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CERTIFIED PLOT PLAN
LOCATION 1�092.!°% 134
SCALE . ...�.r=.3O�... DATE
PLAN REFERENCEN LoTr2�
E»E- �1 �� p .. . . . . . . . . . . . .
a EL Ev
No. 26100 an
�L L ,o nivG r70.v
I CERTIFY THAT THE . . . .... .. . . . .
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
.WHEN CONSTRUCTED.
DATE
REGISTERED LAND SURVE R
Bayberry glace `Realty .Trust
Jacquesa N, Morin, Trustee; �N�E•
-300 'B'earses1.yWay
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MA 0 2 6 01 '
' .Hyannis
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"Town' of - arr�stahle
'~ h. Bui:l.'din Department ;ter " r k . r
C/0. Richard; Bearse, {Inspector,4
�367Mair tr6et �..'
_ , r y `^
Hyannis ,' tMA 0260i
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Town of Barnstable »} `,} i December `25, .-1992
Y y /� ? '
_'Buil'di-ng Department t y
C%0 ;`Richard Bearses, Inspector
367�'Main .-Street
� :Hyannis,, MA" 0.260:1` "��, ;, r `,; ' �• E{ .N a- y. i
Dear 'Mr 'Bearse �
In response to our ,recent `;phone conversation regarding the, f;oundatioii � r
permit yfo:r Lot 28. Bayberry Place I' have 1"ooked into' the matter and have found"
that .an 'oversight: had'in fact_`i-esulted 4 s,
The lot-'had been cleared,;and excavated irisapreparat on for a .�new model: home.
At' the de-e'-lopment My =forms person who riad t'he preliminary,,` foundation--•`plan;.
for- thi•s -dwelling .apparently,-thought" ar: foundation; permit lad been issued`-and' '
:that`:the foundat; on 'was ready,°.to, .pour.and:did so on" the 14th' of .•,ahi`s-December,: '
r � However, ,: the final ,plans were<, noty5'comple`te° at that`;"time as `per; New Engi=and;
Ff Desi'gn aril the f,otinda:t.ion permit h'ad not in fact been •issued: This ; .s fu.rthei
evidenced°, bry,_ the proper �pro0ection_ over hanging'.`a f,o 'ndatiori that" had ,not yet }
eeri fully designed for the ;fiial .strtii.cture. My 'apologes are _n o`rdes for
L t
aving been more:"`spec fic with- my forms person ;� I .accept full
� <responsib'ilit'y for this oversigYit
+
Tv td Yr t✓' brry a. ;y 3 '. 1 .'r .a 1 i t,. .''' .tom a. { 2 F ,`i'y ,.•, � S hY Y _ t T,,r ,' i5 t! :. `, ."« zy t
i;• i
Per t your request, 'Ij had, rendered' the foundation :safe: by capping .the
.,..,
foundation'`and backfilingt`the_.> same until said: Alan's were ,complete .and a
foundation 'permit' could is sue
y
:y d t.. yf. yy r . •, 4
.r
As you are aware,:, . on:;Dece'mber 24, .199.2 I had, come'"in with ;the completed
.plans for L this ,dwelling in antici"pation of .obtanrng the' foundation- permit
And/or ,building :permit' if appropriate, w Il.had _in.-fact dscc�E�ered;when I went f
to , he 'planning board department the same "day that ahis ';lot :#2•.8 was, :one•.of two
lots, that; h. had not- previously, requested to be 'released,:from covenant out. of. :
rthe :28 lot development Obvous.ly this 'was riot a=;good way on -my, .part 'to.` ,
end an .otherwise <good• ver: I Basked to, be :olac.ed ( ri the next available
-agericla tfor conscleririg they release {
.. s e y -x ! •± + 5{ Y .• y 3{ � k -. x Y�'w , •,y r ' .
:- t . n.a. 1 .;>r•• ";. a.w a i t y .: Pa .,�.. -n j i. ,. c. .• f •' , _ r
P<lease be assured`-tKl t .I•,ha�e ' nstr'ucted .all workers to discontinue any
, s. sie,• until final , ndth swork'ori: th t . e ".
