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Town of BarnstableBuilding . € treet A L oved Plans-Must be 1&,", n"I and'this£Card Must be-.Ke s` Post This Card�So That�t is Uis�ble From he S 5 pp, F,. p ) ° 6 Posted lJntil Final Inspection Has`Been Made �° R lthere->a Cert�ficate;of Occu anc is:Re u r,.ed such Buildm shall,Not be Occwpled until a Final<Inspec n has be n made Permit ',: p.. yam.,, q ' g ,...., „ ., .. ., . „ as .5 A. . Permit No. B-19-672 Applicant Name: William Callahan Approvals Date Issued: 03/06/2019 Current Use: Structure Permit Type:`Building-Insulation-Residential Expiration Date: 09/06/2019 Foundation: Location: 33 BRIARCLIFF LANE,CENTERVILLE Map/Lot: 208 111 Zoning District: RC Sheathing: Owner on Record: CASEY WILLIAM 1&THERESA A Contractor Narne WILLIAM CALLAHAN Framing: 1 Y k. 2. Address: 33 BRIARCLIFF LANE F Contractor License. CS 095581 2 _.,�.. CENTERVILLE, MA 02632 t Est Protect Cost: $2,851.00 Chimney: Description: Insulation/Air Sealingc� Permit Fee: $85.00 Insulation: Fee Paid $85.00 Project Review Req: Final: Date'. 3/6/2019 .� �� ���.;w• Plumbing/Gas Rough Plumbing: x' .Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authonzedbyth s permit is commenced withinEshk months after issuance. All work authorized by this permit shall conform to the approved application and the�approved construction documentskfor whlch.thls permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures�ghall be in compliance with the local zone g by laws a d codes. This permit shall be displayed in a location clearly visible from access streeWor road and shall be maintained open for public Insppeeetidn for the entire duration of the Final Gas: work until the completion of the same. s x Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe B dlu nil g and fire Off,rclals are provldedjon�thls permit. S d Minimum of Five Call Inspections Required for All Construction Work y t -' Service: 1.Foundation or Footing � � Rough: 2.Sheathing Inspection 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). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Town of Barnstable Fir �..� .. 0 1 v Expires 6 months from date Regulatory Services,, k Fee EARNgrABLE. * Richard V.Scali 4 Q MASS. i639. ,. Director su Building DivisionN � '� Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 33 '-B rie-r Residential Value of Work$ �`3J V Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address I- r- C./• / 'I Contractor's Name Telephone Telephone Numberco�ap7�� Home Improvement Contractor License#(if applicable),ey" EFG Email: Construction Supervisor's License#(if applicable) (�Q,47 J21Korkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I a the Homeowner have Worker's Compensation Insurance Insurance Company Name /llC6 Dzero4&, 5zLo—y Oaxo:,77 ' Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accom any a permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers-of roof) Re-side Replacement Windows/doors/sliders.U-Value t CZ (maximum.32)#of windows #of doors: Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. I ' *Where required:Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc., ***Note: Property Owner must sign Property Owner Letter of Permission. A c py the 13om Improvement Contractors License&Construction Supervisors License is r i SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Iniernet Files\ ntent.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 I - r�• r Authorization For as owner of the sub�ect'property,hereby authorize B� e & Associates` to act on my behalf, in all matters relative to work authorized b is building permit application for Address of property: 33 Brier Cliff ' Centerville I (Signature of owner: _ J j Prmt Named` r (' OAS L 157t s r t } I 4 LUII' ' 1 �•:J i'��Sl"u .i z�3'v �li"!S� "S�'�'tdE c"'a� , .:*� ��' ��ec:i4 �s £:u i ?...cc= s : CS-009714 RICHARD P.GARNEAU Jai PO BOX 476 West Barnstable SIA 02bb$ 04/0412016 Office of Consumer Affairs d. Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 162600 Type: Supplement Card Expiration: 3/26/2017 BAKER & ASSOCIATES INC: J RICHARD GARNEAU W W P.O. BOX 923 CENTERVILLE, MA 02632 _ _ Update Address and return card.'Mark reason for change. Address Renewal ❑ Employment C Lost Card SCA 1 0 2OM-0511 Y C='�R tC'CJ'/7G?JGC-tLtldFrCLt�Jd-!.'�1��(,L7i31f7.C'pLLG1NftCI _ ce or Consumer Affairs&Business Regulation License or registration valid for individul use only _ E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration, ?$260D Type: 10 Park Plaza-Suite 5170 Expiratlon 3/26/2017 - Supplement Card Boston,MA 021.16 BAKER&ASSOCIATES INC RICHARD GARNEAU 521 SHOOTFLYING HILL RD a�`: 3 u::}`� VrNot _._............_......CENTERVILLE,MA 02632 Undersecretary valid without signatu Cr , y The Commonwealth of Massadjusetts Department of Indusirlal.Accidents y Oflice of Investigations 600 Washington Street Boston, 02111 wnnv:mass.gov1dia Workers' Compensation Insurance Affida-vit:Builders/Conk-acturs./Electricians/Plumbers Applicant Information Please Print b' Name,t�tas�e�IDrgmtizatisx�Trtdividual): ,j' Ad&ess: D J!