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0007 BABBLING BROOK ROAD
.¢ .. l •.. t .. r '.Rt. R�S� i ' n .. _ au �r n k •` n . . 7f a 1s.` f n r,a % ,� � � ' � i fW � ;- .: e r 3 a i;` � R . ,;.,, '1�d1 t.:':5`f �.F.c .-�. w c': .• u, _ t� .. .,N „# �. �' ., . , . - � �. ,�. ., .. i �• • `L �,a k � n,; Q„ � ,. t+ ` �� _ i - � �., � .� . .. v `. � ... ', - _ o . -. � .. a � r. -. -. .. DE 3 0 k TOWN Olkt9kAffiPA' FDING.PERMIT APPLICATION Map Parcel I Application # A56965Y Health Division Date Issued Z�//�► Conservation Division Applicatiore Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Z Village Owner q ,,,�„�,..� Address ,,.. Telephone Sl 7 Cod M.�" Permit Request 06 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 0 Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing '❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number 7 7q 9 413 94N22 Address License# 075 O 3 j Home Improvement Contractor# Email Worker's Compensation # WCOgaS 7 x1- - ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ge-z-) 6.1c) a ( / SIGNATURE DATE l2130 i ( FOR OFFICIAL USE ONLY I - 1 `r g � , APPLICATION # DATE ISSUED " MAP/ PARCEL NO. F7 ,J ,.J ADDRESS - i VILLAGE t OWNER DATE OF INSPECTION: ,"FOUNDATION " IA' FRAME i• INSULATION FIREPLACE k ELECTRICAL: ROUGH FINAL r ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL F FINAL BUILDING ` DATE CLOSED OUT i ASSOCIATION PLAN NO. _- th 77i<e CommornveaUh a,f-Wassadliusetts Depararrent cr,f Industrid Accidents - O `ue o,f.£mws igations ----— ' - 600 Washington Street— —----- ---- Boston ?CIA 02111 - - nvsn-v mass gnv1dia 'ttnrkers' Compensation Insurance Affidavit:Builder-s/ContracttarsMectri;cians/Pluumbers ssPPa�c�r�vr- n�aa �/f/J�� n Name City/Sta&Zip: CA- a Phone Are you an employer?Check the appropriate boa: Type of project(required): I_2011 am a employer with 1. 4. ❑I am a general contrsctor and I 6. ❑New construction employees(full andfor part-time)-* have hired the sub-contractors 2.❑ I am a sale proprietor or partner- listed on the attached sheet'. ?. ship and have no employees. These smb--contractors hav $. ❑Demolition w g, for me in an capacity. employees and have woalcess' w or z c.4rar tY c msurance.t # g- ❑Building addition [NO S4-oflK�iS�'CATrip.tsec�reanre �1�- required] 5. ❑ We.are a corporation and its 10-0 Electrical repairs or additions 3-❑ I.am.a homeoumer doing all work officers have exercised their 11.❑Plumbing rep airs or additions myself[Na ycork=s'camp- right of exemption per MGL 12.❑Roofrepairs insurance required_]1 c.152,§1(41 and we have no employees.[No wormers' 13.❑'Other comp-insurance required-] ..*Any WBc 'fist check box Fl mast also fill out the sectioabr_bowsbowing dmir wozken*compensation policy infomadon- Hom mmem who submit this af5dasti mating they are doing all wol=1 then bae outside contractors mast submit a new afdavk i^d'cg!Hn sacIL fC'aat<actm that check tbds boat must attached m additim sheet shooing the mine of the sub-court wAon and state whether or rat those entities baee employees. If thearb-conttactotshave emgIast�s,they mustpmuide their—k-s'comp.policy number- lam an errtplgvr heat is prn ditg ii�orke-ts'compertsatiarr insurance for my employ em Betoty is thepalicy and job site "intonation. Insurance Company Name Policy 4 or Self-ins-Lic.is U'o q;k 7 `; Expiration late: - 12Afi Job Site Address: ' &m6 LA City tare zip: G .g- ®-t,3 Attach.a copy of the work-ers'compinsationpolicy declamation page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c-1512 can lead to the imposition of criminal penalties of a fine up to$1,50d 00 anddor one-year imprisonment as well as civil penalties.in.the form of a STOP WORK ORDERand a fine of up to$250-00 a clay against the violator. Be advised that a copy of this statement may.be forwarded to.the Office of Investigations ofthe DIA for insurance coverage verification- Ida hereby. ,paqi r ui der thin pains andperiabYes ofpeduiy thatthe inforniatioupr iiW abm bare and correct Sitstature: late: i ✓� Phone g- �7 71 7 02maz rase only: Do)lot w ite in tins area,to be cornpteted by trite artotvn of'iciaL City or"fawn: PerrmtlIkense# Issuing Anthority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clem 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Taformation and-lastruc-ions Massachusetts Geheral Laws chapter 152 requaes all employers to provide workers'compensation for their empIoyees. pararantto this stator,an employee is defiaod,as."