HomeMy WebLinkAbout0021 STUDLEY ROAD i
l
• r ;
tHE Town of Barnstable *PerniYD G2
G Expires 6 months Jrom i date
Regulatory Services Fee
• BARN as p
1639 MASS. ,m S1r Thomas F.Geiler,Director
°ren na qY
Building Division
201,E Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
F www.town.barnstable.ma.us
2-MOffice: 508-86 487AB Fax: 508-790-6230
EXPRESMRMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number /� AL
Property.Address 2 �TG�17�L'�j !Lee /�/1/ilO i,� /�f 3Q l U
®"Residential Value of Work 3LIT,0 L1 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address ;(, TQ,', 23c-12(5;zLA,'2)
Contractor's Name kJt )/LI L� �,ALAZC`�r/ Telephone Number U "��- 0 d 2
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) C',� 5, '17 7
Z/Workman's Compensation Insurance
ChgelC one:
[v] I am a sole proprietor
❑ l am the Homeowner
u l have Worker's Compensation Insurance
Insurance Company Name �-ff 16ff-.A&,e-1(1exA,6 G o U?
Workman's Comp.Policy# Z Z OF r
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
E✓�Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
r
SIGNATURE: 'i Z23
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC
Revised 053012
The CommonsveaUh of Massachusetts
Deparhnent o,f Indusftia1 Acciden&
r= Office o,jlnvestigations
' 600 Washington.Street
Boston,MA 02111 .
wvnwv mass govldw
lVnrkers' Compensation Insurance Affidavit: Builders/Contractors/E•lectricL--tns/Ptnmbers
Applicant Information Please Print Legibih
Nave(Busimwor izationllividaai):-_��f!`y �: �A(✓7iy�'y
Address:
Cityrstate/Zlip: Rba Phone 4- i5-17 -a JV0-�
Are gsfuIam an employer: Check.the appropriate box: Type of project(required):
1_
�5 I contractor and 3
a employer with�_ 4. ❑ am a�� 6. ❑New construction
employees(full and/or part-#ime).* have the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship.and have no employees These sub-contractors have 8_ ❑:Demolition.
working forme in any capacity_ employees and have workers'
[No workers'comp.insurance comp.insurance-14 ❑Building.addition
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 1 I..❑Plumbing repairs or additions
myself [No workers'comp. right of exemption per IVIGL 12.❑Roof repairs
insurance required.]T c. 1.52, §1(4),and we have no
employees.[No workers' 13..❑ Other
comp.insorance.nxpired.]
•Any apphcamt that checks box#1 Most also fill out the section below showing their workers'compensation policy information_
Y Homeowners who submit this afhdsvit indicating they are doing all wcd and then hue outside contractors must submit a new afdnat indicating such.
lContractors that check this.box must attached an additional sheet showing the amne of the sub-conrractors sad state whether or not those entities have
employees. If the sub-contmaors.have employees,they rats[provide their workers'comp.policy number.
I near are employer thatis pm4ding workers'contpensadon insurance for rny ampleyem Below is thepoEq,and job site
haformad0n. p /�
Insurance Company Name: TiU�tCN' /C�� .L�,f U 1410,7,lCl�r
Policy#or Self--ins.Lie.#:: Z �3�' l��C�/ l�/Z Expiration Date: /0 �
Job Site Address: �2 5�Cf !'�t� CityfStateiZip:
Attach a copy of the woi kers'compensation policy declaration page(showing th,e 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 andlor 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 iniurance coverage verifi atiim.
I do hereby certtift a [fir ns�andlpenaatties of p�edury that Me inform above pro ded a ve is true and correct.
F (LG�
Si tore:. % iti' wz` ' Date:
Phone#. �� r�6 o — 3 001 6 21
Official uw only. Do not write in this area,to be completed by cio or town ofcitaL
City or Town: Permitll.icense t#
Issuing Authority(circle one):
1..Board of Health 2.Budding Department 3.C tyllown Cleric d.Electrical Inspector S.Plumbing Inspector
6.other
Contact Person: Phone#.
6
:j
OF SHE 1p�
r r
• BAMMBLE, +
9� MASS.: ,�� Town of Barnstable y
iDrEn t,,�r a
Regulatory Services
Thomas F. Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main.Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, /�!L7t��` ����G2— -r✓1� ; as Owner of the subject property
hereby authorize ;Fi/�4 �� ��CJ2 � to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
'5/ /
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on.the
reverse side.
