Loading...
HomeMy WebLinkAbout0012 BIRCHILL ROAD i - Nat/ --get � } , r , . h 0. q i0 i 61 n t, • st k �a, ,,. ' ��. l� ,. •ram ,' � � - � • .,. � � � �� � �' , ... ' a o r' Lt i ... is. u r , .. _ _ �, ., ., . w ' e ,, _, _ . ,. . ., a ;. ,_ - ,. , ,. .. ,., ., ,.. ;, . ,. .. .. .' � ._ _ .. .. ."s: �. - � � � - _ t Application number. 1 ' Fee................:............. ......... .. .................. Building Inspectors Initials....... ...It..... ................... 16` r Date Issued.* q..................... 9 Map/Parcel......�....6:..............�:.....�................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 131'16041 LL 9s3AZ> ht/®�R✓/L(E NUMBER STREET VILLAGE .Owner's Name: Deny 5-te�AtLc�l Phone Number Email Address: V 5T(W 35� (0 Yftbo,(OM Cell Phone Number s 7 ST 0 R 9 Project cost$ Check one Residential i% Commercial OWNER'S AUTHORIZATION , As owner of the above property I hereby authorize to make application for a buil ' g permit in accordanc with 8 C Owner Signature: Date: G-1f,- IR TYPE OF WORK E Siding 9-W indows (no header change)# ED Insulation/Weatherization 0 Doors(no header change)# Commercial Doors require an inspector's review 13 Roof(not applying more than 1 layer of shingles) ' Construction Debris will be going to YAK a­4�­t%�- 0k)V6SAi CONTRACTOR'S INFORMATION Contractor's name �,�, i ftiuLCy 50AJ- Home Improvement Contractors Registration(if applicable)# 13a 11 \ (attach copy) Construction Supervisor's License# C-6—��j`w (attach copy) Email of Contractor D 5TA'J"55`lQ � 4�GU.�� Phone number S s-737-01 G ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE PERMIT CAN BE ISSUED. OW ` . APPLICATION NUMBER............................................................ r *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No____, if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are.s ject to a building official's approval prior to issuance. AQN The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information xx Please Print Legibly Name(Business/Organization/Individual): �� t..lt��f LiJJ Address: 35-1 69-�I L ► jlqiy �. City/State/Zip: - L)2632-P6ne#: T_tt 737 'c4,1 Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 1 4. ❑ I 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- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P n'• $ . 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 11.❑Plumbing repairs or additions myself. [No workers' comp.` right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company.Name: V_AQ6L6P��) Policy#or Self-ins.Lic.#: ��� a.t {t)S ,5 Expiration Date: 10- 8 Job Site Address: CL 3 tF-4—, tkku- U City/State/Zip: M4; 0 243 2- 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cezd&under the airs nd penalties of perjury that the information provided above is true and correct. Si afore: J Date: Phone#• S-0$— 737`V`/1l 6 Official use only. Do not write in this area,to be completed by city or town official MCity 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 r 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 receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the 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. 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 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 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 Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration T132149 _ 11/27/2020 DEAN F.STANLEY DEAN F.STANLEY 359 CAPT.LIJAH RD U CENTERVILLE,MA 02632 Undersecreta N -t Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards i.4R Constrvttj',r!'Sb,ervisor :ter CS-035037. .4 4 E4pires: 01119/2020 i .. r DEAN F STANLEY # 359 CAPTAIN IJAH RD CENTERVILLE MA 020i '> k - � x- Commissioner ! j i � 4 DATE(MMIDDIYYYY) q`CPR V CERTIFICATE OF LIAB LITY INSURANCE 10a16-2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION O,4 LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NE GA-nVELY AMEND, EXTEND) OR ALTER THE.COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSI.RANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRO )UCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,th policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terns a Id conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to a certificate holder in lieu of such endorsement(s). PRODUCER CO TACT. NA E• SG&D INSURANCE AGCY LL PH NE FAX 540 MAIN ST STE 9 /u �N Atc No HYANNIS.MA 02601 A0 a [ INSURER(S)AFFORDING COVERAGE NAIL A - INS!RERA:TRAVELERS PROPERTY CASUALTY COMPANY OF INSURED RERB:. - E DEAN F STANLEY BUILDING I CONTRACTOR INC INS rRERc. 