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0267 BUCKSKIN PATH
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Zoning District: RC Sheathing: Owner on Record: FOX, DIANE E TR&FOX,PRISCILLA TR Contractor Name: Framing: 1 Address: 267 BUCKSKIN PATH Contractor Licenser 2 CENTERVILLE, MA 02632 Est. Project Cost: $9,000.00 Chimney: Description: White New White Cedar Sidingon Left, Right and Back of house Permit Fee: $45.90 Insulation- Project Review Req: Fee Paid:: $45.90 Date: ( 5/26/2020 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by-this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures 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. i Electrical The Certificate of Occupancy will not be issued until all applicable signtures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:11 Service: 1.Foundation or Footing [ 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue liningis installed 1 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" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT V ,. Town of Barnstable Coln 3a g Post ThisCa'rd-So That it i i `'" F�mg he Street ArovedPlans,IVlustbe:•Retamed on ob-andth�s Gard;Must be Ke,t " - ;_ M! PostedUntil Final Inspectwn�HasBeen Made _ . Permit W;here,oa Certificate of O,ccu anc, �s;Re aired such"".Bu�ldmpshall Nqt be Occupied untii,a Final InspectignryhasWbeenvmade„ M .,- Permit No. B-18-1866 Applicant Name: Russell Cazeault Approvals Current Use: Structure Date Issued: 06/15/2018 Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/15/2018 Foundation: Location: 267 BUCKSKIN PATH,CENTERVILLE Map/Lot 171-023 Zoning District: RC Sheathing: Owner on Record: FOX,DIANE E TR&FOX, PRISCILLA TR � G ntractor'Naame: PAUL J.CAZEAULT&SONS, INC. Framing: 1 z Address: 267 BUCKSKIN PATH Contractor License 103714 2 CENTERVILLE, MA 02632 Este ject Cost: $11,550.00 Chimney: Description: Remove existing shingle roof on the whole house andinstall new Kermit Fee: $58.91 asphalt shingles. c ��� Insulation: "aid: $58.91 Project Review Req: �>z �° Date 6/15/2018 Final Plumbing/Gas Rough Plumbing: -..Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within siz months after'issuance. All work authorized by this permit shall conform to the approved apphcationn antl the approved construction documents for Whk 1ffis permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall tie in compliance with the local zonirg by la sand codes. This permit shall be displayed in a location clearly visible from access street or r d a d shall be maintained open for pu c i for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the 13uildmgI I Fire Officials are provided on trimpermit. Minimum of Five Call Inspections Required forAll Construction Work: ' Service: 1.Foundation or Footing ? Y a Rough: 2.SheathingInspection ' g 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 7 kfa Town of Barnstable REceE�PT KAn 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit t Application No: TB-18-1866 Date Recieved; 6/11/2018 �\ Job Location: 267 BUCKSKIN PATH,CENTERVILLE —� Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: PAUL J. CAZEAULT & SONS, INC. State Lic. No: 1037114 -- n Address: 1031 MAIN ST, OSTERVILLE, MA 02658 Applicant Phone: (508)4� 8-1177CO (Home)Owner's Name: FOX,DIANE E TR& FOX, PRISCILLA Phone: (508)534-9295 w TR 0 rn (Home)Owner's Address: 267 BUCKSKIN PATH, CENTERVILLE,MA 02632 Work Description: Remove existing shingle roof on the whole house and install new asphalt shingles. Total Value Of Work To.Be Performed: $11,550.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for-every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). 1 understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to, accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Russell Cazeault 6/11/2018 (508).428-1177 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $11,550.00 y Type Date Paid ! Amount Paid Check#or CC# Pa T e Total Permit Fee: $58.91 6/11/2018 _ $58.911 XXXX-XXXX XXXX Credit Card 0985 ........ Total Permit Fee Paid: $58.91 li THIS; IS N()T "AERMIT � > Town of Barnstable *Permit# Expires 6 moulhs f•nm issi to r a Regulatory Services Fee ., t S/iRNSTABhE, s bo� Thomas F.Geiler,l)irectoi• Building'Divisir n oL Tom Perry,CBO, Build ing.Cotnmissioner . 200 Main Street,Hyannis,MA 02601 www.town.bamstable.m ims Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint it4ap/parcel Number 1-1 1 6-23 � 1C.