_.every person in the service of another tinder any contract of hire, express or implied,oral or written.." An empfoyer is defined as"an individual,partnership,association,corporation or other legal er>fity,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 trash of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more dim three apartments and who resides therein,or the occ¢pant of the . dwell house of another who employs persons to do maintenance,consfiraclion or r pair 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 const mat buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the instu-ance coverage required." Additionally,MGL chapter 152, §25C(7)states`Ntithea the commonwealth nor'aay of its political`subdivisions shall enter into any contract for the performance ofpublic work-until acceptable evidence of compliance w th the in sur „ce.. requirements of this chapter have been presented to the contrar tu �" ^g aufho Applicants Please till nit 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 mumber(s) along with their certificates) of ins nce. Limited Liability Companies(LLC)or Limited Liability Partnerthtps(LLP)withno employees other than tht members or pmto.=rs,are not required to carry workers'compensation ice If an LLC or L LP does have employees,a policy is required. 13e advised that this affidavit maybe sab ittt-d to the Depauhnent of Industrial Accidents for confirmation offimirance coverage. Also be sure to sign and dateirdte affidavit The affidavit should be retrane d to the city or town that the application for the permit or license is being requested,not the Department of strial A_ccidmts. Should you have any questions regarding the law or if you are regtthed to obtain a workers' compensation policy,please call the Department at the number lists d below. Self-insured companies should enter their self_fi sarance license number on the appropriate Ire. City or Town Officials t Please be sure that the affidavit is complete and prirded legmly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Invesfigafions has to contact you regarding the applicant_ Please be sure to fill in the prmma icrose mmaber which will be used as a reference number. In addition,an applicant that must submit multiple pemutlliceme applikations in any given year,need only submit one affidavit mdicating current policy it�matioa(if necessary)and under"Job Site Address"the applicant sho,Tld write"all locations in (city or town)_"A copy of the-aff davit that has been officially stamped or marked by Ahe,city or town may..be provided to the ' applicant as proof that a valid affidavit is on file for fine pa7#s or Licenses A new affidavit must be filled oirt each year.Where a home owner or citizen is obtaining a license'or permit not related to any business or commercial V&Dture (i e. a clog license or permit to burn leaves eta.)said person is NOT regrffied to complete ikmis affidavit The Office of Investigations would at to t3—k you in advance for your cooperation and should you have any questions. please do not hesitate to give us a call. The Depan:tmenfs address,telephone and faxrrunber: The COMMMWMIa of M ssachu sl_t , ' Depaztment cif ladu3taal Accidents oface ofttveg�tio F�Q�� an Sit �. , r. �. � 4- ,• , t B.Qstou=MA Elul 11 Tt,-L#617 727-49OG�xt 4-06 or 1--977-MA.S `•� Fax 9 617` 27 774 Revised 4-24-4)7 .mas.-gavlEa. AWe Gidde to-Woad Cons-trucdorr in ff4--Ir Knd Areas:11 Ompir Zane Massachusetts Checklist f6r Compauce(78O CKR53o1:2-I-I)r P1 a=k 1.1 SCOPE. - _Mn _ - _ - __ - 11D mph Wind Exposure Category__ Wind Exposure Category..............._Engineering Requh d For Entire Prajed---------------------------_---- -__C 12 APPLICABIUTY" -Number of Stories(a roof which p -2 st,ius Roof Pitch Mean Roof Height _ _ ---•--(Fig 2) —._-___� _It _<'S3• Building Width,W___ _ --(Fi9 ft s BD' Building Length,L 3) Building Aspect Ratio(1",_ ----------(Fig 4).-- ---------- s 3:1 Nominal Height af,Tailest Dpe mg7 -----•-- --(Fg 4)_.- - -- -- <6'8' 1-3 FRAMING CONNECTIONS General minpl-rance with framing orinnecfians".__' (Table 2.1 FOUNDATION . Foundation Walls meeting requirements of 7BD CMR 54D4.1 Concrete-----------------------•-............__..._... . <. ._.---..-•------- ._.-_...__.._.......--------..._.. _ _ Concrete Masonry....... 22 ANCHORAGE TO 17DUNDATIOW-3 5I8'Anchor RDb imbedded or 5S*Prmprieta y Mechanical Anchors as an alternative in concrete Only Sou Spacing general • Batt Spacing from endrjomt iF plate - _-_ _(Fig 5) _ - -- in.5 5'-12", BOIL Embedment-concrete_._ . _ in.it 7" Bolt Embedment-masonry-..--.--.---. ---(Fg 5) -.=-_._t,____.._. in_->15* Plate Washer__ _-_-_-__-_(Fg 5) _----- -r>-3`x 3 3.1 FLOORS FfoorfiwTiing member spans checked __-_____._.-_(per 7BD CMR Chapter 55)�------------ Maxirrrum Floor Opening Pimension_.__ _-_�___•:_ (Fig 6)--------__. ��____..__._. ft<_12' : FullHeight Wail Studs at Floor Openings less than 2'from Exterior Wall(Fg 6)......................................... ldltornchrr Floor Joist Setbacks SuppDMng Loadbearng Walls or ShawwaD ..--___-(Fig Maximum Cantilevered FloorJDisfs T SuppDrfing LOadbearing Walls or Shearwrall_-__.-(Fig 8)-------_.-=---._------_---.__-_._ft s d FI�arBrdcing at Endwalls _ �_ .__=- __._ Floor Sheafhing Type -(per7BD CMR C'iapter 55) Floor Shaathlrig Thickness CMR Chapter in. d nails at <.in edge F ' in field 4.1 WALLS Wall Height tnadbearing walls._: _—___ __--- _(Fig 1D and Table 5) ft 510' Nan-Laadbearing walls (Fig 10 and Table 5) ft'S-2(' Wall Stud Spacing -. ---------___:_--_----—(Fig 10 and Table 5) in-5 247 n.r. Waif Stuty Offsets -- ._. ��_-(Rgs 7&B)_. ----.