QAWPFiLES\FORMS\building permit forms\EXPRESS.doc
Revised 070110
oFTHE r Town of Barnstable
�Pv ti�
Regulatory Services
BARNSCABLE• ` Thomas F.Geiler, Director
MASS.
039. ` Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office:. 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-
family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws, rules and regulations.
The undersigned "homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and.requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official j
Note: Three-family dwellings containing 15,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section
109.1.1 -Licensing of construction Supervisors)-,provided that if the homeowner engages a person(s)for hire to do.such work,that such Homeowner shall act as
supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for
Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons.
In this case,our Board cannot proceed against the unlicensed_person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately
responsible.
To ensure that the homeowner is fully aware of his/her responsibilities;many communities require,as part of the permit application,that the homeowner
certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and
adopt such a form/certification for use in your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 070110
-------------
Office of Consumer Affairs&BusiiSess Regulation
rCME IMPROVEMENT CONTRACTOR
jistration: 1'1660g Typepiration 6/29/2014 Individual
BILLY CAUTHEN
BILLY CAUTHEN
86 BETH LANE
HYANNIS,MA 02601 Undersecretary
-4��
' N'lassachusetts - Depai-tment of!'uhlic SaretA
' Board of Buildin!- Re!-ulations and Standards
Construction Supervisor License
License: CS 9975
BILLY E CAUTHEN
86 BETH LN .
HYANNIS, MA 02601
k
J Expiration: 8/13/20-13
( nuuisiuncr Tr#: 1683
NOTICE
N NOTICE
TO a TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/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:
ZURICH-AMERICAN INSURANCE GROUP
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(GZZUB-4395P74-9-12) 1 0-01 -12 TO 10-01 -13
POLICY NUMBER EFFECTIVE DATES
DOWLING & ONEIL INS AGCY PO BOX 1990 '
o _
HYANNIS MA 02601
NAME OF INSURANCE AGENT ADDRESS PHONE##
m
o�
CAUTHEN, BILLY E 86 BETH LANE
HYANNIS
MA 02601
EMPLOYER ADDRESS
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
NAME OF HOSPITAL ADDRESS
008990 W20P1G02 TO BE POSTED BY EMPLOYER
i,
Town of Barnstable *Permit#•�
Expires 6monthsfrom issue date
i )AMSUBM : Regulatory Services Fee �17- �2
r ntnss. p
� Thomas
i6yq... �0 F.Geller,Director p
QED MP't
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601 �•P�ESS PERMIT
Dffice: 508-862-403 8 -
Fax: 508-790-6230 JUN 11 20OZ
EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY
Not Valid without RedX-Press Imprint TOWN OF BARNSTABLE
>/parcel Number c2-Z.,
)erty Address
Q6aA //0 gcv
� � s
Zesidential U Value of WorkLIZ
r
ier's Name&Address I I
o
zi Stadte� j6d
tractor's Name SNP Telephone Number �3
ae Improvement Contractor License#(if applicable) l'� 70 co
rn
strruuction Supervisor's License#(if applicable)
Vorio an's Compensation Insurance
Check one;
❑ I am a sole proprietor
❑ I am the Homeowner
[gl�ve Worker's Compensation Insurance
ranee Company Name (I;tl/L l` � .1 V�/l iV�
kman's Comp.Policy# �L` h 10
ut Request(check box) (�
❑ Re-roof(stripping old shingles) All construction debris will be taken to (C i f" j t� fey
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows. U-Value (maximum.44)
�ther(specify) —gyp w1/1 "&I/\ W VWAQ
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
ature
ms:expmtrg
6711
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Horne Improvement Contractor Registration
Registration: 126701
Type: Supplement Card
- Expiration: 07/08/2002
SNE PRODUCTS/FOUR SEASONS SUNRO
HAROLD PETERS
600 PLAIN ST
MARSHFIELD, MA 02050
F Update Address and return card. Ptark reason for change.
Address_ 1 1 Renewal -1 "i Emplovment I I Lost Card
Board of Building Regulations and Standards License or regislratlon valid for fndhfidul use only
a HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 126701 Board of Building Regulations and Standards
Expiration: 07/08/2002 One Ashburton Place Rm 1301
Type: Supplement Card Boston,llla.02108 ,
SNE PRODUCTS/FOUR SEASONS
FSARRYVETERS _ . .