�-- � Property Address ZCc-.7 7?k( IG G 1 1-1 ?tc j r (Alff ke 7 �j'2 �7 residential Value of Work '(in 5 o Minimum fee of$Z5.00 for work under$6000.00 = Owner's Name&Address ----- ZC -7 A 02 G�Z_ -- Contractor's Name USC_0 . "k-tVi-e Telephone,Number 4; 39i,8 /,S// Home Improvement Contractor License#(if applicable)_ Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance .tea LESS PERMIT Check one: ,9111-1am a sole proprietor A U G � � ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance 1-OWN OF BARNSTABI E insurance Company Name § ram rep. Policy# Copy of Insurance Compliance Certificate must accompany each permit. F: nnit Request(check box) y - ❑ Re-roof(stripping old shingles) All construction debris will be t_ken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side. #of doors l + 78p,, A, a (/ari jXrReplac'ement Windows/doors/sliders:U-Value i maximum.44)#of windows F1Where required: Issuance of this permit does not exempt compliance with other tower department regulations,i.e.Historic,Conservation:etc. *.*.*Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requi e SIGNATURE: C`1I.?sers\decillik\AppDatalLocal\Microsoft\Windows\Te rary Internet files\Content.0utlook`4STGU500\EXPRESS.doc Revised 090809 • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street , Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): VASCO NUNEZ Address: 79 Mayfair Rd. I it City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ElI am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 1 am a sole proprietor or partner- listed on the attached sheet. t 2• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ ' C 0 Policy#or Self ins. Lic. 1.77 Expiration Date: (7 19 1 Job Site Address:-- Sk t lam( C�•��rh City/State/Zip: �{Lr,Y 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 c�ertitif—y-under the p ins and penalties of perjury that the information provided above is true and correct. Si nature: Date: I(; �C1 1 o Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License#' Issuing Authority(circle one): 1. Board of Health 2, Building Department 3, City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector' 6. Other Contact Person: Phone#: ' Y Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees: Pursuant to this statute, an employee is defined as"...every person in the service of another.under any contract of hire, express or implied, oral or written." An employer is defimed as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until.acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate he. 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 6f Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications.in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax #617-727-7749 www.mass.gov/dia a euS s;noq„M P118A ou is 9IIZO vw`uo;sog OLTS amnS-wield 11aud Of �. uo ulnsag ssaalsng.pug s t!u{Iv tamnsuoD;o 03 p v :o;uan;a.t pun033I 'a)ttp uol;uuldxa aq;a.to,;aq j dluo asn 1nplAlpui,to;Pt19A not;u�;s!Ia to asua3lrl Sd(j/Aof)•ss8N*MAAM :o;as;ag -asua311 slq;3o uol;u3oea t ao;asnw sl T-` "Massitchusetts- Department of Public Safeh apoa Sulp!!ng a;e;S s;#asng3uss4q Board of Buildim, Regulations and Standards aq;;o uoll!pa;uamn3 u ssassod o;aanlleg Construct on Supervisor License License: CS 69680 Restricted to; 1G s0tuoHA11Wg3 Z I-JI p013u1saaun -pp VASCO E NUNEZ'III O I. :ol PaPuasaN 79 MAYFAIR RD a S DENNIS, MA 02660 • Expiration: 10/3/2010 ('nn�ntissiunup Tr#: 4248 y ,p� ✓Jie i0aiiron:c>7�r o�./pQ�rc�apsc�iccae�Q _ . . "\ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration A24793 y I ' Expiragon 8/25/2t)11 Tr# 286910 Type,.,: Indwlduat ., . !' Vasco E.Nunez,Ifl Vasco Nunez, 79 Mayfair Rd , S.Dennis,MA 02660 Undersecretary i I f . f - Town of Barnstable Regulatory Services Thomas F.Geffer,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.townbarnstable.maus • - ' ' Office: 548-862.403$ ' Fax: 508-790-6230 property OwMer Must Complete and Siam This Section ' d If Us ABusl er as Owner of the subject ptoperiy hereby authorize � �� 4 �=- to act on my behalf al]matters relative to work authorized try-t]�s em -building pnst applicatio for. 62. (Address of job) Signatureof Owner Date t Name 0:pMUa:0WgUUMkbWSI0 Town of Barnstable BARNSTABLE.+' Regulatory Services 9 MASS. 059. Building Division plED MAC a, 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection be dc Location ZG? Permit Number Owner Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: 0a�� s nc�ce� per C� � i Please call: 508-862-4038 for re-inspection. Inspected by Date 7& 0 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �� Parcel _'Application # to Health Division Date Issued W 10 Conservation Division Application Fee Planning Dept. , - , Permit Fee l� Date Definitive Plan Approved by Planning Board 123 0 JOV-- Historic - OKH _ Preservation/ Hyannis Project Street Address Village CR)kTek.t)X 1\e Owner �°� scr01 �� �.�?rAq� �-oX Address �7 Telephone S0 S S 3�— 01�q S Permit Request �� 1©X �O X 14 to". 