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0091 BERNARD CIRCLE
m � r � y .. ,. . b � .� :. _ ,. _ : , r : h G 0 0 ',I r f Town of Barnstable *Permit#Expires 6 months from issued to Regulatory Services Fee ULMSTASIE 1 v� uasa $ Thomas F.Geiler,Director r 16J9. Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY yt Not Valid without Red X-Press Imprint Map/parcel Number / .6 57 Property Address �l b e tul lZ p (7/2c/e , G� ff Residential Value of Work / fro Minimum fee of$35.00 for work under$6000.00. Owner's Name&Address �?le ' 6l-elf C47/f ,—P. %ve' Aeg"I'en- .9l ,8e/T A1,14d c,,;gMe '' C PGt'fP pv/�lQ Contractor's Name j'�Uj3��T T dLL�ORTI� Telephone Number '�� l 5�/y c�olya < z2l` dome 2POr lleOeMeWf�&,C) Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ° [ Eiworkman's Compensation Insurance *PRESS PERMIT Check one: ❑ I am a sole proprietor SEP 1 9 ZQ12 ❑ I am the Homeowner - Q/I have Worker's Compensation Insurance Insurance Company Name �OWN ggRNSTABLE Workman's Comp.Policy#--wG G S'a j D 5'.V 7G 1 ,2 0 jr Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side J yyeut! ly; Ye Vvdo4/ P #of doors Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows_ '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:` C:\Users\decollikWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.outlook\DDV87AAZ\EXPRESS.doc Revised 072110 THE FOLLOWING IS/ARE THE BEST, IMAGES, FROM POOR QUALITY ORIGINALS) ' '. IMF � DATA. - - ,�a, �e�pa�n�YLa��acueaGG�ea�C/pLadaac�itcveCtit ........ ...L_ '. .. -. 4\ ffice of Consumer Affairs&Business Regulation License or registration valid for mdividul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration Expiration 10p74Q 6/23/20t4 Office of Consumer Affairs and Business Regulation Office 10 Park-Plaza-Suite 5170 W �• Supplement Card Boston,MA 02116 CAPIZZI HOME IMPROVEMENT1NC. ROBERT ELLSWORTN.=[.a 1645 Newton Rd. Cotuit,MA 02635 a Undersecretary Not valid without signature 7. -- Massachusetts-Department of Public Safety WU Board of Building Regulations and Standards Construction Supervisor. License: CS-061438 �USF."fTS O1A 1 - ROBERT TIWORTH 69 PALMERAD MASTIPEE 02 49 k Expiration Commissioner Expiration I vi 1r Client#:47298 CAPIHOM -A'iCORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 6/08/2012 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: Karen Walther Rogers&Gray Ins.-So.Dennis PHONE o,Ext: AX No): 877-816-2156 434 Route 134 EMAIL ADDRESS:• = ' South Dennis,MA 02660 1601 508 398-7980 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Grange Insurance Co. INSURED INSURER B:Associated Employers Insurance Capizzi Home Improvement,Inc. INSURER c Capizzi Enterprises,Inc. 1645 Newtown Road INSURER ri COtuit,MA 02635 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. LT ADDLISUBRI TYPE OF INSURANCE NSR WVD POLICY NUMBER MM/DDY/YYYY MM/DDY� LIMITS A GENERAL LIABILITY MPB1075H 6/08/2012 06/08/2013 EACH OCCURRENCE $1,000 000 X COMMERCIAL GENERAL LIABILITY PREMISES(E.occur°nce) $500,000 CLAIMS-MADE a OCCUR _ MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 r GENERAL AGGREGATE -$2,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOC A AUTOMOBILE LIABILITY M1 M28044 6/08/2012 06/08/201 COMBINED SINGLE LIMIT Ea accident $500,000. - ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ X Drive Oth Car $ A X UMBRELLA LIAB OCCUR CUB1076H 6/08/2012 06/08/2013 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE - $5 000 000 DED I X RETENTION$10000 $ B WORKERS COMPENSATION YIN N WCC5010547012011 12/25/2011 12/25/201 X WC STATU-I - OTH- AND EMPLOYERS'LIABILITY - IFR ANY PROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $1,000 000 OFFICER/MEMBER EXCLUDED? I N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000 000 If yes,describe under DESCRIPTION OF OPERATIONS below - - - E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOO Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©198 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S82889/M82857 TLH f The'Commonwealth of Massachusetts } Department of Industrial Accidents - Office-of Investigations 600 Washington Street Boston,.MA 02111 www.massgov%dia Workers'-Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber's Applicant Information Please Print Leaibly Name(Business/Organizatibn/Indivi dual): "Vex /1J G Address: . ifs 1V61- PI LU/d p City/State/Zip: f ® �- ,r 8,2 .� Phone M .3*240P y4 9S*,/�*Are 4ou an employer?Check the appropriate bog: Type of project(required): 1. I am a'employer.with' 7© 't' 4. ❑'I am a general,contractor and I employees* full and/or art-time .* -have hired the,sub-contractors 6 ❑New construction ( . P 2.0 I am a sole:proprietor or partner listed`:on the attached sheet. 7. ❑Remodeling shipand have no em to .ees `These sub-contractors have P Y 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Build* addition comP•insurance:$ ' [No workers'comp.insurance: ' 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 Y.El 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 A� - employees. [No workers' 13: Other W 0 n�OWJ -: comp.insurance required.] *Any applicant that checks box#t must a$so fill out the section below showing their workers'co ropensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have' employees. If the sub-contractors have}wployees;they must provide their workers comp.policy number, r I am an employer that is providing workers'comperisation'insurance for my employees Below is the policy and job site information. Insurance'Company Name ff.��aLl���l�'` ���L��/ d' V v®'.44064 C�Q V W�G�Oi Polic #or Self-ins Lic. /'a2�a2, l,Z 0` Y 7 Expiration Date_ y� I _ Job Site Address: y ' rJ��� City/State/Zip: 1, 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 2Skof MGL c.152 can lead to the impositionof 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 maybe forwarded to the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certify under a pains and enal es of perju that the information provided above is true and correct Signature: 'Date: 9 i�1 ZUIv } Phone �U0 YOLIKf . 