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0084 BIRCHILL ROAD
'`i,�. � � �� � ": wa. _ ., -, ., c �.. F Y J v h h . _ �, :. F T �- ., n n.. y m .. [ t. re � .' � - y �. 7. - .. �� A �. � Y 4+ , { � .. - �1 - � r F�{ �1 !!!!� _ _ li �. .. ;� ''r a 'k e •s :, f 12 8tJIL�ING D �C EPT ( - p FEB D 6 2020 r,.. nn r Energy, Inc NoMeWork�OwN OF B ARIVsTABLE Insulation Affidavit HomeWorks Energy has installed insulation at the following address that meets or exceeds Massachusetts building code and IIC requirements. Project Address: Permit Number: B-20-296 Robert Granquist 84 Birchill Road -Barnstzrble Massachusetts 02632 Location Material Addt'I Thickness Final Assembly R-value Attic Floor Green Fiber Cellulose 6" 49 Basement Rim Joist 6"Owens Corning Fiberglass Battinf 6" 19 Sincerely, Scott Veggeberg HomeWorks Energy Inc. CSL#103832 HERS Certification#3081658 HomeWorks Energy 101 Station Landing,Suite 110 Medford,MA 02155 wxpermitting@homeworksenergy.com Town of Barnstable Buildin t Post This Card So That it is VisibI Orom'the Street Approved Plans,Must be Retained on-Job,andithis Card Must,be Kept9 i f € is § '�: `. - - _ • 1 , Posted Until:Fina) Inspection Has Been Made- a aat° Where a Certificate of Occupeneyzis3Required-such Building shall Not be Occupied,until a�Finalanspeetion has been made i Permit .-............. a............4.m,aw<wa w....,..«wMw....e.wn.ew.an.,.,.-re..E.. .w..r€wiw. Permit NO. B-20-296 Applicant Name: HOME WORKS ENERGY INC. Approvals Date Issued: 01/30/2020 Current Use: Structure Permit Type: Building-Insulation- Residential Expiration Date: 07/30/2020 Foundation: Location: 84 BIRCHILL ROAD,CENTERVILLE Map/Lot: 189-022 Zoning District: RC Sheathing: Owner on Record: GRANQUIST, ROBERT C& PINE, ELENA,TRS Contractor Name: ,vHOME WORKS ENERGY INC. Framing: 1 Address: 84 BIRCHILL ROAD Contractor License. 181138 2 CENTERVILLE, MA 02632 � �.m. .Est Project Cost: $5,745.19 Chimne y: Description: Insulation -Permit Flee: $85.00 At v Insulation: .Fee Paid:' $85.00 Project Review Req: )� ( Dote: 1/30/2020 Final: ! Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced with in"six rnonths,after'!issuance. All work authorized by this permit shall conform to the approved application°and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shal(be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,publlc inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building end Fire Officialsare provided on this;permit. Service: Minimum of Five Call Inspections Required for All Construction Work: f' 1.Foundation or Footing - Rou h: 2.Sheathing Inspection - g 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final' Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application number. .... b...... ` ............. +N OF BARNSTABLE Fee . Y S ............................... NIT" -N ?0 AN 6- 00 #. II Building Inspectors Initials. a .........•......•..•••..•..... i 15_�0 "°�.. Date Issued:.....! 3;IZ ........................................ Map/Parcel.........1.'.f.�.....acp TOWN OF BARNS'TABLE EXPEDITED PERMIT APPLICATION: SCANNED ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATIiERIZATION JAN 3 0 2020 PROPERTY INFORMATION Address of Project: g LA bl rGh�1 Rma rr�de t� C'.cN-E�Vsu•l� NUMBER STREET VILLAGE Owner's Name: Ohg d e (Q✓1G,U► Phone Number 6(�3314 W a Email Address: QeA P►nLo-0 gf0.1 CO M Cell Phone Number 3 14 0 0 Project cost s 5! 0 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize S 15 E A` 7/�C JA M t✓ to make application for a ^dance with 780 CMR Owner Signature: - - . r Date: TYPE OF WORD ❑ ❑ header change)# �Insulation/Weatherization Siding Windows(no g ) ❑ Doors(no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 2-5 ( 0 Cfrj f2a! LG�1, A h�Qq l Ca CONTRACTOR'S INFORMATION Contractor's name S C-.0 E G Cr e e t 2 C-, Home Improvement Contractors Registration(if applicable)# f I J (attach copy) Construction Supervisor's License ".(attach copy) Email of Contractor YIQ A_ �. .i Phone number O •�/•I• 101 APPLICATION NUMBER *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. CA Cr Purpose of Event %K Cheek'.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 201bs. 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 - :. ' lift 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 - 4. Date —2S-202 0 All permit applications are subject to a building official's approval prior to issuance. f SCANNED _ JAN 3 0 2020 - i - PLAN VIEW Name: .I Oo f+= Site ID: 3 537`(1 1 z Finished Sq.-Ft:' Phone: r J 7 331 y o bd' -;Year of House: /!lay Electric Acct#: , Address:Ell '�;,O; l j_) #of Floors: ! Gas Acct#: #Occupants: L DUCTWORK INSPECTION Ducts Insulat0d?❑ Duct Linear Ft. uct Square Ft. Duct Air SealingHours Duct Insulation `'� 4 �• ,.. - k Duct Insulation Removal BASEMENT INSPECTION r t Existing S ec'ing Ln/Sq.Ft. Bsmt Wall AG 70 � Crawl Ceilingr Crawl Rim Joist (i C? Bsmt RJ w Sill .Ong Bsmt RJ NO Sill - Vapor Barrier �_sgf-- Bsmt Door Y N Blower Door? WALLS&GARAGE Drill Location? ! Siding Ceil.Height Existing Speeing -Sq.Ft. Framing Exterior Wall 1 r_ ;:Is x x Balloon Platfor a } Exterior Wall 2 x x Balloon/Platform , Overhang x x Garage Wall x x Balloon/Platform 14 Garage Ceiling x x t 4 • � F � t insulati6 Sweeps: a__ WX St�ipPing� WORK SPEC'D BUT NOT CONTRACTED RPAD BLOCKS PRESE MANDATORY) Attic Basement Crawls ace Other: K&T Y Moisture Y ombustion Sft Y Kneewall Overhan Gara a Asbestos Y old>100 sq.ft Y CO Detector MissingY Ductwork _ Exterior Walls- - - - Vermiculite Y Structl Concerns Notes for Lead Vendor/Work Not Contracted: •. ` •� - - } �Yaf'."t- a..8 i - ...