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0374 STRAWBERRY HILL ROAD
.�7� Sre�e a hfY/ ,Pd a✓e- <sy ,y f � ��_ `T"ET°�.� TOWN OF BARNSTABLE BAHHSTADLE, i "6 9 BUILDING INSPECTOR APPLICATION FOR PERMIT TO ............................................................................................................................. TYPEOF CONSTRUCTION ......................................................................................... . .......................................... ...................1940 . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according-to the,followV rma ion: Location .....'�J ,�•••'••... . ProposedUse ..................................... ....................... ........................................................................................................... Zoning District .. ............ .. .. ...I.....................................kddres Fire Distri fj..............,................. :,.................. Name of Own .. . . ....................... ... ........ .. Cz�� J Name of Builder ........................� ......................Address ..................., Nameof Architect ....................A...........................................Address .................................... ............................................... Numberof Rooms ..... .....................................................Foundation .. .. .. ... ................... ............................................ Exterior .... . ......... ......... ................ .....................................Roofing ............... . ............... .......a........................................... Floors ....... . :.. ... ..........n.......................................................Interior .... ........ ......... .......................................................... Heating ...Plumbing .......:......... .. Fireplace ......... ....:..... .........................A roximatP Cost ........ Difinitive Plan Approved by Planning Board ________________________________19________. �6 9 S� Diagram of Lot and Building with Dimensions ��G h// I I hereby agree to conform to all the Rules and Regulations of the jqwn of Barnstable regar �ing the bove construction. V r Name Cape Cod Building Supplies, Inc. No ....11 2.. Permit for .......one story,..._... ...single family dwelling Locati6nl ...Strawberry Hill Road ......................... ann�.s .... ........................................... Owner .........Cade Cod Building Supplies, Inc. Type of Construction frame .......................................... Plot .........................:.....Lot .....: �................... . ........................ Permit Granted September 26 .........19 67 ........................... Date of Inspection ....................................19 Date Completed .. J. .- Q..........19 6 r i PERMIT REFUSED ... ......................................................... 19 i a ................................................... ........................ ............................................................................... 1 ................... ........................................................ Approve ................................................. 19 ............................................................................... ............................................................................... i Assessor's office (1st floor): Assessor's map and lot number .............. .. .. .......•1.....,... DIs,TA"M Board of Health,(3rd floor): Sewage Permit number .. 33AHD9'fADLE, �r�R� E�Engineering Department (3rd floor): ' Y i House number •......................... 1� 7..�!•... ! .�!1..... o YPY a� Definitive Plan,Approved by Planning Board .___,__:____,_ _:__..-______:_19_____ __'. APPLICATIONS 1PROCESSED 830.-�9:30 A.M. and 1:00-2:00 P.M. only :TOWN OF BARNSTABLE BUI,LDING .INSPECTOR APPLICATION FOR PERMIT TO 4`? �- d ��Zecc f3..4�.............. y........... TYPE OF CONSTRUCTION ......L�!.D.OD..... 8!la'? ..................:............................................::...............:.... ` .......czZ: ...............19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: • Location /....... .......