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0406 BUCKSKIN PATH
ups� �- f : . _ �.. , � � � : . , * , .. y . .� .. ., 9 "' �� .. [ Y - � � .. .. � F ' -.. ,� _ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division "U"No Date Issued Z--/S 11. Conservation Division Application Fee Planning Dept. 14 2g17 Permit Fee 5 . 06 Date Definitive Plan Approved by Planning Board 0F194R 1ISr,x w: t: Historic - OKH _ Preservation/ Hyannis Project Street Address R4 Village Owner Address Telephone Permit Request �✓,��L.,,_2_�,._ r ,� s .� I 1'� ��l��f!..1 k {;� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Z Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name mile mec n truction Telephone Number i PO Box 52 Address wesa Dennis 9 A 02670 License# Cell (508) 280-6964 .-eau 54863-3 _a c ,a�3 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 9- na SIGNATURE DATE �`I/Yl/7 FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. iblassachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-058633 Construction Supervisor MICHAEL.J MCCARTHY P.O. BOX 52 WEST DENNIS MA 02670 _ r1 Expiration: Commissioner 04/10/2018 Office of Consumer Affairs and Business Regulation 10 Park Plaza -- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2017 Tr# 264961 MICHAEL MCCARTHY MICHAEL MCCARTHY P.O. BOX 52 -.... _......_._.... WEST DENNIS, MA 02670 ___.........___._..---_-.....-- Update Address and return card.Mark reason for change. Address D Renewal = Employment ; Lost Card SCA 1 20M-05/11 =�/![P IC'OJ720YRC!-%L.LPCCI(l�C��-��CLJ3G C�1%X'(C Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: kpr egistration '�69393 Type: Office of Consumer Affairs and Business Regulation xpiration: :0j..¢12t}17 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 MICHAEL MCCARTHY i1 MICHAEL MCCARTHY 6 RANGLEY LN. SOUTH DENNIS, MA 02660 Undersecretary ` Not id with oft signature The Commawe alth of MRSsRchmeas Department of1mko blAccide►1h I congras S&eE4 Suite X00 Boston,MA 02114-2017 wwwtntasspy1ft Workers'Compensation Insurance Affidavit:BdNW e/Contractors/Electridans/Plumbers.. TO BE FILED WITH TM PERIVIIfMG AUTHORITY. Anglicant 'on Pima Print 1 Name(Business organization&dividoao: / ' -4- Address: Q-G. 1�3ri 5 Z City/St1WZip: we,)- Ocn,., M k 01c7t-Phone#: 52t -.Wc, -CT(c. Areyew an a~Check the box: Type of project(required): 1, Lem a aVbyar with employees(fid!and/or pact taae).} 9. ONew cons&xtion 2.[I am Ole pmpsietororpefter hip and have no employees woddng forme in g, g any cgmdty.lKo workers'uM.insuranceleie repied.] ' 3.01 em a hon ginner doing an work myseM(No wod ma'c=V6 insnremca required.]t 9. ❑Demolition 4.[I em a homeavner and will ha birhtg txatbaobre to cooduet gip work on my property. I will 10131luildfasaddition ensue dss all contramm either have warren'compensation imrarceor are sofa 11.0$leettital repairs or additions prep'etm whb co erplevem' 12.[Plumbing ropairs or additions 5jo I am a general contractor and I have hired the sub-contractrrs Herod on►bo attached sheet. These sub•connactats have employees and bwo workers'comp.foo mnce t 13.�Roaf re�sirs 6.13 we are anvarstiorr and its officers have exercised their sight of exemption per MOL c. 14.[]Other 152,J1(4),and we have no employees.(No workers'comp.f mmee tegoired•I *Any epplfeant drat cbecks bar#1 must elm frill out do section below showing their workers'compereation policy ini nn im. 'Hemgownera wko submit this afftvft inficd ing they era doing all work and then hire outside comamrs nest submit anew affidavit indicating such. kanklmrsdocheck this bar amrst attached anaddidenal sheet showing the naren ofthe sub tars and sate wked eror netd:ow entities have aqployeas. Ifd►e strb oamraotors have employees,they must provide their wodrers'comp.po)iry number. I am enemployePi*gt bProdit woAM'co ion iButwesce.fog'&V employem. Bolowf8 thepol►cy andjob site Insurance Company Name: � .