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0021 THIRD AVENUE (HYANNIS)
�i �� �E . -2 Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 4/21/17 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit B-17-337 01 y VO Dear Mr. Perry v This affidavit is to certify that all work completed for 21 Third Avenue,West Hyannisport has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey I BIKE Town of Barnstable *Permit# j�- F�Tres 6 months from issue date Regulatory Services Fee BARNSTATIM lift r MASS. Richard V.Scali,Director 1639• ,0� PRET14 �� 5 ° Building Division. ({�Paul Roma,Building Commissioner MAR 10z®1T 200 Main Street,Hyannis,�A� www.town.barnstable. a.us r VS Office: 508-862-4038 r1408-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �J ,I O Not Valid without Red X.--Press Imprint - Map/parcel Number 1 C Property Address �/, a!&y, � � z < U Residential Value of Work$t63 a Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address R66-4 i -A,,rd v,ot . 1 ; 14 y w,,,�,.s �nrd /,))A 6,26 7 Contractor's Name J �.iYtM &rl e r—dA Telephone Number Home Improvement Contractor License#(if applicable) J 7� Email: / q�. y%1,��, . C 0'0""7 Construction Supervisor's License#(if applicable) C .S _J 0 770 y ❑Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner' a' I have Worker's Compensation Insurance 4 Insurance Company Name Lci'lartrt in Workman's Comp.Policy# l' Copy of Insurance Compliance Certificate must accompany each permit. . Permit Request(check box) x - ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping._Going over existing layers of roof), ® Re-side 0. Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows 4� #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License.&Construction Supervisors License is required. SIGNATURE: QAWPFILESTORNIMbuilding permit forms\EXPRESS.doc 0 U" 01/25/17 17m Commomvealth of Mafsrrdiuse& Department cf rmiusbial Accidews OfTwe of frrne� ga#irrns. 600 WashulgWn Street --- fv�vt�mcus:�r�v�riin Workers' Cun3pensatian.Iusurance Affidavit Bmldexs/Cantracturs/FlectriciansfPlarabers APPHcant Infarmafign. Please FFmt F Iv Name arfyG�- At3drt:sS city-/:5ta-& b,,� % Placne . Are you an employer?:Cbeckthe appropriate bon Type of project.(regaiz-ed: I.9 I Mn a employer Wift 4 ❑I am a general eonhmctar and I G.'❑New coast mctibn employees(full aM&Or part-lime).* have hitedthe suit-conbmdors 2.❑ I am a sole propzietar arpartuer- listed on the attached sleet: 7. ❑Remodeling ship and have no employees These sub-contractors have 8..❑Demoaoa waling forme in any capacity- employees andhave wod=- 9_.❑Building addition LNp�g'comp.itacnranre comp-i murance I required 1 I ❑ We are a-oorporativa and its 1I❑Elec acal repans'or additions 3.❑ I mn a homeowner doing aft work officers have exorcised their 1L❑Plumbing repair or additions nqzelf[No worms'Camp-' right of exemption per MCI. 12-❑Roofrgmim incarranceiQ�yd,]1 C-152,§l(4) andwehaveno employees.[No work=' 131:1 Other rasp_ia=wxz requireel] #b apag dedsb=flmsLisafiIIa�tfiescioabekwshm &eawo&erec�pe 1aHepiM5amua� ffa. a submit dui zMdar*imrkrlmg they mn doing aH vrvA sad&&hire Gutidec=txcksamst submit a new aTulaidt mdirsdiao sadl- It'autracflos$zitchartt}us boxntiust addiii®alsheddwwiagthemeofthe and state whetherarnat lime eatitiesbwe Mployees.IftbesvlrtaatactJ=hZVerMlpIogez%thegmastpmvddethea srarlrE&C=Tp.palicgatMrez: I am an glripiir t7iatir prmridircg narrri¢rs'catrtFertsrrftort utsrirarrcevr }�¢mplaj�¢es Betvty is fit¢prr�ic}•artrI job sag tnformcrtrart / - . Insumnce,Company Name L�1+1tA✓7� �lrl s Pooficy 4 or Self-ins_Ile-Ilk6Z l �� F�piratibnDate: /0 % / Job Site I A,ddre= " aof j, o .