�. �r... .........:.................................... Ile Proposed Use ......`rL'�. .��.... .. !/�.......(�f!J�l!l.!1 .... ..... ... ..................:...................................... Zoning District Fire District ......... ...t................................ Name of. Owner ...AlV / ...ILiQ.V.0r.1,1.........:Address ........ ..... .......................... Name / .� -r!............Address ... .. ... �- Name of Builder .. .../.1.�{...:.,...s.:.. '�lY ........ ��P C :......1 ...... ...hl%.e.............. Name of Architect ..... .......,.Address Number of Rooms .............:..................... ....:....Foundation ... �,. . /"O!//f r ...................... Exterior..... 41.0:f!P.7.)............t1.�V...�....................................Roofing ...........�Sf'.i! ........................ Floors' ...:..Interior . ........., Heating /(//��t�. ................................. .....................Plumbing ...........r( W.ir........... .......................................... Fireplaceoeve, Approximate Cost .:.....1 .��G!. y Area :' •........ ..<. . Diagram .of Lot and Building with Dimensions Fee ........� �............:......... �i 1. F0 .f. ._ 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 . r ... ...&" � ............................ Construction Supervisor's.License `�. ....... HAOGH, JOHN & MARY , ,E. 31934 ` Build Gara BYeezewa° .........Permit for ...........�� y .. ` ....Singl'e Fam l-y+..D4dG.11�.�lg......... > Location 7 4x.?wb.�xx � ..H.i 1 J... ad Owner i.. John &' Mary Ha 'h Type of Construction T ;Frame.. ........l� ,� 1 X r r h•. t ' •�✓_ ................. "' •� .. � "5�.•.7E — �' •— a n ..ram .I - .- .. ` •_ - xt Plat ..... Lots`- � ... Permit�Grale May .,25, 8.9 1 ,. Date of Inspection ..................................f.19 ,.' Date Completed ......... .......t" 19 �� 7 �• 'rt. �� yam• r - f x' - fu * ^ � sy`, y/? r 1.•' - .. .' < _ .. ° �� � �� �• ^ � � + + ... - of ` ... r 2 l *:. -,10V { .�� - , Y�.' • ,-:. x,;w p,`�i't �"?I+° a.. x'* 'r1'M�a3°"Nb•�. wi+ - „a,,�.�.„nkf�! •..". _ .;i': .b-:G a.i&: Assessor's office (1st floor): F T Assessors map and lot number ..................... ........... /........... Q..���� ` ,Board of Health (3rd floor): 7� Sewage Permit number .. ...,. ..,....... :.....1-�.?m t BAfld9T11DLE, `14Engineering Department (3rd floor): rsea House number ...... .3 ...A '1..... o�''Fo�ara`e� ........................... Definitive Plan Approved by Planning Board -------------------------------- APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only . TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....5 . ° ��rg�� ........ d IJ �,����`Le4lr TYPE OF CONSTRUCTION ......1?mp..... /�Qfl1 l.. /A......•....'•5... ...........19.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............ ......57r'Z Zr.J.G3�` ���`1.... ��.�`.!.:....../' .cry /.. �... /1hIJ.S:.................�... ............. Proposed Use .......S..'!.....��........ ?1/�t�......DuJ�?I// .:..t f--� ZoningDistrict ........................................................................Fire District ..........., ... .............'.....................................{.... Name of Owner .-�0 >v�..4...�1,4/ ....j�,l/�. .........Address ........J�....fl/ .... :�..... ?ll,ll4t5, .... Name of Builder /.....�J....17 r ............Address ...A .34?A .AA,...... ............. Nameof Architect ..................................................................Address .................................................................................... Number of Rooms Foundation �d ...J/Q•UI#Gr .' Exlerior .....A1.A.0./7.......... ff/-t/G11................................Roofing ......... .S ..r!(�7 ...................................I.......................... Floors ......................................................................................Interior .......... Heating Plumbing J//A.�r/ Fireplace .................. .D/f/!!