.Obtained." . My, opoligies for any ,confusion
Sincerely.
x '
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FOUNDATION PLAN ROOF FRAMING PLAN =MEET NUMBER.
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92MES
I - 9216]A4
y��oF THE r,0 Town of Barnstable, Massachusetts
• r
Department of Planning and Development
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WASSS. E'0 Office of The Planning Board
A1A.SS. o.
i639• ��
ATED MA'i A 367 Main Street,Hyannis,Massachusetts 02601 (508)775-1120 ext. 190
June 20, 1989
Aune Cahoon, Town Clerk
Town of Barnstable
Town Hall
367 Main Street
Hyannis, MA 02601
Re: DEFINITIVE SUBDIVISION 4701 - SPECIAL PERMIT MODIFICATION
Open Space Subdivision 4701 ; "Bayberry Place" ; Subdivision Plan
of Land in (Centerville) Barnstable, Mass . Prepared For Bayberry Place
Realty Trust, Jacques N. Morin, Trustee; Plan dated 12/20/88; Low 8
Weller Engineers ; Assessor's Map 273 , Parcel 86, 90, 91 , 8 110-4.
At a duly posted meeting of the Barnstable Planning Board held June
19, 1989, it was voted to APPROVE the request to MODIFY the SPECIAL
PERMIT, pursuant to Section 3- 1 . 6 of the Zoning By!aw of the Town of
Barnstable, to allow the reduction in sideyard setbacks from Fifteen
( 15) to eight (8) feet for all lots, with the EXCEPTION of lets 1 , 3 ,
11 , and 12 , in subdivision #701 , "Bayberry Place" .
Respectfully,
Nj
Jos p E. Bartell , Chairman
nstable Planning Board =
JEB:vk GN
oar TOWN OF BARNSTABLE 35600
Permit No. ...... .........
BUILDING DEPARTMENT ($420. 00) ��nIQ3
TOWN OFFICE BUILDING Cash
7 .M�
w ` HYANNIS.MASS.02601 Bond
CERTIFICATE OF USE AND OCCUPANCY
Issued to Bayberry Place Realty Trust
Address Lot #28, 34 Statice Lane
Hyannis, Mass.
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
i
August 27 93
-Building Inspector
i
�I
.� pja aS-0
ten•
Assessor's office(1st Floor): g
Assessor's map and lot number a 73 , /),?/
� TN¢T o�°�
Board of Heal jh(3rd floor): `
Sewage Permit number `3-7 2
Z BAWSTAILL i
Engineering Department(3rd floor): VAea
House number 16- 1639.
Definitive Plan Approved by Planning Board 19 �Fo YAY d
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN . OF BARNSTABLE
BUILDING . INSPECTOR f
APPLICATION FOR PERMIT TO /1/S L • f 6 9 ri'-`
TYPE OF CONSTRUCTION P '
1-2 / aid 19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ��dT 02� cS7,74 T 7C t-AitJt- kIVOA-VV/S ,
Proposed Use
Zoning District '- ( Fire District
�vs7�
Name of Owner �A-r„ .. rc Ls � I Address 3o �-�4,�s�S' !N/�i . t-f ti.!!!
/�', K- b,, 1w z� Address cc- c•/41-, zt-Z_
�1 4- O zri
Name of Builder ,�
Name of Architect lU t �r e Address l of �
Number of Rooms ! Foundation 1,bo r[r E4 C-D A/C.ce�.
Exterior C Cap Roofing As
Floors IV1,aq� Interior 064i..r�1
Heating Plumbing
Fireplace / Approximate Cost 4 01
Area I��
Diagram of Lot and Building with Dimensions (f}sA bov '� Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.