600 PLAIN ST
MARSHFIELD,MA 02050 �� ��
' _' Administrator f Not valid without signature '
.. •�: ✓tea loOflNl[0 aL v/'[Q30Qf/lU.esr0 � •
' BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR iT
Number- CS 074638 (i
Birthdate: 08/10/1952 !'
Expires:08/102002 Tr.no: 74638 t
Restricted To: 00
HAROLD G PETERS JR
171 WALNUT ST
BRIDGEWATER, MA 02324 Administrator ,
00•35.000 d enclosed space
(MGL C.112 S.80L)
1A•Masonry only
F; 1G-t 3 2 Fanugr Moines
Failure to possess a anent eaft-n of the
Massachusetts State Suddmng Code' •
is cause for revocation of this license.
- 1
OIG SAFE CALL CENTER: (888)344-7233
` a. ,
__ The Commonwealth of Massachusetts
== - = Department of Industrial Accidents
RE• � _- _ _ Ol//ce of/nvest/gations . : -
600 Washington Street
Boston,Mass. 02111
'--� Workers' Compensation Insurance Affidavit
name' SNL Ya A:re l C
location• (n o o e(a1q �54pt 2 \
city AAAdrs k;,�etk / M 0105-0 phone# q3a 6
❑ I am a homeowner performing all work myself.
❑ I am a sole ro rietor and have no one workin in ca achy
%%%%�//% %/%%%%%/ /%%%////% %%/////I//%/%%//G%��%//%%��%/O/%%%%/%%%%/%�/�%%%�%%%�%%���%/�%/
��'r.am an employer roviding workers' compensation for my employees working on this job.:::: :::
� .providing ;:::..::::....:.....
coat sn <.nanie:><>::<:::: .'':<:': >;:»:::<:;
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❑ I.am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
compensa
tion olices:
the following workers comp p.............................:..::::. ::::::::::.:::::::::::. :.::::::::::::;:.:;.;:.;:.;:.;:.;:.;:;<.;::;:.;:;<;;;;;;.>:::;::.;:::;.;:.::<.:.;:.;;::.;::;>:;:.;;:.::::
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:C.14•i:::ti.i.Cv4:/.i.•::�•,i:x}i..i,v::l:3;.i}i:Y:;w`�::4in;;R}:i•:i:'.:-::::l:i.4i i:•:'
c an n
adelxes
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100
�1 :•w.•-rr
ixsurnaC .
Failure to secure coverage as requited under Section 25A of RdL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification
-----.-.---I do/erebycerti&under thepaim-and-penalties-ofperjury that-the-information-provided-above-is-tui-e_and-co1r-red
Sigaature -_-
� QQ Date j f 21 02-
.C�".�.� � � - --
Print name Lil Phone# �,, 93V r 130G
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
[ Licensing Board
❑checkif itnmediate response is required ❑Selectmen's Office
. . . ❑Health Department
contact person: phone#; ❑Other
(revised 9/95 PIA) "
II
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is.defined as every person in the service of another under any contract
of hire, express or implied, oral or written.
An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the.1legal representatives of a deceased employer, or the receiver or
trustee of an individual,partnership, association or other legal entity, employing employees. However the.owner.of a ...�.
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or-renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the'
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority. _
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law or if you
are required,to obtain a workers' compensation policy,please call'the Department at the number listed below:.
City or Towns
e bottom of tCie
complete and Tinted legibly.' The D Department has provided a ace at th
Please be sure that the affidavit is comp peP P space
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 pennitllicense number winch will be used as a reference number. Tlie�'afFidavits maybe returned to
the Department by mail of FAX unless other arrangements have been made
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. .
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
_Department of Industrial Accidents
Office of Investigadons
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4960 ezt. 406, 409 or 375
ti
ACORD CERTIFICATE OF LIABILITY INSURANCE °"TE`M""
04/24/20/2002
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
HUBBARD & PRESTON INSURANCE AGCY. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4 JUNIPER ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MEDWAY,MA 02053
508-533-0513 INSURERS AFFORDING COVERAGE
508-53 -0 '
INSURED RESOURCE MANAGEMENT, INC. INSURER A GRANITE STATE INS. CO.
