HomeMy WebLinkAbout0074 STEVENS STREET �f----- � --------.._�.
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f TOWN OF BARNSTABLE
SIGN PERMIT
PARCEL I1 309 231 GEOBASE ID 22523
ADDRESS 94 STEVENS STREET PHONE
Hyannis ZIP -
LOT BLOCK LOT SIZE
DBA DEVELOPMENT f DISTRICT HY
PERMIT 19757 DESCRIPTION FIRST CHURCH OF CHRIST, SCIENTIST (10 SQ.FT.
PERMIT TYPE BSIGN TITLE SIGN PERMIT i
CONTRACTORS: Department of Health,�Safety
ARCHITECTS: and Environmental Services
TOTAL FEES: $25.Oo
BOND $.40 O�tME
CONSTRUCTION COSTS $.00
753 MISC. NOT CODED ELSEWHERE * + I
* BAMMBM
MASS.
OWNER FIRST, CHURCH OF CHRIST i639.
ADDRESSED
B ILDING DIVIS'ON
��'li'�'�st-�r..�`
DATE ISSUED 12/05/1996 EXPIRATION DATE
9L
02I05l199.6 09:26 1-508-790-6230 BARNSTABLE BLDG-DIV O / PAGE 02
` .-1 own onsarnstame pit w.
epatmat of Health Safety andnvronmental Services
f
Application for Sip Permit
Applicant: & 4 C_,V\,)9jQLo� C���s� �� Assessor's no.o o,�':_
Doing Business As: LC Telephone 5O�-_T1
Sip Locatfon 9
atreet/road: rwu�o � � G o. .�
Zoning District b� old I 's i District? no
-� S $ shy y
Property owner
Name: cto C�1rxn - Telephone
Address: V'ilIage
Sign Contractor
-\2. V.�C�Q�Cce��n C Telephone �5- SEA- + 3
Address: 99 5 tZov�
Description
Diagram of lot showing location of buildings and edstiaig signs with dimemiotisy location and size ref the new si
to be drawn on the reverse side of this application.
Is the sign to be electrified? Yes � �,� _;� no (Note:. if yes,:a wiring permit is required)
I hereby certify that I am the owner or.that I have the authority of the owner to make application, that the
.information is correct and that the use and.construction shall conform to,the provisions of Section 4-3 of the
Town of$arnstabk Zosdrtg Ordina Cw.
Date signature of Owner/Authorized Agent
Size . $. Permit Fee �C5 0
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• I���2 PAY '-- ``f
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FIRST CHURCH OF CHRISL SCIENTIST, HYAN IS, M.a f L WnW%"
auu�,
51 AM 0
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� ►.� - Town of Barnstable ildi g 1
; Post This Card So That it is Visible Frain the:Street-Approved Plans Must.be Retained`on lob and,this.Ca'rd`Must be Kept
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'"" Posted Until Finalilnspection Has Been,Made �' � k": '; rX
N
rmit" Where a Certifieate ofQccupancy�s;Regwredsuch Buildmgshal(Not be Occupied:unt�l.a F�nalm;Inspecton�has beenm'ade `. Pe
Permit No.r B-17-135 ' Applicant Name:
Approvals
Date Issued: 02/14/2017 Current Use: Structure
Permit Type: Building-Sign Expiration Date: 08/14/2017 Foundation:
Location: 94 STEVENS STREET, HYANNIS Map/Lot: 309 231 Zoning District: OM Sheathing:
Owner on Record: FIRST CHURCH OF CHRIST Contractor Name: Framing: 1
Address: 94STEVENS ST Contractor License:_ 2
HYANNIS, MA 02601 o ;Est Project Cost: $0.00 Chimney:
Description: Christian Science Reading Room. :,Perrriit'Fee: $0.00
Insulation:
" Fee Paid: $0.00
Freestanding sign. Text area limited to 6 sq including hanging portion. Final
Post not to exceed 3'to top. Date. s' 2/14%2017
Project Review Req: Christian Science Reading Room. Plumbing/Gas
Rough Plumbing:
Freestanding sign. Text area limited to 6 sq'including hanging u y Zonin Enforcement Officer
portion. Post not to exceed T to top. 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 forwhich this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas:
This permit shalt be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the_Building and Fire Officials are provided on this permit. Service:
Minimum of Five Call Inspections Required for All Construction Work ( z x
1.Foundation or Footing Rough:
2.Sheathing inspection T.
� � �
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
t
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUMRECIPIENT-
Town of Barnstable e
Regulatory Services Uj`o/4
SARNWABM " Richard V.Scali,Interim DirectorMAS& ,/,9* Ca� �y
39- Building Division �oGL�t 19'®
Tom Perry, Building Commissioner OP
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
5
-Permit# ,--Af3
Building Official approving
Application for Sign Pernrnut
Applicant: /��� 1!' + S/ QL;O '4' Assessors No.
Doing Business As: 54 M-2 'I elephone No. ! 77
Sign Location
Street/Road:
Zoning District Old Kings Highway? Ye o Hyannis Historic District? Yes,FD
Pro
Nampe � ✓� .c/t �i��Gl►S'� �G/ .f''� Telephone: 7a 1 77/6 7& r"�
Address: S/•Y'-P/1 S V n.���.,, C` Village: 6/4 ''I n'[is
Sign Contactor ��
Name: J( war am/ Telephone: J�Q __ $ �`� () .
Mailing Address: j �il�c']� _ �r 4lM0
Description
Please follow the cover directions.You must have an accurate rendition of sign with dimensions ando
location.