•�l L►<<�►1: c..9 i�—t�rz 1a..s. Pac5r>ta of sell=ins.Lic.#:� 5 C']*-I^7 s-'7`! Expimdon Date:_ )1 - t Job Site Address: City/Statezip: Attach a Copy of the.workers'a mpensadeni-polley dederation page(showing the Oki number and expiration date). Faun=to am=coverage as required under MOL c.152,125A is a criminal violation punishable by a fma up to 81,500.00 an/or one-year imprisonment,as well as civil penalties in the A)m of a STOP WORK ORDER and a fee of up to SM.00 a ' day against the violator.A copy of this statement may be ftwarded to the Office of investigations oftle DIA for instuance coverage verification. I do hereby under ofp qwy thddW iaqfbrmatlonpwvMd above>h trtreernd correct S' Date: J b,10 P1iik�B#,�ffPj -(f6�_ Offldd no onht, Do not write in this atva,to be completed by city or town gAWd City or Town: Permft/Liernse# Issuing Authority(rime one): 1.Board of Bieafth 2.Building Department 3.City/Town Clerk 4.EleeWcal inspector S.Plumbing Inspector IL Othe1' Contact Men: Phone#: i :q �'1 MCCART9 OP ID:KS CERTIFICATE OF LIABILITY INSURANCE FD 1 2/2 012 0 1 YY) 12/20/2016 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: It the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, 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 endorsements. PRODUCER pA�E^cT Dennis Office Bryden&Sullivan Ins Agency FAX p E of Dennis Inc. 508-398-6060 AIc Noll:508-394-2267 485 Route 134,PO Box 1497 E.MaIL So.Dennis,MA 02660 ADDRESS: Dennis Office INSURERS AFFORDING COVERAGE NAIC# INSURER A:National Liability&Fire Ins INSURED Michael McCarthy INSURERB: Construction Inc PO Box 52 INSURER C: West Dennis,MA 02670 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE ADOLSUB POLICY EFF POLICYEXP LIMITS LTR POLICY NUMBER MM/DD MMIDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ TO RENTED CLAIMS-MADE 1-1 OCCUR PREMISES Ea occurrence $ MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECTT ' LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBacINcid ED SINGLE LIMIT $ ent ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS eraccident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LtAB CLAIMS-MADE AGGREGATE $ DEDT RETENTION$ $ WORKERS COMPENSATION X ST TOTE ERA AND EMPLOYERS'LWBILnY A ANY PROPRIETORIPARTNER/EXECUTIVE Y/N V9WC747574 12115/2016 12/15/2017 E.L.EACH ACCIDENT $ 1,000100 OFFICERIMEMBER EXCLUDED?, Y❑ N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Michael McCarthy has Opted to Exclude himself for Workers Compensation benefits. CERTIFICATE HOLDER CANCELLATION CAPELIG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. BOX Barnstable,MA02630 AUTHOR1ZEDREPRESENTATNE 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ofTM ,tO . Tqo of Barnstable leguatory 'e�cces " Richaid'V.StA,.Directuir. 9$_ i6f9 Rldidmg Division. `IbruPerry,C3uild►ng Gominpssurier 00 N s�z"t',Hya�s,.M,A" :a 6az n�-vto���.barnsEabCc.ma.us: ' Ofhco: 508=8624038 Fax: ,608 7%0-6230 Co apse e= n Si;za 'his..Scc�ibn U:Usr A S. xcY�r Qwner pf the si bjecr; zopc�i:j herebyuti?Aiiue: Y :tn act on.rn i��alf i in ahimattcrs.rdau"6 to wo�k:authoxized by this buiIdi g permit apptcation for ecIA LIO (Address of f ob) ` .. r. s"fit �vr�`a ' �s,.�.i Y`• r,y.. POoeanesumsae resparisibLyfof tie applzcaa�:PcaLs aice ric�t: o.be.fil�ec.car uLilited`laefore f�nre.:s: nstalled and all''-ii�1' Ins p thous,ire:,pc ,)riiiA,.-and, c:epitecl.. Signattut of Owner- Sign atuxe!o#Applicant - Print N rne. — Priac Nacre 0_EORMS Ol'vT'F.12.QrRI-Ai. oNPC1c 2.S' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # ' 6 30YC, Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis C Project Street Address yoG g,,J&c(.s�e_4L I _ Village �c•14r,�+�(c Owner S�ti. •,1` _ ' Ti r Address Telephone��� Permit Request c.4. tc.l..