(ZCitY'ISkatet P: � G"vr0? ,fl7/fi dG�,� A,iEtach a-mpy of the workere campensationpolicy declaration gage(showing the policy number and eipirati date). Failure to secure coverage as regmred under Se-cEion 25A of M-CI.m 157 can lead to the imposition of criminal penalties of a fine up 10$L50D.OU im dror one yearimpFisa as well as riiil penalties im the faun of a STOP WORK ORDER and afore, of upto$250.00 a day 26-ainst the violalmr- Be adidsed'tiat a copy of this statement maybe fmwarded to the Of of Imrestigations ofthe DIA for iasuraace coverage vedfitaion- .I do hey-*cedo,wtdcr&e pains andpaial�Frs ofhediuy Aatthir info rmatidaprom-a W abmv fs tra.a acid carrect Sit3tature: Date: l Piaae A_ Qjo%al use only, Da not write in flais area,to be cainp&ed by city artopra a;oicat City or Town: Pern;tUcense;g Lnuing A:nflority(circle one): L Bomd of lIcAth It $mT�Degartmeat 3.Cliytro n.Clerk 4.Beclriad hmpector 5.FhEmbmg Iu pecter 5.Other Contact Person Phone 9: ormation and last ructions ., hL-m l;rsse#fs Geberal Laws ehaptEr IU regrx=an=Ploy=to provide woEas'oompeasation far f f employees- e�'is defined as`�.everype�sdnm the sedvice of another mdcr may comtract afhaey Pm.�to Phis sfaia�,���y egp=ss or implied oral or writ" An.=Vk yer is defined as-aa i.adividztat,pMta=sbrp,amocisf%on;corporation or other Iegal entity,or nay two or mode ofthe foregoing=agaged>a a joint eoirapi:ise,aadinclndmgthe legal ofa deceased employer,or faze rere ivt r or trustee of an individual,pmt3 P.associaftan or otherlegal entity,CployMg CMPloyeCS- However the owner of a.dwelling house bavmgnot mare than firee apartments and who resides therein,or the occagant of the- dwrMag house of another who emplays pesons to do mHhfE=ce,caustar''on orrepai=wo&an such dwelling house or on the grounds or bm7dmg app=ft=antfheretn shallnotbcoa=r,of such employmea the dretnedto be an employer." MM chaps 152,§25C(6)also states that`every state or local licensnag agency shall wifiiTiold the issuance ar renewal of a license or permit to operate a buskess or to construct bufldbags in the commonwealth for any applicant:who loos not produced acceptable evidences of compliance with the hmm:rzare coverage reqused. Additionally;MG` ,chapter 152,§25C()states-Neither the nor fiy ofits political snbdrvisions shall ; enter into any contort far-die perfm==W ofpnbliC WMk u�tl acceptable evideace of compE a.cewith the imm-dace. ter haul=been et�d to the cm3tactma ardhouty." r-eTemets of dais chap pry - Please fill out the workers' compenssation affidavit completely,by g it e bakes that apply to your situation ancb if necessary,supply s)mmne(s), adffi=(es)andphctnennmber(s).alongwdhtheir=tdacate(s)of msmr-mce- Limited Liability Companies(LLQ or Limited.Liability-Par ozmbips(LIP)witb.no employees oilier than the members or pmtams,=not regtmed to cony worice& compensation iasm-an=- If au L LC or LLP does have employees,a.policy is requi md.. Be advised that this affidayitmaybe snbm;ti-_i to the Deparhnent of lndusfaial Accidents fbr confrnnahon of fi sarm=coverage Also be sure to sign and date-he aidavit. The affidavit should be retumed to the city or town that the application for the permit or Iiceuse is being requestxL not the D ep artmeat of L fxi$1 A�;cidea Shouldyon have any gnestans rega�mg the law or ifyou are req� to obtain a worl=s' compensation policy,please call tho Deparbn eof at the mmmber Bsted bclOW Self-insured companies sb ould en r their self-;n�,ra„ce liceasenr�.ber anthe appropziaft:Iiae. City or Town Officials Please be sal a that the afdavit is complete andprlyd legibly The Department:bas pro-vided a space at the botfmn of the affidavit for you to fill out m the event the Office of lnvestigatius has to cordactyomregarding the applicant_ Please be mere to ffr71 in the per�L l cense mxmber which will be used as a refev.