Name I
Construction Supervisor's License 0 l s,j
BAYBERRY PLACE REALTY TRUST
} No 35600 Permit For 112 Story
.�,oingle Family Dwelling
Location Lot #2 8 , 34 Statice Lane
Hyannis
gwner Bayberry Place Realty Trust
Type of Construction Frame
` Plot Lot
Permit Granted January 7 , 19 93 I
Date of Inspection 19
Date Completed 19
. -, ,. -'F[:-vi ,a;.T'•"��.y':.�!�,. Q..•..n 4�rj Y 5�-"Y zG _ y�, ���
_ - - iv v,� Lt: r'r r-it -�"i'"t7•,uu,{3y.A'!Kti� +�.. .. �`.
TOWN OF SARNSTABLE 35600
• BUILDING DEPARTMENT ;` Permit No........... ...
I RAM" I cash ($420. 00)
TOWN OFFICE BUILDING ..........
'ra ur HYANNIS,MASS.02601
• Bond ................
CERTIFICATE OF USE AND OCCUPANCY
Issued to Bayberry Place Realty Trust
Address Lot #28, 34 Statice Lane
Hyannis, Mass.
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE..
August 27, 93
19 ....... i/�"•:••..............
B ild►ng Inspector
TOWN OF BARNSTABLE
"PAYABLE TO• BUILLAG CO1'7!
SONERS OFFICE
• DATE �'
Jacques Morin ACCT.n "O/,, /6Q
300 Bearses Way '
Hyannis, MA 02601 VEND-Cr # 126q/(:::,
AIE % '��0 00
PO#
APPROVED BY
t
OF BARNSTABLE, MASSACHUSETTS
,:;A 273-0f 6' DATE •: ;TiUc:i�.r f
19 93 PERMIT NO. 1T
f) r15
APPLICANT I'aCarY EVE: ,l;Jl ADDRESS C.`:.`i�"[3rVl "�e I, 1`':u. #00905 5
(NO.) (STREET) (CONTR•S LICENSEI
PERMIT TO $L221Ct L)wC:1?2:%4'' ( 1 � I STORY `�'=-`'�. 1?•r F I:1i�-;� I�G%f..11i,,), NUMBER
UNITS
(TYPE OF IMPROVEMENT) �t NO. (PROPOSED USE)
Lot #28 3`S Jt_i"L�.lc,. �` lnef hy-al-Illis ZONING
AT (LOCATION) F c-J.
(NO.) (STREET) DISTRICT
BETWEEN AND
(CROSS STREET) - (CROSS STREET)
SUBDIVISION LOT
LOT BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE' USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: al�.'.WL� #3 I24
300 bear.,Ls Way,
AREA OR - _
VOLUME 2173 sq ..-• It. ESTIMATED COST $_ _ - FEEMIT s J" �4 `'
(CUBIC/SOUARE FEET)
- OWNER Trust -
ADDRESS , tl t�i iat?�J: ;! / i_ i.l,:i BUILDING DEPT.
BY
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF,► EITHER TEMPORARILY OR
PERMANENTLY.ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY SE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL APPROVED PLANS MUST RE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: E CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR
LECTRICAL, PLUMBING A140
I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- -MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MINAL INSPECTION
TI TO LATHE FINAL INSPECTION HAS BEEN MADE,
3. FINAL INSPECTION BEFORE -
OCCUPANCY. -
POST THIS CARD S�► �T IS �ii S e � �iic�A� S T HET
/a1
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
2 Z ✓ t i"r1Al � E; �124G) z
tt Z J�13
3 7 HEATING INSPECTION APPROVALS ErNEERI D ARTME
BOARD OF HEALTH
Z�C//
OTHER SITE PLAN REVIEW APPROVAL
4'�
WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE
TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN
CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION.
111 -
j yo�lYtto`
The Town of Barnstable
j /A11f711L1' : Inspection Department
367 Main Street, Hyannis, MA 02601
508-790-6227 Joseph D. DaLuz
Building Commissioner
March 9, 1993
Mr. Jacque Morin
300 Bearses Way
Hyannis, MA 02601
Re: 34 Statice Lane, Hyannis
A=273.086 (part of)
Dear Mr. Morin:
I received a request on this date to do an insulation inspection at 34
Statice Lane, Hyannis.
Records at this office indicate that a rough frame inspection has not
been done.