__._ _'It s d 42 nCTERI OIL WALLS' l • E Wood Stride Vic_- fl in. LaadSaaring OaiLs_ -Fable Non•-L.aadbearing waft'__ Gable Ford Wall Bracing 1 • Full Height Endwall Studs__ _--- -_.__:..___Fig 1D)_ --_— WSP Attic Floor Length _.- _ {Fig 11)__- __.____ ft;ffi13 'Gypsum CerTing Length(if WSP nat used) Fig 11) __._._____ ft?_0-9W - and 2 x4 Continuous Lateral Brai e Q S ft o.c_(Fig 11)_-_-------------------_---- __--- or 1 x 3 ceiling furrng strips @ 16"sparring-min.with 2 x 4 bloddng @ 4 it spacing in end joist or truss bays Double Trap Ph-& 5prim Length .- .-.---_ -.(Fig 13.and Table _ft Splice Connection(no:of 15d common nah.-)' (Table AT-VC guide to TVood Corrstruc6an aft Higfr KindAreas: IIO fnph ff'rnd Zorie ' Massachusetts CheckUst for Compliance(7so UKR53012.1.1) Laadbaaring Wall Connections - LaL-ral(no.of 15d common nails)_—___.._ (Tables 7)_____---_-- --- Non-Lmadbearing Wall Connections Lateral(no.of 16d common nails)-- -_--_—(Table B) Load Bearing Wall Openings(record largest opening but check all openings for compliance to Table 9) Header Spans __r — __.___(Table 9).—____ _fit in.5 11, Sid Plate Spans —.--- -.__ ___-(Table 9) Full Height Surds (no- of sfiids)— _(fable 9).._._... _�____— Non-L ad Bearing Wad Openings(record largest opening bait check all openings for compliance to Table 9) Headei Spans-:_-___._.._ ____.._ ___.. __._..__(Table 9)—__ _ _fit' in_5 Iz Stit Plate.Spans----_ - — _—_(Table 9)-. —ft_in.512' Full Height Studs (no.of studs)_ _(Table __-�- 51wior Wall Sheathing to Resist Upfdt and Sheaf Simu taneausly4 Minimum Building Dimension,W - Nominal Height of Tallest Dpening2 .................. Sheathing Type_ - -_____._(note 4)---_� Edge Nall Spacing —_ —.— (Table 10 or note 4 if less)-----_.:- in. Feld Nail Spacing..__..._—..—.._ _.._.(Table 10)_ in. Shear Connection (no.of 16d common nails)(Table 10)__. Percent Ful�-Height Sheathing—_—* ----(Table 10)_� 5%Additional Sheathing for Wall with Opening>•6'87(Design Concepts) Maximum Building Dimension,L Nominal Height of Tallest DpeningZ—--------------------------------------------------------_._ Sheathing Type (note 4) ._—_ - -_--_-__-- Edge Nail Spacing_..._ —_ —_(Table 11 or note 4 if less)__ ___ h Feld Nail Spacing---- ______. _(Table 11) in. Shear Connection(no. of 15d common nails)(Table 11)._._.—,_..____ Percent Fu&Height Sheathing— (Table 11)_. 5%Addifional Sheathing for Wall wrlh'Opening>6'8"(Design Concepts)_..._. Wall Cladding Rated for Wind Speed? 5.1 ROOFS_ Roof framing member-spans checlked7_—___ .(For Ratters use AWC Span Toot,see BBR:S Website) RDDf Overhang ----•---- __-- ------________(Figure 19)____.__-.. ft 5 smaller of 2'or L13 Truss or Rafter Connections at L oadbearing Waifs Proprietary Connectors -_ .(Table 12) U= plf Lateral__-__----(Table 12)__ _ .—.—..-_L= pff Shear— _—.--(Table Ridge Strap Connections,if collar ties not ased per page 21... (Table ------- T= pif Gable Rake ft s smaller of 2'or L/2 ' Truss or Rafter Connections at Non-Loadbearing Walls Proprietary C inneriors Uplift 14)_-_- U= lb. Lateral(no-of 16d common nails)_-(Table 14)--------------------------------------L= . lb. Roof Sheathing Type __ _-- -(per7B0 CMR Chapters 58 and 59)............. Roof'She thing Thickness____..._. _. ____._.__ _in.?7116`WSP Roof Sheathmg Fastening___-.____ _ _ __�(fable 2} — Notar ` •1. • This r_heckdst shad be met in its entirety,excluding the specific exception noted in 2, to comply with the requirements of 78D CMR-53D12.1.1 Item 1. If the cheddist is met in its entirety then the fallowing metal straps and hold downs art not raquked per the WFCM 110 mph Guide: a Steel Straps per Fgure 5 b. 20 Gage Straps per Figure 11 c. Uplrr-t Straps per Figure 14 ci All Straps per Figure 17 e. Comer Staid Hold Downs per Figure 18a and Figure 18b 2 'E ception:Opening heights ofup to 8 fL shall be permitted when 5%is added to the percent fulkheight sheathing raquirements sh6wn in Tables 10 and 11. 3_ The bottom siff plate in exterior walls shall be a minimum 2 frL nominal thickness pressure treed#Z-g*L-- AFVC Gi de to Wood Corz &zra on zrr Ili h KndArerrs_ 110 mph frrd Zorte Massacliuseits CheckIist for Comip`liarice pso CRR5-01?:l_I)r 4. a. From Tables 10 and 11 and loc os of wall sfieafhMg and Suildmg Aspect Ratio,determine Perc:&nt Full-Height Sheathing and Nail Spacing requirements b. Wood-5iiucbtr-al Panels sfn be minimumtfiidaiess of 7/16'and lie installed as fo�loi�rs L Panels shall be Installed'vial strength ars para{Mel to studs. z--An r�nta�1.joints stair— iz aL On single stoty constn.!CbDn,panels shall be attached to bottom plates and top inember of the double top plate. plate and to band joist at bot�m of panel.Upper attachment of lower panel shall be made to band joist and lower attachment made to lowest plate at Hirst floor flaming. v. Horizontal nal spacing at double top plates, band joists,and girders shall-be a double row of ad staggered at 3 inches on center per figures below:Vertical and Horizontal Na-i ng inr Panel