359 CAPT LIJAHS ROAD INS 4RER D:' j CENTERVILLE,MA02632 )Ns "RERE: I: IN RERF: COVERAGES CERTIFICATENUMBER: i I REVIS16N NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTE BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWMTHSTANC NG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TPI.IS 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 :,ZEDUCED BY PAID CLAIMS. INSR ADDL SUBR PO ICY EFF POLICY EXP { 1 TR TYPE OF INSURANCE INSO WVO POLICY NUMBER MN DIYYYY) (MMIDDIYYYYI ! LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CWMS-MADE❑ OCCUR DAMAGE TO RENTED S S(Fa occurrence) MED EXP(Any one n) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL`AGGREGATE $ POLICY❑ PRO- ❑ LOC PRODUCTS-COMPIOP AGG S JECT OTHER: S AUTOMOBILE LIABILITY OMBIN D SINGLE LIMIT g ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS i BODILY INJURY(Per accident) S HIRED NON-OWNED 11RqCLRQ�AMAGE S AUTOS ONLY AUTOS ONLY 4 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S € $ DED RETENTION S { E WORKERS COMPENSATION 4 PER OTH- AND EMPLOYERS LIABILITY [ STATUTE ER ANYPROPRIETORIPARTNER/ YIN EXECUTIVE OFFICERIMEMBER-__- --N-_..N I A... ...._..., _..-- EL-EACH ACCIDENT . $5100,000 7PJUB 10-08-2018 10-08-2019 EXCLUDED? E.L.DISEASE-EA (Mandatory In NH) 2E498575 EMPLOYEE S$500,000 If yes,describe under E.L DISEASE-POUCY S$100,000 DESCRIPTION OF OPERATIONS below J LIMIT S� i DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Rema ;Schedule,maybe attached if more space is required) WORKERS'COMPENSATION BENEFITS WILL BE PAID TO MASSAC USETTS EMPLOYEES ONLY.,, FURSUANT TO ENDORSEMENT WC 20 03 06 B. NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FO 'BENEFITS IN ANY STATE OTHER THAN MA IF THE INSURED HIRES,OR HAS HIRED,EMPLOYEES OUTSIDE OF MA.THIS POLIC41DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA. I CERTIFICATE HOLDER CAPCELLATION Town of Barnstable 200 Main at HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED EFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE Hyannis,MA 02601 IELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A { ORIZED REPRESENTATIVE 0 1 9811-201 5 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are (stered marks of ACORD r a INSULATION 2Q3 : I' IS.3 ®® fllIR RATTSGLASS QUI Il33 INSYTfOAM fUSPlNDlD YATTS DURlSf INSUIAitON DSIlIN6f 1-8.00-696-6611 DIVISION Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 r Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application: All work has been inspected by a certified Building Performance Institute '(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village c s,-4At/ey Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes ( ) ( ) ( ) ( ) ( ) Floors ( ) ( ) ( ) ( ) ( ) Walls ( ) ( ) ( ) ( ) ( ) Five�� Gvor Il /��r l�'or�►�ol y Sincerely V ssi r, President Ins ation, Inc. I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel - Applicafi0 Health Division _={ j„FDA IQsubf_ Conservation Division Apo Iication Fee Planning Dept. DtI Y!",� PermiF Date Definitive Plan,Approved by Planning Board Historic OKH _ Preservation / Hyannis Project Street Address Village ,� Owner_,�9z°��i�9,lo« / � G�SC Address .