Please contact this office immediately and prior to sheet rock
installation.
very truly yours,
Richard R. &rse
Building Inspector
RRB/km
Certified .Mail P 375 771 539 R.R.R.
L930309B
(00(C 3
°Ft Town of Barnstable *Permit#
Erpir onths from issu ate
k Regulatory Services F
anrtxsrnar e
v mass; I Thomas K Geiler,Director
QED Mt►'1 s
i OWN )P BAR TAB"' Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma us
Office: 508-862-4038 Fax:508.-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
/ - Not Valid without Red X-Press Imprint
Map/parcel Number r�?Sb 1���) .
Property Address `T s e-,jl Le �Oe�/�1 �11
esidential Value of Work Minim_ um fee of$35.00 for work under$6000.00
Owner's Name&Address /"(&CQG.rtQ 1 Ross
Contractor's Name l� (x�-rU Sfii �S 6 Telephone Number 5'd 6 �j 1 t L/�
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
[have Worker's Compensation Insurance 1 J
Insurance Company Name A)A7-,L �Tfcocvt t)`I IJG��
U
Workman's Comp.Policy#�17�Q _ YO
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 -
#of doors
P-lReplacernent Windows/doors/sliders.U-Value �.� (maximum.35)#of window
*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
requ't•ed „
SIGNAT
C:\Users\decollik\AppData\L cal icrosott\Windows\Temporary Internet Files\Content.0utlook\DDV87AAZ\E}CPRESS.doc
Revised 072110 -
Page 7 of 7
CAPIZZI HOME IMPROVEMENT INC.
SPECIFICATIONS AND ESTIMATES
STATE OF MASSACHUSETTS
LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT
I,
OWN THE PROPERTY LOCATED AT
IN ,MASSACHUSETTS.
I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR
A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING
CODE.
I GIVE MY PERMISSION TO LESSEE
TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS
STATE BUILDING CODE.
SIGNATURE OF OWNER:
OWNER'S ADDRESS: {_
OWNER'S TELEPHONE:
LESSEE'S SIGNATURE:
LESSEE'S ADDRESS:
LESSEE'S TELEPHONE:
APLLICANT'S SIGNATURE:
APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635
APPLICANT'S TELEPHONE: 508-428-9518 -
RESPONSIBLE OFFICER:
RESPONSIBLE OFFICER ADDRESS:
RESPONSIBLE OFFICER TELEPHONE:
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration.aq'06740 Type: 10 Park Plaza-Suite 5170
Expirat on,-�6T25)Ln-12. Supplement Card
ti � PP Boston,MA 02116 •
CAPIZZI HOME'IMP} OVEMENT 1NC. -
GARY GLISTAFSON=N-' €i -_', _
1645 Newton Rd. ` _= �-
Cotuit,MA 02635 ��'���''� ,
Undersecretary /o id without signature
Massachusetts- Department of Public S<tfetN
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 74640 _
GARY GUSTAFSON;
8 SHORT WAY
SANDWICH 'MA 02563
Expiration: 11/29/2012
('ummissioner Tr#: 7058
x^
• t
• Client#:47298 CAPIHOM
ACORM CERTIFICATE OF LIABILITY INSURANCE F D06/04/2010
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 NAME CONTACT Karen A Walther,CISR
Rogers&Gray Ins.-So. Dennis PHONE 508-760-4630 508-258-2230
434 Route 134 A/C,No,Ext: (A/C,No):
ADDRESS: waltherka@rogersgray.com
P.O.Box 1601
" CUSTOMER ID#:
South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIL#
INSURED INSURER A:National Grange Insurance Co.
Capizzi Home Improvement,Inc. INSURER B:ACE Property&Casualty Ins.Co
Capizzi Enterprises,Inc.1645 Newtown Road INSURERC:
-
Cotuit,MA 02635 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.