0191 kw\ 0�p iAeNse- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 14113' Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family, wr/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes W-rq*o On Old King's Highway: ❑Yes ❑ No Basement Type: &'Full ❑ Crawl �alkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq'ft) - - . Number of Baths: Full: existing new Half: existing new LM Number of Bedrooms: existing —new ON Total Room Count (not including baths): existing new First Floor Room CounfN Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other C 0 Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: W existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name t %mho 4�CZ Telephone Number Address 14 sT-Iyut ei ye License# 101 7 5O Home Improvement Contractor# 39 Worker's Compensation # (s60 LJ 60*6?h(UW1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO &wu1e.k%UrJ EX-1 I - SIGNATURE DATE FOR OFFICIAL USE ONLY „ APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATIONS fo� llo P�o►M J FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO.. 'It Tfse COMIHonwe-alth of Mass achusetU Deparymeni of lIR dustriiyl�4ccio'ertts Office of lnvesfigr,2ions 600 waY h..ington Street " Boston, AlfA 02111 • � wtvw.rnc�ss.gou/did . Workers' CompensationYtigarance davit: Builders/Contractors/EIectrician�IPIuu>bers Please Print LeExblY Applicant Info rmation ��1® Name (BusinasslOrgani�tion/Individual): '����5 Ft0 Q �.�"1P'r1ot�'.9��1VP1 . Address: 4 STi ro 9 City/State/Zip: 1 etc r�ohh1�1 �'Sfo Phone.#: A - Y u an employer? Check the appropriate box: Type of project(required): 1.IJ I am I 4• [� 1*a a general contractor and.1. 6° w a ction a cr�loyct with full and/or partaimt)•* hays hired the strb-coniractars cmplayccs ( listLd on the attached shcct 7, ❑R.cmodcling 2.❑ T an1 a'sole proprietor or partner-. Thcsp sub-contractors have ship and have no eniployces S, ❑Dcmolitian cmployces and have workers' 9 d Building addition working for me in any capacity. . [ND wor):erS'.GOII1p.-msvrancc, comp. instuance,t , 5. []We are a.corporation and its 10.[]'Elcctrieal repairs or addifso r uircd] offaccrs have exercised lhci2' 1I_ I Plumbing repairs or aAditio 3,[� T am a homeowner doing all work right of exemption per MGL mysd [No workers. comp. 12.❑Roofrcpairs _ ins„rance requiicd]t c. 152, §1(4), and we havt no '` c�loytes: [No workers' �13.❑ Other �. c0mp.insurance rcquired.] „ y applicant that chcel�box#]mast a5so fill out the tcction below showing t}teir tvorkcra' compensation policy information. + t Homeowntrt who eub,tit this affidavit indicating tbcy arc doing all work and thcn hirr outside contr�ior5 must submit a new a$davit in di casing Neh. i--DTI aclnr;tfiat chock N,box must ztbmhrd an additional chest showing Lhc name of thc'sub�ontrattrnz and aiaic whether oT not.those cntidrs hays crtrploycrs, ifthc sub-,-ontractors.havc employed,thcy.mud pttrvidb their workers'comp.policy nwnbcr. ram an employer M d isprcviding workers'cornperta'uli.on insurance for rny•&nployces'`B.-To [s the paCicy artdjob site • inforrnaflorr. . A . Y �`�'•�� I]]SLl1amGC �.oIIlp3ny lVZ]71G: Y� d►� '`, �N�1!® AVAte Policy k or Sclf--ins Lic..'#: �l,©�0--,039 SI"1 19��� Expiration Date:- n 7oh Sitc A'ddrecs: 6 : 1�` S' `I rP TL\ City/gtatdZip: CeiV70,Uldle- M6, Attach a copy,of the workers' compensation policy der-laration.page (showing the policy number and expiration date) Failure to secure covcrago.as required under Section 25A of MGL c. 152 can lead to'thc imposition Dfcrimirial penalties of find up to I,SOO.00 andlor Dnc ycaz imprisonrnc-a as wt11 as civil penalties in the form of a STOP WORK ORDER and i fi of tip.to $250,D0 a day against the violator. Ec advistd that a copy of this'statimcrit mzy by forwarded to the Ofjjec of Investigations of the bIA for ing=-Mc mycra c writ catiom 'I'do hereby cerCrfy.under Ch pus acid penalties ofperjury e ay the irrfor-rtmado�provided above is Crue and cojTecC Si stars: Dat- Phone k N 391- Official use only. Do nof:write in thlr area, tb he core rbWed by city or Coven official • City or Town; Pertnit/License# Issuiog'A.utb'ol"it. (circle one): " I. Board of Health, 2• Building Departrnent'3• City/Town Clerk 4. Electric Inspector $• P..lumbing Inspec{or 6. O th e r `or ation and Inst �Ions Massachusetts Gcncral Laws chapter 152 requires all employers to provide wockocfs' P ndtrocr a y contra for lhirces: M erson in the scrvi pursuant to this statute, an employee is defined as "...cYcry p express or implied, oral or wnttcn-" co oration or other legal entity, or any[wo or moze An erreplDyer is defined as "an individual,partnership, association, rp of the foregoing engaged in a joint enterprise, and including the legal rcprescntatives of a dcecaslod`mP1How vcrhthr receiver or t il-steo of an individual, partnership, association or other Jcgal entity, employing mp y owner of a dwelling house haying nor, occupant of tho t more than three apartmcn Gand nshtru ti n.o�cp it work h on such dwelling house dwelling house of another who employs persons to do-maintcnan or on thero'mds or building appurtenant thereto shall not bccausc of such employrncnt be deemed to be an employer." 