�X6, k1d /-) �"// J City/State/Zip: Phone#: &ti Aree an employer?Check the appropriate boz Type of project(required): I_LJ lama employer with 4_ ❑ I as a feral contractor and I employees(full andforport-time). s have hired the sub-conhwton 6. ❑New c stn�ctit�n 2.❑ I am a sole proprietor or parr listed on the attached sheet_ 'I. ❑Remodeling 'ship and have no employees Thee sub-contractors have g. ❑Demolition working for me in any capacity- employees and have woticers' 9. ❑Building addition [No workers'comp.insurance comp-insurance.: requued] 5_ ❑ We are a corporation and its 10.R Electrical repairs or additions 3_❑ I am a homrowner doing.all work officers have exercised their 1I_❑Plumbing repairs or additions myself o workers' right of exemption per MGL � gip- 12.❑Roof repairs insurance required]T c. 152,§1(4),and we have no employees-[No workers' 13..�Dth lDlnc i[1.f1' comp_insurance required.] 'Any appiicam iher checks boa##1 mug also fill our the section below showing their workers'compensation policy information_ Homeowners who submit this affidavir indicating they are doing all work and lBen hire outside contractors oust submit a new affidavit indicating sacli ICanractors that check this boot moist attached an additional sheet showing the name of the sorb cuutractrras and state whether or not those entities bzv4 emplayees. If the sub-contractors have employees,they:mast provide their workers'comp.policy number. lain err employer titat is prm idiatg workers'compensation irrsurrrnce for my employms. Bekw is the pmlicy and job sdxr information. 62W Insurance Company Dame: Policy##or Self-ins-Lic_4: Expiration Date:y�,3•/lO Job Site Address: & -> A60-/00 6" City/StateiZip: Attach a copy of the workers'compensation policy dectaratiob 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 for wwded to the Office of Investigations of the DIA for insurance coverage verification. I do heby . rti unlerthl nd tties of pedn ry that f7einrmadon provi&W abati•e is fte and correct S' e: Bate: S / Phone i#: Official rase only. Do not write in this area,to be completed by city or fun ofcw' l City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing.Inspector 6.Other Contact Person: Phone#: 6 f Client#:9742 2BAKERAS ACORD,, CERTIFICATE OF LIABILITY INSURANCE DATE(MWOD/YYYII) 04/22/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:NTA CT Dowling&O'Neil PHONE F ac No, o E t:508 775-1620 A/ No): 5087781218 Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO BOX 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:National Grange Mutual Insuranc INSURED INSURER B:Associated Employers Insurance i Baker&Associates,lnc. INSURER C: P O Box 923 Centerville,MA 02632-0071 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. LTSRR TYPE OF INSURANCE INSR WVD POLICY NUMBER BR MM/DD[YYY MMLDD1YYYY LIMITS A GENERAL LIABILITY MPJ7223M 4/19/2015 04/19/2016 EACH OCCURRENCE $1 OOO QQQ X!COMMERCIAL GENERAL LIABILITY PREMISES Eaoxunence $500000 CLAIMS-MADE LX OCCUR MED EXP(Any y one person) $10 OOO PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 j POLICY 7 PRO LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED --- I AUTOS :AUTOS BODILY INJURY(Per accident) $ I HIRED AUTOS I NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ i I � $ — UMBRELLA LIAB OCCUR EACH OCCURRENCE $ j ;EXCESS LIAB CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ B WORKERS COMPENSATION WCC50050024542015A 4/23/2015 04/23/201 X 1,WC STATU- OTH- AND EMPLOYERS'LUIBILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICERIMEMBER EXCLUDED? a N/A E.L.EACH ACCIDENT $500 000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500.000 it yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S149786/M149785 MER OFIKE T Town of Barnstable *Permit# ~O Ezp' months jr sue Ante ' ► . a ulatory Services � •nxtvsTAg[.e. _ y MASS. / cb i639 SEP j ?� Thomas F.Geiler,Director 12 5 I - Building Division �k 9 Za i2 W,Y OF�� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint . Map/parcel Number Propel ddress rT Lisle 00*+y/j It-, Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&`Address t I11 � Contractor's Name(MJt 1 / S t" F n I Telephone Number t qy -! - Ill/ Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) y�Workman's Compensation Insurance l Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance. - Insurance Company Name : Workman s Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to uum ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side - #of doors ❑ Replacement Windows/doors/sliders.U-Value . (maximum.44)#of windows 'Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic,Conservation,etc. . ***Note:: Property Owner must sign Property Owner Letter of Permission. A copy of the o e Improvement Contractors License&Construction Supervisors License is. i•eq SIGNATURE: C:IUsersldecolliklAp talLocallMicrosoffllWindowslTemporary Internet FileslContent.OutlooklQKIH7METXPRESS.doe Revised 070110 