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0065 BUCKSKIN PATH
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F I I , t 1 8 t 9 '1 Z o .2,,►sKe��.+ a� z��,o1�q v Town of Barnstable � � � ing .g. m . x. x SARNSnrA Post,This:Card 3o That�t is VisibleFrom tkeStreet Approved Plans IVlust betRetained on Job and tXhis Card Must be Kept lli b p; Posted Until Final.lnsp ion Has Been Made r , i ° Where a�Cert�ficate of OccupancyasRequred,such Buil.dmgYshall Not.be Occupied untila Final Inspect�on;.has been made �,a..,-. .,, �,.r �,_,n�• ....�,, ;�.� �-1 mom,. �s ..,4. �� ...�; . -,.�.' ,.�,— Permit _...�... Permit No. B-19-2642 Applicant Name: Henry Cassidy Approvals Date Issued: 08/19/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 02/19/2020 Foundation: Location: 65 BUCKSKIN PATH,CENTERVILLE Map/Lot: 170-050 Zoning District: RC Sheathing: Owner on Record: MEDEIROS,JUSTIN M&BRYANNA L Contractor Name: HENRY E CASSIDY Framing: 1 Address: 65 BUCKSKIN PATH 1= Contractor License; CS=100988 2 CENTERVILLE, MA 02632 Est. Project Cost: $4,300.00 Chimney: Description: Insulation/Weatherization Permit Fee: $85.00 Insulation: Fee Paid:. $85.00 = Project Review Req: t Final: µ � Date. 8/19/203.9 I Plumbing/Gas h PI m Rou in .u b } Building Official Final Plumbing: auti. wi hin six months,after.issuance. k honzed b this permit is mm t This permit shall be deemed abandoned and invalid unless the work , „y p commenced e P Al[work authorized by this permit shall conform to the approved application and ttie approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by lawsand codes. This permit shall be displayed in location clearly visible from access street o�,road-and shall be maintained open for public mspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued untilall applicable signatures bythe Buildm`g and Fire Officials are provided on this;permit. Minimum of Five Call Inspections Required for All Construction Work.fi; Service: 1`.Foundation or Footing ' Rough: 2':Sheathing Inspection 3. All Fire places must be ins P ected at the throat level before firest flue Img in is installed Final Ili 4.Wiring&Plumbing Inspections ections to be completed prior t Frame Inspec tion 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 All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: . _ Tow_n of Barnstable Lilllil � g s �p [ Po`st�This,Card So That"it`is Visible From the Street Approved'Plans Must be Retained onaJob and this Cartl Must be Kept' " a�wss Posted Until Final Inspection Has'Been Made. i ° where a Certificate of Occupancy is Required,such Buldmgshall,Not be Occupied until a"Final Inspection has been made: Permit v:ere Permit NO. B-19-120 Applicant Name: RICHARD P FOGARTY Approvals Date Issued: 02/04/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 08/04/2019 Foundation: Residential Ma Lot 170-050 Zoning District: RC Sheathing: Location: 65 BUCKSKIN PATH,CENTERVILLE f t4 Contractor Name: ,RICHARD FOGARTY Framing: 1 Owner on Record: MEDEIROS,JUSTIN M& BRYANNA L j = Contractor License 130373 2 Address: 65 BUCKSKIN PATH # -- i �'"`"-•. Est. Project Cost: $3,000.00 Chimney: CENTERVILLE, MA 02632 Permit Feb: $85.00 Description: TAKEOUT EXISTING 2ND FLOOR BATHROOM REMOVE TUB AND Insulation: Fee Paid:.' $85.00 TILE SHOWER, REMOVE TILE FROM WALL, REPLACE FANITY WITH Ile Final: lr NEW 30" VANITY REPLACE TOILET, NEW TILE FLOOR,"LIGHTS AND Date: f, 2/4/2019 k J/G BATH FAN IN CEILING ,.. Plumbing/Gas Project Review Req: NO STRUCTURAL WORK Rough Plumbing: •.,:BuildingOfficial Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after`issuance. All work authorized by this permit shall conform to the approved application and theFapproved construction documents for which, this permit has been granted. Rough Gas All construction,alterations and changes of use of any building and structures shall 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'public inspection for the entire duration of the Final Gas: work until the completion of the same. - !f ' Electrical. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:' ; ` Service: 1.Foundation or Footing -/ 2.Sheathing Inspection _ _" _ � Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 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" (asset forth in MGL c.142A). Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: - //99 4i► Application Number....g.........!...l............. ........... * BARNSIASLE, + MASS. Permit Fee...... ...'gs....................Other Fee........................ 1639. FDM�6 Total Fee Paid................. TOWN OF BARNSTABLE Permit Approval by... .. on..... /..` .�r1..... BUILDING PERNIIT° �D..........Parcel........ .' .................... map......... . ........ . ..... APPLICATION Section 1 — Owner's Information and Project Location GG � Project Address �clC- .C/��i) Village' A ertlt l Owners Name p �edPrl yS Owners Legal Address eac 011P? Ira/A - City &'J'kP/c%IIe State /nd. Zip D z��Z Owners Cell# 7J�/—Z��-/9Z f/ E-mail b I ei 0 6 ( �i4�, C"0/79 Section 2 Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use " ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire'Alarm Rebuild El Deck Apartment Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar Z `� d © Renovation ❑ Pool ❑ Insulation z N Other—Specify U' r Section 4 - Work Description l t exClSf Z Ce/ oa/ t!,f ,y! e .S u>'er le rn Wall, l re 17eLdl 36 /i r n Last updated. 11/152018 Application Number...... ........................................... Section 5—Detail Cost of Proposed Construction* a Square Footage of Project Age of Structure Aw t x, -2;- Dig Safe Number'y If t # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method `'� MA Checklist,❑ WFCM Checklist ❑ Design Section 6—Project Specifics- Z Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ® Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal ❑ Municipal Z' On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: %6&)17 �q�,�-� /l I am using a crane ❑ Yes ® No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes '❑, No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage # of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required' Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes © No Last updated: 11/15/2018 d r Barnstable Bldg.Dept. Approved by. Permit:#el t ` e4el , 1 y 1 p 6 G/ 1 a _ , Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards Consi<r�Od*A §bpprvisor CS-063941 pires: 11111l2020 -: RICHARD P F-0GARTY �gm 106 BEECHWEpD RDa OF ,' a CENTERVILLE MA, 02632 ?S" • F�f{'1S'S�337�1� • Commissioner C z, " rjeu6! oWmPeenjON.. Ammmepun ZMW Vw'3•I'tl/w31N3O p Qa GOOMHO338 90t . 