�................................................Approximate Cost ........�tAm< Area 44,a..�..�J4�'. �� •' r.. Diagram of Lot and Building with Dimensions Fee . . .................... 7 7, Yo tG Afa le— ,r O r� g6 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 .................................................................... Construction Supervisor's License .......... �9................... HAUGH, JOHN & MARY A=248-154 No 31934 . permit for Build Garage. . . ./Breezeway.... .... . . . Single Family Dwelling Location 374 Strawberrv/Hill Road Owner John & Mary Haugh ........... .. ............... Type of Construction ......Frame.. ... ...............:........... ............................................................................... Plot ............................ Lot ...I............................ 25, Permit Granted ........May.........................19 88 Date of Inspection ....................................19 Date Completed ......................................19 Town Barnstable . r i 60o � °Fm�r° �'V a� Pe rmt# expires 6 onth from issue date °- Regulatory Services. Fee F �• Thomas F. Geiler,Director hr nss N� Building Division- ED±tJtD`t , 7 2oo8 Tom Perry,CBO, Building Commissioner �� / 200 Main Street,Hyannis,MA 02601 N OF 8ARNSTAE3LE www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION. - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Numbe&%' Property Address 3�zi( Z5TPC Awdt alep V ;Ejl t ( esidential Value of Work �y��t '- Minimum fee of$25.00 for work under$6000.00 Ov✓ner's Name&Address t"T 004 IS 4 of se5 T VZF ,A,a�6 f s LET. ���7z1� �A- C-7. Contractor's Name_ �7�,v�bS ( d��l( Telephone Number .2� >S'-g� tl'j �i Home Improvement Contractor License#(if applicable) ❑Workman's CoraKasation Insurance Ch one: I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy#_ �7) PIZy I;A�7-22 Copy of Insurance Compliance Certificate must be on file. Permit Request(c ox) Re-roof(stripping old shingles) All construction debris will be taken toZ ❑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. t"Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:\WPFILESTORMS\building permit forms\EXPRESS. Revise020108 i_ CHARLE' S - - TOTAL INVESTMENT with SOFFIT 8995.00 SOFFIT OPTION. Supply and Install SMART SOFFIT VENT SYSTEM on the TOTAL INVESTMENT with SOFFIT VENTINGMann House Eaves. POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Sheathing,Missing Metal Flashing, Side Walling or Any ®themar ent Deteriorated Tim Boards Plywood Will be done and charged for as an Extra: Materials Plus 20% ' ywood P ry Needing Replacement PARENT SCHEDULE: A Deposit of One Half is du and.Labor at theRate of� 50.00 per Hour. Payment for the Balance is Due.Immediately Upon Completion.Sign of this Roof Proposal and the Final WO SCHEDULE: � All Roof Work is Normally Scheduled for Completion Within Deposit providing the Materials are Available. 30 Days of Acceptance and Receipt of Please make checks payable to CHAR-LE CHAR-LES C CHA "E COREY Warranties the'Shingles and Labor for 5 ears. CERTAINTEED Warranties the shingles and labor 100°/® for the First Years and then on a pro-rated basis for 30 Yeas Total if the shingles CERTAlNTEED Warrants the.Shingles up to a becomes defective:. CATEGORY FI HU CANE-110 IVIPII WIND WARRAN I I' CERTAINTEED Warrants the Shingles to be Algae Resista nt for Fdil 10 Years: This Proposal Ma �e Withdrawn By Its If Not Accepted DepositedR . Within Thirt Ida s Or Before The Next Price Incre s ials In Mate eceived . . CHARLESCOREY carries Workman's compensation and Public Liability Insurance on thew DAT F ACCEP ANCE: bove work C P ED:BY: 4 4 q -SUBMITTED BY: DOREEN E. EANKHORS'I' HOMEOWNER CHARI,E f ROOFING CTOR . - C- H-IL- ARLES -CORE Y___ n! __c Rxeoder Rooker 1694 FALMOUT'H RD 115, CENTERVILLE, MA 02632 . 17 V� ' 4.'.V s s. e �t G.`.�,tlw?