25 also stags that"every state or local licensing agency shall withhold the issuance or MGL chapter 152, § C(� 'In the or permit to ope rate a bush rear*lyal of a ljceuse. ace of com li ace with eslnsT�ran�common er g� gmr d'th for y Applicant Trho has not produced acceptable eYrd P Additionally',MGL,ohaptcr 152, §25C(7)states "Neither the corumonw�bc t lch-Yidcncc of c,0mplizmcc withL the inaura_mcc entr•into any contract for,rho performancc of public work until P e have bccn presented to the contracting authority.". zequireuzents of this chapter Applicants. ' the workers' compensation affidavit completely,by chce)Lzng the boxes that apply to you Please fill out r situation a-nd, if necessary, supply sub-contractors)namc(s), address(cs) and phone nurnbcr(s) along with their ecrtifieatc(s)of insurance, z imitcd Liability Companics'(LLC) or Limited Liability Paztn rsh ps (�2)an��o O c=r LLP does s othcr man the mombcrs or pntnors, arc not rcgwzcd to carry workers compensation ins of employees, a policy is required. Bc advised that this affidavit mayto sign nd date theDaff rtMc tTll0 a$davitlshould Accidents for confirmation of insuranec coverage. Also be )� bo returned to the city or town that thc•application for.the permit or license is being rcques�to obtajnla wfl��t of indnstxW Acddcnts. Should you have any questions regarding the law to .you arc requir compcnsati:on policy,plcasc call the Department at the uurgbcr listed below. Self insured companies should enter Choir self-insuranGo liccnso number on the a ropriatc lino. C1ty or To-MA OtIlcfals Please be sure that tbo a.flsdayit is complete and printed legibly. The Department has provided a spaccardiag �tcthc bot� of tho affidavit for you to till out in the event the Offico of InyDll besuso d as aotions rch co noncc numb z.rIn addition, an applicant Please bo sure to fill in the permit/Licensc number winch wi yen car,nccd only'submit onp"affidavit indicating cuzTcnt tbat Must submit multiple pern itl1 ccnsc applications in any gi y , policy information(if peccssary) and under"Job Site Address" tho.applicaat should write"all locations i may br nd�to c or town)."A cbpj'of the e$da�+it that has bccn b c f0ifaally�tampe�� or r liccns s A now y the city atfidaYi.must bo filled out er town ach app�ra nt as proof that a valid affidavit is on file f r fu p year.'ylhero a home owner or citizen is obtaining a liccns e or p,canit not related fo any business or commercial venture (i_e, a dog license orpermit to bum leaves etc.) said persog is NOT required to complete this affidavit operation and Tbc Of5ce of lnvestiga-dons would hke to thank you in adyance for your co should you haYC any Qucsdons, plcasc dv not hcsitato to give us a call Tbc Department's address, tclephone-and fax number The Commonwc4th of N1as.sarhll,rats D,-pu mmt of Ind-ust 0 A.ccidtfnts Offzce of Iztyestiptjoas' 600 Washin�fioa Street Boston, MA 02111 TG1; # 617-727-490.0 cxt 40,6 w 1-8'77-MASSAFE Fax# 617-727-7749 Revised I1-22-06 wyww.mass.goy/dia I - Town n of Barnstable gyp¢THE row - �,. Regulatory Sc vices: w BA_"STAULE, Thomas F. Geiler, Director Building Division Tom Perry,' Building'Comm4ssioner 200 Main Street, Hyannis,MA 02601 www.torvn.barnstabie.ma.us Office: 508-862-403&° Fax: 509-790-62' property Owner Must Coampzete anal Sign This' Section If,Tjsif Lgr A Builder �� as.Owncr of the subject property A(ZO a�o�y behalf, -hereby authorize C� in all matters relative to work authorized by this building permit application for: (Address of Job): GCNt �r, vllle� Sign tore of O ner G�7, off` Print Name If Property Ovmer is applying for permit please complete the Homeowners License Exemptiofl Fo.rrri on th'e reverse side, ti Town of Barnstable of-THE rye Regulatory Services h Thomas F. Geiler, Director f f Br,"STk LE, ' MAS-1 Building Divisioll s6Tp• pTEO},{P1p Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 R'wSY.town.b2rnstable-72-us, Fax: 508-790-6230- Officc: 508-862-4038 ---- c===� J30A4EOWNER LICENSE EXEMPTION Ficase Print DATE: JO$"LOCAT)ON: street Yillage number "HOMEOWNLR": home phone t/ work phone# name CURRENT MAILINO ADDRESS: zip code city/town state The current exemption for"homers"was e�tended to in esu of ,ossess a hp n d`�rdoMded that the rown r acts and to allow homeowners to engage an individual for hire who do p suQerYisor. Dy-yLdJTION OB HohiE01'YNER persons) who owns a parcel of land on'which he/she resides or ateeess to reside,to on whi use and/or efarm t uctures,d,�ed to be, a one or two-family dwelling, attached or detached structuresrY person Who constructs more than one home ll? " aformta ero d eptable to the Building Offic al, that he/she shall be "homeowner" shall submit-to the Building Official on.a responsible-for all suchwozk crforrricd under the bvn crmif, (Section 109,1.1) • . The undersigned "homeowner" assumes responsibility for compliaricc with the State Building Code and other applicable codes, bylaws, rulcs.and.regulations, Th'e undersigned "homeowner" certifies that he/she understands the Town °�Bwith said procablc cdugesandent minimum inspection procedures and