Attachment 5. (=fazing pratec6on:a)'new house Qr horizontal addition—required if projectls 1 mile or dosertn shore(general)y,south of Rte.28 or north of Rte 6) b)vertical addition—not required uriless there is extensive renovation to the first floor c)repfacement►vMdows—needs energy conservation compliance only(chap 93) 6.Wood Frame Cormimciion Manual(WFCM)for 110 MPH,Exposure B maybe obtained from the American Wood Council (AWC)websilm— I . wt tames FIEM ox ATE"= .i !t - • if ii , 1 rt n ) 1 o t l }[t I 1, i al It flrL o « !r hF i= L . G7 tf 11 ., ..11 12 f = yam( >L 41 L hi STAGGERED fl ill iyf Sea DaWl on Nexf Page Vertical and Horizontal Nailing Det2fi for Panel Attachment Verli�ai pnd Harriantal Nailing far Panel Aliscfimanf f B rnstable s6gq. ,0 Town oa - -Regulatory Services- - -- -- CleII6r17TJ�.7ti1—D�ITGLL� .. 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_ ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: ` (Address of Job) Signature of Owner. -Date Print Name. . If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side.- , QAWPFILESTORWbuilding permit forms\EXPRESS.doc Revised 040215 Town of Barnstable r Regulatory Services dFT aryl, Richard V.Scali,Director Building Division 11MMSTMIXMAMg Tom Perry,Building Commissioner 1639. � 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 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 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 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 to amend and adopt.such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 x Owens Corning Basement Finishing Systems ® of New England Mannal,Karen&Richard i Contractor / Agent Authorization From 7 Babbling Brook RdCenterville,MA 02632 508-360-1625 j 508-790-9407 I .. CGCQ /� Qi authorize 'Owens Coming Basement Firuslung Systems of Boston to sign the building permit application on my behalf,.to perform the work at: Home Owners Signature: Date: Project Manager Signature: Date: i 60 Shawmut Road • Canton, MA 02021 • Phone: 781-821-0060 • Fax: 781-821-8552 0 www.ocboston.com Massachusetts-Department of Public Safety ,.Board of Euiiding Reguiai:ions and Standards License: CS-075131 EDWARD T.ALIO - '; 30 STORMY)liIIL Dedham MA 02026 �V},._ -;� �. Expiration Commis�sionne'r' 02/27/2017 ' Office of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, M •s�sachusetts 02116 Home Im roven� ontractor Registration P � . Registration: 137943 z J F Type: Supplement Card Expiration: 1/29/2017 LUX RENOVATIONS, LLC. EDWARD ALLEN r 1 0 60 SHAWMUT RD ----- " CANTON, MA 02021 °n 1f s`��'v Update Address and return card.Mark reason for change. >ca 0 2otu-0i� [] Address Renewal (] Employment Lost Card Vfea�omUnzaaua�a��ar✓u�ae�a , ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVg T CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistratio ? Type: 10 Park Plaza-Suite 5170 Expira _ j,? Supplement Card Boston,MA 02116 LUX RENOVATION? OWENS CORNING tf"'ISHIN_G SYSTEMS EDWARD 60 SHAWMUT RDCANTON,MA MA 02021 Undersecretary Not valid without signature .ACC>RP CERTIFICATE OF LIABILITY INSURANCE °ATE(MWDDDNYYY) F9,,5/2015 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 endorsements PRODUCER CONTACT s. Andrew G.Gordon, Inc. •c �� . PHONE FAX 306 Washington Street .781-659-2262 .781-6594725 Norwell MA 02061 _ E-MARE IL .info@agordon.com ' INSURERS AFFORDING COVERAGE r NAIC# INSURER A:Peerless Insurance 24198 INSURED 4440 ' INSURER B:Star Insurance Company. 18023 Lux Renovations, LLC INSURER C:Pil rim Insurance Company 4 21750 Owens Corning of New England 60 Shawnrut Road JNSURER D: Canton MA 02021 INSURER- E. y • „ , INSURER F: " COVERAGES CERTIFICATE NUMBER:1319789055 ° ' 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,IMTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSD POLICY NUMBER - M�Y EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CBP8512851 9/5/2015 9/5/2016 EACH OCCURRENCE, $1,000,000 DAMAGE TO RENTED CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence' $100,000 ' , MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO X POLICY a JECT LOCI < �' a PRODUCTS-COMP/OP AGG '$2,000,000 ' OTHER' ' r'' ' $ C AUTOMOBILE LIABILITY «_ ,1117/2015 PGC10007161409 1/17/2016 Ea accident) $1,000,000' ANY AUTO a'. BODILY INJURY(Per person) $ _ ALL OWNED SCHEDULED` ` X AUTOS AUTOS '- r BODILY INJURY(Per accident) "$. NON-OWNED, ^ R PERTY DAMAGE X HIRED AUTOS X AUTOS 4 `w f_ y° Per accident $ A X UMBRELLA UAB X OCCUR CU811953 9/5/2015 '9/5/2016• EACH OCCURRENCE $1,000,000 EXCESS LIAB' CLAIMS-MADE AGGREGATE $1,000,000 DED I X I RETENTION$ I $ w B. WORKERS COMPENSATION ,' WC0428715 n 5l24/2015° 5/24/2016 PER - OTH- AND EMPLOYERS'LIABILITY ' Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE * �r�e. E.L. ACH ACCIDENT.. $1,000 000 OFFICERIMEMBER.EXCLUDED? , N�/A 5 '• ,t - (MandatoryinNH) E.L.DISEASE-EA EMPLOYE '$1,000,000 * If yes,describe under DESCRIPTION OF OPERATIONS below ' "' E.L DISEASE-POLICYLIMIT $1,000,000 � r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) t ` CERTIFICATE HOLDER ° fi CANCELLATION b' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION "DATE -THEREOF, NOTICE"•WILL BE DELIVERED IN, Lux.Renovations,LLC,` ', ACCORDANCE WITH THE POLICY PROVISIONS;. 