INSURER B:
281 MAIN ST. SUITE 5 INSURER C:
FITCHBURG, MA. 01420 INSURERD:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EFFECTIVE POLICY EXPIRATION
ILTR TYPE OF INSURANCE POLICYNUMBER DATE MM/DD DATE MM/DD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY _ FIRE DAMAGE(Any one fire) $
CLAIMS MADE ❑OCCUR - _ MED EXP(Any one person) $
` PERSONAL 6 ADV INJURY $
-' GENERAL AGGREGATE- $
GE N'L AGGREGATE LIMB APPLIES PER: PRODUCTS-COMP/OP AGG $
POLICY PRO--JECT LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY - - "AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY: - AGG $ -
EXCESS LIABILITY EACH OCCURRENCE $
OCCUR ❑CLAIMS MADE "AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X CY LIMITS ER STATU-
JOTH-
EMPLOYERS LLABIU TORTY 2160486 03-02-02 03-02-03 E.L EACH ACCIDENT $100, 000
A - E.L.DISEASE-EA EMPLOYEE $5 0 0, 0 0 0
E.L.DISEASE-POLICYLIMITi $100, 000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS -
COVERS THE EMPLOYEES OF THE NAMED INSURED LEASED TO ALTERNATE
EMPLOYER:SNE PRODUCTS, INC.D/B/A SANDCASTLE SERVICES DBA SANDCASTLE
SUNROOMS DBA SANDCASTLE BUILDERS DBA SANDCASTLE HOMES DBA FOUR' SEASON SUNROOMS
SUNROOMS 600 PLAIN ST. MARSHFIELD,MA. ' 02050
CERTIFICATE HOLDER AoomoNAL INSURED;INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
SNE PRODUCTS, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
600 PLAIN- ST. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
MARSHFI ELD, MA.02 05 0 - IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON,THE INSURER,ITS AGENTS OR
EPRESENTATNES.
U ORIZED REPRESENT THE
c:• 1
ACORD 26S(7/97) E)ACORD PORAT N 1988 .
yr PabDucER r-xL-jIL-I 1 T IIVJUMH1VU L PID JA oA.,... ..-_-
I SAND C-2 0 9 i 2 C
TH=CONFERS
ISSUED AS A MATTER OF INFORM;.T;C
MFST Insurance O NO RIGHTS UPON THE CERTIFICATE175 Derby St. Ur}it 40 HFICATE DOES NOT AMEND.EXTEND C•R
Hin ham ALE AFFORDED BY THE POLICIES _J;
9 MA• 02043
Richard Eagan, Jr.
COMPANIES AFFORDING COVERAGE
'` COMPANY —
Phone No 781-740-6300_. Fa.No - I C A CNA• Insurance Co.
INSURED -
COMPANY —-- -
B Travelers Insurance Company
Sandcastle Northeast LLC COMPANY ---
600 Plain Street C
Marshfield, MA 02050 COMPANY -- -
COVERAGES
D
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING:.NY REC;;IRE:!ENT .TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUI.IENT JITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUE OR MAr PEP.TAW -HE INSURANCE AFFORDED BY THEp EXCLUSIONS AND CONOITICN r. L;ryE POLICIES DESCRIBED HEREIN IS SUBJECT TQ ALL THE 7ERA15
-_S OF SUC_ S .EMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS
LTR TYPE OF INSURANCE POLICY NU61SER _ _ POLICY EFFECTIVE POLICY EXPIRATION — -
DATE.MM/OC/Yn DATE !.IM/DD.YY, LIMITS
GENERAL LIABILITY
A X COMr.IERCIAL GENER..:L_:ABILI-Y 20.52 GENERAL AGGRE•:, TE S
018716 CLAIMS MADE 08/01/01 08/01/02 PRODUCTS
_ ° S2 . 00:
OWNERS d CONTRAS-;R S PRO- . - _ PERSONAL 3 AOV INJURY S S 1 O O
EACH OCCURRENCE S $! O
FIRE DAMAGE Anv one r re•
AUTOMOBILE_IABILITr .. MEC•EXP Anv cne ce•s-- S It 1 rw C C
B _ A I-810-o24D97.75-IND-01 COMBINECSINGLEL:l,IIT
OB/O1/O1' 08/OI/02 _ � $l . JCI
AllLL CWNE CwNEO AUTOS
X SCHEDULED AUTOS BODILY INJURY--- -- -_
X .IREO AUTOS
i.Per cerson: S
X VON-OWNED AUTOS BODIIY'NJURY- r --•
(Per acc:oenn - -S
'AGE:�ABrLITr
PROPERTYCAMAGE S
GA .