`Gy Is—�F 3 Ok`Ny - AR O W li E V T U RU'U LSTYLE November 21,2008 o Q O F 14 Q, R 0 P Of S,A , CRAIG E. &DOREEN E. LANKHORST INSTALLATION ADDRES+: 34 FRANCIS STREET 374 STRAWBERRY HILL ROAD BOSTON, MA 02115 CENTERVILLE,MA ,Phone: 1-.617-566-3878 Phone: 1-508-771-8.744 EM: lanky3961k@netscape.net COY & COY hereby proposes to perform the following services.in a neat and professional manner and in accordance with the manufacturers specifications and local building codes. Remove and Haul Away All of the Old Asphalt Roofing Shingles from the,Entire House. Supply and Install ONE PIECE.OF LEAD FLASHING Cut Out Mortar and Install New'. Supply and Install _. `CERTAINTEED LANDMARK 30 AR: 30 YEAR WARRANTY, 10 YEAR SURE START PROTECTION, CLASS A FIRE.RATED, 10 YEAR STREAK FIGHTER WARRANTY-ALGAE RESISTANT,250.POUND EXTRA HEAVY WEIGHT, SELF-SEALING, 110 MPH WIND WARRANTY, STORM/HURICANE NAILED w (6 NAILS PER SHINGLE),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 C�N'TAMINENT COLOR: Supply and-Install; . .CERTAINTEED WINTER-GUAR (lee& Water Shield ) WATERPROOF UNDERLAYMENT SYSTEM on Roof Eaves,Valleys,Under the Step Flashing. on the Skylight,Chhnney and Gable Walls. Supply and Install #I5 BLACK SATURATED FELT UNDERLLAYMENT PAPER Supply and Install "`-WHITE.ALUMINUM DRIP EDGE on All Eaves. Supply and Install -AIR VENT SHINGLE VENT 11 RIDGE VENT on'Main& Breezeway Ridges. Supply and Install ALUMINUM & NEOPRENE SOIL PIPE FLASHINGS Supply and Install NEW KITCHEN & BATHROOM EXHAUST VENT Clean and Remove Debris from work area after job is completed. CERTIRCATE OF LIABILITY INSURANCE >ATE(HRWDA7YY?T 04/08/200-8 loom THIS CERTIFICATE 1S::.1_SSUED AS A NATTER OF INFORNIATiON ,HI.EGEL INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 SIN ST HOLDER. : THIS CERTIFICATE DOES NOT AMEND, EXTEND: OR- .ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 9ST. YARMAUTH, MA 02673 INSURERS AFFORDING COVERAGE NAIC# 3ti1 Buckmiller - INSUREeA:NORTHLAND INSURANCE INSURER B: TRAVELERS INSURANCE 3A BUCKMILLE"R ROOFING - 04SMER C. - INSURER D: r.umi8, MA 02601 - INSURER E: - - s OVERAGES TFE POLICIES OF INSURANCE .LISTED BELOW HAVE BEEN ISSUED TO TrIE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ++ POLICY E FECTIVE POLICY E)MRATIDN - i (DISRD TYPE OF INSURANCE POLICY tAA�98ER - L11V7S DATEO M MNI DATE 0&VDDfM -GENIERALMOUTY CP46859564 05/15/07 05/15/08 FACHOcamRIENCE s.1,000,000. X LLNAAERCIAL GENERAL LIABILITY - _. PREMISES(Ea ocnamce) s 50,000 cLivMs MAoE occuR MED ECP ony nne person) s EXCLUDED. ---- — PERSONAL 6 ADV INJURY S1,000,000 GENERAL AGGREGATE - s 2,000,000 - GENI.AGGREGATELIMITAPPLIESPER: - - - - PRODUCTS-COMPIOPAGG s2,000,000 - --- - POLICY EC LOC AUTCHOBLELIABILITY - MINED - - - . COINED SINGLE LpAIT $:ANY AUTO - (Ea acadeo) ALL OWNED AUTOS _ - BODILY INJURY $ - SCHEDULED AUTOS - - (Per person) HIRED AUTOS - - - - - BODILY INJURY $ - NON4YWNED AUTOS ` (Per a ddeN) .- PROPERTY DAMAGE _ - '(PeraceiPmq $ �. GARAGE LIABILITY AUTOCNLY EAACCIDENT S ANY AUTO OTHER THAN EA ACC s - - - - AUTO ONLY: AGG:: $ — `. OORtYIA L a 1 EACH OCCURRENCE $ - 4 OCCUR CLATt MADE AGGREGATE $ -. DEDUCTIBLE RETENTION S. - _ - - I$` - 3 3 . ST wDRKERSCoMPEi"'noNANc 7PJUB-7430A7-07 04/11/07 04/11/08 X TORYLAInaITs ER EIRLOYERS UARNUTY `. .•'1,7PJUB-7430A7-08- .' 04//il/08 04/11/09 E-L EACH ACCIDENT s-100,000 - 4 ANY PROPRIETORIPARTNERADmcunVE 1 _ OFFICERIMEMBER EXCLUDED? EL DISEASE-EAENIPLOYEE $100,000 _ IT yes"des vbe under -YES . SPECIAL PROVISIONS beRaw ( _ E-L.DISEASE_..POLICY LIMB- $ 500,000 . OTHER ESCRIP IC N OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSMENT I SPECIAL PROVISIOM '.HE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PAM BUCIQUIJ R I ;ERTIFICATE HOLDER` CANCELLATION :GREY &COIZEY .SHOULD_ ANY OF THE A;HOGE POLICIES BE cmwmrrn on-we THE`..EXPIRAnm , 1694 EAU40UTH RD 4115 DATE THEA180F. THE/ISMIM I VALL ENDEAVOR TO MAIL 21 DAYS WRITTEN 'MUKRVIIME;. MA 02632 HOT= To THE.CERnaCATE HOLDER NMED To THE LEFT. BUT FAILURE TO-;Do_ sD SHALL 'f RNPOSE HD 011l GATION OR..UAI� :`oF MY IKIND UPM THE INSURER ITS 'AGENTS OR REPRESENTAMEk . .. AUTHOROM R ESN3NTAUVE AX_ 508-775-0155 ' ICO D 25(200110) ©ACORD CORPORATION 19N -\ The'Commonwealth of Massachusetts ., Department of Industrial Accidents Office of Investigations ' ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): cote t Address: Co Q1 L�t6t1�7�7 acry City/State/Zip: ° Phone.