requirements and that he/she wr p Y requirements, 1 , Sionture of Homcowner Approval of Building Official `• . . Note; Throe-family dwellings containing 35tro000 cubic feet or larger will be regtured.to comply with rho DnCL1. State Building Code Section 127.0 Constru HOMEOWNER'S EXEMPTION on Su crvisors ;provided that if the homeowner engages z person(s)for•hirc to do such The Code statrs that: "Any homeownerperforrning work For which a building permit is rcquircd shall be exempt from the provisions of this section(Seceion 109.1,1 -I-iecnsing of eonstrueb p. ) work, that such Homeowner shall net as supwisor, the res onstbilitics of a supuvisor(see Appendix Q, Many homeowners who use this exemption ate unaware that they arc assuming P ariiwlarly Lion s lack. Rules &'Rcgu)a'lions for Liecnieenscd c onionJn thucsc,sour Board cannot trocc d against cthe unlicensed person snit would xjth t licensed when the homcownerhires unlicensed P Supervisor. The homeowner acting as Supervisor is ultimately responsblc. To ensure that the hom�wncT is sl fully a lltc roof his cT Tcss ofsi Sutpcs',a.. y0n the Iastispagc oft this a ssuc is atform rcrrurril n lytused by that the homeowner ccrtifythat hdshe n - r—Ardificalion for use to your community. .40IER (508)540-1919 FAX- (508)457-1269 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION aaquoit Insurance Agency ONLY AND. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 516 Waquoit Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Waquoit —MA, 02536 --- ._ .w INSURERS AFFORDING COVERAGE NAIC# INSURED .INSURER A:Nautilus MInsurance Croup ---_ Harold L. Loyd INSURER B:The Hartford Underwriters 4 Silver Beach Ave INSURER C: .INSURER D: North Falmouth MA 02556 wsuRERE: --._.~.11 _.^--- �------••------- ---_.------ 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, iN-Si •I) -- '------ _...-.._..----- — POLICY EFFECTIVE PO CY FaWIRATION LIMITS TR C POLICYNUMBER, p MM/ODIYYVY DA E MW ' GENERAL LIABIUTY EACH OCCURRENCE : $ _ -1'000•r_OpO DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrgMI___,,$_ _ 50 000 A _ CLAIMSMADE U OCCUR NCO55575_ . 11/17/2009 11/17/2010 . MEDExP(Any oneperaon) - $ _ 10,000 PERSONAL a ADV INJURY $ — 1,�00 L000 - GENERAL AGGREGATE S. 21000 000 GEN'L AGGRE_GATF LIMIT APPLIES PER;. ., PRODUCTS_yCOMPW AGO B 1 000 r 000: X POLICY PR0- LOC AUTOMOBILE LIABILITY COMBINED SINGLE.LIMIT S ANY AUTO (Ea accident) ALL OWNED AUTOS 3 BODILY INJURY (Par person) $ SCHEDULED AUTOS ` HIRED AUTOS n BODILY INJURY. $ NON-OWNED AUTOS - (Per Ac6denl) _ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT_ $ ANY AUTO - OTHER THAN EA ACC 5- —_ AUTO ONLY; AGG $ 'EJ(CESS I Y44BRELLA LIABILITY - - - ' EACH OCCURRENCE $ I _....._ � .. - AGGREGATE X• 0CCl71i� 1IMS MADE _ : ----- DEDUCTIBLE -- C RETENTION " $ S WORKBRS COMPENSATION WC STATU-. OTH- B DRY-LIM T.5.-- E. AND EWECOYERS`'LIABILITY YIN; j • ANY PROPRIETORIPARTNER/EXECUTA'/ E,L_EACH ACCIDENT OFFICE91MEMBER DCCLUDED7 i, S (Mande6brylnNH) 6860tMO398N98610 2/14/2010 2/14/2011 El DISEASE-EA EMPLOYE $ —_ 100,000 If yea ddsurDe under ek DISEASE-POLICY LIMIT $ 500,000 SPE61Ag-PROVISIONS bebw OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (SOB)190-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIEShFCANCELLEOBEFORETH2EXPIRATION Town" Of Barnstable Building papartment DATE THEREOF,THE ISSUING INSURER WILL.ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE.CERTIRCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,JTS AGENTS OR REPRE6ENTATIVES. AUTHORIZE QFPRESENTATIVE' ACORD 25(2009/011 . , ®1988.2009 ACORD CORPORATION. All rights reserved. . INS025lzwqui i The ACORD name and logo are registered marks of ACORD �.uu„urrrg neguranous artd Sta1i'd YZTs" License or registration valid for individul use o HOME IMPROVEMENT CONTRACTOR before.the expiration date. If found return to: Registration: 156230 Board of Building Regulations and Standards Expiration. 6/15/2011 Tr# 285111 One Ashburton Place Rm 1301 Type DBA Boston,Ma.02108 • LOYD'S HOME IMPROVEMENT HAROLD LOYD 4 SILVER BEACH AYE: NORTH FALMOUTH,MA'02556+ Administrator Not valid witho t signature Dc 'trrrcnt of Bo u'd of BuiIdinLr Pulili(' Sift t� Construction Suca'hitioll.s an(1 Stun(l.u•tl's / License: Pervisor License .CS; 101750 . Restricted to:'00 -- .HAROLD LOYD ' 4 SILVER B I f EACH AV NORTH FALMOUTH MA ( rmnnsioncr Expiration: 7/8/2012 ITr#: 101750 j f _ - ti , • .—._�.__.. ...._ t - .t I.. ,.. • � ... a Iw... i4 _..:....ten I, N. ACK I i • .t c'r^'Y'�'tl of —7' '::tG"_l..�a__LA.rII—....A"' t pp r V�y � tL CL ti �.�L _.L... � ' t \'°•'�;u � �,Yf/ I I �yq � • W� -t-4— Y i --4 ` op, JJ i 1 7io I IWO aj a�w �j i • I f • IS NOT UTILIZED. 2Q. �4SFMFti iN 11 CHARCOAL FILTER r V (FINAL PLACEMENT BY \ CONC. BLOCK 43.38 TH HOMEOWNER \ PATIO x 3.82 x 43.77 \. I I BENCH MARK — TOP OF CONC. 45. 4 43.8 PP 0?3' x 43.64 AROUND STEPS EL. 44.4 44 , x TH1 _x 43,50 \TH2 4 O� \ 44 3.97 \ •j CONNECT ENDS x 7¢ "� Q44. 