=ce number_ lu ad diiion,En��''aiipp,,rlric ant that must submit multiple penniillicense applications in anp given year,aced only submit one affidavit mdik.++,�eament policy mfonnation�if he y)and under'JOb Situ AdL�- &*the applic�should v;rite"art Iacati-,W in (city or- town)_"A copy of the-atTldavit that has been.officially stamped cr mmia d by the y or town may be Provided in the " applicant as proo-ftbat a valid affidavit is oa fie for future permits or licenses A new affidavit must be filed.out each yaatre year.Where a home owner or citiT�is obtaining a.license or pewit not relatedp any bn r;T,�s or couunercial (ie_a dog license or peon¢to burn leaves said person is NOT'required to complete Ibis affidavit: The Office oflnyesligaframs wouUl-amto iiankyoum ance adv for your coopeaationand shorrldyomhave anygaestions, please do not hesitate to give us a call- The Depsrt nmfs ad&mss,telephtme and fix rmmbe. CGnmm�n �of Massach - DEepar mt of li� 1 Accident t - fD4Washivan MA CdIII , T(�_L #617' --4 QA 4-06 car I-977-hgASgl� Fast 617 727'749 Revised4-24-07 a � Town of Barnstable ` Regulatory Services SARNMALL NAM Richard V.Scali,Director ►�' Building Division Paul Roma,Building Commissioner • 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maus Office: 508-862-40.38 Fax: 508-790-6230 Property Owner Must ,Y Complete and Sign This Sectio n If Using A Builder as Owner of the subject property hereby authorize&WA) &a,, 4 A &)17 ' t%i�, to act on my behalf, C (G in all matters relative to work authorized by this building pet uit application for. 14 VC/ (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. - tore of Owner Signature of Applicant + Print Name, Print Name Date r d H Scanned by CamScanner p� a�nmmoracueczl ��i�uraea exe Office of Consumer Affairs S Business Regulac /tion HOME IMPROVEMENT CONTRACTOR TYPe: Individual 7 a istration Exoication --- 36 08/02/2ol8 Jeremy Anderson '~ Jeremy Anders' Y� , 80 cranberry ndg�r Marstons Mills M, �._02r6•�8 — Undersecretary 36 - r Massachusetts .Department of Public,Szfety Board of Building.Regulations and Standards Constructiori-Supcn-isor License: CS-107704 JEREMY ANDEk5bN° 80 CRANBERRY_RIb Marstons MiLs'I R 026 k,,' Expiration (ice :: _ 10/13/2017 be forse°r r e e Office the ex 87strati° -....__- U i'dr�O�C0hs1,ration�a�elic/f, - °st°n 41'4 ;2,U to S airs'ato 1 ncl r ta�ai use 16 0 eusrne SrRe9ulatniy /°n ti .f • of�a��d •i e �� �ftho4t S�9nafy f Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m3)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS r P 1 1 AC�®�. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)03/10/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Larissa Camba LEONARD INSURANCE AGENCY P"�"E �5os)a28-ss21 FAX A/C No): ADDRESS: Larissa@leonardagency.com 683 MAIN STREET SUITE B INSURERS AFFORDING COVERAGE NAIC# OSTERVILLE MA 02655 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: ANDERSON JEREMY DBA ANDERSON BUILDING MAINTENANCE INSURERC: INSURER D:' 80 CRANBERRY RIDGE RD INSURERE: MARSTONS MILLS MA 02648 INSURERF: COVERAGES CERTIFICATE NUMBER: 133598 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, . EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDY� MM/DD/YYYY LIMITS POLICY EXP LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGERENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PRO- JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A. BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-0WNED Pereccdent $ HIREDAUTOS AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ ' EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION °' X1 SPER TATUTE ERH AND EMPLOYERS'LIABILITY - - ANYPROPRIETOR/PARTNER/EXECUTIVE YIN _ - E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED7 NIA N/A N/A 7PJUBOG35777416 10/13/2016 10/13/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under _. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensationAnvestigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ` THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 367 Main street ' AUTHORIZED REPRESENTATIVE Hyannis MA 02601 L Daniel M.Cr 4y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILftYPERMIT APPLICATION I J . IV D�p77 Map `j Parcel k 0- T� ��Q;? Application # J Health Division ��dFeq ®� Date Issued 2/Zy//7 Conservation Division �A/8%t� Application �— Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation/ Hyannis Project Street Address Village Owner 1A,e v�- y qn Address kl NAA(e,Ws Ir. Telephone s Q I T 5 35 II Permit Request R�� `��13 and �'�� c���ul`OSP� aVl� `�° �`r�efq�W +n q&jGr �cnSc Dan L 4e- uIA 1,1 lA �° I� �� j II Cry ,O I L £SAD S r�� Ce, 1�LOSP,� '�Pd [� I 'T14)Cf5 G Ae- 4fP61ed CA t o,.7W r DIA,OT, dj �aum+ W4 upok% +0 km 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 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 A No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION I, (' (BUILDER OR HOMEOWNER) Name it ti m tC���e �7 Telephone Number d R g 03 M Address �A6 rao License# da 6 Home Improvement Contractor it 380 Email Worker's Compensation # q 0`�00 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE a t FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. .. i tt� t•,.r.{i a''�S'} 7 %r — ¢ li�' +•'�y "'p,'^'j L. ,l a'��p�$ +L..:� __ _ � - +.• -a ^_ }: rCorii»ionwealtli of Massachusetts �; Z,+ a s. ,z> 1 a Departitent of Industrial Accidents. ,{i t ! 1 M' ! 1. 11 J +' I `� 71. .. qr; t-r" tri lIL7. r i a 1 Congress'StreepSuite'1:00 .°..:i, j+ ;r r =s Boston,§MA-02114-2017� �s .�t .si� - a r,.;-:c".> •S �.,,,�,, ,. •. ,,ge ,2.i' *ai;ti�'rr !' r� 5�n- "e,1-,ire 3 r t..i3 r a. '1 .. www Mass gov/dla i +v s a ► ►ra , s^r' r a�, a V Workers'Compensation Insurance Af idivit Builders/Coniractor Iectiicians/Plumbers:.--'— PTO BE FILED WITH THE PERMITTING AUTHORITY. Aunlicant Information' . .-:- Please Print Legibly Name(Business/Organiiation/Individual):Cape Save Inc } • , Address:7-D Huntington.Avenue ',T a;, i - South Yarmouth, MA 02664 >, , 508-398-0398 City/State/Zip: Phone.#: Are you an employer?Check:the.approprlate box: Type of proJect(reyuired)� _ 1.�✓ 1 am a employer*:m*`i mployees(full.and/orpart-rime)* ' `k»' L r�: a i a 14 15 =e '7_ ❑'New construction _ .. 2. I am a sole: rietor or artnershi and have no employees working for mein, { ❑ ProP partnership p y , g t x t& ❑Remodeling'. any capacity:[No workers'comp insurance required.], 9. ❑Demolition- •a e a 3.❑:I am a homeowner.doin all work m self. required]t . ` - g y [No workers comp.,insurance i ' _ C . ' - _ .'I O❑Building addition g p. &.v y Property- I will ❑ K _ try 4.❑ensure thaall ontra to ileithel 6i hr have workers'comlIensationl nsuranee.or are sole 11. Electrical repairs 1 irs or additions I proprietors with no employees. 12.❑Plumbing repairs or additions t 5.❑I am a general contractor and l:have hired the sub-contractors listed on the attached sheet. T3. Roof repairs t ' These sub-contractors have employees and have workers'comp-iattrance:% — t 6.❑We area coiporation:and:its officers have exercised theirright of exemption per MGL e; 14.❑✓ Other Insulation. i 152,§1(4),and we have no employees.