60 Shawmut Rd t Canton MA 02021 ' AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(264/01) The'ACORD name and logo are.registered marks of ACORD x r Mannal, Caren &Richard 7 Babbling Brook Rd CONTRACT Customer Name Centerville,MA 02632 I Customer Signature,"44',ee,/',/Ua , q �Gll SKETCH Contract Date 508-360-1625 Sales Representative Signature ATTACHMENT Customer Phoned _ 508-790-9407 Contract Price V.. 1 2 3 4 5 e 7 5 9 10 11 12 13 14 15 15 17 19 19 20 21 22 23 24 25 20 27 26 29 30 31 32 33 04 35 36 37 39 39 40 41 42 43 M 45 -46 47 49 49 50 St S2 53 54 55 56 57 56 59 60 'yV1 �I I I I I• I I i l.. !. .; i i 2 i I � I I ! I ! I i I I I - - � ... _L.... __i_.......---- ,_ I I 10 12 AZL44 Rid j I � i i 14,.._..m - I I ' .•�. i !�. i ' .._.. I I I i ,.._ I _..lr._- _ , _I I i i I 17 i IS I i I 20 i II, I 1 I- 21 22 23 I � I ,I . 24 27 i i I 1 za I J,-.. �_ ; I j j Q ,.I ._ � _ i � I. I i L f , I ..I F i ! I L. . � � I � . i ;-• � _f �..._ j G I _._. iH t 20 .! I ..� . . j I i i I i I I Imo34 . r I j NOTES: ['�p GvtS p 14L o Each box equals one foot unless otherwise noted.This sketch Is a good faith representation of the work to be done,it is understood that ail dimensions derived from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,jacks and/or switches are subject to change If necessary. 7. BASEMENT ENT f . FINISHING SYSTEM'" DESCRIPTION The Owens ComingBasement Finishing g ..:. ..... .. System'Is comprised of lightweight Y fiber : panels PVChneats(which replace conventional :,,.<f�,;f. .., .:f. ts ..�..�:.::..:.:�:.�:.:..: ..n framin and foamed PVC torn moldings In ,,\ .::..........::::...:.�.. .:.. ........n.... .... �. , •. .>i:-;.,:.irk.>:;�:..:;»:::::L.:::non::::,::::,::...........:.... _..�.:..,::_...._..... g (which re moldings Place torn lumber.The torn snap Into the IIneaI s ho lding In the panels In lace sna.: •.... .u....:., Moldingsand wall panels a are removed to ::..::... a ;;:; >:,;.i,:: ,r...::.::::::::::::::.:..:,.:.. r::,..:n.....--...............-.,:::.::::.:.........._,�:.:::::.::..._....................._..._::::.::::::.............. P easily : provi de easy access to home's foundation o datlon Because traditional - o al wood an d d paper- based based building ma terials rere re placed d 'th fiber �lass and PV mk!, als the B m 1 ase ent Fini s .::>.:....:.r.rr.:.... .:.. g shin I g Sy stern" offers inherent rent resistance to moisture, : , v mold s>o d an mil dew.*ild ew The � I system is covered by •� I� t,�r,� a lifetime limited transferable warranty* ' from Owens Coming. USES N The Owens Coming Basement Finishing System'is an innovative stem designed to system � insulate and finish basement walls.It insulates, acoustical « n.n.v.... w..:.,,.....,r..:............... ....:...,........ N treats and aesthetically finishes walls in a few simple steps.The system can be installed over both masonry foundation walls PHYSICAL PROPERTIES and interior partition walls built with either wood or metal members. Property Test Method Value For Fiber Glass Board. WaterVapor Sorption ASTM C 1104 <20/.by wt.@ 120NF, 95%RH 4"x 48"x 2-I/2"Panels Compressive Strength ASTM C 165 Lineals @ 100/6 deformation 25 sf• A Trim Molding; @25%deformation �:90i1Psf w�, C�). Thermal Resistance ASTM C 518 Cove Molding -fl1 Vertical Battens Normal Density ASTM C 303 ,3.2 PCF Base Molding For Finished Panel.• `'" Outside Corner Noise Reduction Coefficient ASTM C 423 yya Casing Type A Mount . J95Jamb Extender - --= Chair Rail Surface'Buming Characteristics ASTM E 84+ Qlass A FlamaSpreaG125 -Meets Class A Bum Rating Sjmoke Developed Color Choices: InteriorTextile Finish Fire Classification NFPA-286 Meets Acceptance ° Panels:"Linen Mist"woven fabric Criteria Trim:All trim available in White or Woodgrain. Mold Resistance ASTM C 1338 Pass In addition,vertical trim available in fabric look ASTM G 21 Pass finish or fabric wrapped to match panels. +The surface-burning characteristics of the finished composite panel were determined in accordance with ASTM E 84.This stan- dard measures and describes the properties of materials,products or assemblies in response to heat and flame under. CODE COMPLIANCE controlled laboratory conditions.Data from ASTM E 84 testing cannot be used to describe or assess the fire hazard or fire risk of materials,products or assemblies when considering all of the factors pertinent to an assessment of the fire hazard of 2000 BOCA Evaluation#21-24 a particular end use.Values are reported to the nearest 5 rating. See ICC-ES Evaluation Report No.ESR-1872 at www.icc-es.org. "While the materials and design of the Owens Coming Basement Finishing System"resist mold and mildew,the System can not prevent or mitigate mold if the conditions necessary for mold growth otherwise exist in your basement. "*See actual warranty for details,limitations