8otZ0 VW`uo;sog llkidJO�a1jdN31a to£4 eling-aaeld uojjng4sd au0 OZOZ/LZ/ZO EL£OEl uogeln6aa sseulsng pue sne y aawnsuo3;o aolgp UORWIZIR3 PORASMSEI :o;uanjej puno;A •eiep uolwjldxe a4;ejo;eq lenpwpul:3dA1 ltluo asn lenpinlpul jo;Allen uo138J3sl69d U013Vti1NO31N3W3AOUdW13WOH uolteln6aa ssaulsng is sjlegv jawnsuoo;o aaglo _ � �T/arr,��vprn�l,��o f�Jzrainzar�¢�oa�t'� a f 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/Plunibers Applicant Information Please Print Legibly Name(Business/OrgmizationandividuaI)' Fa 7 5/- Address: 16d- 19eec�i u o� a� . City/State/Zip: 2dZZ ° Phone#: O —Z Y: i� Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.® I am a sole proprietor or partner listed on the attached sheet.. 7. 0 Remodeling' ship and have no employees These sub-contractors have 8. 0 Demolition _ working for mein any capacity. employees'and have workers' 9. ❑Building addition, [No workers' comp.insurance comp.inc„ranCe 3 Weareac required.]; ❑ . corporation and its I0:0 Electrical repairs or additions S. 3.El officers have exercised their I am a homeowner doing all work � 11.El Plumbing repairs or additions ' myself o workers'com right of exemption per MGL Y � P. � '12.0 Roof repairs insurance required]t - c 152,§1(4),and we have no employees. [No workers' 13.0 Other d comp.insurance required.] *Any applicant that checks box#I 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 poluy and job site information. Insurance Company Name. Policy#or Self-ins.Lic.#: Expiration Date: 7 R Job Site Address: � �5 ,i1 ��T/7 City/State/Zip: Ad 02,0? 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 rider the ams and pen` gfperjury that the information provided above is true and correct. Si store: Date: / Phone#: f-a 7 6 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." fined as an indium arts association,corporation or other le or two or more An employer is de dual,partnership, on, rp gal entity, any 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 lime. 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Mwsa&usetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-49M ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia Application Number............................................ Section 9- Construction Supervisor Name o 4Telephone Number fob- Z 7y-7S' �� a ar p Address jof &JI Waad City i+Ile. State _Zip p Z6-;�Z License Number CS' 6 639Y/ License Type 'C�V Expiration Date f/�i�la Ze Contractors Email .'nowa f v k' comer Cell # 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. i Signature Date Section'10—Home Improvement Contractor Name � i' ' 04 F 4.a Xl Telephone Number S69 27c/ 7rrd- II / / � Address A. �i�rh c,J ooQ �. City &Ae y/le State _Zip 42d�?2- Registration Number f 362 7S Expiration Date Z /07/zy I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation r"equired b 780 and the Town of Barnstable.Attach a copy of your H.LC.... Signature Date Section 11 —Home Owners License Exemption Home Owners Name: Telephone Numbers Zug-i9y 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 C and the Town of Barnstable. SignatureA9�- � Date / APPLICANT SIGNATURE Signature Date % // /l r Print Name Ae1 / a �r'� Telephone Number 2j�F61' E-mail permit to: 1p. U f'Qk' 'aryl Last updated: 11/152018 Section 12 —Department Sign-Offs 4, Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ ; Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval j a Section 13 —Owner's Authorization I, b'N1(mm, as Owner of the subject property hereby authorize afl/ agr to act on my behalf, in all matters relative to work authorized by this building permit application for: 6S gacks LaP0q1,'Ile . /I1�. 0 2632_ (Address of job) RMO QU= 111111,9 Signature of Owner date fb Mcdelm Print Name Last updated. 11/152018 r , , gj2A& ,4941 �Vve Town of Barnstable *Permit# p Expires 6 months from issue date Regulatory Services Fee • snxusr�, • . M"S& Richard V.Scali Director Building Division Tom Perry,CBO,Building Commissioner APR 200 Main Street,Hyannis,MA 02601j'opy 2 02018 www.town barnstable.ma us l�//""41 OF. Office: 508-862-4038 �r 90-6230 4&Z EXPRESS PERAUT APPLICATION - RESIDENTIAL ENTL ONLY 1-7 O _ Not Valid without Red X-Press Imprint Map/parcel Number Property Address [?'Residential Value of Work$ QQd Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1-1(jr. 4 t4j&Q-5 F,i Contractor's Name &rr 4Eg5So E,/ Telephone Number y7 Home Improvement Contractor License#(if applicable) /73 73 L Email: Construction Supervisor's License#(if applicable) C?c156 77 1!rworkman's Compensation Insurance . Check one: ❑ I am a sole proprietor . ❑�am the Homeowner L� l have Worker's Compensation Insurance Insurance Company Name d-t j5-F j2t jX J TO R L--_-. Workman's Comp.Policy# 2—• 31 S- S 1073 Copy of Insurance Compliance Certificate must accompany each permit.• Permit R t(check box) Requee-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to &Y-AE6T;E1Q,' ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (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. *Where required:.Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. „ SIGNATURE: �t�r,, "�,tt,C,a/►t� Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC - Revised 040215 ! _ n ,i y _ 27te Commomweah*of fimwdr=etts D,epm1nrerrt of ludustrird A cid-erds - Office o,f rMWS69afiom 600 Wa%hijiSgion Street -- Boston,MA 92111 tivipm,mass garldia "rorimrs' CampensatinuInsn-ance avit:Builders ntractursMectdcians/Ph tubers _� Ap IIIf a f}II Please Pi ink Nsme � Address: �.'ifySCII� Are you an employer?Check the appropriate box 'Type of project(required): 1_❑ I am a employer with. 4_ ❑,I am a general confractor and I ❑Newemployers(fdll anwor part-time * have]Tired.the sub-contractors .6. 2.❑ I am a sole proprietor•orpartner- listed an the attached sheet. 