#: , ^ Are you an employer?Check the appropriate bo Type of project(required): L❑ I am a employer with . 4. am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. New construction 2:❑ I am a sole proprietor or partner-' listed on the attached sheet. 7. .❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• $ 9. Q Building addition [No workers' comp.insurance comp. insurance. 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its+ ❑ P 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'-comp. right of exemption per MGL 121]Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors 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. r Insurance Company Name:' Policy#or Self-ins.Lic.#: _7"OV 7"0A 7= e2,R Expiration Date: Job Site Address: # City/State/Zip: k�so v tii /io 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER'and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce unde th ar and penalties of perjury that the information provided above is true and correct. signafore: Date: ;Qlozvool>1-a Phone#: Official use only. Do not write in this area,to be completed by city or lawn official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more "77-6-f—thei foregoing engaged m alomt-en rprrse;a meln3m`g"tfie legal=representia�ives.�fdec�as�d employer,ar.the- —-— receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-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,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly..The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where'a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Dgparttnent of Industrial Accidents Office of Investigatkas 600 Washington Street Boston, MA 02111 Tel. #617--727-4900 ext-406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia _ a Uard or� t Co►jsti ,on�SuRegulatio>f an �crc� ' Stang L'cep"Se pen'tSor License lards fExptratlo Cg 2881 1. n 2-14/201 ! Re 0 y L t tnction578106 t CHARLES E., r 1694 F COREY. AWO H I r C�N.TI3ERVllLE RD#� .a e_ r__ Commissi j _ oner 1 _T/ze �ri'arr�nzoozus � o� cic�ucaelza I ._$,pard of Building Regulations and Standards a HOME IMPROVEMENT-CONTRACTOR Registrat�ona 136066 Expl,rafion ft/2010 Till 268785 . n • rf� ?�Ype ��- I . `,was COREY&COREI��F`[OME�IMPRtOUEMENTS l.ff �CHARLES COREYt 1- 1694 FALMOUTH RQ;.#115 GENTERVILLE,MA 02632 Administrator - r 3 I License or registration valid for individul un-ply before the expiration date. I€found return to: Board of Building Regulations and.Standards One Ashburton Place Rm 1301 i Boston,Ma:02108 1 Not valid without-signature - - - - - i F e -� 5l� a �� f��� Town of Barnstable *Permit# doC,l' �L � Fxpires nihs frog issue date { Regulatory Services Fee ,A U(G, Thomas F.Geiler,Director ' Building Division YSI i / r-- Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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 9gr6 15q 194 /b ;2sidentlal Address /N �f:�' IA 1201.S � ) Da&61 Value of Work 3 JW60 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Cral j Ctn d bore_e. Lan Khor sS _ Contractor's Name ( t t M Telephone Number �'t7� �S 7 Home Improvement Contractor License#(if applicable) C�2 a 0 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner Def5a've Worker's Compensation Insurance Insurance Company Name � � � r 1904e 6/ L 'Tr. Workman's Comp.Policy# hI C L/ Q 077 L5 00 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑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 f th Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg ; Revise061306 / 1 rotrdorBodttn 1 ; t t; 'et ulatious and Standard.. } t1C iE IMPROVER7ENT CONTRA+J RACTOR , Reg stratlon�.150220 }. Ezpr`raton 315/2008 s Tr# 1.1�11 zT UP JEREMIAH ItI I ` GAChOh JEREMIAIi GAGN©NE-, 52�,A(\WALE•�1IA�� ���` r,,yf� � ' r NOTICE NOTICE TO a TO EMPLOYEES � EMPLOYEES V The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS ' 600 Washington Street, Boston, Massachusetts 02111 617-727-4900-http://www.state.ma.us/dia 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: Insurance Company: Atlantic Charter Insurance Company Policy Number: WCV00771500 Effective Dates: 4/3/2007 TO 4/3/2008 Insurance Agent: Robert E. Bouchie, Jr. Insurance A eg cy,_Inc. _ PO Box 400 Cataumet MA 02534 ' •� ROBERT E. BOUCHIE, JR. Employer: Jeremiah J. Gagnon a� Insurance Agency, Inc. PO Box 551 1352 Route 28A•P.O.Box 400 - West Yarmouth, MA 02673 Cataumet,MA 02534-0400 Bus.