i Town of Barnstable w snxnrsrnsEE, • ° , ' � Regulatory Services iOTEn���A Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner ' 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ` Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) - 3%n'dure of Owner Date , �-p v. Print Name a , - '-, QAWPFILESTORMS\building permit fonns EXPRESS.doc ° Revise020108 q Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-094500 JAMES S PEACOIC ' PO BOX 171 " OSTEVILLE MA-02�32 Expiration Commissioner 07/22/2014 Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991m3)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS 1 Cpc�soriraruu��cl/�o/,C%`1r,:ltac•�%alella f Office of Consumer Affairs&Busihess Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration 151.853 Type: Office of Consumer Affairs and Business Regulation CV10 xpiration 7/7%2014 Private Corporation 10 Park Plaza-Suite 5170 ~ Boston,MA 02116 SCOTT PEACOCK BUILDING&REMODELING INC JAMES PEACOCK 1046 MAIN STREET SUITE=-7 OSTERVILLE, MA 02655`+` Undersecretar -- Y Not valid without signature ' aC DATE(MM/DDIYYYY) ,4co CERTIFICATE OF LIABILITY INSURANCE 06/2s/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Germanl Insurance Agency -- - NAME: PHONE - - FAX 908 Main Street (AC,No Ext: 508 428-9194 A/c No: 508 428-3068 E-MAIL + i Osterville,MA 02655 ADDRESS: ' INSURERS AFFORDING COVERAGE NAIC p e INSURERA:SAFETY INS CO INSURED INSURER B Scott Peacock Building&Remodelling,Inc. P.O.BOX 171 INSURER C Osterville,MA 02655 INSURER D: Commerce&Industry Ins.Co. 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 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 EFF POLICY EXP - LIMITS LTR POLICY NUMBER MMIDDIYYYY MM/DDIYYYY - A GENERAL LIABILITY CP00001152 7/5/2011 7/5/2013 EACH OCCURRENCE $ 1,000,000 ff COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $. CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY y COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED ♦ ., PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ D WORKERS COMPENSATION WC 005-81-5464 6/22/2012 6/22/2013 we SLATY- I I oTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101;Additional Remarks Schedule,If more space Is required) • - - - j CERTIFICATE HOLDER CANCELLATION 3 f SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'_ Scott'Peacock Building&Remodeling,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL- BE .DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ; Fax#508-428-7625 _ SCOtt_Peacock@verizon.net .. AUTHORIZED REPRESENTATIVE ;, . ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents tKK � Office of Investigations 600 Washington Street , ,` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information nPlease Print Le, ibl Name (Business/Organization/Individual): C(:C..C��Li �ck r� I / 1' `I t l_- Address: la� , 91 ' City/State/Zip:() ki . AM M155 Phone #: ' qT "Izo - gt!ob Are you an employer? Check the ppropriate box:' Type of project(required): 1.0 1 am a employer with 4. ❑ I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-.contractors 6. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have ship and have no em to ees 8. Demolition workingfor me in an capacity. employees and have workers' Y9. ❑.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 114❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 oof 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. I am an employer that is providing workers'compensation insurance for my emplovees. -Below is the policy and job site information. n Insurance Company Name: Policy#or Self-ins. Lic. #: 1. V�J�U l 1 Expiration Date: /Zz Job Site Address: City/State/Zip V(Xr/J� 6 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 D1A for insurance coverage verification. I do hereby c /fp under the p in and penalties of perjury that the information provided above is true and correct. Si nature: ( � / Date: Phone#: `1�� r lU 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#: _ _ Assessor's map and lot number ..... ., .. /.,�/......... SEPTIC SYSTEL nN.��J�U Toy Sewage Permit number .... .gs.��gs ............. ......: ti... ; �t+dTI� House number i' 9 LE. i .............. r , 39- REGU TOWN REGU TOWN '.OF - -BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO +. .`�............................................................ TYPE OF CONSTRUCTION ��� ...%.'� y f'1�! w:............................................................................ ......... !. 19.. 5, TO THE INSPECTOR OF BUILDINGS: The undersigned hereby a plies6 f'or�a ermit according to the following information: Location ....... . " .........��. : � e/ l�L- ... .... a:.! V. ..y.../. ...fie ............................. ProposedUse ... ........... . .. . ........... ...... ...... ....... .. ............................................................................................................. Zoning District .........................................................................Fire District ......... 33 Name of Owner . AA 'kt.°!