3.00 OF PIPE TO %� "3 29 VENT \ ®k6.13 ¢9 x t T EXISTING \ E4s,-, 4zy `SO 46.8 DWELLING NG \ FNT . x 567 47 7.22TOP FNDN. LOT 16 50.3 \ / 15,191 t S.F. 152 \ / BASEMENT / -SLAB EL 43.0' / 3.07 A9 / I x 2.22 1 9.k9w57 GARAGE 110 4 \�W S 48.04 9.13 x 49,82 _ I 01 LACES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE 1k 6 49.40 IATELY GRANTED BY THE BOARD OF HEALTH AGENT OR 0' / J .ALTH INSPECTOR .2WORK AND HEARING REDUCTION PROPOSALS APPROVED / ESN OF,t14s IE BOARD OF HEALTH REVISED DURING A PUBLIC / �`'� �S� ti .NG HELD ON MARCH 10, 2009 / TILED SYSTEMS ONLY SOIL ABSORPTION SYSTEM UATIONS PROPOSED MORE THAN THREE FEET BELOW E WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) / 'WITH H-20 LOADING, BUT IN'NO CASE SHALL THE SAS ;�. r,n,\Tcn LIMP THAN SIX FEET BELOW GRADE. �50.68 ��p,��`cco r' :: �ofTNETo�° TOWN OF BARNSTABLE BARNSTABLE, 1639. i "o M BUILDING INSPECTOR � aY a' APPLICATION FOR PERMIT TO ..... ...... .......................................................:........................................................ i TYPEOF CONSTRUCTION ...... _ ........ ................................................................ ......................................... ..//' .` . .........................19../..:Z TO THE INSPECTOR OF BUILDINGS:- IZG The undersigned hereby applies for a permit accordin to the following, information: &""' Location ..........s%�..................�.................I ..... ............ ........ .................... ...................:...................................... ProposedUse ....Ji`" ? .................................................................................�......7./.1/,�C.,�. ,<e" Zoning District ................................... Fire District ..... 9.. ..... Nameof Owner.. ...............................................Address ................................................................................... e Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .......... ..................................................Foundation ........................................6eXe-,�e�-. Exterior ....,�. .. � ...........'"�� ®® ................................................Roofing ...... . ... .. .... ...... !....... ! '✓. ......... FloorsG ..........:......................................Interior .......... ............ .....GrLj � .................................. Heating ....... ...'.... ....................................................Plumbing ........./....... ` =......................... Fireplace ...............Approximate Cost .. ( T Definitive Plan Approved by Planning Board ---------------_-__-----------19--------. C _t LU O w c� Diagram of Lot and Building with Dimensions LL OLo `J / SUBJECT TO APPROVAL OF BOARD OF HEALTH BOO fn mca 1L Gj C. ' C o i O LU = a, W 00 WSW, ~ m .w► J a G cn = LLJI--- Ld zz CS' z - c 7' CIL < z wE— C1 V) d Q O� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Namew,r .. ................. ..r.,... ................. ............. Al an [�s�Il" A~~=� one story ^ No ....�����.. Permit for .................................... � single family dwelling ---^--- —^'-----~'~'--'~—^--`--^ /� ' c�� � Buckskin Path Loco��� ��on --..--..—.—..------..------.— . � Centerville � ..--.—..—.----..--.,~~_--.`.,—.----- . Alan 6ml7 Owner _--.---_............_______._____ frame Type of Construction .......................................... —.-..-..--.—.--.—.----..—.~---'--.. . #n6 Plot ............................ Lot ----......----- � � Permit Granted -- ----..--lV 72 Date of Inspection .................................... - PERMIT REFUSED . � —.—_—._.-----..--.-------.. 19 -----.---_—.---.—__._._~__..______ ----'--''---'----'--------'.-----''' � �J .--_------.-.--..-------...---..---.—..-. � --_—.----.----'----------------. 0� 00 10 -^ Approved � lg ~----------'''r'.�` '— ~- ^ ----'`--''--^-----~^^'---~`^^^^—^ ' , -------'---------'--'—~^^```^^^~' | ' | � / Fx;pjrB -- ��t �, o\ Fee N/ \�;! Regulatory Services .��,isr t ip� Thomas F.Geller,Director S� v � Mess ° 9�p te7� �� Building Division rf0 Ml►y oissioner Peter F.Dl�iatteo, Building . . 367,A is Strew, Hyantns,MA A 0Z601w Office: 508.562 '038 Fax: 508-,90-6? 0 �PPLICa'I'ION - RESIDENTIAL ONLY EXPRESS PERItiITP - Vot Valid without Rstt X--Press ItnFrtt:t .lap:parcel Number 1 J7d- Property:address Value omork 2lesidentiai Owner s;v'atne&address 1 t d Co Jan G (v D Telephone Number Contractor's Name Home Improvement Contractor license':(if applicable) License_(if applicable) Construction Supervisor'st ® • ices- twori®aes Compensation Insurance • ,p��S Qtecic one: 1001 � MPR � , Qum a sole proprietor C1 I am the someoaaer Q I have Noricff s Commensation Insurance OF APR D-n Ck Insurance Company Fame _ . 1J Woriar=s Comp.Policy Permit Request(check box) Q Re.roof(stripping old shingles) Re-roof(not shipping- Going over existing layers ofroofj J Q'Re-side a Replacement W indo«5. U Value_-,__ tion. ❑ Other(specify) t regulations. Historic.Consenl ::-• t c iilace with other town deps� *Where required: Luu=ce of this petsnit don not exesnp omP Simature f Coll' y �`� �:.