and restrictions. Mr FEATURES AND BENEFITS Feature Benefit Pre-finished,integraed components Installs in about 2 weeks' Snap-out moldings and panels Complete interior foundation access Resilient glass fiber construction Will not dent like drywall Moisture resistant materials Resists mold and mildew growth 2 1/2"thick panels Added RI I Insulation Tackable surface Hanging pictures or papers without leaving permanent holes with proper use of picture support plate High Noise Reduction Increased comfort, Coefficient(NRC) outstanding sound absorption Wall panels indexed 1-3/4"off of floor Helps to minimize flood damage potential Removable base molding Provides wire chase for speaker wires, TV cable,computer,and other low voltage cables Lifetime limited transferable warranty" Offers homeowner peace of mind Dupont Teflon®fabric protector Stain resistant Certified installers Individuals trained for quality installation Ceiling design flexibility Integrates easily with drop or drywall ceilings "Based on an average basement,with two certified installers. **See actual warranty for details. IIMruIM FIX IN W _ OWENS CORNING REMODELING SYSTEMS,LLC ONE OWENS CORNING PARKWAY TOLEDO,OHIO,USA 43659 1-800-GET PINK' www.owenscorning.com Pub.No.44071-H.Printed in U.S.A.June 2007.THE PINK PANTHER'& 01964-2007 Metro-Goldwyn-Mayer Studios Inc.All Rights reserved. The color PINK is a registered trademark of Owens Corning. 02007 Owens Corning. T 781-871-8252 TO f , E OF rE F: 781-857-1977 17 AM,, c• 45 DIV CTC)� May 23, 2014 Thomas Perry, CBO Town of Barnstable Building Division 200 Main Street Hyannis, MA 02601 RE: Insulation permit#201309233 Dear Mr. Perry, This affidavit is to certify that all work completed for insulation work ati7=Babbl�rBro-ok Road has been inspected by a certified building Performance Institute(BPI)Inspector. All work performed meets or exceed Federal & State requirements. Sincerely, Victor Cimino 267 N. Quincy Street • Abington, MA 02351 www.insul-proinc.com TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map f F-*1 ' Parcel ��Y App lication /aL c© Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Ltoy Date Definitive Plan Approved by Planning Board aK. �9`/� d14- Historic - OKH _ Preservation/ Hyannis Project Street Address Village e' /� C. r trsl P'a7� ,,Owner J?I c_llat, Het eta tea Address 7 13el(I Telephone` �5'08'- 2 TO- /`�06-7 C 0-av ' �01?L-3(U/-le3,11 Permit Request %`C Al� asv �l 5. a, e � ec�rceav s' cep"a e Ar Square feet: 1 st floor: existing - proposed 2nd floor: existing proposed. Total new `Zoning District 4 Flood Plain -Groundwater Overlay �ProjectValuation Construction Type -o Lot Size Grandfathered: ❑Yes ❑ No If yes, atta '7jj upporting docmnentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) " Age of Existing Structure Y Historic House: ❑Yes ❑ No On Old King's Highway: des ❑.No Basement Type: ;9 Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (s .ft) ' + Number of Baths: Full: existing 2 new Half: existing new Number of Be&&ms: 3 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 ANo Fireplaces: Existing New Existing wood/coal stove: ❑Yes No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:X 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 euaec i' "aatia-1 Telephone Number c Address -- ti'�0 11��t�j G C - License# rwI/ / Home Improvement Contractor# Worker's Compensation # AL"L;CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO &1,A P A `SIGNATURE �cai�L DATE 16 Z11 FOR OFFICIAL USE ONLY APPLICATION# t j DATE ISSUED i� MAP/PARCEL NO. 4 � ADDRESS VILLAGE OWNER i�♦ DATE OF INSPECTION: .-,FOUNDATION_ FRAME o 0 j, INSULATION ini FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL j. GAS: ROUGH FINAL r 'A FINAL BUILDING ;r 'k DATE CLOSED OUT ASSOCIATION PLAN NO. r,T :r ?he Gonlm6 wealth of Massachusetts Department of Industrial Accidents Office of Investigations W 600 Washington Street Boston,MA 02111 fvnm mass gaWdire . - Workers' Compensation Insurance Affidavit;Ballers/Coi ftactors/Electriciansoumbers 4 Applicant Wormation ', Please print LpAhv Name(Basmen/Oigmizatio 7 / / roe lC�l! Address: 3a�9 ,! �J y - _ City/StateJIZip- Cent e r tii l /` G' Phone# Are you an employer? Check the appropriate boa: Type of project(required)_ 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6, ❑New construction employees(full and/or part-time).* have hired the sub-contractors ; 2.❑ I am a sole proprietor or partner- ship on the attached.sheet. 7, ❑Remodeling slip and have no employees These'sub-contractors have g- ❑Demolition employees and have workers' working forme in any capacity. 