Is the sign to be electrified? Yes (Note.-Ifyes,a wiringpermitis required)
Width of building face 4-ft.x 10= / Y x.10= X
Check one Reface existing sign or New 2Total Sq.Ft of proposed sign(s)
Ifyou have additional signs please attach a sheethstingeach one with dimensions ( I
If refacing an existing sign please provide a picture of the existing sign with dimensions. 2
J .
I hereby certify that I am the owner or that I have the authority of the owner to make this application,
that the information is correct and that the use and construction shall conform to the provisions of
§240-59 through§240-89 of the Town of table Zo ' Ordinance.
Signature of Owner/Authorized Agent
r
�- Date.._1 l7
SIGNS/SIGNREQU revised110413
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
�t cL
' Map Parcel �� ' �„ Ri�ST BIB Application #�U S (
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. w , �ax Permit Fee
MII
Date Definitive Plan Approved by Planning Board' tu' ',t11
Historic - OKH _ Preservation/ Hyannis
Project Street Address 1 C1Z.nCJ y�
11 1
Village Cl crCl l ^� 1
Owner �K 0 aN SSA ) � G Address �� �04n—S
Telephone 5��a (02, (:)/3S)
Permit Request afcn,�,e— :5;;,,-rj L:,;6e-
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation0s)bliz>1.n(PConstruction Type
Lot Size Grand-fathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new 'size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
�7y a3 CIS%
Name O Telephone Number
Address ` �(. n ( License
1 (Alol Home Improvement Contractor# { / (CU6
Email O -X�� �'O�� 1 ,Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTI FROM THIS PROJECT WILL BETAKEN TO
V.9 G
SIGNATURE DATE I 5
FOR OFFICIAL USE ONLY
L
APPLICATION#
`DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
is
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
a--
FIREPLACE
rr +
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
He Comynanytwafth of Massachuseft
Dq7arhnmt ofrudustricrl Accidents
Office of InvesA.0tions
600 Washington&reet
Rostoq,ALI 02111
wtt'v►t. nas&grv'/dice
W,orket-s' Compensation Lmmmuce-4Lffidavit:Builders/ContractursMectricians/Plumhers
Applicant Infarmation Please Print Legibly
Name(13usineaslOrganizafionlfndividuai)�j��� y >��
Address:
City/Stat�Zip 6�a Phone
r
t�-e�an employ: " eck_the appropriate box Type of ict
run( (01' 4_ I am a contractor and i �]e �'�I�'�-
l._ I am a employer with 6- ❑New oonstnxton
employees{full and/orpait-fame}_* have hired the sub-:ontiactofs.
2._❑ I am a sore proprietor or partner-
listed on the attached sheet. 7: ❑Remodeling
ship and have no employees These sub-oonttactors have g- ❑Demolition,
working for me many capacity employees and have workers' 9_ ❑Building addition
[No wo
rkers' comp.in&i anre comp_msuranml
required_] 5_.❑ We are a corporation and its 10_❑Electrcal repairs or additions
3_❑ I am a homem ner doing all work ofti,cers have exercised their 11_.❑PI g repairs or additions
myself [Na,2vor1;ers'comp- fight of exemption per MGL 12. ' Roof repairs
insurance required-]I - c.152, 1{4},antl.we lTHve nt3.
employees_[No worl=s' 1 _.❑Other
comp-insurance required.-]
"Awry anplixBmt that checks boa trl must also fill out the section below showing dl&wok kers''compensation policy infnrmaticnt_
gameowners wbo submit this afffidavrt indicating they are doing all nmk amsd then hn7e outside contractors mast submit a new afidnk mebcating sn rh
Contractors thst check this box must attached ffi additional sheet showing the name of the its cntdi ors and state whether ornot those enlitJOShWe
employees- Ifthe su7acont mcturs have employees,they must provide their workers'comp-policy number.
lam an employer that is prm idi g it'orkers'compensation irmirance for my employees Below is thepolicy and job site
information
insurance Company Name: � 5 lr 2 i
Policy#or self-ins-Lic-k Jso►l�{ �p- 1 y Expiration Date:
Job Site Address: v\ n CifyfStateiZig: nn
Attach a copy of the workers'compensation policy-declaration page.(showing the policy nu er and expiration date).
Failure to secure coverage as required under Sectioa 25,E of MGL G 152 can lead to the i npositi,on of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonnNmf as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up.to$250.00 Oy against the violator_ Be advised that a copy of this statement rnaay be:bnvarded to the Office of
Investigations o YM4 DIA Ex nsurance coverage verification
I do her-aby c i tkspmns andpenatl"ies ofpetaury that the information primiideda ,e is true and correct
S.iEnature:-' Bate:
Phone#
Of Eiial use only. Do not write in this area,to be completed by city or town officiaL
City or Town: PerEaitUcense#
Issuing Authority(circle one):
1.Board of$e2fth .Building Department 3.City[Fown Clerk 4.Electrical Inspector S.Plumbing Inxpeotor
6.Other
Contact Person: Phone#:
6
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto 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 petormance of public work until acceptable evidence of compliance vrith the insurance
requirements of this chapter have been presented to the contracting authority." I
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,U
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their ceitificaice(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 Indusii� al
Accidents for confirmation of in si=ce coverage. Also be sure to sign and date the affidavit 'I1?e 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 Accid(--nts. 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-insurannce 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-AU be used as a reference number. In addition,an applicant
that must submit multiple permit/licanse 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 uz (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be.provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would Ile 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
Degaitment of Indust dal Accide. t
Office ui Vestiptiaus
640 Washangtan Street
Boston,MA 02111
Tel.A 617--727-4900-W 406 or I-a77-MAS E
Revised 4 24-07 Fax#�617-` 27-7749
W-MUS—gnv/dia
First Church of Christ, Scientist
94 Stevens Stet— PO Box 86
Hyannis,MA,02601
December 23;'2014
Timothy Johnson
PO Box 169
West Hyannis Port,MA 02672
:Dear Tim,
This letter will authorize you to perform the work quoted in'the RFP received from you
November 12,2014,`to replace the roof of our main church auditorium,foyer,and connector,
located at 94 Stevens Street, Hyannis,MA
As previous noted,the area around the church is to be cleaned up after each day's work,free of
nails and debris. Our members were most gratefulfor you attention to this detail when you
replaced the roof on the Sunday School.
