ORDER and a fine: of up to$250.00 a day-against the violater' Be t-advised that a copy of this statement may be forwarded to the Office of.t Itntestigatians of the DIA fi7r' coy era � � cation_ I do fi rtrfy rander t prrirr nd pe{`na s o :ury that the information prosided abM is hue nd correct Signature. Bate_ Phone 9: official use only. Do not trrite in this are , bs conipteted by city or town ofrciaL City or Torn 1 ' , 1j (. PermitUcense# Lssuir g Authority(circle one). 1.Board of$eaItil .Bedding Ilepaz tment,3.,CitF/Town Clerk 4.Electrical Inspec-tor 5.P'iumbing Inspector 6.Other Contact Person: i s. Phone#: ,# 6 M. t, - 9 v Massachusetts -Department of Public Safety Board of Building Regulations and Standards j Construction Supervisor Specialt}' License CS 9 1 cc 3AMES p CURL E 287 FULLER AD Centerville 1ViA 02 2 '' Expiration Commissioner 01/28/2016