9. ❑Building addition , [No workers' comp.insurance camp_insurance.Z required_] 5. ❑ We are a corporation and its 1t3_❑Electrical repairs or.additions 3_ I am a homeowner doing all work_ officers have exercised their 1I_❑Plumbing repairs or additions naysel£ [No workers'comp- -fight.of exemption per h1GL 12_❑Roof repairs insurance required.]F, c- 152, §1(4),and we have no employees-[No workers' 13-0 Other comp.insurance required_]; •Any applicaM that checks box#1 mast Rho fill out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing an wmk and then hire outside contractors most submit anew affidavit indicating such_ ° tContractors 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. Ifthe sub-contractors have employees,they must pmvide their workers'comp.policy number. I atn an employer that is protiding nlorkers'compensation ithsttrrutce for trey enzptoyelm BeIoty is die policy rind job site irtfortrtrttiott. N •' - ,, Insurance Company flame: a Policy#or Self-ins.Litt'.# ~ Y Facpiration Date: — Job Site Address: CitylStatelZap: , Attach a ropy of the workers'compensation policy declaration page(shoving the policy'number and eapir�tion date). Failure to secure coverage as required under Section 25A o€MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year iniprisonment,as well as civil penalties in the.farm of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of: Investigations of the DIA.for insurance coverage verification. I do heroky cerh j�,rtniler t pain nd h'ies of tty that the infortuatton provided a cis true and correct Signature.: P �'O -•3C�-. l�3/ official use arliy: Da not write in tilis a etz,to ba completed by city ur imam vfficiat' GitP or Town: PermitlLicense# z Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citv/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector t.Other Contact Person: Phone#: 6 . Town of Barnstable . • Regulatory Services ¢' Thomas F.Geller,Director IILHAaa. �¢ , $` Building Division Tom Perry,Building Commissioner } 200 Main Street,-Hyannis,MA 02601 ' www.townb arnstable.ma.ns Fax: 508-190-6230 Office: 508-862-4038 = HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: _ t / village / nnnber G__�� •Sow=7Id,�'4/a7 .5'G� 3� `HOMEOWNER": home phone* work phone# name CURRENT MAILING ADDRESS: e r-ta Z 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,vrovided that the owner acts as supervisor. DEFINNON OF HOMEOWNER Person(s)who owns a parcel of land on which seecscesso he resides dto such use and/orlfarm structurech shere is,or is A Person who constructs be, more one than one- family dwelling,attached or detached structure accessory 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 1091.1) ; esponsibility for compliance with the State Building Code and other applicable codes The undersigned"homeowner"assumes r , bylaws,rules and regulations: The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro ores ;re;q?rguts and that he! complywith said procedures and requirements.� ' Signature of Homeowner 1 V Approval of Building Official - e;._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 permitisr iced s all be exempt homeowner from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided engages a persons)for lure to do such work,that such Homeowner shall act as supervisor" ing e responsibilities of a supervisor Many homeowners who use this exemption onstructio Supervisors,aware ote Seare ction n 2m15)'This-lack of awareness often (see Appendix Q,Rules&Regulations for Licensing C 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 Supervisors ultimately responsible. fully aware of his/her responsibilities,many communities require,as Part of.the To ensure that the homeowner is 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 formlcertific afion for use in your community. ,. C:1IIsecs\decollHc\AppDatalLocallMicrosoftlWmdowslTempotsry InternetFiles\ConuntOutlooklQRE6ZUBI�IFJtPRESS.doc Revised 053012 r .,:: � .-..:.i�-.-�-...;*i-,.�'�i..',..:,—.;,.r.��.-,.�,I�-�I.,.-:.Iy,�.,.,�.":...--."*-,�:-".--:,-,!;�,-.-�'�.�.;-�:.-�;:,.-*,:.---:,..'!...,..I��'.-::��.���",�!i-.-:-.� . .'•.� .1� ...,.T '.. "LV:S.:. .'.!'!... .. .'r:: 'r! 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Permit Fee 11,3Date Definitive Plan Approved by Planning Board Z'/-7 Historic - OKH _ Preservation/ Hyannis Project Street Address 7 8ri ol% Village Owner/Chl/'J /14�7/7q/ Address 757bbtiizg Telephone 3Gf 3600•-1[Q( Oz. (o3L i Permit Request �l�1�z1 Gi /6 � i�1I� ��`� CP`lr/c/� 7,� /c1��; i�J�,l� 'tG 'e l/ 117 Jqlz,111 i If,,ile- f,"— f'p4 ,,,e~,4aJ '�-7 ,r,lY.�fi � -77-16 f',14ig✓j�il� ffl( Ie.�,l r/JSGJ fi� C�.n,�xioD'1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation S;y�G 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 rev Number of Bedrooms: existing _new . e� Total Room Count (not including baths): existing new First Floor Room Count, Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other =' 9^m3 _-A Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑-res ❑ 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 _I APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �`� C/Mir Telephone Number Address ?.(7 /y 023-r/ License Home Improvement Contractor# /`l%/l1 Ennai L V1cP-rP-1nJ,1tP ,he.c,�% Worker's Compensation # XINI 172- Kff4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 12-1/2-113 is 1 FOR OFFICIAL USE ONLY f APPLICATION# DATE ISSUED t 4 MAP/PARCEL NO. j. ADDRESS VILLAGE �.M i Y OWNER i_ �t fk DATE OF INSPECTION: I; L` FO.UNDATI.ONst :: aaxa {.