[No workers'comp.insurance re9uireci j { s' •� *Any applicant that checks box 91 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 mustsubmit a new affidavit.indicating:such. I ♦Contractors that check this box must attached:an additional sheet showing the name of the sub-contractors and state whether ornot those entities have '• " i employees. If the sub-contractors have employees,they must''omidetheir workers'comp.policy number. - i I am an employer that;is providing workers'compensation insurance for my employees. Below is thepoltcy and job.site lnformahon. _- _ _ --—- Insurance Company Name- Star Insurance Co. = Policy#or Self-ms Lic# WC085540700 h •r &piration Date: .4/9/2017". I •n?:wy 1ob Site Address: 2l Third Avenue WC4/State/Zip:West Hyannis Port t r.,Attach a copy_of the workers compensation policy declaration Page(Showing the Policy.number•and expiration date Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation:punishable by a fine up to$1,500.00 i 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 -- w�day against the violator:A copy of this statement may forwarded;to the Office of Investigations of the DIA.for insurance-,-..- — r coverage verification. _ a I do hereby certify.under th pains and penalties of perjuiy'that the information provded.above:is true and correct Si ature: Date: 7/17 1 1 Phone#:508-398-0398 Official use:only.`Do not wnte in this area,to be completed by city or town ofj�ieiaL { :,u City ity'or ,. 1,2,�Yt �. . ..�^ .¢• ,� *s� �.Permi .. :�.Town f. tlLicense# Issuing Authority(circle'one}."`, I.., • �"°"� 'l � � �' i ,- 1.Board of'Health.2..Building.Department 3.City/fown Clerk 4.Electrical,Inspector 5.,Plumbing.Inspectoi `. 6.Other +,fi ,err l _y, 3! ntact Person. ___Phone*: _ +;:?t3�-. k� �'a,,, F-�. ['.r ,, n+ 1,; :.xrr.tiCt"�'=:_xn r .. i,-*1•i¢.:`-t�� :3- ;s'`•� ' 7ATE(MMIDDIYYYY) Act CERTIFICATE OF LIABILITY INSURANCE `. 0/24/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTA71VE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les)must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT COME: Colleen Crowley Risk Strategies Company HO No E : (781)986-4400 FAC No:(781)963-4420 15 Pacella Park Drive ADE-M�SS:ccrowley@risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAIL* ;Randolph MA 02368 INSURER A:Liberty Mutual Insurance Co INSURED INSURERS Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc INSURERC:Ohio Casualty/Peerless Insurance 24074 7 D Huntington Ave INSURERD:Star Insurance Co INSURER E: " South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL16101422377 REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/� MM1DD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED— A CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 100,000 r BL91757246490 10/16/2016 10/16/2017 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE�7 LOC PRODUCTS-COMPlOPAGG $ 2,000,000 OTHER: $ COMBINED SIN7CETrV= AUTOMOBILE LIABILITY Ea accident $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 1xx SCHEDULED AB9A46796600 11/6/2016 11/6/2017 BODILY INJURY(Peraocident) $ AUTOS AUTOS X HIRED AUTOSNON-OWNED PROPERTY AMAG $ AUTOS Per accident X. UMBRELLA LIMB X OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LIAB CLAIMS-MADE ;' AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 US057246490 10/16/2016 10/16/2017 $ WORKERS COMPENSATION, Officers included for c ( '�,l X PR STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE 'Y/N Coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N/A D (Mandatory In NH) , I WCOSS6407 4/9/2016 4/9/2017•, E.L'DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Evidence of Insurance / Insulation Specialists � I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Barnstable County ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact 460 Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02061 _ Michael Christian/CLC O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) O e Tom 1'pr�y,�enl�ng.Gomimission®i� 204 Main St6et T yannis-MA 02691. w ;totivnb�rast�Ie.rria.a$':. Office: SD8=862-4038 FaX 501- 0-6230 lob ;r-f s. as C}amex�f st1. .sue ect ro art Ze �yamfioiize:. 