[G 4-cY/iv..av/(.cirL;<LGL1G L/• l.�f'�(,(,�,, _ GUc1Y.G(y Board of Building Regulations and Standards — HOME IMPROVEMENT CONTRACTOR RACTOR Registratl'on: 134618 Expiration: 12/18/03 Type.: Private Corporation R. C. HOMES WILLIAM DICKEY 41 MEETING HOUSE LANE SAGAMORESEACH,MA 02562 Administratjr- fiver's License 09-03-61 0E 03-0 rat Date Date o'84111 xpires Sex Heigl0". DM S33873042 gel I (� Number e�3 fo (rartii)t1 fi y 7 JONES L.ISIYC BUZZARDS BAY, MA �.., 02632 .. .!.`IE VCL7?7-)IdL✓idi 't?il�/-it- G` ..'l'rflJlCLCi�ccilt:G • r BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS O44470 Birthd6te: 09!03/196 Expires: 09/0312002 Tr. no: 1136 Z 'd 988i3—EEB t t30S) S3WOH 3N eLO : T T 20 20 _Add SQQPQgnr'c nf;---- ,,-_I ftppoMap Parcel ermit# - 7- -I Ffonservation Office(4th floor)(8:30- 9:30/1:00 2:00) Date Issued Board of Health,(3rd floor)(8:15 -9:30/1:00-4:45) Fee cis d t) Engineering Dept.(3rd floor) House# ��� IHE g.) BARNSTABLE, MASS 19 . , 1619. .� TOWN OF BARNSTABLE Building Permit Application . Projec dress-7 &AS UN Village (p n tulL I I ¢.ss. O A 6 3 Z.. •Owner - M". SaA Mary Address zo i3wask tx-'00 CewkwvAe, Telephone 508- - 9013 Permit Request p 9 i K, - If rt CL L^0 r4 If- ',First Floor square feet Second Floor square feet Estimated Project Cost $ 2."0.00 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 ✓ Two Family Multi-Family Age of Existing Structure 20 ^�g .�. Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms 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 Information Name key tAco Telephone Number SOP - 3 IS--72 7 7 Address 7 1) fyek o,& License# sovy. va ►IMA .msc �7 Home Improvement Contractor# Worker's Compensation# (p,�i e)8 J 9 K ID 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 SIGNATURE �/ DATE OG lo6ot.. .Z/T'!t! BUILDING PERMIT DENIED NOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY ! IT NO. PE M . D TE ISSUED _ M P/PARCEL NO. ' ADDRESS - VILLAGE OWNER - DATE OF INSPECTION: - f FOUNDATION ' Y FRAME � x INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING- ROUGH FINAL E ' GAS: ROUGH FINAL - ! k FINAL BUILDING •'�' � ' ! x 1:� - } } 4� 77 DATE CLOSED OUT S 1 ASSOCIATION PLAN NO. r The Town of Barnstable ' umm $ Department of Health Safety and EwAmnmental Services .. •' Building Division 367 Main StteCk Hyannis MA 02601 Ralph Ctrossen Off= 508-790-6227 Building Comm Fax: 508-775-3344 For office use aniY Permit no. • Dau AFFIDAVIT HOME IMPROVEMENTTOO���TIONw . SUPPLE coon,alterations;reaovatioa,repair, modernization,C°avesMM MGL c 142A requires t�the-rewwtru cd imptvvemeM.srsno%al, demoIitian, or casisauaion of an addition to a� �� building cowaining at least one but not more than four dwelling units or o� along with other to such residence or building be done by registered contra==with cerWn ti tequirc ere 0� Est. Cost Type of Work: -ORAOIL Celk V. Address of Work: Oa ner.Name: •• s qu Date of Permit Application:--A " Z�1 40 I hereby testify that: Registration is not required for the following rc mn(s): Work excluded by law B_ob under SL000 uilding not owner-occupied --Owncr ping own manit Notice is hereby gh=that: RS OWNERS PULLING'T1 R OWN PERMIT OR DEALING WRI;IINREOT �CE TO THE FOR APPLICABLE HOME DAPROVEMEN i' WORK DO N p1tHiTI,ATION PROGRAM OR GUARANTYFZJND UNDER MGL c I42A SIGNED UNDER PENALTIES OF PER.IURY I hereby apply for a permit as the agent of the owner: Regisnrtion Na Date Conuaaar name OR w TileCunurrt,n>+•Caltlt of?Itasracllwctts • .«;,: .. �.���. Department of Industrial Accidents i;!'. 'r; 600 11 ashin,,7nn Street Bmwon.Afters. 02111 Workers' Compensation Insurance AMIdavit _.�� Ple se 1'RINT'1e tbly• . . . .. A,Rpiic��n nfbrmatio'n .. . �—����� • Mirs• Sa\Macy losation Z G'1 �uCc C�CtMV Ca�� Sill, w ❑ I am a homeowner perforining all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity (t]' I am an emplover providing workers' compensation for my employees working on this job. c^;pan: name Mie GC AUC •oddre . s , \aN Ay lii. - Y A *WLS S '� phone 0! AO,? c31t'tQ'" 2 77 .S• sit n M►w.. Vw •# (OS 1 ❑ I am a sole proprietor.general contractor,or homeowner cucle one and have hired the contractors listed below who the following workers' compensation polices: empany nJM address: citti phone#r 1 inturnnre rn pelitry# � '• _ c. 'ac , --- .`•.x..rsn-i-.-r-�.rres�-+s�� , i' RT F�— �"` - — _ " m .Im•na e- city phone#! •• neiier# . .. i .-g- - co- nce :Attach additioaai'ahee!if rieeeasar _�»: �"�"�'<='�`^"'`""—' """'•" ` ��" "W Failure to se coverage as required under Section 25A of A1GL 152 tan lead to the imposition of criminal penalties of a fine up to S1300J1t1 sae; cure One%•cars'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. 1 tmderstand thid copy of this statement may be forwarded to the Mee of Investigations of the D1A for coverage verification. 