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Date:
Thomas Perry, CBO
Building Division
200 Main Street
Hyannis, MA 02601
RE: Insulation Permits
Dear Mr. Perry,
This affidavit is to certify that all work completed at:
Street: :12 .'TowA IxpuSe -le.rrince ,
Village:
has been in pected by a certified Building Performance Institute (BPI) Inspector. All work
performed meets or exceeds federal and state requirements.
Permit application number:
Issue date:
Sincerely,
Francis Sheeh
President
Frontier Energy Solutions, Inc.
502 Harwich Road "
Brewster, MA 02631
Office: 774-237-0410
Email: fssfrontierenergy@gmail.com
mOISIAIG
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
� j V CC To ai?1' Tt
Map Q Parcel ��"I Application #ZD q050QS
Health Division 1t� I if Date Issued S- `� 1, Ply'
Conservation Division Application F
Planning Dept. aa.. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address 0QJ^ R.
Village l fi,n�c s
Owner (_qo(' et, 1_0 inA S 6ti1\ Address 1 L (o[N n '(err-
Telephone g 3 3 _ �-3 601A D 2-6 0
Permit Request Vv 0_^_ V r (e (ly(o�;e- 1'S
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Constructionlype
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) ' D 0
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 ❑pNo If yes, site plan review#
Current Use VC,e_5 ��CIL- Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name r-ro(V S&[U Vd A- fel pho e Number Z3 7-
Address9 i11__ rVv\G h Qv e^`A License#
Home Improvement Contractor# �0
Email en 2r �&oykao ( , 01(�N-Worker's Compensation #VUUG-00—40 i S3 5-44YA
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
31 v�� ro Q U � WCA, , - 0 2 �
SIGNATURE DATE J
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
f OWNER
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DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
S �
FIREPLACE
I
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
Q i
t FINAL BUILDING M
c
i DATE CLOSED OUT
ASSOCIATION PLAN NO.
----------------
- The Commonwealth efMassachusetts
iDepur�trraea:at of Industrial Accidents
lj, ice a,f Znvestigatloars
6Qt�l�ras��gpon Sheet
Boston,M 02111
ww .mass gov/dia
Workers'Compensation Insurance Alf davit:Builde�s/Contracters/Electr c ans/Plumbers
Aa2lacaltMFMA on R s fib. l�i�r
��
Name
Address:SO- ,.
IMA
Are you an employer?Check the appropriate boz ::.Jype of
I. 4 ,a .contractor and I project(required)--
am a employes tizifln _ am general. 6. .0 Neww cvnsiracticn
employees(fail and/or part-time).* have hired thesub-canttraes
2_ 1 am a sole proprietor or parmaer listed ores tIia.attachod sheet:. . I-U modeling
ship and have no employees bese jab-contaactors have. _.. $.:0.I3epaoiition
worlang for me W any capacity. employees-and Have workers'
[No workeW camp ursurance comp..insurance t �. �.Building addition
. } iVe are'acorporation and its I'(3 O Electrical:repaug or additions ' E
3. I am a homeowier dotrig all.work. officers have eaerczseci`theit i i' ,Piumbiag_r+epairs or additions
i trtysel£[No urorket s'comp: `r►glzt of exemption pee P�QL L121 :*: Et c ISl,'§t(41 and we have no :insurance a 3a_0 1 am a hotneowner ac�gssa employees. tQwork
general tractos(iefe .eo14Y.
.iasurattce.cotzap ]
' 3+appiic t that cheekcsbox#3.must aW fia our the section.Esetaw snowing.dick woftw eompCnSafioA�oHCY mfa iiM
i. t`Htutteawnrxs who subrWitthib affidavit indicating they are doing aU wotk and:ttten.hi oulside rontrao m must submira new.afftdavtt bw=ting such;
P. 3CottttxctaYs that dtec3rthis baz iuuatattaed a�additioaaT sheet sttovving the traasxi of the sob-�s and state avhetheror not those entities haave..: 7
�:: ers�toyep.-If the.s��-�m�Sctrns.6a�emPtc+yew.then rmn�t:pcuvids.nc�ir:wax;Yers'.EomP:Pgtitl+n -
t
f Ian ant-a pitiyt that is pmiding wo 4ets'compemaation instrsrancefor my empleyem Below is thej bl site
informada
insurance Compaay.i~Facue: S +: t
Policy#or Self-ins.Lac.. : `t,-� � K Expuatiou Date:
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Job SiteAd&es LU C2
Attach a copy of the workers compensitlou.policy declieratt-04.page.(showing the Isus am and ezpn_a' Iou elate).