� Telephone 2 so Permit Request 9� eve Ael> j�',Jee 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: Q< Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 2Mo On Old King's Highway: ❑Yes I&No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION J (BUILDER OR HOMEOWNER) Name Telephone Number Address &16 dZ l �Zz License # 1dd0 Home Improvement Contractor#� 7 Worker's Compensation #PG D/f,5-..25�11 i T ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ( © \ \ /\ x FOR OFFICIAL USE ONLY , � \ APPLICATION* . DATE ISSUE \ MAP/PARCEL NO : , } } ADDRESS ' VILLAGE : OWNER DATE OF INSPECTION: . . . ( . } ! { FOUNDATION \ -FRAME { , INSULATION' `! § FIREPLACE ' ; • . \ Z \ z % ELECTRICAL: ROUGH FINAL . ƒ PLUMBING: ROUGH . FINAL } GAS.: , ROUGH FINAL � - - $ . ƒ :NALBUI D|NG i7f . f } . { ` z DATE CLOSED OUT ASSOCIATION PLAN NO. { { \ . 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC HENRY CASSIDY ,I 455 YARMOUTH RD. — -- HYANNIS, MA 02601 t ------ — ------ ---- Y} - t % 1�r. zUpdate Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CAI %r 50M-04/04-G101216 Office o-�``''mer Affalrs B,u,��s n/e Regulation License Or registration valid for icdividu!use cn-!y HOM RtY�1�°fS`'rtAZ� before the expiration date. 1f found return to: — Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Nark Plaza-Suite 5170 Boston,MA 02116 OD INSULATIO:N,JNC_,_ HENRY CASSIDY t �`l 455 YARMOUTH RDz_ ar — HYANNIS,MA 0260:,I ,Nr Undersecretary At ith t si ture I �1a" ic•husetts-Department of Public Safety Board of Bu`itd_in!o Regulations and Standards ®, construction Supervisor License License: CS 100988 HENRY CASSIDY 8 SHED ROW WEST.`�-ARMOUTH MA 02673 Expiration: 11/11/2013 Pi ('unnois.'ii,nir Tr#: 7620 Date: 4/19/2012 Time: 10113 AM Tot Cape Cod Insulation, Inc N 1508-778-5735 Rogers Gray Ins. Pages 002 Client#:4597 CCINSUL ' ACORDTM CERTIFICATE OF LIABILITY INSURANCE, DATE r 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 - NAME": Margaret Young ' Rogers 8t Gray Ins.-So.Dennis PHONE 508-760-4607 434 Route 134 C N°E't aIc,N°:508-258-2102 ADDRESS: oun ma ro ers ra P.O.Box 1601 ADDREss: Y g @ 9 g Y•com + PR DU R South Dennis, MA 02660-1601 ' cus7oMERID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Cape Cod Insulation Inc INSURER A:Peerless,Insurance 18333 • 455 Yarmouth Road INSURER B:Ohio Casualty Insurance Company. INSURER C:Atlantic Charter Insurance Hyannis, MA 02601 INSURER 6:Commerce Insurance Company 34754 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. N R - DDL 3UBRI POLICY EFF POLICY EXP TYPE OF INSURANCENSR NVQPOLICY NUMBER MMIDDIYYYY MM/DDIYYYY LIMITS A GENERAL LIABILITY CBP8263063 04/01/2011 04/0112012 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES a oa7urrence $100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000,000. . - GENERAL AGGREGATE $2,000,000 4 - GEN'L AGGREGATE LIMIT APPLIES PER: r ,y - ....r- PRODUCTS-COMPIOPAGG $2,000,000 " POLICY PRO- ' T rLOC $ D AUTOMOBILE LIABILITY 11MMBCKVMK 01/2011 04/0112012 COMBINED SINGLE LIMIT ANY AUTO - (Ea accident) $11,000,060 - ALL OWNED AUTOS - ° - BODILY INJURY(Per person) $ ' X SCHEDULED AUTOS ` •- BODILY INJURY(Per accident) $ ' ,, PROPERTY DAMAGE X HIRED AUTOS fi - $ y - • - - • . (Per accident) X NON-OWNED AUTOS $ B UMBRELLA LIAR 1LXV 110CCUR 0001254514645 04101/2011 04/01/2012 EACH OCCURRENCE $1 00O 000 EXCESS LIAB CLAIMS-MADE 1 AGGREGATE $1 000,000 - - DEDUCTIBLE X RETENTION 10000 C WORKERS COMPENSATION WCA00825902 6I3012011 06/30/201 X WcsTATu- OTH- . AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/EXCLUDED? E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLIIDED? � NIA' - , � - -. . (Mandatory in NH)I E.L.DISEASE-EA EMPLOYEE s500,000 f yes,describe under .. DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $500,000 - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) ' Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - r THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ` ACCORDANCE WITH.THE POLICY PROVISIONS. • m AUTHORIZED REPRESENTATIVE - ' 3 ®198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD #S80552/M68179 MEE r The Commonwealth of Massachusetts Department of Industrial Accidents z � m Office of Investigations W 600 Washington Street F 7� 0wa Boston, MA 02111 "M g�0�' www.mass.gov/dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): e Cnd nn e, Address: City/State/Zip: P2 (S_ 41A 0,2 6 G'I Phone#: 6 09 '27 6 ` f,;�__Zq Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with a_ 4 ❑V I am a general contractor and T have 6. El New construction employees(full and/or part-time)." hired the sub-contractors listed on 7. ❑ Remodeling the attached sheet.