-- ANY AUTO AUTO ONLY EA ACC:OENT S
.OTHER THAN AUTO ONLY
EACH ACCZENT S
ABILITY AGGREGATE S
A X ENCE
_!aBRE:_:.FORM ^�=BC�a`�, EACH ..S S2,00C, ;C-
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zero t_Or15APE_ �Usa
ul to the insures
•
I
CANCELLATION
----- j• SHOULD ANY OF THE ABOVE CESCRIOEO POLICIES BE CANCELLED BEFORE HEEXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MAIL !
Sandcastle tle VO -heas• LLC _. DAYS ti:RITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED iC THEc--
600 Plata Street LT- ;
BUT,FAILURF. 0MAIL-SUCH NOTICESHALL-IMPOSE NO OBLIGATION OR LIABILITY - I�
Marshfield �*.A 02 S L� OF.:NY rINO uohN THEC ,t
_ChfpaNv n5 AGENTS OR REPoESENT_Tn ES j
`uTH0 F;'ZED..EPRESLNr.:TIVE
S'11'a5! 4 a
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w
CONMOMER "FORM INFORMATION —. S10, ROO' MS79
Massachusetts State Building Code (780 CMR, Appendix J, Section J1.1.2.3.1)
The Massachusetts State Building Code (780 CMR) includes provisions to ensure that houses and house
additions meet energy efficiency standards. This supplemental CONSUMER INFORMATION FORM is to
be filed as part of the building permit application when a builder/contractor or homeowner,
constructing/installing a house addition with very large percentage of glass to opaque wall, seeks to utiiize a
special energy conservation exemption option for "sunroom" additions to an existing house (780 CMR,
Appendix 1, Section J1.1.2.3.1). This FORM is not intended to. prevent a homeowner from selecting a
"sunroom" of any size, configuration, orientation, form of construction or percent glazing, but rather is only
intended to assist homeowners in becoming aware of some of the important energy conservation and year-
round comfort considerations involved in selecting and utilizing a "sunroom"addition.
The connection of "sunroom" structures to residential buildings may create comfort and energy
consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the main house. In
the selection and construction/installation of"sunrooms", included below is a non-required, open-ended list
of product and design considerations that a homeowner may wish- to consider before actually
constructing/installing a "sunroom". It is recommended that consumers carefully review these options with
their designer, builder, or contractor, in .order to minimize potential energy consumption and/or house
discomfort issues. In addition, the qualifications and reputation of the company or individuals to be hired
are important considerations.
PRODUCT AND DESIGN CONSIDERATIONS RELATED TO "SUNROOMS"
• Solar Orientation and Natural Shading
• Type of Glazing
• Insulating value
• Solar beat gain
• Frame materials
• Glazing to frame sealing and gnsketing materials/seal durability and/or
weather tightness of the sunroom
• Adequate ventilation -Operable windows and fans
• Applied Shading Systems
Insulation ievel in floors,walls,and ceilings
• Possible Sunroom isolation from the main house via a wall and/or door or slider
• Heating and Cooling Methods:'Efficiency,Zoning and Controls
Homeowner Acknowledgment
The Massachusetts State Building Code,'Section 11.1.2.3.1, requires that the actual property owner (not the
owner's agent or representative) acknowledge receipt of this CONSUMER INFORMATION FORM prior to
issuance of a Building Permit fora project that includes "sunroom" additions to an existing residential
building. in accordance with this requirement, the undersigned hereby.acknowledges that she/he has read
the information in this document concerning sunroom comfort and energy conservation.
Signature of Actual BuildLI Owner Date
/V d4w Se,or 1\J t�:A Z c S f ud.f,e
Print Name Address of Permitted Project
2l 5146 aA (�08� 0 —'0(oZ ('
Owner Address (if di ferent than project location) Owner's telephone number
Assessor's map and lot number ......... LJ.... ...
SEPTIC SYSTEM MUST BE
INSTALLED IN COMPLIANCE
Sewage Permit number ....... J`z. �....••••.••.......•••••• WITH ARTICLE II STATE
SANITARY CODE AND TOWN
e�QyofTMETort� TOWN OF BA.R.N YTASBLE
IMNSTAIME, i
=opo,M6 9 RUBL® SC INSPECTOR
APPLICATION FOR PERMIT TO ........ .e...........W��. ...... ......................
TYPEOF CONSTRUCTION ......... ........A:��.e............................................................................
.........................lf .7..........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ` 60-1 l.................................. .....................................................:......................................... ...................................
ProposedUse ....... X................................................................................................................................................