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)-, , F 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Page 7 of 7 Capizzi Home Improvement Inc. STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT' OWN THE PROPERTY LOCATED AT IN v1 l� MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LES SEE TO APPLY FOR A BUILDING P:DE; 'T IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING -- SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: 1 0� ylZz1�0 i 0M V ( zx� �°�' van of Barnstable ` *Permit# f /1�� 9 APR. 6D �1 Expires 6 moot! fr nr is ue date ` T° 2010 Regulatory Services Fee + saxtvsrABLE. + -r MASS. � Fe��1VS Thomas F. Geiler,Director �pJf1 MAC A`0 - 71A��� Building Division- Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax:.508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid with Red X-Press Imprint Map/parcel Number M& 057 `. Property-Address ( �i� i XC� i7X� esidential Value of Work ed .d of Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address S2i "-Z_L"A, � Cant ae4�r Telephone.Number oveme eus pplicable) . Co ion upervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: . ❑�am a sole proprietor �J 1 am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit: Permit Request(check box) ®Re-roof(stripping old shingles) All construction debris will be taken to ' ❑ Re-roof(not stripping. Going over existing layers of roof} ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows l *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. I ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. SIGNATURE: lassachrrsetts The, Commonwealth ofN Department of Industrial Accidents Office oflnvestigations doo Washington.Street c_ Boston, MA 02111 rvfv P,mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl <Name(Business/Organization/Individuat): i -,,Qddress;` � /Sta /Zi Phone a`City Are you an employer? Check the appropriate bK Type of project(required): 1.F1 I am employer a em to with <,4� I am a general contractor and I ❑P Y 6.� New.construction employees (full and/or`part-time).* have hired the sub-contractors . 2.❑ I am a sole proprietor or partner- listed on the attached sheet.. 7, ElRemodeling ship and have no employees These sub-contractors have g,. Demolition NY for me in an capacity. employees and have workers' g. Y P Y 9. Build' addition [No workers' comp. insurance comp.insurance,$ . required.] 11 5. 0 We are a corporation and its 10.❑ Electrical repairs or addition 3.❑ I am a homeowner doing all work officers have exercised their l 1.Q Plttinbing repairs or addition myself. o workers' com right of exemption per MGL y [N p. � 12.0 Roof repairs. insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 1311 Other comp,insurance required.] ''Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those enti ties 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 thepolicy and job site information. Insurance Company Name: t Policy# or Self-ins.Lic.#: Expiration Date:, Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy'declaration page(shoving 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$1,500.06 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fins F 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 certify under the pains and penalties of perjury that the information provided above is true hnd correct. Si:ature: 1 Date: /v �P1iOF onAe#... Official ztse only. Do not write-In this area, to be completed by city or totvn'official. -City or Town: Permit/License# Issuing Authority.(cirele one). 1:Board of Health 2:Building Department 3.,City/Town Clerk 4. Electrical Inspector S. plumbing Inspector .b. Other y, Information and: Instructions i Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as".,.every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more ed in a joint enterprise, and including the legal representatives of a deceased employer, or the of the foregoing engaged � P the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However in not mor e than thre e apartments and who resides therein, or the occupant of owner of a dwelling house having P ouse dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling h or on the grounds or building appurtenant thereto shall.not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Checking the boxes that apply to your situation and, if Please fill out the workers' compensation affidavit completely,by g necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not.required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contac'you regarding the applicant. Please be sure to fill in the permit/license number which will.be used as a.reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the.applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617427-7749 Revised 4-24-07 www.mass.gov/dia The Commonwealth of,111assachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 3' wfvw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel?ibly Name (Business/Organization/Individual): —✓� Address: 10 M 4 K t: 4/Vt; City/State/Zip: HAN11view /RA L 0;2 Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a er with employer 4. ❑ 1 am a general contractor and,I P Y6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑`Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and havemorkers' 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 homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions ___myself.[No.worke..rs' comp., right of exemption per MGL 12.❑_Roof.,repairs insurance required.] t c. 152;§1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Belofv is the policy andjob 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 certify under thepains andpenalties ofperjury-that the information provided above is true and correct. Signature: Date - ' Phone# S-0 Sr-- 3 , !;Z t;?-- , Official use only. Do not write in this area, to be completed by city or town official City or Town:: Permit/License# Issuing Authority (circle one): 1. Board of Health 2..Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the association or other legal entity, employing employees. However the receiver or trustee of an individual,partnership, g tY> owner of a dwelling house having not more than three apartments and who resides therein, or;the occupan t of the dwelling house of another who employs persons to do maintenance, constriction 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,NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,.are not required to carry workers' compensation insurance. Tf an --L :C or`LL' does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the.Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permiUlicense applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may'be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts i Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia r- Town of Barnstable' f-1HE " Regulatory Services o� Thomas F.Geiler,Director • Bwrtrtsrnst.r. - . Building Division 9� s619. g,�� _ PTEDya Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 myW.town.barnstable.ma.us �r Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street vil age UA " OW HOMENER": -- (� �.0-''� name home phone#1 ork phone#1 CURRENT MAILING ADDRESS: ' z (�o2 76 C5, 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 whoconstructs 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/ 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, requi ements: Signature of Homeowne ` ,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. 3' 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 supeivisor(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 hclshe 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 fomi/certification for use in your community. VE rod Town of ]Barnstable Regulatory Services anxxsrAsLX. ' Thomas F. Geiler,Director 9 MA8.9. $ i) Building Division �fD►v1A'�� Tom Perry,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 Own r Date , L.EN JUI2JD/4 Print Name if Property is applying for permit please complete the Homeowners License Exemption Form on the reverse side. . 0 F K a 0 Q so 78 6 GE 121 . 625:L2 DECLARATION OF TRUST ESTABLISHING THE 91 BERNARD CIRCLE REALTY TRUST I, ANNE DWORKIN, do hereby declare that I and my I successor(s) in Trust hereunder, will hold all such properties as may be transferred to me as such Trustee, or to any successor Trustee(s) hereunder, in trust for the sole benefit of the beneficiaries for the time being hereunder, upon the terms hereinafter set forth. All references hereinafter to the term "Trustee" (although hereinafter generally used in the singular), wherever used herein, shall be treated as a reference to such person (or persons) of such gender and number who are at that time serving as Trustee (or Trustees) hereunder, and shall, as applicable, include as the original Trustee, and such person or persons who hereafter are serving as a successor or additional Trustee (or i Trustees) hereunder. All rights, powers, authorities, and privileges reserved hereunder by and for the Trustee (or Trustees) may be exercised by the original Trustee or by any f person or persons who hereafter is or are serving as Trustee or Trustees hereunder, subject to the provisions hereof. 1. Name of Trust. The Trust hereby established shall be referred to as the 91 BERNARD CIRCLE REALTY TRUST. i 1 i p, eov..'7806 DACE 122 2. Beneficiaries. The current beneficiaries of this Trust are the persons who are listed on a "Schedule of Beneficiaries" setting forth the names and the respective percentage interests of each such person. such Schedule has been executed by myself as Trustee hereunder and said beneficiaries, and may, from time to time, be amended by an instrument to any such effect as may be executed by the then Trustee(s) hereunder and each such beneficiary. If any beneficiary as, from time to time, listed in a schedule of Beneficiaries is a trust entity, the rights and powers of ouch entity as a beneficiary shall be exercised by all of the trustees thereof, or by such of the Trustees as are empowered by the trust instrument therefore to act on behalf of such trust entity. Except as otherwise permitted by all of the beneficiaries, the interests of the beneficiaries (subject only to descent and distribution by will or by operation of law) shall not be transferable and their respective percentage interests shall remain as set forth on said schedule, as, from time to time, amended. In the event of a transfer of any such beneficial interest by will or by operation of law, the consent of any such transferee to any action by the Trustee shall, at all times, be presumed to have been made and actual consent by any such transferee shall not be required. Any Trustee hereunder may, without impropriety, be or become a beneficiary hereunder and exercise all rights of a beneficiary with the same effect as though he or she were not a Trustee. 2 a BooK 7806 PAGE 123 3. Trust Estate for Benefit of Beneficiaries. The Trustee shall hold any property transferred or conveyed to him or her as Trustee, and all issues and accretions in respect thereto, for the benefit of the beneficiaries from time to time (and all references hereinafter to beneficiaries 'shall be treated as a i reference to those who are at that time the beneficiaries hereof), shall be recorded in their favor or the Trustee shall make provision for dispositions thereof pursuant to the direction of the then beneficiaries. 4. Powers of Irustee(a. Subject to the written direction or consent of the beneficiaries, which shall be conclusively evidenced pursuant to the provisions of Section 8 hereof, the Trustee shall have full power and authority: , i (i) To retain the trust property in the same form of investment in which received, (ii) To sell and exchange trust property or any interest therein for such consideration and upon such terms as he or she deems advisable, including the taking and holding of notes and mortgages and granting discharges and partial releases thereof, (111) To purchase and otherwise acquire any real or personal propertyt to register and deregister in the Land Court'of the Commonwealth of j Massachusetts title to any real propertyf to r r submit the whole or any part of the Trust property to the provisions of Massachusetts G.L. (Ter. Ed.) 3 - 1 i 9 wK7806 ew 124 + c. 183A, the condominium statute, so-called, as the same may be amended from time to time, (iv) To borrow money and mortgage or pledge all or any part of the trust property and issue bonds, notes, or other evidences of indebtedness, (v ) To invest any of the trust property in such manner as he or she may deem advisable without being limited as to the kind or amount of any investment, (vi) To incur obligations and to pay, compromise or, adjust ,all obligations incurred and rights acquired in the administration of the Trust, (vii) To determine whether receipts shall be accounted for as principal or as income, and as to all obligations paid by him whether the same shall be charged against principal or against income, (viii) To execute leases (as Lessor or Lessee) , (ix) To deposit any funds of the Trust in any bank or trust company, and to delegate to any one Trustee, or to any other person the power to deposit, withdraw, and draw checks on any funds of the Trust, (x) To manage, maintain, repair, restore and improve any property owned by the Trust, (xi) To obtain insurance covering the Trust property, 4 ', a K.