7_ ❑Remodeling slip and have no employees These sub-contracture have lt_•❑Demolition wading for me in any capacity- employees aadl=e worjrers' INo workers'comp_ smzme comp.ksuranc I 9_.El Building addition required-] 5. ❑ We are a-corporation and its 10--❑Electrical repairs or adddiaas 3.Elf am a homeowner doing all work officers have e�rcised their 1L❑Plumbingrepairs or additions mp [No workers'comp- right of exempfim per MGL. ,7 insurance reed-]i c.152,§1(4�andwe have no 13-El OchFtoe repairs employeem[No workers' 13-❑Other cone-iam rmce mquired_] •AnyaP HCMMteMtcfiedMb4=Plmastalsofinovfthtsec�cabeloar agtheirwa�cexs'rnmpe�ariaaperzcgiafn®sao� T Hamemnecswho submit t zis affidat in g they an'doing RU waA auk&m hi m ai5i&c0nt3=ra,.ramst svt'tmit anew affxda it inditaxiLg-Suet' ICoittsctots that rhea tlns boa must attached as additiaaal street shoeing tha name of ttte sib-conhzctm3 and state whether ar not those ectitieshavp eaVteyees.Ifthe ub-c=tmaumhave employees,t6eyn=srpmridethek warkers'-mp.pally number I am an errrp r that is praridb warkv:ers cougmwat`darr bMirance for mY earPlaives. MOW is cite po£icy and job site informadom Iasuraa¢eCouiga�*l�atBe: � , Policy 4 or Self-ins.Tic_;g F�pirat>bm Date: . Job Site.t`4,ddses Crfy/Stafe� p_ Af#ach a copy of the workers'coinpensationpolicy declaration page(shoving the policy number and expiration date)., Fart=to secure coverage as required.under Section 25A o€MGL a 157 can lead to the imposition of criminal penalties of a fine up to$U.OD_OD and.-'or one-year imprisoumerk as well as civil peualties,sn$ie farm of a STOP WORK ORDER and a fiM of up to 0-D0 a clay agaimst the violator. Be adtdsed tlTat a copy of this statement way be forwarded to the Office of Irrvestigatioms of'1fie DIAL ftxr imsutnmce•coverage verification- Ida hereby carts;y under thepains and penahVes ofpedk7 thatthe infori zadmrprapMe-dahmv is bw and atrrect Sitmature: Date: Phone A. Official am a+ff. Da not r Fite in d ds area,to be muip£etesd by city ortoirn officia£ City orTown: PermzWLicense* ''sump Authority(ch de one): L Board of Health 2.Building Department 3.fiiy town Clerk 4.Electrical Inspector S.Plumbing Inspector, 6.Other` Contact Person: Phone it: Information and Instructions M ccar],rtSetis General haws chapter 152 regaa�s all e�Ioy�s in provide waz�s'compensation for their=Ployees. R ce of another under contact ofhire, Pmsaantto this sty,an.ea pFay=is deed as. _every person m�e serve. �Y eXprCSS or iarplied,oral or wratt=." An.wTkyer is defined as"an m�idaal,partnwgb.p.association,c0rpor-ation or othe2 Legal enflLy,or any lion or more Of the foregoing ina joint cnbK im,and mchtding the legal sepresmfa±iV=of a deceased employes,or the rmeaver or twtee of an individu parmeishlp,association as other legal entity,employing Cuploye - However the owner of a dwelling house hang not more than three apa d m=ts and who resides therein,or the occupant of the - dwelling house of anolher who employs persons to do make,cansftuction or repair woik on such dwelling house herein shallnotbecanse of sach employmentbe deemedto be an employer." or on.the grotmds or bm�dmg appurtenaut . MGL chapter I52,§25C(G)also StAns chat"every sta1E or local ficeassing agency shall withhold$ze issuance or renewaI of a Rcease or permit to operate a business or to construct buildings in the conrmoawealfh for any aPPUCantwho has notprodnced acceptable•evidence of compTrance with the insurance cove;rzge regmh ed." Additionally.MGL chapter 152, §25CC7)stairs=Neithmthe=m1qxwzalffi nor auy ofitspoIrtical subdivisions shall ewer ruin any conirart for the pmrfzrrmanc e ofpablie work u3tI acceptable evidence of compF=cewith the>nsmnce. regzm-emus of this chapter have been presented to the r o—n act►,g aiithozcty_" ApPIicasrEs . Please fiII otit the workers'compensation affidavit completely,by checking the boxes�apply to your sitaaiion and,if necessary,supply snb-contracinr(s)nam e(s), addmss(es)and Phone numbers) along wit their cmt ficate(s)of h=ance. Limited Liability Compames(LLC)or Limited Liabiility-Partnershzps(I I P)withno e�Ioye:es otb=than the members or partners,are not regnfred to cxny worlace ecmzpensatim ias¢rmce. If an LLC or 7 I.P does have employees,apolicy is requited. Be'advisedfiatthis affrda-Vitmaybe sabmitted to the Department of Industrial Accidents for confirmation of;n= ce coverage. Also he sure to sign and date the affidavit. The affidavit should be,retruned to jhe city or town that the application for the permit or license is being rBgvestA not the Department of n , j.A rl-;dm:L- R=M you have any question regardmg$ie law or ifyon are repaired to obtam a worl=' compensafionpolicLpleasecallthe'Deparimem±atthennmberlisf:t:dbelow Self-fimredcompaniessbould enter their self-fiisa ranee license xminber on the line. City or Town Officials . f - Plmse be sere that the affidavit is complete and primed legibly. The DepattmentIm provided a space at the bottom of the affidavit for you to fM out in the event the Of ofInvesdgafrons has to comaet you regarding the applicant- Please be sure to fill in the pramit/lice nse anmbes which wi71 be used as a m:E� nce number. In addition,an applicant ent that must submit multipIe,permitllicense applimfions in any given year,need only submit one affidavit mdicating cua- p olicy fij:Eb afion(if necessary)and under"Job Site ddress"the applicant should wrhe"all loca#v�ns is (may town).,,A copy of the-affidavit that has been officiaUY stamped or 53 a by the city or town may be provided to the applicant as proof:that a valid affidavit is on file for Ritae pezmits or Hceuses A new affidavitmust be filLcd out each year.Where a homeowner or cit�is obtaining a license or permit not relattd in any business or commercial v6ntu e C e. a dog license or permit to bum leaves etc.)said person is NOT regakcd to complete Ibis affidavit The Office of Invest gafions would Itke to thank you in advance for your cooperation and should you have any questions, please do not hest to give-=a call. The Departmenfs address,telephone and fax number: Delta tmmt o ff ludusfdal AoDidenti- �4� Qn Sires Ba MA 02111 T(�_L 4 617- -49OG Q�ft 4-06 or 1-977 MA 39AFF. Fax 9 617`27 7M Revised424-07 M;Rz 9PIVId OFF rGy •�. - r • • iABN6CABLE, r _. ASS ,� Town of Barnstable prED AA1►'t Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 wwwaown.