•. .... _ . C f � _ '-> ..i^"�,9M - -iF•"� IC x. _ KW WALL AND KW FLOOR Blind Spec? ❑ O R #� KW SLOPE AND GABLE END Blind Spec? ❑ 4 F FRAMING EXISTING SPEC'ING S .FT. WALL x X _ ._ SLOPE X - X .: FLOOR X x GABLE X,--x_ ACCESS X ` TRANS X X ANS X ATTIC t TTIC ._ SL _ ,... .. SLOPE x X 1 EXISTING VENTING?"' `— -"":• - e 4 EXISTING VEN G? EXISTING PIPES? Y/N — -- - M KW Ve ng Vent BF BF Hose Damming Sheathing Access Temp Access _ KW Venting Vent BF Temp Accent !m• J st1 j I J.--9 > -1� ` �d�zC�tJeS , '� �_�== Inwlated Wall X X Rec'd light O+Inz.Hose® Vent BF 6FV Chlnn.O Damming'' ' 12"Roof t,12RV Air Handler AH Temp Acceis DPUBDomm OS •Hatch®•Wall Hatch a,,--Door o�-jg'Roof Vent RV { -- f vol:' -L.X...0OS8 39(l story) e xZ — ATTIC!'^ Blind Spec? •❑ x --X ATTIC 2 Blind Spec? ❑ x 15.4 12OAT - Existing Spec'Ing__• Sqft Existing Spec'ing Sqft 13613story) I , nfl one t�'OiSL=- DUnfloked Trusses crossBatung Floored —r -' Floored \ net,e o Duct Wo Cath Slo e Cath Slope �, >6"Loose one ! �- ' Walls 1.? of (, '34/O Walls - _ __. Access ' enting Pro avents Vent BF BF Hose DammingVenting Pro averts Vent BF BF Hose Damming WHF Box. . ct 2 / t u Temp Aces + t / µ CIL / + a i Sheathing Acce _ yr �� °I Sq.Ft/300= 1 - (ExiA.NFA Venting)__(Needed _Sq, /300 (E:Irt.NFA Venting)_ `�(Needed —NFA Venting) ✓� --� - - •NFAVentinglr Roof? e Existing Venting? ; (e Existln Ventin? ti vp f Homi�ftrks rr n rurr n Energy, Inc To whom it may concern, Scott Veggeberg is a current employee of Homeworks Energy Inc.and operates under our insurance policy. Policy numbers that Scott is covered by are as follows: Commercial General Liability:793006065002 Automobile Liability:6244378 Umbrella Liability: 7930060660002 Workers Compensation and Employers' Liability: ECC-600-4001017-2020A All HomeWorks Energy permits are pulled under his CSL license. The insurance provider is AIM Mutual Insurance Company. If you have any questions or concerns please contact Director of Weatherization Adam David Glenn at 774-365-2446 or adam.glenn@homeworksenergy.com. Thank You, Adam David Glenn Director of Weatherization HomeWorks Energy. 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 Please Print Legibly Name (Business/Organization/Individual): HomeWorks Energy Address: 101 Station Landing Ste 110 City/State/Zip: Medford MA 02155 Phone#:(781)305-3319 x5007 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 200 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 These sub-contractors have ship and have no employees T 8. ,❑Demolition . working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.; 9. ❑ Building addition 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 1 I.❑ Plumbing repairs or additions myself. ' right of exemption per MGL y �o workers comp- 12.❑-Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.0 Other Weatherization employees. [No workers' 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. Below is the policy and job site information. Insurance company Name: NH Employers Insurance Company Policy#or Self-ins.Lic.#:4001017 Expiration Date:1/1/2021 Job Site Address: City/State/Zip:bfnsLa l IMA 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 certify under the pain_ dlpenalties of perjury that the information provided above is true and correct. Signature: `i '"i^'= �' Date: ZOZO Phone#:(781)305-3319 x5007 / wxpermitting@homeworksenergy.com 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#: Construction Supervisor Re:Address (or)application# Name Scott Veggeberg Telephone]number 508-273-7593 Address 101 Station Landing City Medford State MA zip 02155 License Number 103832 License Type Expiration-Date 10/13/19 Contractors Email NSA Cell# 508-273-7593 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,Attach a copy of your license. Signature Date j ©2 f HOMEENE-01 LLARIVIERE ACORO' CERTIFICATE OF LIABILITY INSURANCE D 1211919//2019Y) 019 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 have ADDITIONAL INSURED provisions or 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 Lisa Lariviere NAME: Foster Sullivan Insurance Group,LLC PHONE FAx 163 Main Street (A/C,No,Ext):(978)686-2266 301 (A/C,No):(978)686-6410 North Andover,MA 01845 E-MAIL ,certificates@fostersullivangroup.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Homeland Insurance Company NY 34452 INSURED INSURER B:SafetyIndemnity Insurance Company 33618 Homeworks Energy Inc. INSURERC:NH Employers Insurance Company 13083 Homeworks IIC LLC 101 Station Landing Suite 110 INSURER D: Medford,MA 02155 INSURERE: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX�OCCUR 7930060650002 4/1/2019 4/1/2020 DAMAGE TO RENTED 500,000 PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PEST LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY CEOMBII acctlEeDtSINGLE LIMIT $ 1,000,000 ANY AUTO 62"378 4/1/2019 4/1/2020 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILYBODILY INJURY Per accident $ X AUTOS ONLY X AUOTOS ED PR P.ER ntDAMAGE $ A UMBRELLA LIAB Xd OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE 7930060660002 4/1/2019 4/1/2020 AGGREGATE $ 2,000,000 DED I X I RETENTION$ 0 $ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YI NSTATUTE ER — ECC-600-4001017-2020A 1/1/2020 1/1/2021 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ �WeE.L.EXCLUDED? Nlandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Homeworks Energy Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN gy ACCORDANCE WITH THE POLICY PROVISIONS. 