It is our understanding that you will begin this project on or before the l2th or the I9th of
January 2015, depending on the weather. °
We are appreciative of your commitment:to this work,and look forward to its completion.
Sincerely,
Netty Hoagland, Chairman
Executive Board
negy@,inetg!p.com
4 5-272-6726(m)' s
508-681-0352(h)
1.
CO at "
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��°cam
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r registration., and for,mdivldu;use or lY O'
�.. . . . :.. �vncoracuea�t�c QUvLcuJaccc�iu�ettd Tie
"Off ice:of;Consume.r.Affairs''&Business Regulatton
.'.
tion
tion
:.
Office of Consumer Affa►rsiand BusinessrRegula
OMEIMPROVEMENT`CONTRAGTOR".
Type' park Plaza Suite5170
egistration 179608 10.
Expiration
8/21'I2016 Indiv,idua, Boston,lVlA 021�0
TIMOTHY JOHNSOt ��
s
1
NSON�A
H ,,. x
` �bU
I� O
�Y J
T H
O -,a IMsignature,. T F..
180 EGA
RD g-- ; No l without
I ' Undersecretary
HYANNI$,MA 02601
First Church of Christ.Scientist
94 stelvcns.Strect-110 Box 86
Hyannis,MA 02601 '
bill)Son Bud ding'&Hzsfue•irazprovetfie zt
,
I
". I h»9cttez vol l'authon e'vnti Io ovr'lun'l -tiaank qugted,iti the R'r recciivd fixim you
tio�°cn tz r l2;?{ll f,to r tiiGettz�rc+�f a#i5ur'riz ziza chzzr'clz.i�ialituriuri;fry}tcr,and conneei6r_:
located at()4 ttit�iciz�filrc�L H� rlk. aA.;
_ s fret!c�tzq-�tr t l the area-arotuid ihi chui�en i� u l cl aned a atier=e tch ii:zy's v>rzrh.`Cr c 1'
paik and debris,_Our tneubers evere_mosi gratefitl'Ibr.you.attentivn'to'iN &tai-f wlicta�°uir
. .. - ru�lated t.lze rtazzf+zz7 the Stuzda�"�chvral;Y :.
+ 10 uu'nnders,tatfding Wit.you will begin this oto' %t erp yrbet-o tlie��l2t3z or rfi�1l9ih lof
7antzkm'10'1 s,depcn ing,ly0 tli�w�e9tlzer.
4i'e uis a pxWci iGe,�z9 yt zir corattnfzincnt r ltis x�r ,and look fbnvard to it";Cojnlaleiitzzl,Ritil Jones
w
-
�� ' .._.
l.y ectztii'e�z,tzrti-r 1� _
508 71�7-3829.
MAIN STREET AMERICA ASSURANCE COMPANY Policy Number: MPT7064K,
Named Insured: TIMOTHY P JOHNSON CONSTRUCTION Effective Date: 1.1;-10-2;014
Agent Name: BRYIDEN & SULLIVAN INS AGCY IN;C Agent No. 2000481
SECTION II LIABILITY' DECLARATIONS
COVERAGES: LIMITS
Liability& Medical Expenses—Each Occurrence, . $ 2,.0 0 0,.0.0 0'
Personal &Advertising Injury Limif' $.- 2.,000., 000
Damage To Premises Rented To You $k 5 o ,, 0;0.0
Aggregate Limit-Products-Completed Operations $ 4, 0 0 0,,.0 0 0
f ,
Aggregate Limit-Except Products-Completed Operations $ 4 .0 0 0, 0 0 0!
Medical Expense Limit -:Per Person $ 10,000
LIABILITY--SCHEDULE
STATE: MA TERRITORY: 018 PREMISES NO 1/1
CLASS CODE: . 74171 DEDUCTIBLE-PROPERTY DAMAGE LIABILITY: NONE
CLASSIFICATION: CARPENTRY` -- RESIDENTIAL -- THREE STORIES OR ;LESS
PREMIUM BASIS .. EXPOSURE ` ' RATE ADVANCE PREMIUM
PAYROLL 2 8„ 50 0: . $ 1-,,6 7 6
I
BPM;'D.LIAB,IT Peg 1
INSUREDCMW` - <
NOTICE NOTICE::
TO m TO
W 7
EMPLOYEES EMPLOYEES
B
e Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-7274900
As required by Massachusetts`General`Law,.Chapter 152,See ioris1l,2.2, & 30,.this w111 give you.
notice that I(we),have,provded payment to our,injured employees under`the-above mentioned.