$ 2. ❑ I am a sole proprietor or partnership These sub-contractors have 8• ❑ Demolition and have no employees working for employees and have workers' comp. 9. ❑ Building addition me in any capacity. [No workers' insurance.$ 10. ❑ Electrical repairs or additions comp insurance required.] 5.[] We are a corporation and its 11. Plumbing repairs or additions officers have exercised their right of ❑ 3. ❑ 1 am a homeowner doing all work exemption per MGL c. 152§(4),and 12. Roof repairs myself. [No workers' comp. we have no employees. [No workers' 13. Other insurance required.] t comp.insurance required.] `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 attach 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.Below is the policy and job site information. Insurance Company Name: A t) C sl.) (-0(4t:6 CZ, " Policy#or Self-ins.Lic.#: WL:A d©.-15-!20 / 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 ma e forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here c i under theiv pins and penalties of perjury that the information provided above is true and correct. Signature: Date:_ Phone#. 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#: t - ot.mey:,; save PCOHIAAL70R6 PERMIT AUTHORIZATION FORM` — owner of theproperty located at: - (Owner's Name, printed) - - - IZ giCd'►il1 � NUS = ' ' _ (Property Street Address) (CityfTown) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on'my behalf,and obtain a building permit to perform insulation and/or weatherization`work on my property: - !!=S1 Jn H " Owner's-Signature 'FOR CSG OFFICE USE ONLY Conservation Services Group has:'assigned„the following Mass Save Home Energy`Services, Participating Contractor to ttie above referenced project: f _ Partic pating,Contractor - Date Rev. 12132011 x • , f i Town of Barnstable °F'["E'O`�ti Regulatory Services ^ ..°, Thomas F.Geiler,Director ► BARNSTABLE, Muss, Building Division i639• 'OrFp Mpi a Tom Perry Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 COMPLAINVINQUIRY REPORT Date:(I— I Rec'd by: -72i# Complaint Name. jy� Map/Parcel Location Address: Originator Name: Street• ) Village•&IU&State:.)"4—,u4,— Zip:. Telephone: Complaint Description:40f 5 Owz bj-i)n Lz)avl//j 4 -lic Mul, j or — 1 jd)ku�- omk- t Cb kz,( k FOR OFFICE USE ONLY Inspector's Action/Continents Date: Inspector: Additional Info.Attached E - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map pp-- �� l Vr�� Parcel � � 9 - .4. Permit# Health Division ; F Date Issued_ 'zxoc� F ; Conservation Division , FeeL `d� Tax Coll for a a Treasurer Planning D ` Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address C14L<— Village G Owner :P545f, � "� Cs72FLLc 500LY Address Telephone t Permit Request 5T P If, - le l�0'�/� ", t 0-6 . 425 1 �6 0,a C Square feet: 1s�,floor: existing proposed 2nd floor: existing proposed Total new Valuation ysoo` Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑ No If,yes, attach supporting documentation, Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House:. ❑Yes ❑ No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count • Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric, ❑Other i Central Air: ❑Yes O No Fireplaces: Existing ,New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑existing ❑new size Pool: 0 existing ❑new size Barn:0 existing ❑new size Attached garage:O existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization 0 Appeal# Recorded❑ Commercial 0 Yes ❑No If yes, site plan review# C Current Use Proposed Use �j BUILDER INFORMATION Name Telephone Numbers S�l� Address 9® e H&:(�Y 7�� /-b License# C Iaox �S3 Home Improvement Contractor# Cb'j'Y 1 A►-(pf O ,� Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 2!