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder o as Owner of the subject property , hereby authorize to act on'nay behalf, in all matters relative to work authorized by this building pemvt application for: (Address of Job) Signatate of Owner Date Print Name . If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPMESTORMS\building permit formsWRESS.doC Revised o4o2is Town of Barnstable Regulatory Services prr roy, Richard V.Seali,Director Building Division xsrnx�. + Tom Perry,Building Commissioner `m�' 200 Main Street, Hyannis,MA 02601 ED F www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXIKHMON Please Print DATE: JOB IACAnON: number street village "HOU EOV I,E : name home phone# work phone# . CURRENT MAILING ADDRESS: - City/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year ear period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be reMonsible for all such work performed under the building-permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signat=of Homeowner Approval ofBuildiug Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires anlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. . To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. 'Q:\WPFII,SS\FOP,hMuilding permit forms\EXPRESS.doc Revised 040215 � 333 Persson Construction, Inc. 22 Colony Ave. Bourne,MA 02532 -Phone: (508)759-8959 www.perssonremodeling.com perssonwindows@hotmafl.com PROPOSAL SUBMITTED TO: r ONE: ATE: Pugh and Veronica Walsh /30/16 STREET: JOB NAME: CHITECT: 5 Buckskin Path ITY,STATE AND ZIP CODE: JOB LOCATION: DATE OF PLANS: Centerville,MA e hereby submit specifications for: Strip off old roof shingles from entire roof and remove to the dump. Inspect roof deck. Install a layer of 30 lb. felt paper on entire roof,deck. Install ice and water barrier on all eaves and in all valleys. Install new aluminum drip edge on all eaves, new flanges on all plumbing vents, and new flashing where needed. Install new 30 year Tamko architect style roof shingles on entire roof. Shingles ill be fastened using 6 galvanized roofing nails to insure 130 mph wind rating. Color will be [l1gc_irj i*4 :5i.,lTE, Install ridge vents on all ridges. ob site will be left clean, and all debris will be removed to the dump. Start date (weather permitting) finish date 3 ie. MANIC #102365 MA CSSL#99507 YOU HAVE 3 BUSINESS DAYS TO CANCEL THIS CONTRACT e Propose hereby to furnish material and labor—complete in accordance with above' pecifications, for the sum of: ($8,900.00) eighty nine hundred dollars. Payment to be made as follows: $3,000.00 down,balance on completion y work preformed beyond the scope this contract will be billed separately as extra work This includes conditions which could not be foreseen by the uthorlZed Signature: contractor.In the event the customer does not keep the payment terms,work shall n n Work progress is au conditions.ase,and customer agrees to pay any legal fees incurred to collect payment K / P S S O 1+ bject to weather conditions. Note:This proposad may be withdrawn if not accepted within 30 days. Acceptance of Proposal—the above prices, ` specification,and conditions are satisfactory and are Signature: hereby accepted. Payment will Pe badVas puttined. Date of Acceptance:4Si afore: . Massachusetts Department of Public Safety. Board of Building Regulations and Standards License: CSSL-099507 Construction Supervisor Specialty KENT E PERSSON 22 COLONY AVENUE BOURNE MA 02532 rjZ7 Expiration: Commissioner• 01102/2018 � �e tpammza�z a�C>�a�acc�uaeGta Office of Consumer Affairs&Business Regulation jOME IMPROVEMENT CONTRACTOR egistration: 1.73732 Type: xpiratio n- Private Corporatic PERSSON CONSTRUCTION ING KENT PERSSON 22 COLONY AVE. I BOURNE,MA 02532 Undersecretary Construction Supervisor Specialty Restricted to: CSSL-RF-Roofing CSSL-WS-Windows and Siding Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOV/DPS m License or registration valid for individul use only l 1 before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation n 10 Park Plaza-Suite 5170 Boston,MA 02116 i Not valid without signature i AC RV® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD"YYY) �� k 12/29/2015 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 G H DUNN INS AGCY INC CONTACT - 215 MAIN ST PHONE FAX BUZZARDS BAY, MA 02532 ' /C No.Ext, A/C No): E-MA ... ADDRESS: ' INSURERS AFFORDING COVERAGE NAIC# INSURERA: LM Insurance Corporation 33600 INSURED PERSSON CONSTRUCTION INC iNsuRERs: 22 COLONY AVE INSURERC: BOURNE MA 02532 INSURERD: r INSURERE INSURER F: ` COVERAGES CERTIFICATE NUMBER: 27904365 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 ADDL SUER - . LTR TYPE OF INSURANCE IN POLICY NUMBER MMDIDY/YYYY MM/DDY�'I LIMITS COMMERCIAL GENERAL LIABILITY .. EACH OCCURRENCE' $ CLAIMS-MADE OCCUR - _ DAMAGE TO RENTED - I PREMISES Ea occurrence $ . MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC `" PRODUCTS-COMP/OP AGG $ $ OTHER: $ _ f, AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - $ • a. Ea accident ' ANY AUTO t -( - BODILY INJURY(Per person) $ ' ALL OWNED SCHEDULED t • - - ' AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE - AUTOS Per accident $ - .. $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $• EXCESS UAB CLAIMS-MADE - - AGGREGATE $ , DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLO ERS'L ABILIITY Y/N WC5-31$-363103-025 8/7/2015 - 8/7/2016 � STATUTE EERH ' ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ SOOOOO ` OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In If yes,describe under •* E.L.DISEASE-EA EMPLOYE $ 500000 ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ :500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is4equired)° Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. , This certificate cancels and supersedes all previously issued.certificates,only as.they relate to workers'compensation coverage. CERTIFICATE HOLDER = CANCELLATION '. iJ. BENSON BUILDERS ; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 56 MAPLE ST. THE EXPIRATION DATE THEREOF, NOTICE WILL ..BE DELIVERED IN -PO BOX 78 ACCORDANCE WITH THE POLICY PROVISIONS. BUZZARDS BAY MA 02532 i AUTHORIZED REPRESENTATIVE ` LM Insurance Corporation ©1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 27904365 1 1-363103 1 15-16 WC shankar.gadaleglibertymutual.com 112/29/2015 5:36:02 PM-(PST) I Page 1 of 1 e C`taagrr�Q, sr�crr