ehapter`by insuring.with:
Associated,Employers'lnsurance Company`
NAME OF INSURANCE COMPANY
R'O. Box 4070 Burlington,MA 01803-0970
,ADDRESS OF,INSURANCECOMPANY
WCC-500-5011456-2014A 1'1/02/2014-.1.1/02/2015
POLICY NUMBER 71
EFFECTIVE DATES
.88 Fal'mouth Road
Boyden&Sullivan Insurance Agency Hyannis, MA02601 . (508)807-0380
NAME OF INSURANCE AGENT ADDRESS PHONE
Timothy P Johnson Construction 180;Megan Rd Hyannis,MA 02601
EMPLOYER ADDRESS
'09717/2014`
DATE
MEDICAL,TREATMENT"
The above named`insurer is required m cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers.:Compensation Act:A,eopy of the First Report of`Injury must be given to the
injured,employee The employee may select his or her own physician. The reasonable cost of the services
provided by the `treating physician will be.'paid .by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer.has'arranged for such attention at the
NEAREST.AND.BEST MEDICAL FACILITY
HOSPITAL ADDRESS
TO,BE ,POSTED BY EMPLOYER
V ERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY'
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue; Burlington,Massachusetts 01803-0970
(800) 876-2765 NCCI N0 46959
POLICY NO. WCC-50075011456-2014A
PRIOR'NO. WCC 500-501 t456 2013A
ITEM
1. The Insured: Timothy'P.Joh:nson
DBA: Timothy P Johnson"Construction
Mailing address: 180 Megan Rd FEIN:,**-**'5559
Hyannis,MA 02601
Legal Entity Type: Sole Proprietor
Other workplaces not shown abovei
2. The policy period is from 11/02/2014 to 11/02/2015 12:01 a.m.standard time at the insured's mailing address.
3: A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employ ers''Liability InsUrande:'Part Two of the policy applies to work,in each state listed in item`3:A.
The limits of liability under Part Two:are! Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $' 500,000 policy limit
Bodily injury by Disease $ 100,000 each employee
C. Other States Insurance: 'Coverage Replaced by Endorsement WC 20 03,06 B
D. This Policy includes these Endorsements and'Schedules: SEE SCHEDULE
4. The premium for this policy will be,determined by our Manuals of Rules,Classifications, Rates and Rating Plans.
All information required below,is subject to verification and change by audit.
Classifications Premium Basis_ Rates
Code Estimated Per$100 Estimated I ,
No. Total Annual Of Annual.
Remuneration Remuneration i Premium
INTEA 988017
INTER SEE CLASS 60DESCHEDLI E
Minimum-Premium $500 Total Estimated Annual:Premium $3,817
jGOV GOV Deposit Premium $1,004
STATE CLASS
MA 5645 State Assessments/Surcharges
$3,466.00 x 5.8000% $201.
This olic including all endorsements, is hereby countersi ned b
p Y, 9 y 9 y LL -- — 09/17/2014
Authorized Signature Date
Service Office: Bryden&Sullivan Insurance Agency Inc,
54 Third-Avenue 88 Falmouth Road.
Burlington MA 01803_ Hyannis, MA 02601
WC 00 00 01 A:(Z->11)
Includes copyrighted material oftho"National,touneil.on compensation Insurance,
used with its permission.
i
First-Church of Christ;Scientist
94.Stevens Street—1'O'Box 86
Hyannis,M.A 02601
Jmbaxy.5,2014
Johnson Buildiq ctic klt>rne ltttpr vetnent'
West.:H.)am6c;llort,,IMA 02672
l)c;iir'I'ini,
I1t0s letter will titthotrze:ittu to ptsrtorriAhe wrirk.qugted id:the UP rccely d fr0m vrw_
November 12.2014.w re place,the roof of dtir�nnin-churclx_auifitt�riurn;fo}'t ri and conneateir;
located at HAG Ste-ens Street,1lyrinnts,,lfiR,
As prcx•ious;noted the;irca at•ound;the church is to be cle6n d.up atier e 3ch d ty's work,free of
nails Anil dcltris.:(7ur utcntbirs crc nxost:yraicfid The vr�u attentit7n to.this deiait when you
replaced the r6ofon the-Sand ty School,
It is our:unde.rstattdiit=;thai you will begin this,prnicct wit or before the 1201,or the 19th o1'
Jattaary,20,15.demanding on the weather,
we•areappreciative oldyour commitment-to this work,and look forward to its contttletion.
E~tcculi e.Boar+
508-73 7-3824
First Church of Christ,Scientist
94:Stevens Strcct—PO Roo 86
Mvu n nis,MA 02601
lanllarr 5,2014
Johnson Building&Home Intproi,eineilt
PO Box 169
West Hyannis Port.kA 02672.
This lcrirr wili authorize you to perform the wtifk quoted in the RF11 rc ived'i'ro1l1 you
\otern1wr 12.014,to replace the roof ofour niai,n church auditorilin fo}er,and cpnnector,
locsated at 9.1 Stevens-Street.Hy;innis, A4
previpit5 noted;3hc arca,�uruund the eltprch is tp he cicanetl iu.p alter eacli da}F':s.work,free of
ciails<trtcE:cictari5. (aatraatetnliersrw>eremw-t. rit4ful,tt?i`'ys+ii tp;tlais detail svhen'yott ,
rr'placet�the rra«f oii the�;tinday Sch�ot;
It Our understanding thar'�ou willategin this pro,ject'ou orJxfore the`12ihor the I9th of"
January 2015,depending on the rvcathur.
We are to this work,and look formir•d:to its:con ipletion:
Sinti�ret�,.
Rita I,i',Jones
Executive Board'
t�,rr rElt?,ttC tz ;
509.-7:37-3524
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
ti
Map Parcel \ Application #
Health Division Date Issued �1 l
Conservation Division 'Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address � )
Village cfi
Owner R\���, �� .� Address
Telephone
Permit Request arj C47 +
UJ 1A,
2 C L�e
X �&
1 ti
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation ®t�� �� Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes LdNo On Old King's Highway: ❑Yes 16 No
Basement Type: ❑ Full ❑Crawl 0 Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
t...r
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ 'I a C)
NJ
Commercial ❑Yes ❑ No If yes, site plan review # T .