101Station Landing Ste 110 Medford,MA 02155 _ AUTHORIZED REPRESENTATIVE +4-A ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Busiriess Regulation 1000 W ashingtor7 Street-Suite 710 Boston;Massachusetts 02118 Fame Improvement Contractor Registration Type- C:r,rpdaaclon .r Rpgrslr�tich'; lF3i 19A HOME'WORKS ENERGY,INC- > Krartfia D3+02r'2V21 i 01 STATION LANDING STE?>D MEDFORD,NIA 02155 update Addrosr and Raium Gard. O'fic3 of Cantu maHalrs 8 BVSie�Ta>rYaul9ilon R strat7nn valid rGr lndivittual u6a urdy ROME gAPROVErAENT CONTRACTOR ni - TYPE:Coroa-etcn botnre 11ue expiration auto.H Found esiurn to: - svet�p r rion 4fflea at Consumor Affairs and 6usfruras Regulation istt3e 73.0:. t202' to W'Nash" a"Strsct-Suits 710 :46�sE'.":CRKS ENff7CY.ING. 9Vcton,M 0211 MA.XVEGGE@ERG 1015TA.TION LANDING+5TE 110 LJ - 4�d a6kt puP.S I®nature - - ?.1CF7F0RD.rIk%•:2*5 Under seta r Coritnion Weattli C}t'r'tl:s:+Set r::hUSft S. r construction Supeitvisor Specialty , Division of ProleSst6nai Licensure Board of Building Regulations and Standards Restricted to: off,1= CSSLAC-Insulation Contractor - ConsEtru:tion-5 pefvi€iorSpeci.'3`lly .t GSSt -103832 I«. Etcpires 10l1312021 i SCOTT VEGGERERG 8 COVINGTON ST 01 BOSTON MA 02127 i �tiyt Failure to possess a cut lition of the Massachusetts. State Building Code is r:. or revocation of this license. Commissioner _. For informaltual:about this license J } •* Call(617)727.3200 or visit www.rnass.govJdpl Insulation/Air Sealing Permit Authorization Specialist: Curtis Bridge Company: HomeWorks Energy. Email: Curtis.Bridge@homeworksenergy.com Address: 101 Station Landing HofneWorks Cell: 5083641715 Medford,Ma 02155 s_r_w. nt Phone: 781-305-3319 Customer: Robert Granquist Address: 84 Birchill Road Email: 0 Barnstable MA 02632 Site ID: 3937971 Phone: (617)331-4080 1,the owner of the property identified above hereby authorize HomeWorks Energy Inc.,or their Partner to act on my behalf in obtaining any building permit that maybe required to perform insulation and/or Weatherization work on my property and all matters related to the work authorized by said permit if one is obtained. Any related permit application cost will come at no additional charge provided that the agreed Weatherization work is completed. Customer Signature: Date: 11/25/2019 Robert Granquist { F Page 1 c 0 grnnome irks mass save Energy, Inc PARTNER 1015tation Landing Ste 110,Medford,MA 02155 (781)305-3319 ext.120 Customer Name:Robert Granquist Email:elenapine@gmaii.com Phone:617-331-4080 Premise Address:84 Birchill Rd,Barnstable,MA 02632 Mailing Address:84 Birchill Rd,Barnstable,MA 02632 Project ID:3940796 Date:Nov.25,2019 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost AIR SEALING Other 13 hr $1,040.00 $0.00 WEATHERSTRIP DOOR &ADD SWEEP Other 1 each $80.00 $0.00 ATTIC FLAT-6"OPEN R-22 CELLULOSE Other 1404 SF $1,853.28 $463.33 VENT FUTURE BATH FAN TO ROOF Other 2 each $237.50 $59.37 COMMON WALL:2" RIGID BOARD Other 55 SF $211.75 $52.94 COMMON WALL:FG BATT+2" RIGID Other 288 SF $1,512.00 $378.00 ATTIC DAMMING- R-38 FIBERGLASS Other 114 SF $280.44 $70.11 VENTILATION CHUTES Other 108 each $376.92 $94.23 BASEMENT SILLS: R19 FG BATT Other 70 SF $153.30 $38.32 Total Contractor Price and Payment Schedule HomeWorks Energy, Inc. agrees to perform the above described work,furnishing the materiai and labor specified for the listed tota price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature: Date: Customer Phone: 0T�� �l 2S`jr Specialist Signature: Date: uMITM TIME OFFER: The prices and incentives in this contract are subject to change in accordance with the sponsoring utility MassSave Home Services Program offers. Proposals can be sent to:inbox@HomeWorks£nergy.com r; Page 2 a W ? name orks mass save Enef9y, Inc PARTNER 101 Station Landing Ste 110,Medford,MA 02155 (781)305-3319 ext.120 Customer Name:Robert Granquist Email:elenapine@gmail.com Phone:617-331-4080 Premise Address:84 Birchill Rd,Barnstable,MA 02632 Mailing Address:84 Birchill Rd,Barnstable,MA 02632 Project ID:3940796 Date:Nov.25,2019 Project Total $5,745.19 Weatherization incentive ($3,468.89) Air sealing incentive ($1,120.00) Total Program Incentive -$4,588.89 Customer Total $1,156.30 Total Contractor Price and Payment Schedule HomeWorks Energy, Inc.agrees to perform the above described work,furnishing the material and labor specified for the listed tota price_ Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature: �� Dater G Customer Phone: Specialist Signature: Date: uMf M 71ME OFFER: The prices and incentives in this contract are subject to change in accordance with the sponsoring utility MassSave Home Services Program offers. Proposals can be sent to:tnbox@HomeWorks£nergy.com 3JR)i Town of Barnstable *Permit# Expires 6 mont from f�e d Regulatory Services Fee snaxernBclr, bs�MAS& �' Richard V.Scali,Director s� Building Division Ton)Perry,COO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY n Not Valid without Red X-Press Imprint Map./parcel Number 7 Property Address S / B l"I `( C� Pi{�L) /`le Residential Value of Work$ 6 y77 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address F,C'1a �/n'e— �p P,/� (�rA-yL Contractor's Name T p S Telephone Number Home Improvement Contractor License#(if applicable) T 82 Email: Construction Supervisor's License#(if applicable) 07 76 7 Xcfpflk.