bag WMhhzgfQFx st;eet Bostarrr MA 02M rvfvW 7n axg0V1dia workers Ccampensafim Insurance� IluildersfCunfracturs/Electricians/Mumbers Appficant Infa=a6un Ptease Pried Tegihly Name 5 5o GtYfSta zip: eo u R,u i- Phone;�: ,Sa$- ZS'q-V 4 S Are yan an employer?Chetd£dia gpprapTiate b T a# a'ect h[✓�I am a enxpla v�itli 3 4 ❑ I stria 915axI I I4Teur rn., =plc gees(full aadforpaf� -)* ha-vehire&tbe sub-cans 2_❑ I am a sole prapfidor orparfner- listed an the attached sheet 7_ ❑Rrrnnrt�l g ship and have aQ esuplcFyees Them-snb oosttartars have g_ ❑Demaldioa WOO ng forme is any capaetty_ employees and have workers' 9_ ❑BBuildtng addifioti [I ortaarkers' CflIDg_i'si�rranre COII2p_snsuranu 1 j_ ❑ we are a cotporaticnand ifs I0�Electrical repairs or additions 3_❑ I am a homes doing aII war- of have emmimd their I f_-❑Plumbing repairs qr additions =Yself o w�keca' right.of e tmption per MGM [N " alp- �152,§1(4). d.we ltas~e t�a� 12�Raafrepaits incun=reT i rea.j-� ( an l3_❑O tff �la�-Wawt�ticrss' Camp_insm-anmrequired j xAix} �pbzsaFihaCchecksbox�IWit#also�out ifiesectionbtlmrchawhagffiraWDd�En'MnmenyatianpoTie inEnnm Kn �ffo-meoatn�s vrhr,,-nbn-�3�is r��dt�i�c.-tag�y aye dnssmt;:�I r,�-�+�t�h�*z o.�'ide coutcxctms amst sol�it s air a�dscit m"'�sorb =CanbMMM that r l�lr thie has mast stiachad sn add;firtnat sheet shvain<g thanmneof ffie salt-canfrxfoa=AststEwhether mnorf nsa have z=glo3'ses. If tha they nnrst pmvida the—I--70 camp.policy uamb-- itm¢��r-rcpdnJ�'rhrrtisgrrrt�u�f�vr&e-rs'cvr�rzsrrlivn insrcrrtacs far rtzl�ets�Fny�cs. �etvtr zs f}teg�&c}arcd job sits irtfvt�rem�ir�t� �. Instance Company Dame: .L//5 y .P1<J7ubt LL PoEcg+9#norSelf-ins_Iic4klk2 3I5 361a3 T�girafsouDate. $� /� Jolt bite G Q t.�KSE1,Jtil iPf�7 E 4 Ci[gfStatxlTsp: Attach a cop y of the,mmrkers°compensation palirT declaration page(showing fhc policy anmber and ration date): Faaum to set_ r coverage as repiredunder Section25A of MGL c 152 can lead to the imposition ofrcimis.al peaafEies of a fine up to�1,50 0D-andlor one-yearim ,as wen as civa penalties in•he.farm of a STOP WORK ORDER-and a Ene of up to$250_QO a day against fhe violator_ Be advised that a copy of this stKtemmt maybe fxwardad to tbt Office of Tnviestag•Rtiom of the DIA fnr in¢a=m coverage vec�c a ion_ .£dfn herej'clert-f;,fp Under thapains midpaualffss of wry fhatfha utf vrmcr{i�n prat e£aba�r�r5 hna and caFrsct Phnae ik Ei cial ass Uri£f. .I}u rt at wriig itt flus area,&b ff cf R pL-W by cif v or form of ciaL Cites or Town: # Is n¢A_uffiarrLy(=It aney . L Bwa d ef$eaIffi 2.$kingDepai1mcnt I CitpTawa Glerlr 4_EIectncalInspector S.Platahinghrsp for ti.C Whrx Contatt Perst= ghane#_ - 5 Massachusetts&neral Laws chVkr 152 reqa�aII employizg to provide wD,-I rs'compeasa ion far their employees . to tais statate an eP is defined as"_-every Person in the sa vice of another under any contract ofhbe, Pursuant• �F�3' t)q=or died, coral or'written_" An en�Tgyer is defined as``an individual,partaaship,associatian,carpara on or oilier legal entity,or any t o or more of the foregoing mgaged in a joiirt mtTprise,and inclUdiag the legal represmrtafives of a deceased employer,-or the receiver or tr-estee of an iadividDal,part am3hip,association or other legal mtify,employing employee;. -However the owner of a dw elling'hause having not more fHan three apartments and who resides therein,'or the occupant of the dwelling house of another who=Tploys persons to do maurtmance,construction or repair wail-on such dwelling house or an fhe grounds or building appurt mant thereto shall not because of SUCH employment be deemed to be an employee." MCiL chapter 152, §25C(6)also sfafL-s t1at aeyery 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 appliLut-Yibo has n6t produced acceptable evidence of compliance with the insurance-coverage mquir-ed." Additionally, MCsL chapter 152, §25C 7)states"NeitHer the commonwealth nor any of its political subdivisions shall enter into arty contract far the perfoffian.ce ofpublic workunt>Z acceptable evidence of CampliEaCe with"the,ncnrance ti requ meats of this chapter have been presentzd to the contracting mtfiority." _ A-PPIican� • Please fill out the wormers' compensation affidavit completely,by checking the boxes fat apply to ycUr situation and,if necessary, supply srrb-co ntractors)name(s), addresses)and phone number(s)along witH their ceruicaic-(s) of insurance. Limited Liability Companies(LLC)or Lim tndLiahiity Partnerships(LIP)wfihno employees oilier$an the members ar partners,are not required to carry workers' compensafion in�ce. If an LLC or LLP does have employees;a policy is required. Be advised that fhis affdavitmay be submitted to the Department of Industrial Accidents for Confrrmafion of iDE=Ce Coverage. Also be sure to sign and date the az ri davit The affidavit should be refumed to the city or town that the application for thee prnut or license is being requested, not the Department of Industrial Accidents. Should you have any questions regards the law or if you are required to obtain a *orkers' compensation policy,please call the Department at the number listed below. Self-mimed companies should eater their self-i �rance license number on the appropriate line. City,or Town.Officials .. Please be sure fHat the affidavit is complete and printed legibly. The Department has provided a sTace at the boti�m. 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 pemitllieense number which wrll be used as a reference number. In addition,an applicant that must sulimit multiple pennitllimase applications m any given yew need only submit one affidavit indicating c' eat de "Job Site Address"the applicant should write"all locations iu (city or � rnaiian if necess and under policy info ( ary) PP town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be proN ided to the applicant as proof that a valid affidavit is on file for futurr.permits or licenses. Anew 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 v(mb.re (Le. a dog license or permit to bum leaves etc.)said person is NOT rearmed to complete this of idayit T1e Office of luvesfgitions would hike to thank you in an advce for your caoperadon and should you have any questions please do not hesitate to give tit a calk The Department's address,telephone and fax numbf-r- a1 CDramDawWth ofM ssachuszt� DEpaz ant cf Industrial Acc e5� '- ' 3 of kvf,- tiwla GGG W,-t*mgan&ft,=t RaADD,MA 02111 617 727-4- at 4-06 ar 1-977 hLC SS . F=## 617-727-` 4-1� R eviseti 4-24--0 T Town. of Barnstable *Permit# ` 0-0, k !