�.- r...._......t'... eooN b6 PALf 125 A xii) To obtain advice of counsel and to rely thereon, and to employ, appoint and remove such other persons, agents, managers, officers, brokers, engineers, architects, employees, servants and assistants as he or she shall deem advisable, and to define their respective duties and fix their pay and compensationt but no Trustee shall be held personally liable for the act or default of any �. such person, ; (xiii) To grant permits, licenses, and easements over any Trust property for utilities, roads, or other purposes including imposing restrictions i reasonably necessary or useful for the proper i - maintenance or operation of the Trust property, (xiv) To do anything and everything also necessary and proper for the sound management and administration of the Trust property, (xv) To execute any and all instruments incidental or necessary to carry out any of the foregoing powers. Any Trustee shall have full power and authority to delegate, by suitable written instrument, to any person or persons, acting singly or together with others, whether or not serving as a Trustee hereunder, full power and authority to perform such acts and to execute such instruments which such Trustee might do or perform under this Declaration of Trust. 5 ....,...... Ste DOOK7806 PAGE 126 Any and all instruments executed pursuant to powers herein contained may create obligations extending over any periods of time, including periods extending beyond the date of any possible termination of the Trust. Notwithstanding any provisions contained herein, no Trustee shall be required to take any action which will, in the opinion of such Trustee, involve him or her in any personal liability unless first indemnified to his or her satisfaction. Any person dealing with any Trustee shall be fully protected in accordance with the provisions of Section 8 hereof. S. Term of Trust: Termination. The Trust may be terminated at any time by the beneficiaries by notice in writing to the Trustesi and the Trust shall terminate, in any event, twenty (20) years after the death of the original Trustees) hereunder. In case of any such termination, the Trustee shall transfer and convey the specific assets constituting the trust estate, subject to any lease, mortgages, contracts, and other encumbrances or matters affecting the trust estate, to the beneficiaries in proportion to their respective interests. 6. Resignation. Removal Addition, Suagession of Trustee. Any Trustee hereunder may resign by written instrument signed and acknowledged by such Trustee and such resignation shall, as respects real estate interests in the name of the Trust, be recorded or filed with each such Registry of Deeds or Registry District of the Land Court, as applicable, (the "Registry") within each such County in which any real property interests of 6 i Book 7806 vacF 127 the Trust are then located and in which this Declaration is to be recorded. At any time or times, a majority in interest of the beneficiaries may, by written instrument to the following effect, remove (with or without cause) a Trustee and/or add one or more �. t additional Trustees) hereunder. The removal of a Trustee, if exercised by the beneficiaries, shall be reflected by a ' � Certificate, reciting such removal, executed and acknowledged by any Trustee then in, or succeeding to such office, and recorded or filed (as and if applicable) with the Registry. if, for any reason, the original Trustee or any additional Trustee as appointed by the beneficiaries shall cease to be a Trustee hereunder, such Trustee shall be succeeded (and,.any further vacancies in such office of Trustee shall be filled) by such person as may be designated by such written appointment as the beneficiaries may, but without obligation, effect (provided at least one Trustee remains in, or is appointed to, office). Any person appointed or succeeding to the office of Trustee i hereunder, pursuant to written appointment by the beneficiaries, as aforesaid, shall become a Trustee upon acceptance of such appointment, to be represented by written,instrument to that effect signed and acknowledged by such,person and thereupon duly �. recorded or filed with the Registry. A statement by such successor or additional Trustee, in such written instrument of acceptance, that he or she has been duly appointed as Trustee, • ` pursuant to the provisions of this paragraph, and that he or she iy ' 7806 vacr 12 ��. BOOK 8 accepts such appointment, shall be conclusive evidence of his or her appointment as Trustee hereunder and of the facts upon which such appointment was predicated. Upon the appointment of any additional or successor Trustee, the title to the trust estate shall thereupon, and without the necessity of any transfer or conveyance, be vested in the said additional or successor Trustee jointly with the remaining'' Trustee(s), if any. Each succeeding Trustee shall have all the rights, powers, authority and privileges of a Trustee hereunder as fully as if named as an original Trustee hereunder. No Trustee shall be required to furnish bond. 7. Amendment of Declaration of Trust. This Declaration of Trust may be amended from time to time by an instrument of amendment signed by the then Trustes(s) hereunder and the beneficiaries, provided, in any event, that no such amendment shall become effective until either (a) such instrument of amendment or (b) a certificate by any Trustee, setting forth the Iterms of such amendment, has been signed, acknowledged and recorded or filed (as and if applicable) with the Registry. B. Trustee Resoonsibillty/Reliance by ThirQ Rarties. No Trustee hereunder shall be liable for any error of judgment nor for any loss arising out of any act of omission in good faith, but shall be responsible only for his or her own willful breach of trust. No license of court shall be a requisite to