INSR TYPE OF INSURANCE DL UBR POLICY EFF POLICY EXP
LTR NSR WVD POLICY NUMBER MM/DDNWY) (MMIDDNYM LIMITS
A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO PREMISES Ea ocTED
currence) $500,000
CLAIMS-MADE OCCUR MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $13000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO- F LOC - $
A AUTOMOBILE LIABILITY M1 M28044_ 06/08/2010 06/08/2011 COMBINED SINGLE LIMIT $ "
(Ea accident) 500,000
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
X SCHEDULED AUTOS "
PROPERTY DAMAGE $ - I
X HIRED AUTOS (Per accident)
X NON-OWNED AUTOS Uninsured $250000/500000
Underinsured $250000/500000
A X UMBRELLA LIAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE $5 000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000
DEDUCTIBLE $
X RETENTION $ 10000 - $
B WORKERS COMPENSATION NWCC45843208 12/25/2009 12/2512010 X WC STATU- OTH-
AND EMPLOYERS'LIABILITY YIN ITORYLIMITS IER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? ❑N N/A
(Mandatory in NH) - - E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Carpentry
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town Of Bourne ACCORDANCE WITH THE POLICY PROVISIONS.
24 Perry Avenue
Buzzards Bay,MA,02532 AUTHORIZED REPRESENTATIVE
0198 -2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S52550/M52541 KW _
The Cothmonwealth of Massachusetts
Departrrcent oflndustrialAccidents
Office of Investigations
' d 600 Washington Street
o � _
Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Piumbers
APPlicant Information - F Please Print Le 'bI
Name(Business/Organization/Indivicival): . YD
Address:
4
City/State/Zip: Phone.#: C Z�• �/
Are you an employer? Check the appropriate tioz:
Type of project(required):.
1. . a employer with �' 4• [� I am a general contractor and I
employees (full and/or art time).* have hired the stub-contractors 6. ❑New construction
❑ I a a a"sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
shipand have no em Io ees These sub-contractors have
P y 8. []Demolition
working for me in any capacity: i employees,and have workers'
comp.insurance.$ 9• []Building addition
[No workers' comp.insurance P• •
required.] 5. We are a corporation and its' 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work = officers have exercised their 11.0 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. er
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing-peir workers'compensation policy'information.
$Homeowners who submit this affidavit indicating.they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information t
Insurance Company Name:
Policy#or Self-ins.Lic.#: N W5j 3 Expiration Date: ?�
Job Site Address:_ -1 C�t�'� (� (Cj'Lp City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expiration date).
Failure.to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a '
fine up to$.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 MA for in urarice covera e verification.
do—hereby eer-tiffs u ain am penulties a peyu- that fhs irtfoxrtzation pr-aviderkaliave is-tr-ue and-carxect
Si afore: ,mil L/ —
Date
Phone#: '4.
Official use.oily: Do not write in fhzr area,•tb be completed by city or town offciaZ
City or Town:, PermitEicense#
Issuing Authority(circle one):
.I.:Board.of Health 2.Building Department 3.,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Othe`r
Contact Person: Phone#:
Town of Barnstable *Permit#�G�7���/�
Expires 6 months front issue date
Regulatory' Services , Fee - -
X-PRESS PERMIT Thomas F.Geiler,Director n
a7 PERMIT
Building Division
DEC _ 7 2007 Tom Perry,CBO, Building Cormnissioner
200 Main Street,Hyannis,MA 02601
TOWN OF BARNSTABLE www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
.EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number of /
0 9 C�01 3
Property Address S�Q- c�� 1' G�
esidential Value of Work Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
3 y S o j3 �� /✓ lJ��o
Contractor's Name FA Q-Aj--t— C8-" Telephone Number
Home Improvement Contractor License#(if applicable) l .5 3 Co
Construction Supervisor's License#(if applicable) C S 4 G (C
101workman's Compensation Insurance
Chedl one:
❑ I am a sole proprietor
❑ I am the Homeowner
2W have Worker's Compensation Insurance
Insurance Company Name T -
Workman's Comp.Policy# S J o L 3,5 c5 o �j
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
0-Re-roof(stripping old shingles) All construction debris will be taken to a �cJ Cat.