%�� orkman's Compensation Insurance (�AR 201Q Check one: ❑ I am a sole proprietor TOWN ®F 8/`ult1�I ®LE ❑ I am the Homeowner I!l /'1 f1'!1 I r t D I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# WM R1 9-72•! Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripling;old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over. existing layers of roof) ❑ Re-side 0 Replacement Windows/doors/sliders.U-Value • f7i (rnaximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&;Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation.etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requi d. r SIGNATURE; .r C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOI DHR\EXPRESS.doc Revised 040215 (renewal Agreement Document and Payment Terms byAl lder$en' dba:Renewal By Andersen of Southern New England Elena Pine&Robert Granquist Legal Name:Southern New England Windows,LLC 84 Birchill Rd RI#36079,MA#173245,CT#0634555,Lead Firm 91237 : Centerville,MA 02632 w1xoow RE LA.I.M 10 Reservoir Rd I.Smithfield,RI 02917 - - - H:6179530532 - Phone:866-563-2235 1 Fax:401-633-6602 1 sales@renewalsne.com . Buyer(s)Name: Elena Pine&Robert Granquist Contract Date:02/13/18 Buyer(s)Street Address: 84 Birchill Rd, Centerville, MA 02632 Primary Telephone Number: 6179530532. Secondary Telephone Number.' Primary Email: elenapine@gmail.com Secondary Email: Buyer(s)hereby joindy and severally agrees to purchase the products and/orservices.of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement- Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement'). , Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: M477 By signing this Agreement,you acknowledge that the Balance Due,and the Amount' Financed must be made by personal check,bank check,credit card,or cash.. Deposit Received: $2,158 Balance Due: $4,319 Estimated Start: Estimated Completion: 8 to 10 weeks 8 to 10 weeks Amount Financed: $0 Method of Payment: 'Credit Card We schedule installations based on the date of the signed contract and secondarily on Cash/Check the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. Notes: Depo paid by CC and Bal paid.by check;tx Barnstable Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement:No alterations to or deviations from this Agreement will be valid without the signed,written consent'of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1).has.read this Agreement, understands the terms of this Agreement;and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,.on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. . NOTICE TO BUYER: Do.not sign this contract if blank.'You are entitled to a copy-of the:contract at the time you sign YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 02/16/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION,; WHICHEVER DATE IS LATER:SEE THE ATTACHED:NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC. dba:Renewal By ndersen of Southern New England Buyer(s)- Signature of Sales Person _ Signature Signature Cory Scanlon Elena Pine Robert Granquist Print Name of Sales Person Print Name Print Name UPDATED: 02/13/18 . . Pa6e.2 / 10 .J Uffiece of Cor s- me A-Jf fires C�1nd Business Re-c.7 I li�'rY 10 Park Flaza - Sulte 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registrat o Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 SOUTHERN NEW ENGLAND WINDOWS LL BRIAN DENNISON 26 ALBION RD LINCOLN, RI 02865 Update Address and return card.Mark reason for change. Address — Renewal — Employment — Lost Card -Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the expiration date. If found return to: HOME iNHPROVEAflEiUT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 1;_2?5 Type: 10 park Plaza-Suite 5170 Expirations: o/1g/201 S Supplement Card Roston.NLA,021116 SOUTHERN NEW ENJOLAND WINDOWS LLC. RENEWAL BY ANDERSON BRIAN DENNISON r 26 ALBION RC LINCOLN, RI 02865 �_Z;adersecretary Not valid without signature .n CS-09-95 07 SPUA:N D DENNISON 0. / ;�Ivl,3S POND CIRCLE MA 0150 _ I The Commonwealth ofMassachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PER.NUTTING AUTHORITY. Applicant Information Please Print Le 'bl Name (Business/OrganizuioaU(iividual): E e t J 0t v s Address: Z(a Au sloo City/State/Zip: Phone#: '�,fj� _ 2- Axe you an emplover?Check the appropriate box: Type of project(required): ]XI am a employer with Zo 1employees(full and/or part-time).* T.D New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ - 8. Remodeling any capacity.(No workers'comp-insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.),i 9. ❑Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 1 L.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance= 13_ Roof repairs O 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. i '4 therwi l� QC) 152,61(4),and we have no employees.[No worker'comp.insurance required.] 