the validity of any transaction entered into by the Trustee(*). No purchaser or lender shall be under any liability to see to the .8 BOOK % PAGE 128 accepts such appointment, shall be Conclusive evidence of his or her appointment as Trustee hereunder and of the facts upon which such appointment was predicated. Upon the appointment of any additional or successor Trustee, the title to the trust estate shall thereupon, and without the necessity of any transfer or conveyance, be vested in the said additional or successor Trustee jointly with the remaining Trustse(s), if any. Each succeeding Trustee shall have all the rights, powers, authority and privileges of a Trustee hareunder as fully as if named as an original Trustee hereunder. No Trustee shall be required to furnish bond. 7. Amendment_of Declaration of Trust. This Declaration of Trust may be amended from time to time by an instrument of amendment signed by the then Trustes(s) hereunder and the beneficiaries, provided, in any event, that no such amendment shall become effective until either (a) such instrument of amendment or (b) a certificate by any Trustee, setting forth the terms of such amendment, has been signed, acknowledged and recorded or filed (as and if applicable) with the Registry. 8. Trustee Responsibility/Reliance by Third parties. No Trustee hereunder shall be liable for any error of judgment nor for any loss arising out of any act of omission in good faith, but shall be responsible only for his or her own willful breach of trust. No license of court shall be a requisite to the validity of any transaction entered into by the Trustee($). No purchaser or lender shall be under any liability to see to the 8 I 8007806 PACF 129 application of the purchase money or of any money or property loaned or delivered to any Trustee, or to see that the terms and conditions of this Trust have been complied with. Every agreement, bill of sale, assignment, lease, deed, mortgage, note or other instrument executed by any person appearing from the records at any Registry to be a Trustee # hereunder, shall be conclusive evidence in favor of every person i relying thereon or claiming thereunder that, at the time of the delivery thereof, this Trust was in full force and effect and that the execution and delivery of such instrument was duly directed by the beneficiaries. Any person dealing with the trust property or the Trustee(s) may always rely, without further inquiry, on a certificate signed by any person appearing from the records at the Registry to be a Trustee hereunder, as to (i) whether or not the Trust has been terminated, (ii) who are the Trustee(s) or the beneficiaries hereunder, (iii) the authority of the Trustees) to act, (iv) the existence or non-existence of any fact or facts which constitute conditions precedent to acts by the Trustee(s), or (v) any other matter germane to the affairs of the Trust. In the event that the Trustee hereunder shall be a corporation, then any action required to be taken by the Trustee hereunder and evidenced by a written document shall be conclusively presumed valid, binding, effective and legally enforceable in accordance with its terms and the terms of this Trust if such written document is executed and acknowledged in 9 Y; ' H • BOOK7806 Ffia 130 1 the name of such corporation as Trustee by its President and Treasurer. 9. Third Party Riahts Aaainat Trust Estate only. In every written contract made by the Trustee(*), reference shall be had to this instruments and any person.contracting or dealing with the Trustee(s) shall look only to the trust estate or corpus and not to the Trustee(s) individually nor to the beneficiaries for the payment of any debts, note, mortgage, judgment or decree or any other obligation or of any money that may otherwise become due and payable by reason of the failure on the part of the Trustees) to perform such contract in whole or in part or for any other cause or reason. 10. Action by Any 20a Trustee. It is expressly understood that any one Trustee hereunder, acting alone, may exercise any and all powers of the Trustee(s) hereunder, including, without limiting the generality of the foregoing, the execution of bills of sale, assignments, deeds, agreements, mortgages, notes, leases, and other instruments and contracts, with the same force and effect as if all Trustees) had so acted. Executed as a sealed instrument as at the day of ��gerr• !tee/ , 1991. A ♦r''r /EDWORKIN, Individually ANNIE DWORKIN, Trustee 10 wx 7806 PAGE 131 COMMONWEALTH OF MASSACHUSETTS sS. �(C�c,-��'i �2., 1991 Then personally appeared the above named ANNE UWORRIN, and acknowledged the foregoing instrument to be her tree act and deed c before me, My Commi Lion E "ad� i I f 1 • 11 i DEC 23 9 I, y BDOR 78O6 PAcc 131 COMMONWUUM OF NA88ACHUSETT8 5cjrFDc-� • $s. DCcew4 -- (z., i991 Then personally appeared the above named ANNE DWORKIN, and acknowledged. the foregoing instrument to be her free act and deed c before me, jj My Comma lion E i�ad� , g, A 11 DEC 23 91 , r.. . i the Trustee(s) , and (2) a parent, guardian, conservator, or person or persons acting in a similar fiduciary capacity for any permissible income beneficiary (a) who has not yet attained the age of twenty-one (21) years or (b) who has attained the age of i f twenty-one (21) years and is then under any legal disability known to the Trustee(s) . In the event of a- vacancy in the office of Trustee as a result of a resignation pursuant to the terms hereof, a Successor Trustee shall be appointed in accordance with the provisions relating thereto in ARTICLE "EIGHTEENTH. 