I
I
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑'Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other.town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission,
A copy of the Home Improvement Contractors License is required. '
SIGNATURE:
Q:Forms:expmtrg
Revise061306
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
lip 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �}�� � LQ/Q-,--,1- rLU_C fi 10 A-)
Address: _P0 q y-5
City/State/Zip: C yt IIN- Qa�L 3,5Phone
Are you an employer? Check the appropriate box: Type of project(required):
1.C�K/`I am a employer with,� 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.El am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.2KRoof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
y I am an employer that is providing workers'compensation insurance for aW employees. Below is the policy and job site
information.
Insurance Company Name: N F_ ILT-{�-R_7�7-F-0 g- I--`)
Policy#or Self-ins. Lic.#: D 25 0 L S 550 Expiration Date: ' 2 4�
Job Site Address: 3y City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex iration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
r 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 certi er the ains and lties of perjury that the information provided above is true and correct
Si ature: Date:
Phone#: oZ
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#:
r
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����¢� ®��T Registration: 112538
DEAN F►��Ed� �UCTI®IV Co. Type: OaA
exp►ration:
P•C' BOX 1646
3/23/200s
C®TUIT, A4A 02635 Tr# 12792,
DP3,Cq� � �M-05/09-PC8490 - - -
Update-Address and return
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THIS CERTIFICATE IS 10-15-07
ISSUED AS A illA'PTER OF IPIFORMATIOM
WISE & QUINN INS AGCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
449 PLEASANT ST HOLDER. THIS CERTIFICATE DOES NOT AMEND, F�TEND OR
ALTER THE COVERAGE AFFORDED BY YHE POLICIES BELOW.
BROCKTON
24WCB
MA 02301 COMPANY COMPANIES AFFORDING COVERAGE
INSURED A HARTFORD UNDERWRITERS INSURANCE COMPANY
FRASER CONSTRUCTION LLC COMPANY
PO BOX 1845 B
COTUIT MA 02635 COMPANY
C
COMPANY
THISIS TO CERTIFY :.....:..:.::.:::.:::::.;.:.:;•:::::.;:.:;.;::::::::;:;:.:.::::::::;;::.:.:.:;:::::.:.>;:.;•.:::;;:.;:.;:.::::::.;:.:.>;•:::::;:.::.;::::.:::.:.:.;;•:::.:.:;:;:;::.:::::::... .....
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LICIES OF INSURANCE
INDICATED LISTED BELOW HAVE BEEN ISSUED TO THE IN NAMED ABOVE FOR THE POLICY PERT
NOTWITHSTANDING ANY REQUIREMENT, TERM-OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ...
CERTIFICATE MAY O ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL T OS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Co HE TERMS,
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
GENERAL LIABILITY DATE(MMIDDWY) DATE(MMIDDIYV) LIMITS
COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE
CLAIMS MADE D OCCUR. PRODUCTS-COMP/OP AGG. $
OWNER'S&CONTRACTOR'S p PERSONAL&ROT. ADV.INJURY
EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
AUTOMOBILE LIABILITY MED.EXPENSE(Any one person) $
ANY AUTO
COMBINED SINGLE
ALL OWNED AUTOS LIMIT $
SCHEDULED AUTOS BODILY INJURY
HIRED AUTOS (Per Person) $
NON-OWNED AUTOS BODILY INJURY
(Per Accident) $ i
GARAGE LIABILITY PROPERTY DAMAGE $
c
ANY AUTO AUTO ONLY-EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
EXCESS LIABILITY AGGREGATE $
UMBRELLA FORM EACH OCCURRENCE $
OTHER THAN UMBRELLA FORM AGGREGATE $
A WORKER'S COMPENSATION AND
EMPLOVER'SLIABILITY (6S60UB-085OL35-5-07
THE PROPRIETOR/ 09-26-07 09-26-08 STATUTORY LIMITS
PARTNERS/EXEC UTIVE INCL EACH ACCIDENT �•$�•��•.