Current Use Proposed Use w
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) r�? J
Name !eM � ��Fl Telephone Number � ( dJ �
Address License # 1 0('Mn
HtkGnn+e McQW I Home Improvement Contractor#
Worker's Compensation # '501 C 46(0 Q) a
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO -9J�1
SIGNATURE DATE y I
I
FOR OFFICIAL USE ONLY
fr, APPLICATION#
DATE ISSUED
MAP/PARCEL.NO.
� t
" r
? ADDRESS VILLAGE
OWNER
J
DATE OF INSPECTION:
l
FOUNDATION
FRAME
}
f' INSULATION
FIREPLACE
I'
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL ,
GAS: ROUGH FINAL
3 FINAL BUILDING
4
f�
DATE CLOSED OUT
ASSOCIATION PLAN NO.
ti
I The Commonwealth of Massachusetts
Department of Industrial Agents
Office of Investdgations
600 Washington Street
"Boston A M ozrrl
mmmassr gov/dia
Workers'C&apeinsation Insurance Affidavit: Buflders/Contractors/Electridanis/Pltlinbers
Applicant Information PIease Print Legibly
-Name(Busin=s/'organiaation/lndividm l): n
Address:
ci /state zi :!l f_ �0�� .
Area, u an employer? ck the appropriate bog: Type of project(required);
1.L"_1 I am a employer with 4. i am a general contractor and I' .
employees(first and/or purt-tone),
* have hired the subcontractors 6. 0 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
shipd have io ees These sub-contractors have
an no
• eP Y S, Q Demolition .
working for me in any capacity. employees and have workers'
co insurance.t 9. 0 Building addition..
[No workers'comp.ineir, nce comp.
required-] 5• ❑"':We are a corporation and its 10.0 Electrical repairs or additions -
3.❑ I am a homeowner doingall work officers have exercised their,` 11. Plumbing
❑ g repairs ar additions
myself. [No workers' comp, right of exemption per MGL :q a 12,lax oof re arcs
lamrance red.].t. c..152, §1(4),and we have no
p
'employees. [No workers' 1311 Other
comp.insurance required]
*Any applicant that checks box#1 must also fill out the section below showing their workers compensation policy information
t Homcowncrs who submit this affidavit indicati
ng they
an do'
all work and the
n hire outside contractors must submit a new affidavit
da 'n mdicatu•ig 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 subcontractors have amploy=,they most provide their workers'comp.policy number.
I can an employer that isproviang workers'compensation insurance for my emplayam- Below is thepo&-y.and job site
information. <' D
IInstuance Company Name: �c� CV!
Policy#or Self-ins. Lic.# 501 1y PJ�o�,a��a
, Expiration Date:
qr J ao1
1`l cJ \U
• Job Site Address: 1� '��' City/State/Zip: Fa�Dn=e).
Attach a copy of the workers' compensation policy declaration page(showing the policy-numb and
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 tc $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
Invest' of the PIk for ins»nce'coverage verification
I do hereby c u'der the pains and penatfZes of perjury that the information*Provided above is true arzd correc4
Si aiure: Date:
Phone# ?L/ d 1
Official use-only_ Do not write in this area,to be completed by city or town offzciaL
City or Town permit(License#
Issuing Authority:(circle•oiae)
I.Board of Health`2 BuildingDepartmeut 3.City/Town Clerk 4.Electrical'Inspector. S.Pltunbing Ispecto nr .
C Other
Qcmt#ct Person-.' Phone#.
•
y:
r.
a.
` 4
Massachusetts-Department of Public Safety
Boars!of Buiigiing Regulations and Standards
Construction Supervisor
License,: CS401696
TIMOTHY P
l 180 MEGAN RD
Hyannis MA 02601 ,.• -
✓.. . /�/ . 91 ,4,i�.. Exporation i
Commissioner 08/23/2014
. V1ie �pom�n�uuea��a��Jar�iu4�.
Office 6f Consumer Affairs&.Busmen§Regulation License or rpg. y4)ji for individirl use only
pME.IMPROVEMENT CONTFtAGTOR before the e,ptration date. If found.ireurn:to:
egistration: Y3ggg2 Type: f3ftice of Cogsumer Affairs and PSI' s _Regulation
xpiration 1il E3X 1314; DBA 10 Pack Plaza Sai 5170
Roston, 02115
TIMOTHY P JOHNSO 3Pi0"`ION
TIMOTHY JOHNSOIV� '%--'<%+
180 MEGAN RD Y1ti
HYANNIS.,MA 0260t Undersecretary Not li wi hoot signature
NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
4 '
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED EMPLOYERS INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCC 5011456012012 11/02/2012 - 11/02/2013
POLICY NUMBER EFFECTIVE DATES
Bryden &Sullivan Insurance 88 Falmouth Road
Agency Inc Hyannis, MA 02601 (508) 775-0476
NAME OF INSURANCE AGENT ADDRESS PHONE
Timothy P Johnson
dba Timothy P Johnson Construction 180 Megan Rd Hyannis, MA 02601
EMPLOYER ADDRESS
11/02/2012
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
TO E POSTE EM OY111
03/25/2013 02:42PM 5087719111 RITA JONES - PAGE 01/01
ey '
First Church of Christ, Scientist
94 Stevens Street
Hyannis, MA 02601
25 March 2013
To Whom it May Concern:
This is to certify that Rita Jones, as Chairman of the Buildings& Grounds
Committee for our Church, has permission to sign for any supplies needed to
complete the project of re-roofing our Sunday School Building.
To include use of our tax exempt number.