� Expires 6 months from issue-date Regulatory Services Fee Thomas F. Geiler,Director c1 1 L127/C9 Building Division 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 (_7 ( (�S� Property Address f zE2� �=6"J A) �t�J , 11'-/?Zl Y`1s/ /!,L° T o Residential Value of Work 4z,', �, � / Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address / y . , 1 /�, .�'�� fir, ✓�'l r .2/ 7;6 Contractor's Nam a " Telephone Number:f!: 2 •„J Home Improvement Contractor License#'(if applicable) Construction Supervisor's License#(if applicable) W orkman's CompensationInsurance X-PRESS PERMIT Check one: ❑ I am a sole proprietor DEC 2 6 2007 I am the Homeowner I have Worker's Compensation Insurance ' TOWN OF BARNSTABLE Insurance Company Name C',y P Workman's Comp.Policy# �7 ? 2 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roofl ❑ Re-side Replacement Windows/doors/sliders. U-Value Q (maxim' ._ , CIS jj j *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 Permissiad A copy of th�ome Improvement Contractors License is ({]�uired. t7 v.j �5� 3IGNATURE: Z:Forms:expmtrg tevise061306 a� ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' wrdw.mass gov/dia ' Workers`Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Name(Business/Orgmdzatiowbdividual): ea4fi3oXI Address:�i/ �¢� City/State/Zip:& r1J ��302 Phone-#: Are you an employer?Check the appropriate box: :Type of project(required):. I am a employer with �4. I am a general contractor and I 6. ❑New construction . 1.�• _ , employees(full and/or part time).*• have hired the slab-contractors 2.❑ I am a'sole Proprietor or partner- listed on the-attached sheet. 7. Remodeling ship and have no employees . These sub-contractors have 8. ❑Demolition* for me in as capacity. employees and have workers' Qvorldng Y aP tY comp.;�,�,t,�n #' 9. ❑Buildmg addition [No workers' comp.insurance,, co ca required.) 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all-work . officers have exercised their l l.❑Plumbing repairs or additions ' myself.[No workers' comp. right 6f 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 workr,ms'compensation policy information. t Homeowoern.who submit this affidavit indicating 1hey am doing all work and tlien hire outside contractors must submit anew affidavit indicating'such t =tmetors that check this box mutt attached an additional sheet showing the name of the sub-contractms and state whether ornot those entities have ; employees• 1•f1he sub-contractors hair,employees,they must pravidt:their work='comp.poHd°y number. I ani an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site' information. Insurance Company Net= Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/StateJZip: Attach a copy of the Workers'compensation policy declaration page-(showing the policy number and expiration date). Failure.to secure coverage as required ender 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 imprisomaent,as well as civil penalties in the four of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the.Office of" Investigations of the DIA for insurance coyeratre verification --- I do hereby ce der the patnfi, d penalties of perjury that the information provided above,is true and correct: Si afore: Date. Phone# .7 �` �f u��� -j - Official use only. Do not wrfte to this area, to be completed by city or town,official City or Town: ' Permit/License# Issuing Authority(circle one): A.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6. Other Contact Person: Phone#: � r Town of Barnstable Regulatory Services y� KASS. $ Thomas F.Geiler,Director 0.19. ;�.. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us , Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder L 0 0 5 k , as Owner of the subject property hereby authorize / _ '�2. to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address o Job) f Rib b-7 Signa of Owner Date N ►� �,I ti Print NTame If Property Owner is applying for pen-nit please complete the -Homeowners License Exemption Form on the reverse side. QTORMS:O WNERPERMISSION Town of Barnstable - h�P o� Regulatory Services `I sAtixsrAatt;. Thomas F.Geiler,Director: MASS. Building Division ArED ° Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 vrwiv.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number _ street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barristabie Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules Regulations for Licensing Construction Supervisors,Section 2.15 This lack of awareness often results in serious problems,particularly &Regu g p ) P when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:fonns:homeexempt 7_�::Oj 7/27/2007y Time: 2:14 PM To: @ 9,15084207327 Paget 002-003 Client#:21369 20LDECA3 , FM CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/YYYY) 07127/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 9731yanough Rd., PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED _ INSURER A: Acadia Insurance Olde Cape Building Co.,Inc.1600 Falmouth Road,Suite 37 INsuRER INSURER : B Guard Insurance Group Centerville,MA 02632 INSURERD: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MMIDD DATE MMIDDIYY LIMITS A GENERAL LIABILITY BINDER257920 07/10/07 07/10/08 EACH'OCCURRENCE $1 000 QQQ X COMMERCIAL GENERAL LIABILITY - OAMA SE TO RENTED $250 000 -PREMES Me occurrence)CLAIMS MADE Q OCCUR MED EXP(Any one person) $5 QQQ PERSONAL&ADV INJURY $1 QQQ QQQ GENERAL AGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 OOO 000 POLICY PRO- JECT DLOC AUTOMOBILE LIABRM COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND BINDER257926 07/17/07 07/17/08 X I WCSTATU- 0FR EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECLTTIVE E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLOYEEI$500 000 yes,describe under AL PROVISION E.L.DISEASE-POLICY LIMIT $500 000 PECI S S below OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town Of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _I() DAYS WRITTEN Building Dept. NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Hyannis,MA 02601 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE I I --a ACORD 25(2001108)1 of 2 #S48575/M48574 ll'L['Ki LS1 O ACORD CORPORATION 1988 �,�� -\ Board of Building Regulations and Standards License or registration valid for individul ut HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return �,- Board of Building Regulations and Standar - Registration 120111 4, Expiration 18/2009 Tr# 260132 One Ashburton Place Rm 1301 e � Irividual Boston,Ma.02108 Indivi . PAUL F.CAPRIOt��`� PAUL CAPRIO 92 Richardson Road\ Centerville, MA 02632� 6 Administrator Not valid without si ature . r- Parcel '(js Permit# Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Date Issued A.2 Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) Fee s.d Engineering Dept. (3rd floor) House# � f} 1NE d� Planning Dept.