`4 ! —Fpstf 5-17 , SIGNATURE X DATE o S� FOR OFFICIAL USE ONLY , PERM?l',NO. DATE,ISSUED - z - } E MAP/PARCEL NO. ADDRESS f ~ VILLAGE OWNER- DATE OF INSPECTION- FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' z PLUMBING: ROUGH t FINAL GAS:• ROUGH FINAL FINAL BUILDING DATE CLOSED OUT f '� ASSOCIATION PLAN NO. The Commonwealth of Massachusetts CPR, - Department of Industrial Accidents office 011BY850811offs _ 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance davit name 4'A 0 L La P-V FD 2 STn ly tf Z location: /2- 15 t R CH L I LL - citV r— 51�1EP—V I L- - Y✓ phone# ❑ I am a homeowner performing all work myself. I am a sole star and have no one world>1 in ca achy I am an employer providing workers' compensation for my employees working on this job. :. tom an name:: :::::.::::.:...:.....:::: ::.:::...................::.....:::. gtldi ess.: ;.. . .......... otiose'# olicv it insurance co.,,. ., _. ... ... . ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the followin workers' compensation polices: .: cam s name:: 5ddress :.:.....::•. :::..::::::•::•:::::.. ........:: ::......:.............. .... ... :<:on8> h »C?z :::f:;: s.... .,,.,..�'CQGi2`i�'''':iY<ifi:::: :i:;:i:: ;::::;:;:'::;:;:�:; ':�„3iisi;:;.::::::2::::;::...,;::;:.:?;:::.::.:`:;:;;:'::::.::::':.;,:::,•..;:.::.;:q:.: h3481tC n�grEllC 0/1 0=01111.11AME111111-11-111, Pall=to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to Suimoo and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.l I do hereby certify under the pains and penalties of perjury that the information provided above is trw•and correct. Sigaeture �':� — Date nn Phone# • Print name T �V�-- �O �-�' ' official use only do not write in this area to be completed by city or town offldal city or town. permit4icense# QBuilding Department ❑I.k-smg Board ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other Urmed 9/95 PlA Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns 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`---has to contact you regarding the applicant. Please be sure to Olin the pei i iidliceose number which will be used as a reference number. The affidavits maybe retamedio the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imlesuga0003 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 OF IME T The Town of Barnstable - - MASS.: Regulatory Services Thomas F. Geller, Director Building Division Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more thanfour dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. I �p Type of Work: ST-P—I ' 4 F E kb-ot' Estimated Cost Address of Work: f f 12 C 11 Ff/4-L /� , r—C-A 7�k y It,/ µ t®4 Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law []Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav 1. . GTiGe�nmrxa �°�✓�fR40RC/u`delCa HONE.IMPROVEMENT CONTRACTOR Registration, 1p5918 Expiration. S/1/02 Type Individual PAUE K. RONA Wit ;PAO, 'RONA6 CHERRY TREE-" ADMINISTRATORc COTUIT MA 02136 t . lt6 i BOARD OF BUILDING REGULATIONS Ucense: CONSTRUCTION SUPERVISOR 052325 be ; 4. NUmr:`CS` ; 8trtl1all 08/AS/A 947 52001 Tr.no: 947 E�c�ras:Q8b , v��lp �To: 00 PAUL K ROMA BOX 653 90 CHERR`f'`TREE RD � ` COTUIT MA 02635Administrator ' � _gin ..� ,'.�y.,��` _-. .�'.�•� ._ - -— ; BABIST&BLE MASa TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION TO THE INSPECTOR OF BUILDINGS: ~T+fB undersigned hereby applies for o p^mlt aj^cording tp,the followjpg information: ^/oLocation Proposed Use Zoning District Fire District Nome of Owner Address Nome of Builder Address .... Nome of Architect Address .... Number of Rooms Foundation Exierior ..Roofing Floors Interior /...... Heating Plumbing /. Fireplace Approximate Cost Difinitive Plan Approved by Planning Board 19 Diagram of lot and Building with Dimensions . .19 6'^ 0 /y/j .5/. -fsE I hereby agree tp confarm to oil the Rules end Regulations of the Town of Bornstoble regarding the above construction. Name Alan No Permit for single Location Birchill..Eo.^. Centeryille Owner Type of Construction fjT.eJnie Plot lot .m. Permit Granted 19 Dote of Inspection 19 C-*^ Dote Completed 19 PERMIT REFUSED 19 Approved 19