'Pe /,a,l _M *Any applicant that checks box i'1 must also fill out the section below showing their workers'compensation police information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a5iidavit 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. Below is the policy and job site information. _ Insurance Company Name: l rf Pl e n S — A60 f"l Policy 4 or Self-ins.Lic.k: C)`1�{ ! Z [ Z- Expiration Date: 1 Job Site Address: / Y City/State/Zip l Attach a copy of the workers' compensation policy declaration page(showing the policy number and ea ration date). Failure to secure coverage as required under MGL c_ 152:§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-vear 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_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 th ains and penalties of perjury that the information provided bov is true and correct signature: D2te:,� Phone# Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License k 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: DATE(MMIDDIYYYY) ACORV CERTIFICATE OF LIABILITY INSURANCEF1`/ 12/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON ACT CoBiz Insurance, Inc.-CO NAME: 1401 Lawrence St., Ste. 1200 PHONE .303-988-0446 ac No):303-988-0804 Denver CO 80202 E-MAIL COMaiI cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC i INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURERS:Firemens Insurance Company of WA,D.C. 21784 Souther New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1252851165 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBRI ' POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MM/DD A X I COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2018 1/1/2019 EACH OCCURRENCE $1.000,D00 CLAIMS-MADE a OCCUR DAM T RENTED PREMMISES Ea occurrence $300,000 MED EXP(Any one person) $10,000 PERSONAL 6 ADV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $2.000.000 X POLICY PRO-JECT PRODUCTS-COMPIOP AGG $2,000,000 � LOC _ OTHER: $ A AUTOMOBILE LIABILITY I N CPA3158728 1/112018 1/1/2019 COMBINED SINGLE LIMIT $ Ea acc dent OOD OOG X ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED SCHEDULED : BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident A X UMBRELLA LAB X OCCUR CPA3158726 1/112016 1/1/2019 EACH OCCURRENCE $10.000.000 EXCESS LlAB CLAIMS-MADE I AGGREGATE $10 wo.000 DIEDX I RETENTION$n $ B WORKERS COMPENSATION VVCA3158729-20 1/112018 111/2019 X STATUTE ERH AND EMPLOYERS LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECLMVE ❑ I E.L.EACH ACCIDENT $1.000,000 OFFICER/MEMBER EXCLUDED? N/A I _ (Mandatory in NH) EL DISEASE-EA EMPLOYO$1,000,000 IF yes describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000.wq C Pollution Liability 79M 073340000 1/12018 1/1/2019 Each Occurrence $1.000,000 Claims-Made Policy Aggregate $1 .0 000 Retroactive Date 06202013 Detluctible $10000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional.Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map l Parcel A�plicaon # Health Division Date Issued 3 Conservation Division Application Fee Planning Dept. _ Permit Fee it? Lt 3' Date Definitive Plan Approved,by Planning Board q1{l 113 Historic - OKH _ Preservation/ Hyannis Project Street Address W IL Village s � V Z Owner F)W Address Telephone Permit Request L& �� i�/� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning.District _Flood Plain Groundwater Overlay Project Valuatio J D 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: 3 existing Onew Total Room Count (not including baths): existing new First Floor RoM Count o Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood cc al stove: ❑Yes, ❑ No Detached garage: 0 existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ e isting ew: ize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No ___If yes, site plan.review_# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name / GH�IL VP t mf2 Telephone Number Address o, g o 6 q License # C5, lvk,� l �} Home Improvement Contractor# ID Email. Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE y� DATE FOR OFFICIAL USE ONLY APPLICATION# _DATE ISSUED r MAP/PARCEL NO. f. ADDRESS VILLAGE OWNER I» DATE OF INSPECTION: 9fFOU.NDATCON?'z�.- . 1ur : t: FRAME !INSULATION 15 11,5_ FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING o 21�1'-3 i DATE CLOSED OUT ASSOCIATION PLAN NO: The Commonwealth ofllMassachusetts Department of Industrial Accidents Office of Invesfigadons 600 Washington Street Boston,MA 02111 www.mass gov1i is Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information /• Please Print Legibly Name(Business/Organization/Individual): Address: Ro!boy by City/State/Zip: 7V1 , Phone#: Are you an employer?Check the ppropriate boa: Type of project r 4. am a general contractor and I p ( ��� 1.❑ I am a employer with � I �loyees(full and/or part-time).* have hired the sub-contractors 2. ❑New construction 2. I am a sole proprietor or partner- theme 7• remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. � required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.El 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 hue 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 employem. If the sub-cofactors have employees,they must provide then workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 cam 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. Ido hereby kerb under e/p�a' and penalties ofperjury that the information provided abov is true and correct Si ature: G%`!/L ° Date: � Phone#: 72�u `L ' 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.PIumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions 1 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 ofhire, 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-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 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/licease applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a•call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigation 600 Washboan Sheet Boston,IAA 02111 Tel.