Sara H. Hunter,Vice Chairman
Board of Directors
!f further confirmation is needed, pleose call me at 781-799-7774
Regulal�ory Services
Thomas F.Geiler,Director
k Building Division.
Tom Perry,Building Commissioner..
200 Main Street;Hyannis,MA 02601 . y.
_vwwaown:barnstable.maxs
Office: 508-862-4038 Fax '508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of:the subiectproperty
hereby authorize to act on my behalf,
is aE matters relative to-work authoiszed by this building pe=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
- f tined and accepted. 't
Signature of Signature of Applicant
" �4 lapt/
Print Name Piint Name
d /.3
:. Date
t
1
Q:FORMS:DVRTFMBRMMS1ONP00LS 6/2012
g
s.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel .. Application # ab3
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. " Permit Fee 40
Date Definitive Plan Approved by Planning.Board
Historic - OKH _ Preservation/Hyannis
o
Project Street Address �7
Village
Owner 6 6y4h �&Acc Address �Qs &_,,1-6 yr
Telephone f
Permit Request Yey ce- <s',&Z- 0�'e /'��2,/' 2xleljf g r a6ol- W,`f`1 �IPccl
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation -�� Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl 0 Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Air Central ■Ye., ■ No Fireplaces. Existing New Existing wood/coal stave: ■Yes ■ No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial_I Cs ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name �. c����c;F- PLca ,ar�l�i�� ZZ C Telephone Number8' /
Address C License
Home Improvement Contractor#
Worker's Compensation #&,tl 3/51_7X037312&
ALL CONSTRUCTION DEBRIS,RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE _ DATE
r
y FOR OFFICIAL USE ONLY
e
APPLICATION#
,x DATE ISSUED
r,
MAP./PARCEL NO.,
ADDRESS VILLAGE
v
OWNER
DATE OF INSPECTION:
.,-FOUNDATION ,
FRAME
N
INSULATIONS -
a
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL ,
GAS:- ROUGH ; ;' FINAL
FINAL WUIL-DING �
S
_: - DATE CLOSED OUT
ASSOCIATION PLAN NO.
Y?ie Commonwealth of Massach.usetts
Department of Industrial Accidents
' Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensafion Insurance Affidavit: Builders/Contractors/Electricians/Plambers
Applicant Information Please Primt Lep_ibly
Name (Business/Organimfimi/fndh idmal): �p e-ifs
Address:
City/State/Zip: e ; e- Sir Phone#:, p
.Ar
e you an employer? Check the appropriate bor..1.❑ I am a employer with 4. ❑ I sin a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑Ne nstruction
2.[] I am a sole proprietor or partner- listed on the attached sheet, 7. emodeling
ship and have no employees These sub-contractors have 9. Demolition
working for me.in any capacity. employees and have workers'
o workers co c insurance.# 9. Building addition" .
[N mp,insurance
required.] 5. ' We are a corporation and its 10.❑Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their I1.❑Phnnbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12:❑Roof repairs
insiirxnce 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 wor mm'compensation policy information,
t Homeowners who submit this affidavit indicating they.=doing all work and thm hire outside contractors must submit a new affidavit indicating such,
tContractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those.eatrties have
employees, If the sub-contractors have employers,they must provide their workers'comp,policy number,
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Inmrrunee 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 maybe forwarded to the Office of
Investigations of the DIA fur iamzaa a coverage verification
I do her certify an er a and penalties of perjury that the information provided above is true and correct
Si tore: Date: D/2
Phone
Fal use only. Do not write in tliis area, to be completed by city or town ofzciaL
r Town: PermitUcense#
g Authority(circle one):
rd of Health 2.Building Department 3'. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
ct Person: Phone#:
. 0£t KE Town of Barnstable
Regulatory Services J
t F
XAE& g Thomas F.Geiler,Director
a65y. ♦0
++ ` Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 509-862-4038 Fax: 508-794-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the -subject property
hereby authorize 6a ze to act on mp behalf;
in all*matters relative to work authorized by this building permit
(Address Job)
p
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled before fence�is installed and pools are not to be
Utilized until all final inspections are performed and accepted.
Signature of Own �} Signature of Applicant
/�t / % .G 7/��% S
Print Name Print Name
Date
Q:P0x2&:0WrMPER]VMs10rrnoo1s
�w 94 STEVENS STREET
HYANNIS,MA.02601
T REQUEST FOR PROPOSAL/BID March 20,2012: a
TO:Door Replacement Contractor: "
FROM:First Church Christ,Scientist
P.O.Box 86;Hyannis,Ma.02601 x
Attention:Rita Jones
REF.:Request for proposals and bids for replacement of Two Exterior Doors in Sunday School
The First Church of Christ,Scientist;Hyannis would greatly appreciate your financial bid based on your review of the
premises,this description of work and in accordance with this bid format.Your confidential,signed and sealed bid
shall be submitted on this form within the spaces provided,to Ms.Rita Jones at the address noted above and received
no later than 6 APRIL 2012.Any qualifications to the requested work,additional proposals or alternate suggestions to
your bid should be noted on a separate attachment to this form and referenced with(*)as appropriate below.You
should arrange to visit the site to see and evaluate the project scope first hand prior to submitting your bid. Questions
regarding project scope prior to the submission date maybe addressed to Rita Jones at Jones r @comcast.n'et.`
We are requesting your proposals/bids for the following work:
A. Remove and dispose of two exterior doors in the Sunday School. Frame both openings to receive new
doors. Install lead flashing beneath sill. Install two new Masonite Fiberglass insulated exterior grade
doors according to specs on page 3.Insulate around doors,and install interior and exterior trim to match
existing.Once approved,your schedule for completion shall not be exceeded by more than 2 calendar .
weeks.Materials and workmanship shall be consistent with and appropriate for its intended use and patch
to match existing walls where new meets existing.All warranty information shall be noted with your bid
and delivered in writing accordingly upon completion.An overall warranty of your project work is Y
implied for 12 months from completion.