�'.. . .,Address ...rl✓' / ................:... ... . . . . .. ..... . .. . . iName of Builder .... .. .. ....Address C....... .... �........ ...................... :...... _ Nameof Archite ................ .........................................Address ........:........................................................................... Number of Rooms ...� ....................................Foundation ""Y' . . .. . ....A ...... .......................... Exterior `lt ........ .......................................Roofing.......... . ... . ..... ... . ..:.. ............................................................... Floors �..... ....Interior e.............. .. ................... Heating *01�j ..:.... .... .............!` .......Plumbing .: . .00 !d!-A ........�! Fireplace .�.. �.....f:'`�....... . ................ ...4....... ......... proximo a Cost ...........��..�...........�.................... ........ Definitive Plan Approved by Planning Boa d -----------__-------------------19________. Area ......... ......... jr Diagram of Lot and Building with Dimensions Fee /0 o® SUBJECT TO APPROVAL OF BOARD OF HEALTH 1,Y�lL P. AlIF0i4 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of arnstable regarding the above construction. Name . ....................a......4r ............................... Construction Supervisor's License .r .�.: . MURPHY, JOSEPH D. No 2�4.... Per it ADDITION ................................... ..-..�ingle mly .. ............Fai ........... ..AwejjiRg......................... .... .. . ...... . ...... . ...... ..........Location ..33..B.r.iar Cli ff liff...Lane ........... Centerville ............................................................................... Owner ........�!�.Ph.AtANTP.�Y............................ Type of Construction ........Frame.......... . . .............. ............................................................ .................. Plot ............................. Lot ................................ Jul y .19, - , 85 Permit Granted ..........................................19 Date of Inspection .........................I............19 DateCompleted Com ....................... 19 co A M 3z M Assessor's map and lot number ..... ��.. '.. . .�/........ ?H E ropy Sewage Permit number .......... 5.- .7 gs...................... Z BARNSTOBLE, i House number MABa 90O 039. �00 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .... ...,..:.::.......:. .. i1t........................................................... TYPE OF CONSTRUCTION ......� ... !� m............................................................................ r ........................ 19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .......� ... � �. fi ..... .. .(t11�t,e�t f. `.+" vim............................. .. ProposedUse ;�:�.. .:............ .. ..✓....k. ................................................................................................. ZoningDistrict ........................................................................Fire District ............................................................................... Name of Owner � :....... ........... ...........:...............:Address 33... .....t:'.:...................... Name of Builder ..:....:............................. •,.m.P." .Address .. .... . ...........:...... .................................... /f Nameof Architec�.. .........................................Address .................................................................................... 4'Number of Rooms ....................Foundation ' Exlerior ...Roofing C Floors ..Interior j o ................... ............................................... Heating �......;��' !'L :.... .......Plumbing .:. �Yf!.....! '. ................................... o a ......:....T....A roximate Cost ........ .. ...... .+ � Fireplace ...............................,........ ......... � Y +........,........... . .. Definitive Plan Approved by Planning Board ________________________________19________, Area .....4r'.`� . Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH a. 70 wv OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS s� I hereby agree to conform to all the Rules and Regulations`of the_Town°of Barnstable-regarding the above construction. Name' .` .. ..... ..«............... Construction Supervisor's License MURPHY, JOSEPH D. A=2 it No ADDIT i ,Single...Family Dwelling r Location ...33..Bria lif f Lane Centerville ............................................................................... Owner ...Joseph.....D....Murphy. .... . .... . .................................. Type of Construction ..................Frame ........................ ...........................................................:.................... Plot ............................ Lot ................................ Permit Granted ............July 19, ..........19 85 Date of Inspection ....................................19 Date Completed ......................................19 6 /