1 do hereby carify under dye pains and penalties of perjury that the infom mion prmided above is tare and correct Signature v /0 Print name Wt �� •e►.w.. C SWt one#� a'''31r�'72 7 7 official-use oniv do not write in this area to be completed by city or town official cit•or town: permittlicease it n8uiidhM Department pUeensing Board cheek if immediate response is required OSdeetmen'a Otlice (311eaith Departmcat contact person: phone tY; MOther. �` Information and Instructions , Massachusetts General Laws chapter IS2 section 25 requires all employers to provide workers' compensation for t employers. As quoted from.the "law". an employee is defined as every person in the service ofanother under any contract of hire, express or implied. oral or written. An employer is defined as an individual, partnership, association. corporation or other,legal entity, or any two or rr the fore�_oin,enLa�_ed in a joint enterprise, and including''theJeg l representatives of a deceased employer, or the rccci+•er or trustee of an individual , partnership, association or other legaI entity, employing-emplovers. However owner of a dweilinL house having not more than three apartments and.who resides therein,or the occupant of the d++wcllin, house of another who employs persons to do maintenance, construction or repair work on such dwelling or on.the .,rounds or building appurtenant thereto shall not because of such employment be deemed to be an emplo MGL chapter 152 section 25 also states that OMITstate or local licensing agency shall withhold the issuance or rene++•al 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. Additional!+•, neither the commonwealth nor any of its political subdivisions'shall enter into any contract for the performance'of publi'c work until acceptable evidence of compliance with thex`insurance requirements of this chapte been presented to:the contracting authority. - � x ..•.ii; " .. 't!t•�:f.t. . .� ... =.y..... liar ilc(.•...{:w:!'A+s..2:5_D�•:1 .i.iY.-r,�.i� ;-�.•n-'.`is.!:"..nM.. . Applicants Please `111 in the workers' compensation affidavit completely; by checking the box that applies to your situation an 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 of iidavit. 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 requir to obtain a workers' compensation policy, please call the Department at.the number listed below. ,. ... .. .. �tw.. L: .::a�-. . . :�.i•�«."�.��E�•_.y i'��{;�`S.-„'.�fi:�' mail.ww�.7�; y.�tyst i� '... . City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rettune. the Department by mail or FAX unless other arrangements have been made. The Office of.]nvesti cations would like to thank you in advance for you cooperation and should you have any quest: please do,not hesitate to give us a call. , 4 The Departments address. telephone and fax numberi The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 nhon.e-#: (617) 727-4900 ext. 406, 409 or 375 .. ..::.DATE(MM/DDIYY) .. AcoRv �EFtT FOCATE OF Lr4E31L.I1'� IN'�►t�t�ANC.* PD RM :.. 10/02/96 . PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Drake, Swan & Crocker HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lot's Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 COMPANIES AFFORDING COVERAGE Peter G Walther COMPANY Phone No. 508-255-3212 Fax No. A Western World Insurance Co. INSURED COMPANY B St Paul Fire & Marine Ins Co Thermco, Inc. COMPANY Wm. J. McCluskey C 7-D Huntington Ave. COMPANY S. Yarmouth MA 02664 D COVERAGES .:>., 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DDIYY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $2,000,000 A X COMMERCIAL GENERAL LIABILITY 14GL713901 07/19/96 07/19/97 PRODUCTS-COMP/OP AGG $ 1,000,000 CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ 1,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one fire) $ 50 i OOO MED EXP(Any one person) $ 1 i 00 0' ' AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WC STATU• OTH- WORKERS COMPENSATION AND TORY LIMITS ER <...:........:.:;...........:.:.:..,.,:. EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 500,000 B THE PROPRIETOR/ INCL 6316II8898R07896 09/12/96 09/12/97 EL DISEASE-POLICY LIMIT $500,000 PARTNERSIEXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $500,O00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS Insula tion Work CERTIFICATE:HOLDER CANCELLATION .... BARNSTI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town Of Barnstable BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY ATTN: Building Inspector 367 Main Street OF ANY KIND ON T E COMPANY,ITS AGENTS OR VPRESENTATrVES. Hyannis MA 02601 AUTHORIZE EP ATIVE ACORD 25 S(1195) . :.:: . : ........ t9ACdi D G4�tpOttATION 1,908 NOME IMPROVEMENT CONTRACTOR Registration 163926 typi - PRIVATE CORPORATION 6pitAlon 07/l0/96 i TMERMCO, INC. iiliim f. McCiu§key ADMINISTRATOR ��1D Huntington Ave. ' $o. Yarmouth HA 02661 0