B. Bid on the following two designs from ,,N,Ny Alasonitixom :Belleville Fir,textured 2 panel door,
twin lite with clear glass& Belleville Smooth 2 Panel Door HaH Lite Camber Top with Clear Glass.
a,Cost-Lump Sum: "
b.Qualifications: ,° ." l'7
c.Schedule '00:�90s111
d.Signature /Da
B.PLEASE INDICATE YOUR INSURANCE COVERAGE(on an attached page)
C.PLEASE INDICATE THREE RECENT REFERENCES(with contact names and telephone number on an attached '
page)
D.PLEASE ATTACH YOUR PROPOSED SCHEDULE FOR PHASING AND COMPLETION OF WORK.
E.PLEASE INDICATE YOUR PAYMENT TERMS(on an attached page)
F,YOUR PROPOSAL SHALL INCLUDE UNDERSTANDING OF THE ATTACHED GENERAL CONDITIONS
AND DESIGN DOCUMENTS
` The Church reserves the right to select the best bid or reject any or all bids.The Church also reserves the right to
accept your bid for only part of the above"work due to priorities and financial limitations.Due to the time for
membership review of any expenditure of funds your bid will be considered valid until September 15,2012.Your bid ,. '
and interest in this work is greatly appreciated.
Encl:General Conditions Requirements March 20,2012 Vendor's Address&Contact Information /
if% o�� ds'Ies` t'Age/c�
caQ //'ew Svc 1e, A14e
Massachusetts of Public Satcty
Board of Building Regulations and Standards
Construction Supervisor License
Licenser CS 103622
Restricted to: 00
ROBERT JONES +`
206 CEDRIC RD
CENTERVILLE; MA 02632
Expiration: 3/19/2013
Commissioner Tr#: 103622
I.
s
f
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application #
Health Division Date Issued 6
Conservation Division - Application Fee _
Planning Dept. Permit Fee C1
Date Definitive Plan Approved by Planning Board
Historic.- OKH_ _ Preservation / Hyannis
Project Street Address G� Cr✓� S Slfz�
Village ' a-,z.0 "A- _
Owner r Addresses e- e-y Hn0
Telephone
Permits Request�DT awe A e— eA-4--11�4_e, 02 jweLr
Square feet: 1 st floor: existing proposed 2nd floor: existing _proposed _Total new
Zoning District — Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing StrUcture _ Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) _ Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing_ new Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing _—___new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stave: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new size_
, Attached garage: ❑ existing ❑ new size —Shed:.❑ existing ❑ new size Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name � ''(;lephone Number S"ee=� Z-2
Address 2gA5 6eecdt>L, 5W _ License # r41:3 4,22-
Llez,v,//e , ' ®�6 Home Improvement Contractor# 14'ref
Worker's Compensation #4(4&1^3/5- 3 70
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO� -
SIGNATU E DATE
FOR OFFICIAL USE ONLY
APPLICATION#
s' DATE ISSUED
YAP/PARCEL NO. '
i
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
u s FOUNDATION
,i
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
E '
PLUMBING: ROUGH FINAL
s
GAS: ROUGH FINAL
:FINAL BUILDING
Y
K
DATE CLOSED OUT '
4
r ASSOCIATION PLAN NO.
I `
The Commonwealth ofMassachusetfs '
.f Department of Industrial Accideizts
_ a- r9
,t• i Office of Investigations
600 Washington Street
5/ Boston,MA 02111 ,
www.mass go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ". q '•
Please Print Leobly
Name (Business/Organization/Individual):
Address: &t'' 2ea
City/State/Zip: '
ea^r..c'/lC MV a-;ZC`'z`" Phone#: w
Are you an employer?Check the appropriate bo .
Type of project(required):
1.❑ 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' ��=odelir'ig
sruction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 1- 7•
ship and have no employees These ub-contractors have S. E] Demolition
working for me in any capacity. _ ers' comp, insurance.
9. Building addition
[No workers' comp. insurance 5 e are a corporation and its "
required.] officers have exercised their ]0.❑ E)ecfical repairs additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I:Q:Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4) and we have no 12.0 Roof repairs
insurance required.] t. employees. [No workers'
comp. insurance required,] 13.0 Other
*Any applicant that chocks 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 their workers'comp,policy information.:
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: r. 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 upt 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 harcby,oertify unde e p s and penalties of perjury that the information provided above is true and correct
Si a e: °, ,
Date: It -7 3'----P®//
Phone#: ,
Official use only, Do not write in this area,-to be completed by city or town offtcial
City=or Town:
Permit/License#
Issuing Authority(circle one):
1: Board of Health .2. Building Depar tment 3. City/Town.Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: s -
-Phone#: M
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 dweIIing 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 rriaintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract 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.contractor(s)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,.plcase 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 proofthat 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
Daparfmant of Industrial Accidents
Office of Investigations
600 Washington Stet
Boston,MA 02111
Tel. # 617-727-4900 ext 406 Gr 1-977--MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass..gov/dia
Public Sal'ct�
r 1VMassuchusettti Depart�on f and Standards
Board of Building Reou License
B Lic
u e r vis or
� Construction S p
i
� .
License: CS 1 03622 *.
Restricted.to: 00
ROBERT JONES S`+
206 CEDRIC RD n F
CENTERVILLE, MA 02632
Expiration: 3/1912013
��-- Tr#: 1036V
('ununissioner
0
The Commonwealth of Massachusetts{` f
Department of In4sftiai A ccidents,."