1 in a matters m.atevc to;work authorized by this 68dtn genmt apl tin.fo 21 frc(.�I�R Fool kiic and a1 s +espons ,o the; pp c �.1?oc l :ire jx6vto be.f ed aF u d b fare fi Is A ff :aispe� roz�sxe;perfanned- nd.accepted. X - $ tiise of Owner Safe of�pp}cari T hlivim 2a'ut Na � t zv Dde. QiEoru�so��me��nsslnr�oa> Of mAffirndBC aausiness Regulat><on: - l 0 Park Plaza- Sulte 5170 Boston, Massachusetts,.Q.2 b Home imp rovement.Contr actor'Regist radon Registrafion. .171380: . Type Corporation t'� Expiration:" 3l14l2018 Tr# 419291 , CAPE SAVE INC: Yf WILLIAM McCLUSKEY M 7-D HUNTIN&ON AVENUE SOUTH,YARMOUTH,' MA OZ664 ('Update Address a6d return ON.Mark reason for change. . Address. n:Renewal �.Employment Lost Card, SCA 1 83 20M-05l11. - V' JL6 Q�7L37[677.[I!C[GlllL o jaC/1,(6e n ofr.ce of'Consnmer Affairs&Business Regulation License or registration valid for�ndividul use only HOME IMPROVEMENT CONTRACTOR before the expiration date.`If found'return to: — Re istratton Type: Office of Consumer Affaimand Business-.Regulation 9 171380 Expiration 3/14/2018 Corporation 10 Park Plaza-Suite 5170 {I Y Boston,MA 01116 CAPE SAVE INC. 5t WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENt1EW _ SOUTH YARMOUTH,MA-02864 Undersecretary Not valid: i signature . Massachusetts 'Department of Public Safety Construction Supervisor Specialty Restricted to: Hoard of Building Regulations and5tandards CSSLAC-Insulation Contractor 1.,1/111t1 U1.1i111{'.Jl1ItC/.V 111)1'JIICt,141LV xe4 P.�i"�p'.aYe as;i' -License, CSSL 102776 FIS r . WILLIAM JMC 00 37 NAUSET ROAD �9Qf West Yarmouth MA J7 `� ��,�Y{ Failure to possess a current edition of the Massachusetts ,J,,(,,;,,�J .; Expiration State Building Code is cause for revocation of this license. Commissioner 0612812017DIPS Licensing information visit:INWW.MASS.GOV/DPS ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map � Parcel 104 Application #&&I q O 3 3 y Health Division Date Issued S—ZI`H Conservation Division � ' Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address =2/ Z�/eJ Village lAw y `s Owner & . e,ef fL/,*TaA Address Telephone Permit Request kC_dV1 L'J 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 Kin s Highw4: ❑ s 0 No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other , Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existingpw Nurribi,?r of Bedrooms: existing _new T: doom Count (not including baths): existing new First Floor Room CouhtJ t Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other a 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) Name ` �l u�E � Telephone Number576,V' '7_5' Address �d 21/ License # 4��72 Home Improvement Contractor# Email Worker's Compensation # 44 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 5 A/ SIGNATURE DATE S J�� FOR OFFICIAL USE ONLY L a APPLICATION# DATE ISSUED t MAP/PARCEL NO. h ADDRESS VILLAGE OWNER - ,r DATE OF INSPECTION: FOUNDATION r FRAME y INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ` DATE CLOSED OUT ASSOCIATION PLAN NO. i The Commonweah*of Massachusetts Department of Indust'd Accidents Office of Investigations 600 Washington Street Bostor�,MA 02111 www.mass gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information / Please Print Leaffily Name(Business/Organization/lndMdual): —J" �' �d`• e {�ie`� Address: �G Key 4) - niv C,i City/State/Zip: hone '�_` f 1�711>3 Are you an employer?Check"the appr. priate box: 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. ❑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 S. ❑Demolition working for me in any capacity. _ employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp,insurance J 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 l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any:applicant that checks box#1 must also fiLl out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and.stzL,whether or not.those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: .. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address City/State/Zip: - Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK-ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby ceyW#under the p and penalties of perjury that the information provided above is true and correct; S" Date: Phone#: 2 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 S.Plumbing Inspector 6.Other Contact Person: Phone M. Information and Instructions r Massachusetts General Laws chapter 152 requires all'employers to provide workers'compensation for their employees. Pursuant to tliis statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in'a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter-152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance-or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insuriance 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 Iiae. City or Town Officials Please be sure that-the affidavit is complete and printed legibly. The Departrnent 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 submif 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 bum 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 Departarent's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of laivestigations 600 washingtoa st=t. Boston,MA 021.11 Tel,#to 17-727-494Q ext 406 or 1-877-NM AFB Fax#617-727-7749. Revised 4-24-07 www mass.gGv/dia Town of Barnstable 0 Regulatory Services * un9s $ Richard V.Scali,Interim Director '�o�u.�• Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete.and Sign This Section If Using A Builder ale /l . FL11U TOM as Qwnet of the subject to heteby authorize �G�� Gu �t�CL"yV to action ray behalf in all=ttets relative to work authorized by this building permit Ab - (Address of Job) y. Pool fences and alarms are the responsibility of the applicant: Pools are not to be filled or.utilized before fence is installed and all final inspections are performed and accepted. Signatute of Ownet tote of Applicant ERTA Fc wra Ptmt Name Print Name Date Town of Barnstable - Regulatory Services - o�tt rti Richard V.Scali,Interim Director Building.Division : i RARTiCi'ART.F * Tom Perry,Building Commissioner s� 163g, ��� ' 200 Main Street, Hyannis,MA 02601 D �A www.town.bamstablema.us Office: 508-862-4038 Fax: 508-790-6250 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB IOCATIOM' number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zap 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,Drovided that the owner acts as supervisor. MIMION OFHOMEOWNER 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 Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a persons)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,.particnlarly when the homeowner hires.unlicensed persons. In this case;our Board cannot proceed against the unlicensed personas 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 formlcertification for use in your community. na�srorrrcetrnu�.tctt„7,�;..Q„Prmit�frnmc\F.XPRFSS_doc . • Massachusetts -Department of Public Safety Board of Building Regulations and Standards � Construction Supervisor # License: CS-009691 JOHN W SWEE*Y PO BOX 711 W HYANNISPORT M'A 0 6 2 Expiration commissioner 08/12/2015 Unrestricted-Buildings of any use group which - contain less than 35 3 ,000 cubic feet (991m )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS rf &fie cPoorurrOwtvea`Cli a191crr ackid GL I! Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR vegistration: ,178287 Type: j xpiration: _4L1'2016:;_; Individual JOHN W.SWEENEY ` JOHN,SWEENWY 1 68 THIRD AVE. W. HYANNISPORT,MA 02672— Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 .2e Not valid without signature :: -- JACK SWEENEY MASTER CARPENTER 008,775.4730 i P.O. BOX 7 1 1 W. HYANNISPORT MA, 02672 O 7 CD Ul l ' j 1 a 7 a S d 8 9 E I G f 4, d � 5659h"'117 _/ NTGvct' — C — / LEMMING & MGCART HY MORTGAGE INSPECTION-"PLAN 1A" SUAYS)WAS This plan was not done with on instrument survey 38 POND STREET FAX and is to be used for mortgage purposes only. (st?) STONEHAM, MASS. .(617) 279-072x DATE: 12-15-96 SCALE: 1 20' l certify that this dwelling is located approximately a8 shown end conformed to n the zoning byiows of the Town of Barn,table: AM when constructed and is not located in o flood plain hazard zone. a � c Deed & Plan Reference �2 a Bomstobie County Reg, of Deeds BOOK 3081 / PAGE 267 0 PL. BK. 34 / PL. 23 4 LOT 219 car 2 LOT 215 car 213 n 120.00' N I 0000 DECK} x =� o, 7 CQ t:' T ;r ? V !I o LOT192 P e r6r t98 �--oF�; LOT 194 y F� s . 120.00• T I11Rj 0 VEj VIZ F E ,� G7.l.nR/.7.1.I4 nAi YVJ IRTRY13N q gMlWglj Wd 7G'4 MAN A9-4f-_19a. s: '97 12:20PM R J NORTON G0.50886290fl1 P.2 4 , TOWN_ OF BARNSTABLfi ' LOCAMON AV er.� SEWat3$# YII•LAO Sr _.e iv..V S Ag2'T ASSESSOR'S MAP dt L0VP 1NSTALLBR'S NAME PHONE NO, AU N 6@ •?.a"! SEMC TANK CAPACITY LBACIIINQ FAcurr: (type) 802 c t a g-T 'Plo T (size) ,••i-x, NO.OP BBDROOM3 II IMF P>3mirri)ATEi 33W 3 o 5—• -COMPLtAriCE oA'Clr: Seharat OO bistattee Between tile: Maalmum Adjusted Groundwater Table and'Botwm of Leaching Facility Private•Wafer Supply Well and Leaching Facility (if any.wells exist on site or within 200 feet of.leaching facility) ` UP of Wedand and Leacllittg Facility(If any wetlands exist •.—' �Fc t Within 300 feet of I aciun acility) Funds4d by �'' ,,, ,• e ,XFie 3S• � ♦ ! -yid M?f • �' •�• . Aqu Town of Barnstable *Permit#000(O ,i �� Expires 6 months from sue date P S PEDU RIWI a ulato Services Fee - MAY p B Thomas F.Geller,2M6 Director TOWN Building Division OF SARNSTASpcLRn Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 d 1� 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 (0 n ((�� Property Address �-� 3 4QS U. - 44_.)Q It-S Iry)X:�_ residential Value of Work 5 q5 S 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ®r3 Contractor's Name O��J Z�t_ V.,c, Telephone Number So% 0q. Lk(ot-lK) Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ am the Homeowner have Worker's Compensation Insurance Insurance Company Name �� LX>Z 1Z_N—,j �_70 Al Workman's Comp.Policy# U3 c, 33 (,�>1�5 O (t O 2S 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, 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. Home Improvement Contract icense is required. SIGNATURE: Q:Fomis:expmtrg Revise071405 F • � � L\YYYJY V■ \Ys1J\\p\lVY •p\lY\ l \YYl•\YYl uJY Vu\� ' HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: `' Board of BuildingRegulations an T� Registration 128957 g and,, One Ashburton Place Rm 1301 Expiration .fi/14/2007 Boston Type Individual ,Ma.02108 Oliver Kelly Oliver Kelly 9 Peregrine lane South Yarmouth;MA 02664 Administrator Not valid without signature s • KUOIDIO40•W09,0 WO-Sd0 p.1133;sov❑ ;uatuBoldwg'❑ ltt,Hauag ❑ ssa.tppy ❑ •a8us9 joj uossaa)pmW'Pin uagaa puv ssaaPpt a d CI t f71 A -V99Z0 VVy `4jnowjeA 'S - cruel 9uiJ69i9d 6 Allay) JGAllO AIlayl J8Al10 • LOOZ/17N9 :u011ej1dx3 IenPlAIPul :edA.L L9606 :u011eJ;S1698 UOi�L'. ST�A� I0��8I�Li0� �LI2LLT2A0IdLIII ALUOH 80I ZO s:4gpg6essuW -uolsog t 0£I uzooW.,—ooujd uopnggsV aup spl�pu��sy u suo �Insox Suipi ng o pnwg