�. s,. FRAME —INSULATION f'= FIREPLACE it ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING•' �.J j` r: DATE CLOSED OUT } ASSOCIATION PLAN NO. { t"< The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 1 Congress Stree4 Suite 100 Boston,ALL 02114 2017 %MW.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Plectricians/Plumbers Applicant Information Please Print Legibly Name(Businessiorganization/Individual): T hr,-l-12i-d ' Address: City/State/Zi �I i n 7'v� ti 01 3 S ( Phone#: 42 5 Z A, m.re you an employer?Check the appropriate box: Type of project(required): 1. I a a employer with /5 `l ❑ I am a general contractor for I 6. ❑New construction , employees(fall and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and hay a no emplrn ees 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.+ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeonner doing all work- officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152. §l(�4),and Nce have no employees. [Noworkers' 13.[210theri% /�7�i°Uri1 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. tCormactors 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 sub-contractors have employees,they must provide their wormers'comp.policy number. I am an employer Heat is providing workers'compensation insurance for my enployees Bdow is the porky and job site informadm Insurance Company Name: 7-ro ye leri Ind e/,7, x�G`~'�`�f°�' Policy#or Self-ins.Lie.#:X K U8 6 072. Y R S A-15 Expiration Date: 2-/Z 4f//44 Job Site Address: 7 R 4NIo J2111 City/State/Zip: CrWte.-y!l�P Af- 026 3Z 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$250-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi cm under the airs and alties o er ury that the in ormatiorr prorided abmte is true and correct. -- - --- Si at„re: ..: Date f L 12 /� _ Phone#: 7A/- f252 - Official use onh: Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �. 4iSr5 :t$ '_F`�.I:ycr�sw�fii`i•.`'!F°�>E7v. '�x':1;3 • � 3e<,�� �;Ba;;?"t�^tir�g;�'fyiFia`rGG+'is��d S�aii;a<3' , - (t eT�t- ertritPrl 1l2}K_ ' :e •ter F<$._' C8-088969 •fici .. VICTORCIMINO 267 N.QUINCY ST _ ABINGTON MA U2351 , cx��r�:€t:•rt 05/11/2014 le Office ofCOnsuiner »c��zo�zcueull/r, fC�/l�iu«c�rc eft Affairs 8c Business Regulation ME IMPROVEMENT CON License or registration - _ gistrafion: TRACTOR valid for individul use only 149123 before the expiration date xPiration 11/28/2015 Type' Office of If found return to: Private Co Consumer gffairs and Business Regulation INS Private INC. rpora6or, 10 Park Plaza_Suite 5170 ' Boston,MA 02116 VICTOR CIMINO 267 N.QUINCY STREET ABINGTON,MA 02351 Undersecretary Not valid.without signature A6 �a s DATE(MMIDD/YYYY) � CERTIFICATE ®F LIABILITY INSURANCE 5/22/2013 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 CNAME:ONTACT Denise Butcher Strategic Insurance Solutions, Inc. PHONE . (617)558-7100 X122 FAXAIC No).(781)459-8282 2000 Co)mnonwealth Avenue A o'L s.db@strategicinsure.com INSURERS AFFORDING COVERAGE NAIC B Newton MA 02466 INSURERA:SCOttsclale Insurance CO an INSURED INSURER B:COMMerCe Insurance Company 4754 Insul-Pro, Inc. INSURER C Mravelers Inclenn±ty Company 267 N. Quincy St INSURER D: INSURER E: Abington NA 02351 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1352202385 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 A L R POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY) (MM/DDnYM LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 R COMMERCIAL GENERAL LIABILITY PREMISES Ea occv ence S 50,000 A CLAIMS-MADE ®OCCUR PS1656859 /13/2013 /13/2014 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 11000,000 GENERAL AGGREGATE S 2,.000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $ 2,000,000 X POLICY PRO LOC S AUTOMOBILE LIABILITY COMBINED tSINGLE LIMIT S 1 000 000 B ANY AUTO BODILY INJURY(Per person) S AUTOS OWNED X SCHEDULED BEM 0/1/2012 0/1/2013 BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE AUTOS X HIRED AUTOS X AUTOS Peraccident) S S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE AGGREGATE S DED I I RETENTION S $ C WORKERS COMPENSATION X I WC STATU O'H- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT S 500,000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) 6072Y85A13 /24/2013 /24/2014 EL DISEASE-EA EMPLOYEj S 500,000 N yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) } CERTIFICATE HOLDER CANCELLATION ( ) - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE .EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN- ACCORDANCE NTHTHE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Denise Butcher/DMB -- ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. Ail.rights reserved. INS025r7mnnsn+ Tha Armor name and Innn a►a ranictarael ma►Irc of Annion i , i OWNER AUTHORIZATION FORM. (Owner's Name) owner of the property located at (Proorty Address) (Property Address) hereby authorize Subcontractor an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date