#617-727-49W ext 446 or 1-977-MASSAFE Fax#617-727-7749 Revised 4-24-07 • w .mass_gov6dia - r - V 41 7 i E • Town of Barnstable ` Regulatory Services Thomas F.Ceiler,Director ¢, G Building Division { Thomas.Perry,CBO • P Building Commissioner x 200 Main Street; Hyannis,"0260I s R. www.towu barmisble•ma us e. i Office: 508-9624038 t t ."'Fax: 508-790-6230` f E' Property,Owner Must Complete and'Sign This Section' `. df Using A Builder U.- g I. r r as Ownei of the subject property` hereby authorize 'ac Ck V `to act on mq Behalf, in all matters relative to work authorized by this building permit application for tc (Address of Job) Signature of Owner s• 17ate. J 1V Print Name r . if Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the r v reverse side. y, C lUsersldecollikL4ppLYafalLorallMivosofi\WindowslTempoiary Internet Flcs\ContrnL06tlouk\QRE67URNIFJCPRFSS:doc.' - Revised 053012 r S t u `': I e Consumer Affairs &Bus Business Rigid�cc�eCGi Lieen�e or registration valid for individull use on Office of Consumer Affairs&Business R✓:�ulatioq;' $• y i I: ME IMPROVEMENT CONTRACTOR;ME the.expiration date. If found return to: j o egistration T09558 Typei: Officp:of Consumer Affairs and Business Regulation xpiration:; 9/21/2014; ladivldual .' 1,0 Pav k;Plaza-Suite 5170 (} fir; s Bosto�h,.MAa02116 I MARK VOLLMER �;.. MARK VOLLMER c { 1455 SANTUIT NEWTOWN RD I`Il COTUIT, MA02635 Undersefretar '. k Not valid.without signature I I Massachusetts- �eP�rr trncnt of Public S:ttet� Board of guiltlin� Re,, D Construction Su "ul:rtiuns and Staa:.itards pervisor License License:- CS 47667 PHILLIP M VOLLMER ' ,;Z) PO BOX 64 COTUIT, MA 02635 ('unimisvioncr Expiration: 0131 vl Tr#: 598 0 . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1? Parcel �c -Application # Health Division Date Issued �' ' l Conservation Division Application Fee Planning Dept. _ Permit Fee s> , Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street-Address RV -&re,_� ' d l Rd Village Owner P019 GraO bl 7k Address /1? a Telephone 6f7— '756- 653 Permit Requestan4e f Cq ( _q.A Y 6 6�� `) Square feet: 1st floor: existing A4roposed 2nd floor: existing proposed Total new Zoning District Re., Flood Plain Groundwater Overlay Project Valuation ` Construction Type ay Lot Size 0 7 Grandfathered; ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes., -WNo On Old King's Highway: ❑Yes 44No Basement Type: krFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) �® Basement Unfinished Area (sq.ft) Number of Baths:• Full: existing_ new Half: existing ne Number of Bedrooms: existing�ew 01 Total Room Count (not including baths):,existing _new First Floor Room Countw Pa ..: Heat Type and Fuel: Was ❑Oil ❑ Electric ❑ Other Central Air: KIYes ❑ No Fireplaces: Existing New Existing wood/ oal stoves:❑Y�� (Vo Detached garage: ❑ ex g ,❑ ne�s e_Pool: ❑ ex 0 new _ Barn: ❑ e ig Attached garage:! e5xisting ❑ new siiz3 Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes �Mo If yes, site plan review# Current Use ( Q INJ"4 QJ Proposed Use APPLICANT INFORMATION ,. (BUILDER OR HOMEOWNER) - Name Telephone Number ? 2/2 /. /0 Address License# (0209—Home Improvement Contractor# Worker's Compensation # () �4 u- CQ 31 ALL CONSTRUCTION DEBRIS RESULTINGFROM THIS PROJECT WILL BE TAKEN TO tr r SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# 4 DATE ISSUED G - MAP./PARCEL NO.; - t t ADDRESS VILLAGE r' OWNER } DATE OF INSPECTION: -'FOUNDATION 4 • FRAME INSULATION-1 ` FIREPLACE i ELECTRICAL: ROUGH FINAL k I F PLUMBING: ROUGH FINAL € GAS: -g ROUGH 'U,- FINAL FINAL BUILDING;§ ,..� r - f DATE.CLOSED OUT -' ;- i ASSOCIATION PLAN NO. k• 'f Client#:23059 OCEAINCI .r .ACORD- CERTIFICATE OFJ LIABILITY INSURANCE' DATE(MM/DD/YYYY) 10/ 2/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms.and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER - - -CONTACT Rogers&Gray Ins. Kingston PHONE 434 Rte 134 A/c No Ext: FAX No), 877 816 2156 EMAIL mail@rogersgray.com " South Dennis,MA 02660-3700 ADDREss: 508 746-0055 - INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Co 17000 INSURED Oceanside Inc. INSURERB:Everest National Ins.Co - - 217 Thornton Drive INSURERC: Hyannis,MA 02601-8105 INSURER D: 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. INSR' - ADDL SUBR - LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YPOLICY EY MMIDD/YFF POLICY EYYY LIMITS A XP GENERAL LIABILITY 8500053796 1/01/2013 01/01/201 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY - PREMISETO Ea RENTED - $1 OO OOO CLAIMS-MADE �X OCCUR - - MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:POLICY PRO- PRODUCTS-COMP/OP AGG $2,000,000 " _ - , JECT LOC � $ AUTOMOBILE LIABILITY _ - COMBINED SINGLE LIMIT .. - Ea accident $ ANY AUTO - BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED - - AUTOS AUTOS BODILY INJURY(Per accident) $ - NON-OWNED - PROPERTY DAMAGE HIRED AUTOS Per accident - . . $ - UMBRELLA LIAB OCCUR - - EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE - ,. _ AGGREGATE $ - DED - RETENTION$ $ B WORKERS COMPENSATION _ CF4WC00045131 I/01/2013 01/01/201 X WC STATU- "OTH- AND EMPLOYERS'LIABILITY - '- ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? �Y/N - E.L.EACH ACCIDENT $500 OOO " (Mandatory in NH) - NIA 'NO EXCLUSIONS E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5OO,COO . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) - - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE _- THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. , 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" #S92190/M92188 CJIF 1 Massaci usetts. - Department of. Public safety Board of B.uildin`g Regulations and Standards Omstructio Supen-kor License: CS-073097. PETER A LA:ROCHE 18 CEDRIC laOAD Centerville MA 02632 . `M.ral.1Qn �omt ir:ssi`.ner 11/03I2014 Mon Ice of Consoer Affairs;&Business Regulation ME WPM M NT C'ONT.kA TOR w� egistrat16, TYPe: Expiratt _ Supplement OCEANSIDE,:INC.r'; r � V PETER LAROCI E kf 217.Thornton Dr Hyannis, MA 02601 U.fi c secreta'ry License or-registration valid for mdividul use only before the expiration.date: If found.returR to:. OMge ofConsumer Affairs and Business'Regulation 10 Park Plaza-Suite 5170 =.and' Boston`MA 02116 s Not valid without signature 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 Please Print Leaibly . Name(Business/Organization/Individual): Ce�� .�(�jP Address: (:�1 r 7 -Th f 47o oJ)r I U,e City/State/Zip: 5 Phone:#: �G '77 Z Are you an employe Check the appropriate box: Type of project(required): 1.19 I am a employer with 4. ❑ I am a general contractor and I T- 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.0.I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees. These subcontractors have g. J�rD emolition working for me in any capacity: employees and have workers' [No workers' comp.insurance comp:insurance.:. 9. ❑Building addition required.] 5. oration acid its I0.❑.Electrical repairs or additions ❑ We are a corporation, 3:❑ Iam a homeowner doing all work officers have exercised their I I.❑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. Oth 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:: :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 subcontractors 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. : • L ) Insurance Company Name: �/�,(�{Q�T Xla4 f[ f�C�'I 0/LJ Policy.#or Self-ins Lit.#-, 0-}- y Wo n�4J/3�. Expiration Date: : a(G Job Site Address: v' City/State/Zip: r JI I IC � ro YZ 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 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 imprisomnent;.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. ' 1 do hereby certif der pains and penalties of ju hat tl 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#: ( I Il - l7 i Fie I _ �. �. . . _1 Lill { Ap v A-la; 0 W, I I I,I I I i I I i I E - . # ! I - I Lj- . .......... -T iE f II Li --�--►___�_. I I _ I7 1 _ w • // THE RIGHT CHOICE r -- - ---� I ice Use Only since.1971 I . ; JOB NUMBER' Restoration: ==-- 217 Thornton Drive,Hyannis,Mass.02601 508-771-3110 800464-3318(MA.Only):508-775-2848 Fax MASS.HOME BVROVEMENT CONTRACTOR REG.#100121 MASS.CONSTRUCTION SUPERVISOR REG.#000043 ASSIGNMENT' AND AUTHORIZATION TO PAY The undersigned, herein called claimant, has authorized and ordered from Oceanside., Inc. , the materials and/or service's requested. Undersigned hereby assigns- to Oceanside, Inc,e ,any unpaid proceeds due or to become .:due, under '.the claimant ' s policy with the insurance company to pay direct. to Oceanside, Inc or; to include its name .on a. check or draft, for all requested work. In the event that Oceanside' s, claim herein is not covered by, or paid by, an insurance .company, claimantagree to. pay:Oceanside, Inc._ withn` sixty (60) .days after .work has been completed. Claimant understands that Oceanside, Inc. is working for them and•not the insurance :company or the adjuster. Payments remaining due and payable after the claimant has received payment from the insurance company.shall bear interest at one and .one- half' (1-1/2%) percent .per month. r In the ..event that there is, a. breach by the claimant of„any' of the ; conditions. of .this agreement, Oceanside, Inc. shall be entitled ,to recover., as additional_ damages, attorneys' fees, costs and any other collection expenses reasonable and attributable to said. breach. if payment is not received within 60 days, collection action will commence without further notice =to the claimant. l `OS 3 2- DATE.:. Q 3 PHONE: e ;u��i 'SJ�' - ' � '� �I �e P 24H tli S`✓- CLAIMANT'S SIGNATURE. PRINT NAME. If Af( r C r&e. T 7 Zf- d7� MAILING ADDRESS (BILLING) CITY STATE ZIP 9 LOSS ADDRESS .. �SO�)� O 32c15- �-�C ASS prof e2� �-Mtc a f-1 CA— (01Icd°e D --dI6, gQn Cq co INSURANCE ADJUSTER'S NAME/CO. INSURANCE AGENCY NAME g�303�: \\Ocean_serv\customer\documents\ASSIGNMENT 20I l.doc w ---- - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map al Parcel Oda Application # Health Division Date Issued 13 Conservation Division Application Fee Planning Dept. Permit Fee 3 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address �� Village CfYr1;kA VI U f MAt Owner rrkA-IVQ,U IST 1 R.OURT TR45 Address I" WA) W hye_, mop Telephone Permit Request WOW 5MrMeol_K FRO/I RM 7, e 904DW 0,00 1 S#677TR04K kt�PLAO_C , FAYISP FLa02 w rrN V JNyL PLANK A� . � �1D P- UK Square feet: 1 st floor: existing I dbb proposed 2nd floor: existing proposed Total new Zoning District Flood Plain �� Groundwater Overlay Project Valuation �0_0_01 Construction Type � A��iG w Lot Size b Grandfathered: ❑Yes ❑ No If yes, attacG porting c ocuq�ontation. -, Dwelling Type: Single Family U Two Family ❑ Multi-Family (# units) _ Age of Existing Structure �' Historic House: ❑Yes ❑ No On Old King's ighway3❑Y ❑ No -a Basement Type: YFull ❑ Crawl ❑Walkout ❑ Other N rn Basement Finished Area(sq.ft.) G 00 Basement Unfinished Area (sq.ft Ln. Number of Baths: Full: existing 1 new Half: existing new Number of Bedrooms: J existing _new Total Room Count (not including bath;): existing new First Floor Room Count Heat Type and Fuel: U Gas ❑ Oil ❑ Electric ❑ Other Central Air: U(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: 5/existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) JName MAPK klmiok Telephone Number Address mr dux 6q u6 License # �5 1 (�ja"l r , 114 ®o A t 6�J— Home Improvement Contractor# OM-P, Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �ll/�� �� DATE 31YI13 a . FOR OFFICIAL USE ONLY " } APPLICATION# DATE ISSUED p MAP/PARCEL NO. 4 C ADDRESS VILLAGE 4 z OWNER r , DATE OF INSPECTION: .. FOUNDATION FRAME OK 3I14/I3 PxoY, INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING y�3/13 w. ., n •t : t DATE CLOSED OUT , ASSOCIATION PLAN NO. f E TheVommonwealth of.Massachusetts N" ,. . �PiogrthiiiW ACCZ[�e11tS 79 QjTwe Oflavesflgadons •• 600'WashhTtan Street _ Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Appficant Information Please Print Leeibly Name pusmesdorgaaizarian5ndividual): Address:< (o City/Sfiate/Zip: l f M I ' od�K Phone.#: X- �S Are you an employer?Check the appropriate bow a of ro'ect're e 4. I am a general contractor and I P ] ( 4� d):= 1.El am a employer with g 6. ❑New construction . employees(full and/or part time).* have hired the sub-cones 2: I am a'sole proprietor or partner- • listed on the-attached sheet:. 7. �RRemodeling ship and have no employees These sub-contractors have •8. Demolition workingforme iri c employees and have workers' ffiY ?P3' 9. ❑Budding addition [No workers' comp.insu ance comp,mom„once•$ required-] 5. D 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 worl='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. lcmtrect ors that check this box must attached an additional sheet showing the name of flee sub-contractors and state whether or not those entities have - .employces. If the sub-coutracto s have employees,they must provide facir workers'comp.policy number. 'I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic,#` Expiration Date: _ Job Site Address: City/Stawap:' Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure•to scone coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cIIminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as-weII 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 statEmerit may be forwarded to the Office of Investigations of the DIA for insurance coverage yeiffication I do-hereby certify under the. ains•and penalties of perjury that the information providedl/aabove is true and correct §4_v� 44A Date: 3/7�3• Phone# Official use only. Do not write in this_area,to,be completed by city or town official City or'down: Permit/License# Iss"Mn9 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#: . I oF... .......... .......... ..................................................... ............................................... 'e iNAM Town of Barnstable Regulatory Services Thomas F.Geiler,Director i uRd ng Division. Thomas Perry.CBO Building Commissioner 200 Main Street, Hyannis•.MA.02601. www.town,barnstable.ma.as Office: 508-862-4038 Pax: 508-790-6230 Property Owner Rust Complete and Sign This Section f Using A Builder as Owner of the subject property hereby authorize y i/1 I(!� l t/J'�(U/� to act on my betxal in all matters relative to work authorized by this building permit application for. S°Z �1 C'-� *e' (Address of b) /#IkI Signature of Owner bate Pant Name � j ef if Property Owner is applying for permit,please complete the Homeowners license Exemption Form an the reverse side. C:VUserstdcatlilllAPPDataVLocWWicrosoMWindoWsVreaspotaty Internet r4lesToMentOudookQRf 6ZUBNTXPRFS:S.doc Revised 053012 r d/'Xe anr��zoaac�eall/o'O�a�aa`c/cr�eC .'' License or registration valid for individul use only �\ Office of Consumer Affairs&Business Regulallo*-;' IMPROVEMENT CONTRACTOW =before the expiration date. If found return to: egistration: ,109558 Type¢ " Office of Consumer.Affairs and Business Regulation xpiration .9/21/201.4, Indlvfdual j 1.0 Park Plaza-Suite 5170 e D Bosto'n,.MA 02116 MARK VOLLMER MARK VOLLMER 1455 SANTUIT NEWTOWN RD`.' COTUIT, MA 02635 3 Undei•se!retal Not valid without signature Massachusetts- Department of Public Slllct\' Board of Building Re��ulations and Statihtrds Construction Supervisor License License: CS 47667 PHILLIP M VOLLMER PO BOX 64 ry COTUIT, MA 02.635 Expiration: 9/1/2013 ('ommisioncr. Tr#: 598 ' f TOWN 4F BARN"TA L E Olvlrsloi�l O 161101C� , . r� • •spy� , 4 G to , 9,01NA E RMail 5F� �-CAU . TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE bp CONSTRUCTION TO THE INSPECTOR OF BUILDINGS: The undersigned ,here^_qpp]les_igr _a permit according to the following information: Location Proposed Use ,.iC Zoning District Fire District Nome of Nome of Builder Address Nome of Architect Address Number of Rooms Foundation Exterior Floors Interior Heating Plumbing /.U Fireplace Approximate Cost Difinitive Plan Approved by Planning Board 19 Diagram of lot and Building with Dimensions /3 Roof)ng rr../k r..ff: I Sri• -Re 2:^ 'i I I hereby agree to conform to all the Rules and Regulations of the Town of Bornstoble regarding the (^gve construction._^ Nome „ Small,Alan No ..1.9.§.22...Permit for Location Centerville Owner ^ Type of Construction 1:^3^9. Plot Alan Snail , Lot #3. Permit Granted 19 Date of inspection 19 O' Date Completed 19 PERMIT REFUSED 19 Approved 19 z.6t A