Zoning District Fire District
............................................... ............ ................ ........................................
Nameof Owner ..<.....!.:....r:......11...e•Q`C..r!...........................Address ..................................................................../...............
7` Gr,2it� ��c Address ...... "°5.......��..1lJ ,��,����1..
Name of Builder ... ...�t-�.�.......� .�........r�.�....:....
Nameof Architect ..................................................................Address .............................�......................................................
Numberof Rooms ..................................................................Foundation ....... �..... .............................................
Exterior ............ ................................................Roofing .......... ......... C..................................
Floors C'? e:n Tf-.....................................Interior
Fieatin / e ..........................Plumbing .............../�U.. ,.................................................
g .......
Fireplace yy// .............Approximate Cost O' G
Definitive Plan Approved by Planning Board ________________________________19________. Area ......... ...... ................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
F
�6
/6f
I hereby agree to conform to all the Rules and Regulations of thyTownof nstaVe ing the above
construction. '95
Name .. . ...................
Berglund, M. E. '
No .167Q1.... Permit for ....enclose„Por
.................................................................... ..........
Studley Road
........................ yannis........................................
Owner .......... •E.. Berglund
Type 'of Construction frame................
..........................
................................................................................ i
{
Plot ............................ Lot ................................ t
Permit Granted ........gpvgau..7..........19 73
Date of Inspection ..®?1� 17
Date Completed 19
v '
PERMIT REFUSED i
................................................................ 19
............................................................................... r.
................................................... j,
4
............................................................................... f1�
i
Approved ................................................ 19 !
�f
i'
ROOF EXTENSION ccO
20
as 0
I
4'x36' 5'x36' S--'36 51x36' 4'x36'
I ADJUST IN THE FIELD c
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i
NEW GLASS LAYOUT - ; �EXI a
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J STING ROOF J
EXISTING WALLS BELOWCD
ca
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8SLT505 RAFTER
j 5x41-1/4 5A41-1/4
4'x41-1/4 ' ' " ' 5'x41-1/4' 4'x41-1/4'
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4'x4
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w ,
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UNIT DIMENSION Y V
26-3 1/82
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EXISTING ROOM DIMENSION
25'-9 1/8' C�
ROOF LAYOUT
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ROOF E CTENSION c
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(BY OTHERS) c
EXISTING STRUCTURE BEAUTY CAPSILIC Y
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(BY OTHERS) (BY SIDING GLAZING CAP � �
(BY OTHERS)
COUNTER FLASHING GLA7JNG CORD
RIDGE (BY OTHERS)
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UNIT °
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RIDGE BEAM WlTHERMAL BUSHING W if
CLIP ® LE GER c
HEIGHT ° � S
PINE BEAM Y x 51R', 910 x 1112'WOOD SCREW
T,81rYOR10' m Z d
RUBBER FLASHING
RIDGE BEAM SIX T14 x 11/4'SCREWS PINE BEAM 3x 511Y, m &
CUP TRIM PER BRACKET P,8117 OR 10'DEEP
(SUPPLIED) 41
MIN 2x8 LEDGER ADEQUATE FASTENERS
(BY OTHERS) APPROX.Z-V O.C.INTO
EXISTING STRUCTURE C)
--- UNIT&FOUNDATION WIDTH (BY OTHERS)
CD
SHIM AS NECESSARY W
(BY OTHERS)
C
O.C. 4'BAY=4'-3 314' Q
11/4 O.C. 5'BAY=5'-41/4' V
t' FOUNDATION&UNIT LENGTH Q
a
5
g
EAVE MUNTIN GLAZING CAP
OUTER EAVE WOOD BLOCKING IN CENTER i CD
OF EACH BAY 20
INNER EAVE (BY OTHERS) a '
v
TRIPLE 2 x 4
(BY OTHERS) ,
GLAZING CAP
PINE BEAM 3 x 511Y, MUNITIN CAP
T,810 OR 10 DEEP BLOCKG
Lu
THERMAL BREAK
GUTTER • + 7ff GL11S8 y
INNER CAP LL,
STANDARD CROSS MUNTIN o
WINDOW R. .
O CASEMENT WINDOW
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FROM &4r OR V-V
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FOUNDATION ROOF PURLIN W
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112'SHEATHING
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(BY OTHERS)
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UNIT WIDTH
SYSTEM 8 EAVE DETAIL SYSTEM 8 CROSS MUNTIN DETAIL V
Z
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