:. Failure to sere average:* 'reed wi c I52 can lead to dw unposibun€ of criminal penalties:of a
l fine up to S :,5N.00 andfor one-year imprisanraient,as�eii as civil Iseualtiea in the form of a STOP WORK ORDER.and a fine
of up to SZ O.00-a_day against-the violator,. Be advised that a copy of this stateatent maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do ha ebp certi +nnd� �wdpmmhks of perjaary t�eat.th a infer�nz&n pa»vided�ratl<a Ve is. a:aaares�f
Qakial we only to not write in tkis area,to be ra mpieted by city or town offWaaL
City or Town: PSrmwL.icense#
Issuing Authority(circle ones
L Board of Health a.Building g Department 3.Cityfl`ows Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Comet Person: Phone#:
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,. Board£3fBuil
160854
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UD CSS140041,
SREWSMI,- MAL 02661
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•3f1312014 1 : 10: 10 PM . 6740 03/06
'CER"FICATE OF L MBIUW INS�"I�AIOI:.CE GATEII411d 1(YYYY
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THIS"CERTIFICA M IS ISSUED AS A MATTER OF lilFOAMAYtON ONLY AND CONFERS NO Rlt#fTS UPON THE CERTIFICATE HOLDER. THIS .
CERTIFICATE DOES NOT AFFIAPL MY OR NEGATMELY ANEND;.EXTEND,OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIACATE OF INSURANCE DOES"NOT CONSTITUTE A CONTRACT BETS THE ISSUING INSURER(S)�AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDS L
9 PORTANT:.H the certificate holder is an-ADDITIONAL.INSURED,the pOTrcy('res)-must.be endorsed. If SUBROGATION IS WANED,subject to.
the terms and contwiGns afthe poky min fifes>may.mquim art endersemenL.A statement on this certificate does not confer rights to the
certificate holder'in feu.of suchendersemenft
PRODUM 00809-001 JAWCT Jetltey ford
Rogers&GmyhmffanmAgerrsy uagot. (S00}653-#84# F .+ 8}3S8-02d6
434 Route 134
South Dennis,NA 42880 s
"I- -Mutual MaUrance Cm4my 33TS8
.ern s
Frantler Energy Solutims Inc,
r:
602 Harwich Read
Brawstu.NA 02634
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COVERAGES CERTIFICATE ItitUMIER: REVISION:NUN+BER
M7t$S YS TO CERTFf THAT THE POICIES OF iNSLRAVC£USTED BELOW HAVE BEEN ISSUED TO 7F AM E INSURED NAMED ABOVE FOR TIE."POLICY PERIOD
AI TER RIOTWTHSTANDING ANY REQUIREMENT;TERM OR COMITION OF ANY CMRACT OR 01HER DOCUMENT WTH RESPECT-TO WHICH THIS
CERTIFICATE MAY BE IS;LIED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED+(ERIM IS SUB.IECT TO ALL THE TERMS,
EXCLIM10M AND'CONDITKMOF SUCH POLICIES:UP TS.SHOM MAY.HAVE BEEN REDUCED 13Y PAID CLANS.
TYrEOF"ISURM CE. POtICY Rtrmm gags ADOW LNITS
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PERSONALSADVINBM S
EW'L AGGREGATE IMF APPLIES FER $
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AUTOMOBILE LIASS-ITY
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ALL OMED
ALT"s AU OSLED f#OULY Nam(Pe`, $'
HMAUTO3 AN fl PrIOPERTY MAm-
UHIBRELLA LIAR HCLAIMSMAGE'
OCCLIRRU CEF�€SSLIAS - AGGRMATE $
DHI J 1 RefaiTm.s $
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TAWAKimm�R�€ EL.EACR ACCI W $ 1,401#,DOD 00
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PERP7YOPIshel�x -POLSCYtI(dfT $ 1;000;008A0
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- pESCRIPriONF3f QPl$AI'�NSfiDCA78]#&E4"BirCL6S�tdttrch ACOR69{>•¢,.AddNo�rRc�rles.3ched�A,.>$rno4es�ceie:rxiu� .
CERTIFICATE HOLDER CANCEI.LATION
Tom of SandvAdt
130 Main Street SHOULD ANYOF THE.ABOVE OESCKJBED POLICIES BeCANCELLEDBEF
SandeAdv,NA 02663 THE EMRATIDN DATE TRIO OF; NOTICE WILL BE DEI:NHtffi !N
ACCON)ArtCE WITH THE POLICY PROVISM&.
AWHORIZED'l ATrb'E
IOSS ZD9O ACORD CQV4DRAT10N..All r]#Ms resomed.:
ACORD 25 t2010105} The ACORD name and logo are re0 cored marks of ACORD
- 3201
1
OWNER AUTHORIZATION FORM
I, ��uw JQ�Nbo�l
(Owner's Name)
owner of the property located at
(Property Address)
40 Z
(Pr perty Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering;to act on my behalf obtain a building
permit and to perform work on my property.
Owner's ' nature
Date