1 i 1 ARTICLE EIGHTEENTH: Appointment of Successor Trustee. In the event that the said ANNE DWORKIN shall for any reason, including removal, death, incapacity or resignation, cease to serve or fail to qualify as Trustee hereunder, then the Donor's. spouse, EDWARD DWORKIN, and WILLIAM N. FRIEDLER of Brookline, g Massachusetts, shall serve as successor Co-Trustees in her stead. In the event that the said WILLIAM N. FRIEDLER •shall for any reason, including removal, death, incapacity or resignation, cease to serve or fail _to,"qualify as Co-Trustee hereunder, the. then Managing Partner of the Law Firm of WILLIAM N. FRIEDLER, P.C. , or its successors and -assigns in interest,. shall serve as successor Co-Trustee in his stead. In the event that the Donor'.s said spouse, EDWARD DWORKIN shall for any reason, :including removal,, death, incapacity or resignation, cease to serve or fail to qualify as Co-Trustee hereunder, then the Donor's daughters, HELEN JORDAN of Newton, J Massachusetts, and RUTH SHERMAN of Randolph, Massachusetts, 36 jointly or the survivor of them, shall serve. as successor Co- Trustee(s) in his stead. In the event that both the Donor's said daughters,' .HELEN JORDAN and RUTH SHERMAN, shail "for any reason, including removal, death,- incapacity or ,resignation, cease to serve or fail to qualify as successor Co-Trustees hereunder, then the remaining Co-Trustee may serve alone with full power and authority. It is the Donor's intent that after the. death. of the Donor there shall be at least one Trustee of this Trust who is not a beneficiary of this Trust, or a person who is obligated to support under local law a beneficiary of this Trust. If, at any time, a vacancy in- the office of ,Trustee 'shall exist and the appointment of an additional Trustee is required hereunder (and if there is no provision made hereinabove for® the . appointment of a .successor or .additional Trustee or if .such . provision is made but all "of .the persons appointed by the Donor shall refuse. or be unwilling or unable to serve as. Trustee ' hereunder or shall all be beneficiaries of the Trust or persons obligated under local. law ,to support 'any,beneficiaries of this Trust), any such. vacancy may .be filled by the Trustee(s) then, y serving, or if no .Trustee be' then serving, or in default of the exercise of the within, power by the Trustee(s) then serving continuing for a period of thirty (30) days, by the unanimous consent of all of the then income beneficiaries hereunder who .have attained .the age of twenty-one (21) years, who are not under legal disability, and who are, or, in the discretion of the 37 good faith. ARTICLE THIRTY-FIRST: Execution in Counterparts. This Indenture of Trust, and any amendment hereto, may be executed in several counterparts, and all counterparts so executed shall constitute one instrument binding on all parties, notwithstanding that all parties, have not signed the originalor the same r counterpart. IN WITNESS WHEREOF, ANNE DWORKIN as Donor, and the said ANNE DWORKIN, as Trustee, has hereunto set her hand and seal the date first written above. NE DWORKIN, Donor ANNE DWORKIN, Trustee i; COMMONWEALTH OF MASSACHUSETTS G, rf4'DC_k' SS:- , 1.991 On this (Z day of �8cPt�..��'ci 1991`, before me personally appeared the above-named ANNE DWORKIN to me known to be the person described in and who executed the foregoing instrument and acknowledged that she _executed the same as her free act and deed. z - _ _ ' ! \� i• �` ill ~ Rotary Pu lic My Commission Expires: /� /-4 / 48 04--15`10 11:29 FROM-The New Law Center 617-492-4401 T-597 P002/002 F-299 THB rl4aW LAW.CENTER Douglas C.Reynolds,Esq. deynolds@thenewlawcenter.com Law •Dispute Resolution - Organizational Consulting Ext.103 April 15,2010 Via Facsimile: 508-790-6230 &First Class Mail Town of Barnstable Building Division 200 Main Street Hyannis, MA 02601 ATTN: Jeffrey Lauzon, Building Inspector Re: 91 Bernard Circle, Centerville, MA(Property of Dworkin) Dear Mr. Lauzon: I represent Helen and Ruth Dworkin as trustees of"Anne Dworkin Revocable Trust" which owns(through 91 Bernard Circle Realty Trust).the above property previously occupied by Edward Dworkin(please note that the Anne Dworkin Revocable Trust became irrevocable at the death of Anne Dworkin in October 2004). This will confirm that Edward Dworkin is unable to perform any duties regarding the care and maintenance of the 9.1 Bernard Circle property. Mr. Dworkin is now in fulltime care at Harbor Point in Centerville. truly yours, Vrry Douglas C. Reynolds DCR/car COMMONWEALTH OF MASSACHUSETTS - Middlesex,ss. April 15,2010 On this 15th day of April, 2010, before me, the undersigned notary public, personally LU speared Douglas C. Reynolds, and proved to me through personal knowledge or through rsatisfactoY evidence of identification to be the person who signed the preceding or attached iocumenfy and acknowledged to me that he signed it voluntarily for its stated purpose. 14U15y Public My o isstoi ,R086tTSUN f Nfty Pubic SUNduft :\1-DCRt2 ClntsMttrs-Law\DworkinTrust\L-TwnBrnstb-4-15-10.do x D�° Na My CortunftMon ENpkn 3upWber2162018 ,545 Concord Avenue, Suite 15 Cambridge,MA 02138 • Tel.617.492.4400 Fax.617.492.4401 www.TheNewLawCenter.com Page# of pages CeAs~ C'cCS Proposal Submitted To: Job Name. Job.# ' TO Address f�ernG J r�� Job Location91 , Date " Date of Plans (f enter 2 C QZ, 3 /C7 Phone# Fax# Architect We hereby submit specifications and estimates for: -_. eum -� _--_---�-- _fc>�c_�._cc �r_�c_�n_�n�: ��lt �---_�.c�-�___• ._ r_r. _a -t�o�__._�_'_�_.__�------------ s // ter.-`/_,o` s.. _ - -G_ goo ,T�y�"z`'a././ �o dear c?.�'�ia�'u��e.�f`_.�h:�,c�-•es_ _______.__ ..:__. _---.__��.,�/" _ �3!/_ti_-�a.�,__�n_c_�_c�6r�s cup` /_d__e_-cerra�t�e,�-.._a�_cQi.��,se�oQ___a�'�: �r_/ _�__'`•_:,�_..,_ �Qt2!`/�c%S.___ LCCc/"Gi/_�i:.�C.��. _/7?G.4_ttf Cc�'tit�,�'•._�l3/"!�'1�-Gi./I€�1 i.` ....__...._.. We propose hereby to furnish material and labor'- complete in accordance with the above specifications for the sum of: $ ( 11nCWd Oeo l Dollars Cj with payments to be made as follows: �K o® G F P�n com���tr 6n Any alteration or deviation from above specifications involving extra costs will Respectfully be executed only upon written order,and will become an extra charge over and submitted above the estimate-All agreements contingent upon strikes,accidents,or delays beyond our control. Note-this proposal ma be withdrawn by us if not accepted within days. (lcrjeyta re of JJrvyosal The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Payments will be made as outlined above. _ Date of Acceptance 2'z(, �( it-AL Signature —Aeki�— & NC3819 a c _ THE NEW LAW CENTER Douglas C.Reynolds,Esq. ��- deynolds@thenewlawcenter.com Law• Dispute Resolution •Organizational Consulting Ext.103 April 15, 2010 Via Facsimile: 508-790-6230 & First Class Mail Town of Barnstable Building Division 200 Main Street Hyannis, MA 02601 ATTN: Jeffrey Lauzon, Building Inspector .Re: 91 Bernard Circle, Centerville, MA(Property of Dworkin) Dear Mr. Lauzon: I represent Helen and Ruth Dworkin as trustees of"Anne Dworkin Revocable Trust" which owns(through 91 Bernard Circle Realty Trust) the above property previously occupied by Edward Dworkin(please note that the Anne Dworkin Revocable Trust became irrevocable at the death of Anne Dworkin in October 2004), This will confirm that Edward Dworkin is unable to-perform.any,duties regarding the care and maintenance of the 91 Bernard Circle property Mr Dworkin is now in iulltime care at Harbor Point in Centerville. V ry truly yours, Douglas C. Reynolds DCR/car COMMONWEALTH OF MASSACHUSETTS Middlesex,ss. April 15,2010 On this 15th day of April, 2010, before me, the undersigned notary public, personally,. appeared Douglas C. Reynolds, and proved to me through personal knowledge or through = ' satisfactory evidence of identification to be the person who signed the preceding or attaclied; - document,and acknowledged to me that he signed it voluntarily for its stated purpose. o .ry Public... 