(508)564-5560 Fax(508) 564-5531 Workplace: DBA-Gagnon Home Mainten `ice 7980 61 Gunwale Way Yarmouthport, MA 02675 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 ace ordance 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 ..........._... ---------.................... --- --- ---- - -- -- NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ + 600 Washington Street r Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information le /` Please Print Lek7ibly Name(Business/Organizationadividual): (,7. bl �1y� l&�i'on ffo-mQ, main tab 7 ie-A P..\c Q Address: za un as le W of 44 `/ City/State/Zip: 7 at/no A'A 0 0(-+ Off 02(e"7_ hone A -aq q-®1 S_? Arrpan employer? Check the appropriate boz: Type of project(required):. 1. a e to er with ,� 4. I am a general contractor and I y 6. []New construction . employees (full and/or part-time).* have hired the sub-contractors 2.El am a bole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling • ship and have no employees These sub-contractors have 8. Demolition -workingfor me in an capacity. employees and have workers' Y P t5'• $. 9. 0 Building addition [No workers'comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their ll.❑Plumb* repairs or additions 3.❑ I am a homeowner doing all work . g eP myself [No workers'comp. right 6f exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑ Other comp.insurance required.] . *Any applicant that checks box#1 must also fin 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. ZContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their worker;'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. ) I Insurance Company Name: i�0(7�� ! c'I ,,e Tr Policy#or Self-ins.Li-c.#: 1✓ Z/-/, C ®®77/-Toed ExpirationDate: Job Site Address: 374 Sfrac of 4 Wit R City/State/Zip:1t/Q/IP//5_ all ®-14 -7 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 imprisoffient,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. Ido hereby certify under th pai -and penalties ofperjury that the information provided above is true and correct Signature: Date: Phone#: 1y'0 15 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions -- Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two.or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustet-of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the' dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to•operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until acceptable evidence of complfauce with the insurance requirements of this chapter have been presented•to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confumation 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 workeis' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Towu 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 member. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in_(city-or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. to Cammonwealth of Massachusetts Department of Industdal Accidents Office of InvestlgatiQns 600 Washington Street. Boston, MA 02111 Tel.#617-727-4904 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia IHE, y Town of Barnstable Regulatory Services rXAM Thomas F.Geller,Director Building Division Torn Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 . Fax: 508-790-6230 Property Owner Must Complete and Sign This Section if Using A Builder I, rrotiq-. Cam,,K 6" St ,as Owner of the subject property hereby authorize 6HM 0q/10A 140 e'+^Z 147GtiM C-eo act on my behalf, in all matters relative to.work authorized bythis Building permit application for: . (Address of Job) 4ature of JAner Dfaie �! e4(em 1 ct k m—N Print Name Q:FORMS:OWNERPERMIS SIGN _ _ J