Office of lnvesdgddom N
600 Washington Street
{ Boston, MA 02111.
www.mass.gov/din `
Workers' Compensation Insurance Affidavit: Builderst'Contracfors/Electricians/Plumbers.
Applicant Information .
Please Print Leg bl
Name (Business/OrganizationdndividnaI); �. r e
Address: A �� 3 d:
City/State/Zip• ✓i S- Phone
Are you an employer? Check t e appropriate box:
Type of project(required): .
1.❑ I am a employer with 4' [] I am a general contractor and I '
yees(fall and/or part=time).* have hired the sub=contractors 6• New construction
2. I am a sole proprietor or partner-:-- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have
em to ees and haveworkers' ' 8' 0 Demolition
working for me in any capacity. p Y 9. Building[No workers' comp.insurance comp.msu rance.t 0 g addition
5. We are a corporation and its :10. _: Electrical repairs or additions
3,❑ required:] � officers have xercised their.. �.,`. p
1 am a homeowner doingall work
11.[]Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t,, c.-152 §l(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. 3 M
I am an employer that is providing workers'compensation insurance for my employees. Belorv`is the policy and job site .
information
r ,
Insurance Company Name:
Policy#or Self-ins,Lic.#: }
Expiration Date:
41
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 i Tkp
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$250.00 a day against the violator.`Be advised that a copy of this statement may forwarded toy the°Office of
Investigations of the DIA for insurance coverageaverification '
_ y
[do
hereb cerfi under the pains and enalties o e 'u that the information provided above is true aced correct,
.
y f3' P P lP rl.rJ' f
Si attu°ek ? 1
Phone #.
Official use.only. Do not:write in this area, to be completed by city or town official
City or Town..
Permit/Licei se#.
Issuing Authority`(circle one f
1.Board of Health 2.Building Department 3. Crty/Town Clerk 4.Electrical liispectoi S.Plumbing Inspector :>
6. Other
Contact Person: Y
Phone"#:
m _q
F ,
}
The Commonwealth of Massachusetts
Department of Industrial Accidents'
Off ce of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician's/Plumbers
Applicant Information
Please Print Legibly
Name (Business/Organization/IndMcluaI): Z NAM'
tr�
Address: � �I uc. C
V
r.
City/State/Zip: 0 Phone k �P09 3 64-1 3 i 4°
Are you an employer? Check the appropriate box:
4. I am a en Type of project(required)::
1.❑ I am a employer with [] general contractor and I
employees(full and/or part-time).*_ have hired the sub-contractors 6• ❑New construction
2 I am a sole proprietor or partner listed on the attached sheet. 7. []Remodeling=
ship and have no employees These sub-contractors have g 0 Demolition
working forme in any capacity. employees and have workers'
o workers'co ,. com insurance.$. 9•. �Building addition M'
[N comp.insurance P` .
required.] 5. We are a corporation and its I0.E,Blectricid repairs or additions ,
3.❑ I am a homeowner doingall work officers have exercised their
11:[�Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL . , 12:0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees.[No workers'. 13.El,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 arc doing all work and then hire outside contractors must submit a new affidavit in 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 M
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.,
I am an employer that is providing,workers compensation insurance for my employees. Below,is the policy and job site
information
Insurance Company Name:
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). t.
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 wellas 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 cerli)y under thepains andpenalties ofperjury that the information provided above is true and correct
Si afore: Date: D i o
il
Phone'#:
Official use only. Do not write in this area, to be completed by city or town off cial
City or Town: Permit/License#
Issuing Authority(circle one).
1.Board of Health Z.°Building Department 3. City/Town Clerk 4.Electrical=Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Cape Shores Development LLC
828 Sea View Ave
Osterville, MA 02655
508-221-8572
********PROPOSAL********
To:
First Church of Christ Scientists
94 Stevens Street
Hyannis,MA 02601
Description-window replacement
Exterior:
-Remove and dispose of 4 large window units on the rear Sunday school section of
church.
-Strip entire exterior wall of old shingles.
-Rip and replace all rotted material found in the wall between the far left and far right of
the existing windows.
-Re-frame window openings to receive 8 individual 24 x 60 casement windows -2
casement windows per opening installed with at minimum, a double stud pocket
separation.
-Install windows at existing sill height to manufacturers specifications and trim to match
existing exterior trim.
-Install vapor barrier to exterior sheathing and re-sidewall with new shingles
-Paint new windows and trim to mach existing.
Interior:
-Install new dry-wall around window units and finish to match existing.
-Install new trim to match existing.
-Paint.
Materials-
Windows: Pella Pro-Line series with insulated low E advanced argon gas.
Vapor barrier: Tyvek or equivalent
Shingles: White cedar
Trim: Bodyguard(Bodyguard is a pressure treated, double coated pine product that is
defect free and made to outlast typical pre-primed pine by years)
Lumber: Typical kiln dried lumber
Notes:
Cape Shores Development LLC will pull all necessary permits and supply all materials
and labor necessary to complete this project.
All workers are fully insured and will perform the work in a clean,professional manner.
(please include fax#for insurance company to forward policies to)
All debris will be removed from the area of work and properly disposed of.
All warranty's on installed products apply.
Any rot or damage discovered outside the immediate area of the window.replacements
will be brought to the attention of the building committee along with a separate proposal
to fix the affected area.
This proposal includes only the work specifically outlined above.
Payment terms: 50% deposit with signed proposal,balance upon completion.
Amount this proposal: $9,600.00
Thank you for the opportunity to bid this project.
Accepted by:-
� n
Fir t Church Christ Scientist R. Scott Jo
Cape Shop Development LLC
Construction Supervisor license#103622
i
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