(19t floor/School Admin. Bldg.) • BARNSTABLE. De it Plan Approved by Planning Board 19 MASS, o ! ; rfO MAr A TOWN OF BARNSTABLE �- Building Permit pplication Pro ect Stir et Address 67,5— t "f Village Owner Address Telephone • Permit Request First Floor square feet , Second Floor square feet Estimated Project Cost $ D Vd Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family 1// Two Family Multi-Family Age of Existing Structure "07-0 -f- Basement Type: Finished Historic House Ald Unfinished Old King's Highway ad Number of Baths No.of Bedrooms CD Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder formation �rn Name Telephone Number 7 a 7 Address — License# - . dam- Home Improvement Contractor# 105 Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO r SIGNATURE DATE r/ - BUILDING PERMI DENIED FOR E FOLLOWING REASON(S) » FOR OFFICIAL USE ONLY P MIT NO: D ISSUED .. + M P/PARCEL-NO. M _ r RESS VILLAGE 1 ! } OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION ' FIREPLACE ! fi + ELECTRICAL: ROUGH ! FINAL PLUMBING: ROUGH FINAL GAS: , ROUGH FINAL FINAL BUILDING F I g DATE-CLOSED OUT ASSOCIATION PLAN NO. • w :._!• . Tlie Commonwealth of Atassadliusetts >, __ ; • ,t;,l _�y Department of Industrial Accidents . � ' � _ i. _=1� Ofllceollm��gatlo�s • �;: ; •�' 600 if"liinAton Strcet Boaron.Mass. 02111 Workers' Compensation Insurance.ARdavit _ ARAllerint nfot•rnation� i'RiNTMeg- y Inc-ntion- city nhone# ❑ 1 am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ❑ 1 am an employer roviding workers' compensation for my employees working on this job. m id -�a incor•tnce co notice# ❑ 1 am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who ha,. the following workers' compensation polices: comn•tnv rinme• address: city: phone#: incurnncc cn ppitcv# • •• • Lam.. «----;:-•• --,.. .srrr�e:..•.ay.."v�•r•:►.•rr�!in'Ms^�➢F'�'r-r- _ _•_- ___-- ':r�vF�a�etl4°�r►.�c;,�...r,+r.Rs_lr�i►a--.4.!'•a:AT3*_�++�"�'-' compam•name• addres city. phone#: _- incor•mce co '' police# ' ;Attach additionai'sheet if tieeessarr .� - + '�- +"�^" r''°"*' '='"``'"'�- _'••rr .r d;,,�,,; Failure to secure coverage as required under Section 25A of 51GL 152 can lead to the imposition of criminal penalties or fine up to 51.500.00 and/or une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER soda line of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do lrereb=c=jjfj- rile i�anai' ojperlurf that the information pm-ided above is true and coptcL Sienature Pale `f print nameCo �— one# y�9 '7 7 C official use oniv do not write in this area to be completed by city or town official ' I tiny or town: permit/license d r•tBuiiding Department [3Licensing Board check if immediate response is required 13Seieetmen's Once (3fiealth Department ` contact person: phoned; M01her -Information and Instructions ��9�• Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers` compensation for their employees: As quoted from the"law",an emplitpee is defined as every person in the service of another,under any contract of(tire, express or implied, oral or written. An emphtrer is defined as an individual. partnership,association.corporation or other :,gal entity, or any two or more 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 Itou or on the`rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1.52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commomi•calth for any applicant who has not produced acceptable evidence of compliance with the in coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter itz. been presented to the contracting authority. 71. 7.1 w Ina.1Ti. • .` ..y. I!•:•' .M•.w.1.!!.JI;.W-4 A: Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. _. .+ ww••.,+•�•�P ..Via:. r .T..._ •u-:.��v�'r!J _ ' Cite or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plea be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any question: please do not hesitate to give us a call. �•.�rwt�.«....�r.t�+'�+ ... .. _ ... .. :.... - ...... •'• �..•dfis,� r• �-•« _ •a�..4:i�r`w".�v+'_'' .C.��'ir: :w'F�:• The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents - Office of tnuesugations 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 -. phone#: (617) 7274900 ext. 406, 409 or 375 stable The Town of Barn Department of Health Safety and Environmental Services ivision Ma B-- D 367 Main Street,HY=nis MA 02601 Ralph Crt>ssca Off co: 508-790-6=7 Bus ing� � F= 508-775 3344 For office use aniy Permit no. Dau AFFIDAVIT HOME DWROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION ction,alterations;rtaovadon,rt�won'conversion, MGL a 14ZA requires that file"tt�nsutr ed improvement..remo-.-4 demolition. or consauction of an addition tom 7�� building containing at least one but not more than four dwelling units ons, along with other to such tQidenee or building be done by registered eomtactors,with certain==pti mquirtx cnM Est. Cost Type of Work: Address of work: Ovmer.Name: Date of permit Application: I herzb<certify that: Registration is not required for the following rrason(s): Work excluded by law Job under SLOW '—Building not owner-occupied Owner pulling own p=it Notice is hereby given that: CONTRACTORS OWNERS PULLING?fffiiR OWN PERMIT OR DEALING NOT LESS TO THE FOR APPLICABLE HOME IMPROVEMENT WORK DO ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERIURY ; I hereby apply for a permit as the agent of the owner. z 6 Registration No. - n nor ate OR r MAY 28 '96 14:35 THERMCO INC. S YARMOUTH ! P.2f3 i HOM5 IMPROYEMFNT CONT�2ACTORS REQISTRATION i Boar of Bu,i ding Regu ations and Stan ands One Ashburton Place - Room 1301 Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 103926 Expiration 07/10/98 Type - PRIVATE CORPORATION THERMCO, INC. William J. McCluskey 7D Huntington Ave . So. Yarmouth MA 02664 1 I a AY' 2e '96 14:36-yyT-l!HERMCO//��I NC. S YARMOUTH rAA,rr R 6;I �Cr1� �I� Op b DAT PRODVCER ? �., <z. .