OFFICERS ARE: X EXCL DISEASE—POLCY UMrr
OTHER $ i
DISEASE—EACH EMPLOYEE $ 50 00
)ESCRIPTION OF OPERATIONS& CATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CER
..........:.�::::::::::.;::.;;:.::::::»;:;;;::::»::>::»•;:-:s::>z:;:;::>•;:.;::>::;::>�:.::.;;::;>::>::. ER S .COMP COVERAGE.
ULD ANY OF THE ABOVE DESCRIBED POLICIES BE.CANCELLED BEFORE THE
�(PIRA710N DATE THEREOF, THE FRASER ENTERPRISES LLC ISSUING COMPANY WILL ENDEAVOR TO MAIL
PO BOX 1845 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE
"OTU I T LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE No OBLIGATION on
MA 02635 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTA
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Mm MR?
9 CONSTRUCTION
Fraser Construction
o Roofing & Siding Specialists
P.O. Box 1845, Cotuit NIV.-07635
508-42�-2292 Email: fraser construct iongverizon net
www.fraserroofing.com
Phone 1-508-428-2292 & FAX 1-508-428-0123
RE-ROOFING PROPOSAL
PARTIAL/MATCH
PRICE DOES NOT INCLUDE THE REAR ADDITION
DATE: October 29, 2007 PHONE: H 508-778-2714 -
,qA%E: Margret Ross W 508-790-3436
AIL ADDRESS: P.jO Sox 1111 Hyannis, MA 02601
J®$ ADDRESS: Statice Lane Hyannis, MA
FIZASER CONSTRUCTION hereby proposes to perform the following services in a neat
ancl professional like manner and in accordance with the manufacturer's
Specifications and local building code.
-Remove and Haul away all of the old roofing material
-Re-nail all plywood sheathing as needed.
apply and Install - CERTAINTEED LANDMARK /WOODSCAPE AR 30: 30 - Year
warranty, 5 year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant,
Extra Heavy Weight, Self Sealing, Multi- Layered, Architectural Style, Fiberglass
Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with
a Full 10 Year Warranty against ALGAE Containment. 5 year 70 mph wind-
resistance warranty or 5 year 80 mph wind-resistance warranty available with
six nails in common bond area, for an additional cost. See actual warranty for
specific details and limitations.
Color:= RICE- $7,795 Initial
***Price doffs not inclu a the r r addition
SupplE and Install - CERTAINTEED LANDMARK /WOODSCAPE PREMIUM:
lifetime Warranty, 10 year sure start protection, CLASS A FIRE RATED, ALGAE
Resistant, Extra Heavy Weight, Self Sealing, Multi-Layered,Laminated Architectural
Style, Fiberglass Based Asphalt Shingle with New England's Exclusive
COPPER/CERAMIC Stones with a Full 10-year Warranty against ALGAE
Containment. 10 year 90 mph wind-resistance warranty or 10 year 110 mph wind
.resistance warranty available with six nails in common bond area. See actual
Warranty for specific details and limitations.
Color: PRICE- $9,480 Initial
***Price does not include the rear addition
mzr��o4
. 'Possible Extra -An rotted or otherwise deteriorated
,,, Y true boards, plywood sheathing,
lead flashing, or other carpentry needing replacement will be done and charged for as
an extra at the rate of$50.00 per hour, plus materials, plus 20% overhead mark-up
on total extras.
FRASER CONSTRUCTION Warranties the labor for 12
years
FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years.
CERTAINTEED Warranties the shingles and labor 100% through the Sure Start
Warranty duration.
CERTAINTEED Warranties the shingles to be ALGAE resistant for the duration of the
Sure Start Warranty depending on the shingle that was purchased.
Any deviation or alteration from above specification will be executed upon written
orders and will become an extra charge over and above the estimate. All agreements
contingent upon strikes, accidents or delays are beyond our control. Owner should
carry fire, tornado and other necessary insurance upon the above work. We, if not
accepted within thirty days may withdraw this proposal.
FRASER CONSTRUCTION: Carries Workman's Compensation and Public Liability
Insurance on the above work, certificate available upon request.
DATE OF ACCEPTANCE: / U
Home caner Fraser onst etion
f