4 yC �,Omgjys 16 i.ROBEi t'S0N_ t�lofery Pablc, S:\1-DCR\2-C1ntsMttrs-Law\DworkinTrust\L-TwnBrnstb-4-15-10.do x My Canv dmiM EXPVM Sepbember231,2016 6� 545 Concord Avenue,Suite 15 Cambridge,MA 02138 Tel. 617.492.4400 Fax. 61 7.492.4401 www.TheNewLawCenter.com Y r- Tj t y vs MAZZVR rfEMEto , Ni t �-,a i dam: ,� ��•,' ♦ �' 91 Bernard Circle, Cent. 4/612010 1 .. 1 ... 4 1-Bernard Circle, Cent. 4%6f } s r f� 1 i 91 Bernard Circle, Cent. 4/6I2010 i C. 1 (1 91 Bernard-Circle, Cent., 416I2010 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM A , -, I / �C(�J L DATA Y���•;`'.e TOWN OF BARNSTABLE Permit No. ----------_------- } Building Inspector •aun.a � rua oO�OYPYr\ OCCUPANCY PERMIT Bond ---—_ "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. I9... . .................................................................................................__._._. Building Inspector N o . s,f �\k � tr"000 u� Z GONG. N eo Foun�o. -� ZR ri 'OfJ ©U owi-7er: G ELV/S GOA L-�0A/ ScAQ,e-4e r,& CiEltilG L07- I i.v PL . 4(3C. PG . 3 2 A ece°dY COAVriiY rsNgr ' WAF 8t,✓IA,01A.I4* sNow,c.r o,v rNia IS Z.00 A97-4&a 4OA/ 7We y�cov v» As 3fdo W.N NBCBO / A,v ra rNrgT /7' MOM& UoE s coAv,#ro,lrA-r ro .rNA=' .z4P.vi.v0 , BY-L.gM/S O.- rA I& 7RbW" OF 3fi�2Ns y As34E - ��3x tt+x'r►. 61-- 113 Gorcdo/7 r Assessbr's nap and lot number l..Q.. . 0*TNE? O d Sewage Permit number ..�� ./••%�.�............................... n -,-SEPTIC v . ......V.1# f.......... a /�� cSTSTEM MUf�fr Z BARNSTALLE. . House number INSTALL.E� �� 9 '"a o� LE yrCOMP'UANef 00 iMA-1 \�0 r VVV!1TN V �0 MAY a' M- 1ZEND TOWN O BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........................... ...........................................................:................................ TYPEOF CONSTRUCTION ..................................................................................................................................... �rr�........ 7..........19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location D C�� ..............................�� Proposed Use ...... .......... ....... .......................... ZoningDistrict 1- Fire District �—........................................................ .............................................................................. Name of Owner ..G �GtJ/5.......`.c?.����z??'h.�. J� �� S��/.. 4/ ... �..... .......... ..... ...........Address .... ..... Name of Builder :........... ................................... .......Address �` ....... ..................... Name of Architect .... ... ....... ........ lam. ....... ........ ....Address ............................. . ......................... t...... ........ Number of Rooms .......... Foundation 1«- �S .77. /a Exterior ... ' .. L ... . ............................Roofing ...../` 5���i�!9 � ............................................. Floors .. . ....... ..... ........ ................ .....Interior ... ...`� �� ............................... J Heatinglumbing .................................................................................. Fireplace .......................i..........................................................Approximate Cost ......... ©0� Definitive Plan Approved by Planning Board _ ----- Area ............ . Diagram of Lot and Building with Dimensions Fee ` C� ........ ...... . V............�'. ........ SUBJECT TO APPROVAL OF BOARD OF HEALTHQ� �® OO. DG£ xv �l q SF.1.00rIT' o z6 y� i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstablegar g th above construction. Name ... ........ .. ... .:�. ...... 5 GORDON; LEWIS 23174 One Story ` to ................. Permit for .................................... " Single Family Dwellin .................................................... ............. Location Lot #28 91 Bernard Circle ............................................................. _. Centerville ............................................................................... Lewis Gordon rOwner .................................................................. _ Type of Construction .......Frame ......... ................................................................... rPlot ............................ Lot ................................ Permit Granted June 8, ...............................19 81 , Date of Inspections f..................19 Date Co pleted ......... �? R'�%_ PERMIT REFUSED W . A+ ........................................ 19 ........... .x'. .�. ...................................................... ........................................................... ............................................................................... - - Approved ................................................ 19 ............................................................................... f .......................................................... Assessor's map and lot number ...... .vr..... � Permit `�7..:................................ Sewage ` (�V � "................................................. Z�BAH House number ........A..f.. 'J KAM .: 1639. r a Mar TOWN OF BARNSTABLE BUILDING 110PECTOR APPLICATIONFOR PERMIT TO ............................................................................................................................. TYPEOF CONSTRUCTION ..................................................................................................................................... �. .. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......... �Ar'�� J% /.. .�.. .. ..... .................................................� ................ ....... . ....� _ Proposed Use ......: �tilC:,..�.. ............! R�-AIG. r /7GGi�J G�- ............................ .................. ........................... ..................... Zoning District 4 C .............................Fire District ........:: �.�. Name of Owner .... .�4. ...... �" ' �TZ/�ca� a............Address .. � �<.: .... ' C':..... Name of Builder ..............................Address ...........� ��^�!-. . . 1...../...................... ........................... c7 �,ems../ `� E �}s N!5 "� .Name of Architect .....:................... ........ ... ...Address .......... r Number of Rooms .........:,.`�.....................................................Foundation ..... ....�- S.r %' ���j A Exterior :� ,..........................................Roofing ...... ................................................... cam- f. f f l� r,.. .;,+!,/•. Floors / ... .� ... Interior ....•!..... ? . , " .:...................................... .. ... .. ... tiOHeating W... .... ....... . Plumbing ................. f........... ..................................................... Fireplace ....(4�........................................................................Approximate Cost ............v..................................................... b ; Definitive Plan Approved by Planning Board _____ ___/�'�______19 Area Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 1, i I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... '.�....... !'... !` VGORDON, LEWIS CLZ 8-57 No .:.23174 permit for , One Story .............. .-Single Family Dwelling ............................................................................... Location Lot *28 91 Sernard Circle .................................................... '.r Centerville Owner Lewis Gordon......../; Type of Construction ,.,,Frame Plot .................................Lot �........................... Permit Granted ......... 19 Date of Inspection ......... ........................19 Date Completed ........ .............................19 a PERMIT REFUSED ..... ................. 19 �..... ......................... ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... Assessor's office(1st Floor): J)6- Assessor's map and lot number o Conservation ✓ —� Board of Health(3rd floor)/. • Sewage Permit number ✓ �� �—Z221 t D ]tADt2 � rua Engineering Department(3rd floor): �o oe39. House number �o ror r. Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO N 8o-Om TYPE OF CONSTRUCTION jai f o2� 19 `jam TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit acc�cording to the following information: Location --- I-d— `�( t�l�/N�ti4'� �, dE C-4j j-4:w Proposed Use St/ a/ e >M s s Zoning District ' District Name of Owner r L �� - �� ��`Kddress 91 c-L Name of Builder ��� �� �/'O '2�c-V Address Name of Architect Address Number of Rooms / Foundation 7 l® �'°'� S®tv4of �✓13 G-"S Exterior r--� U4- L Roofing mot&fsnloa 116096 Floors Interior Heating Plumbing Fireplace Approximate Cost y�S�e o. Area < S - D�_ Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. NameG ^Q/`� Construction Supervisor's License ADWORKIN, EDWARD & ANNE No 35404 •-- permit For BUILD SUN ROOM Single Family dwelling t Location Lot #28, 91 Bernard Circle Centerville r Owner Edward & Anne Dworkin Type of Construction Frame i a Plot Lot Permit Granted September 29 , 19_ 92 Date of Inspection 19 ' Date Completed 42y 19 J r o k'- V Arl ;a 1 \ / II,A3 v Zp (,n _'o8 9� L O Joe, \ 1 � 1 BLOC. 7- 0 A-1 7- ?O — FT, $ / OE' j E -9 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE::. J fi/� l z m aio� , Z- JOB LOCATION `7 1 'R e 4x� rz r> Number Street Address Section Of Town "HOMEOWNER" G la ujo-moo 7:;)u-/d a I<i Name Home Phone Work Phone PRESENT 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 such 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 to six 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, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements HOMEOWNER'S SIGNATURE cLcv�c.�--sue APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127 . 0, Construction Control. MISC5 fix_ HOME OWNER'S EXEMPTION The code states that: "Any Home Owner 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-) Home Owner engages a person(s) for hire to do such work thato such dHomet if Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware ,that they are assuming the responsibilities of a supervisor see Appendix ppendx Q, Rules and Regulations for Licensing Construction Supervisors, Section 2 . 15 ) . This lack of awareness often results in serious problems, particularly when the Home Owner hires unlicensed persons.. In this case our Board cannot proceed against the unlicensed person as it would with licensed supervisor. The Home Owner acting as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, many communities require, as part of the permit application, that the Home Owner 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. i I r. S-c PIS 7��y j {germ.- No C,5 Nr> IY25f657 oFINKE , Town of Barnstable Regulatory Services • BnaxsTAeLE, 9 MASS. Thomas F.Geiler,Director �p i639. �� rF039 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 April 8, 2010 Stephen P. Mazzur 10 Mark Lane Harwich, Ma. 02645 RE: 91 Bernard Circle, Centerville Map: 148 Parcel: 057 Dear Mr. Mazzur: In accordance with 780 CMR 5118.6 you are hereby notified that a stop work order has been issued on the above property for violation of 780 CMR 5110.1 which states in part "It shall be unlawful to construct, reconstruct, alter, repair, remove...without first filing a written application with the building official and obtaining the required building permit and all other required permits therefore." Please be advised that failure to obtain the proper permits by April 22, 2010 may result in this office filing a complaint with the Building Board of Regulations and Standards against your home improvement registration. Penalties may include fines and/or suspension and/or revocation of your registration. Please call (508) 862-4034 with any questions. Thank you for your anticipated cooperation in this matter. 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