�: 0/05/95 Drake-,Swan aE Crocker Insurance THIS CERTIFICATE IS ISSUEDAS A MATTER OF INFORMATION ONLY ANO"NFERS hr0 RIGHTS UPON THE CERTIFICATE Agency, xae' HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR. 14 Lo t's Hollow Rd• ,PO Hex 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Orleans MA 02653-0429 COMPANIES AFFORDINt3COVERAGE Peter Cy Walther COMPANY 508-255-3212 A - Western World Insurance Co, rasVRED COMPANY B General Star Indemnity CorVany Thermco Inc COMPANY , Wm J Mccluskey C American Stater Inauzance Co 7-D Huntington Ave C0Zi,,7Amy • -""�" S Yarmouth MA 02664 [ - O Aetna Casualty 6 Surety rOVERAGE$ THIS IS TO CERTIFY THAT THE POUCIE5 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 MAYBE ISSUED OR MAY PERTAIN,THE WSURANCE AFFORDED BY THE POLICIES DESCRIBEq HEREIN IS SUBJECT TO ALL THE TERMS, -- EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE OEEN REDUCED BY PAID C1,NMS. LF TYPE OFINSVRANCE POtICYNUMBER POLICYEFFECTIYE POLICY EXPIRATION LIMITS DATE(MMJ=YY) DATE IMWOONY) GENERAL LIABILITY GENERAL AOQREOATE s2,000 0OO ". A 7C GOMMFRdnt�,ENpRnLtlABltrrY NGL708125 b7/19/95 07/19/96 PROOUCTB•COMPOPAQO 62 000 000�000L000_'�CLAIMS MADE OX OCCUR PERSONAL II!AOV INJURV ,,0.00 000 OWNPR'S b CON'IRAC'TOR'8 PROT EACH OCCURRENCE $ 1 000,000 FIRE OAMAOE IAnyene RId S 50,000 M8D EXP(Any 9ne Pawn) I 1 0 0 0 AVIOMOBII,E LIABILITY C ANYAUTC 24847626 10/14/95 10/14/96 COMBINED SWOLE LIMIT $1,000,000 Ai,L OWNFO AUTO$ — — — X SCHEDULFOAUTOS BCOILYIN�IVRY f {PoI Perpon) X I0REDAVTO5 X NON.CWVNIADAV►OS BODILY INJURY S (Pa eecldenC -- — -- PROPERTY DAMAGE S OARACE LIABILITY ALTIQCNLY.EAACCIDENT I OTHER THAN A1110 ONLY; ,.�•.' _.. .-...._......•-- - — EACH ACCIDENT b AGGREGATE 1 EXCESS LIABILITY EACHOCCURRENCE f 1,000,000 $ ){ UMDRF,LLAFORM 1UG324702A 07/19/95 07/29/96 AGGREGATE - OTHER THAN UMBRELLA FORM y1 D WORKERS COMPENSATION AND STATUTORY EMPLOYERS'LIABILITYTHE :,• !�,' ^_.. EACH ACCIDENT 15O0,000 PARTNEPRIXECUFTORf INCL 006CO024996032CAA 09/12/95 09/12/96 DISEASE•POLICY LIMIT 15001000W—_ PAR iNfRS/EXECUTIvE OTI*RRbARE. _ EXCL DISEASE•EACH EMPLOYEE 15O0 000 OTHER DESCRIPTION OF OPP RATIONSIL36AY!ONSIVEMgLES18P8C1AL ITEMS CAN CERTIFICATE FIOLOfR '' CANCEL LA LA ION OMCS}sbRl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE YHi: EXPIRATION DATE tNEREOF,THE ISSVINO COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFY, •• - BUY FAILVRE TO MAIL SUCH NOTICE SHALL IMPOSE NOOBLIGAVON OR LIABILITY Oil ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AVTH0AfZFO REPRESENTATIVE AcoaD as•s ta�»a� �,:: Peter G Walther • • �•••�� �+.ACORD ooRPOIRATioF!a88 I THE• � 'TOWN OF BARNSTABLE i • i BAHHSTOIILE, i O 39-Ar BUILDING INSPECTOR a APPLICATION FOR PERMIT TO ....: ..,f..,�,,.--,,, ... ......... .' .. TYPE OF CONSTRUCTION ..e........A:z;...A19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit accordi to the following information: Location ..... ..... .............. .............. . ..Z ........................... ProposedUse .. ...................... ......;-...................................................................................................................... ZoningDistrict ................................ .....................................Fire District .............................................................................. Nameof Owner .. ..............::. ... .........................................Address ......... "........ .........:........................ Nameof Builder ........�...............................1..........................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms Foundation ...... "- ...................................................... ....... ..... .............. Exierior . ....... . ........ ......... 4..........................................Roofing . ..... ^ �................... Floors ..... ........................................................Interior ... .... ... ... .. .. r ......................................... Heatingav "- t.�l..:.l• ,�...!.................................................Plumbing .... ..................................................... Fireplace .��/" "L' �. .... ...............................Approximate Cost .... ... :..........................:.............. 7 Difinitive Plan Approved by Planning Board ________________________________19________. �? 24 Diagram of Lot and Building with Dimensions 7 '�o , gym 0 OfM co � n �' rn co � Un ~� W -rI W C-: 0 0 _D y �-.. rri == ' Z CJCJ '� Uj (n �, 4 .a 6 d ^Y'9 m I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding a above construction. e Nam ...... . ................... ................. Small, Alan E. � C 1 �0'70 , No ....12783 Permit for ....1 1�2 story, 4 � single. family dwelling-garage Location LD��.....Buckskin Path..•..•.......'-.....• .. ; ............................................................ Centerville ............................................................................... Alan E. Small Owner .................................................................. Type of Construction frame ................................................................................ Plot ................... ......... Lot $.......... ' Permit Granted ......December 2..................................19 69 Date of Inspection X..f0.,V..... ........19 Date Completed ......................................19 PERMIT REFUSED.-,, ............................... ............................. 19 f ........................................................................... . y ................................................... ........................ ............................................................................... I t ti r Approved ................................................... 19 3} ............................................................................... .................... ......................................................... i