� 11 �c/j..�-�� �• ���« t c.� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 1 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family LY Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas . ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing U new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size.—Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Milue McCarthyConstruction— Address PO Box 52 License# West Dennis, MA 02670 Cell (508) 250-6964 Home Improvement Contractor# CSIL-58633 III "-169393 Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO r-- SIGNATURE DATE 1/9 hc FOR OFFICIAL USE ONLY .APPLICATION # h DATE ISSUED V MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. j 2 " Tip o , lila, Ot7ySe ices Direct'nr. , 1omE Yerip,6uildmg(omtiussiorier k 1bia Srme4 Hyannis 0260 ta`tin barivtabI inam.s •r Of CO: 484624038 ex: •508 79.0-623:0 1'ropz- -Ownez .Must: if I-ffi A B:w.�d�r o �L✓i �r^t aS G- per Ofrtlie sub ect o crt r C r .licz�bywtitla�iue� _„!-���•��-�. . .. co�r�,,onr�rtyLehalf;,. in a11:ma m s;re'l-anve lto woik authoraed,,by this b.a& Femalt:applicatic)n:kox� . :S qO PoUI fncs and alazris. are the responsby :°I' nls are;nc�t:to be;fill�d; r`uulced lfc.�rr;'fenre..is'ira�ta�Ied`aricl all 'iuQl' »as �cuc�ns ark per'0rDkd,.anc�;accept c _, s fi gnatwe,of Ovsmer Sipaiime,of Appl ca nx JO P.m Name: Pimt Naple.l. , VA 3/1 tt �- bate Q:FORMS,OYv'i.'FRPL-.UAJSS1ONPOOL'i I 'r Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massack usetts 02116 Home Improvement C att Victor Registration Registration: 169393 r _ 'r� Type:` Individual !; Expiration: 6/16/2017 Tr# 264961 MICHAEL MCCARTHY �! MICHAEL MCCARTHY —1- P.O. BOX 52 ,� WEST DENNIS, MA 02670 _ date Address and return card.Mark reason for change. sCA1 Ca 20M-o5/11 Address ❑ Renewal G Employment ❑ Lost Card �e�pa7nn�aa�atue¢CCf2 a�C��iiaaac�iareCZ`s .Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: , _%9393 Type: Office of Consumer Affairs and Business Regulation Expiration_ 6N6l Q17 individual 10 Park Plaza-Suite 5170 x Boston,MA 02116 MICHAEL MCCAR�AWW kX a tY��', / MICHAEL MCCARTF4 ,�' 6 RANGLEY LN. �> SOUTH DENNIS,MA 0260 Undersecretary Not lid with oft signature Massachusetts Department of Public Safety �y Board of Building Regulations and Standards License: CS-058633 4, Construction Supervisor ; MICHAEL J MCCARTHY, xk a P.O.BOX .� ` WEST DENNIS MA 02 70 a /1`^'� Expiration: Commissioner 04/10/2018 The Commonwealth of Massachusetts ' Department offn(lustrialAccidents 'l 1 Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 www.mass gov/dia Workers'Compensation Insurance Affidavit:Build ers!Contrac tors/El ectricians/Plumbers, TO BE FILED.WITH THE PER1kIIING AUTAOItITY. Applicant Information Please Print Le ibly Name(Business/Organizationfrndividual): Mike McCarthy Construction- ox 52 Address: we%t Dennis, MA 02670 CeU 08) 280-6964 City/State/Zip: a#U1C_169393 Are you an employer?Check the appropriate box: Type of project(required): I.191am a employer with !�_ employees(full and/orparwime).O 7, ❑New Construction 2. am a soe,proprietor or partnership and have no employees working for me in ❑I l i 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition ' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised lheirright of exemption per MGL c. I4.Q/Other b✓C.f l«,,«h,` 152,§1(4),and we have no employees.f No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out The section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. lConlractors that check this box must attached an additional sheet showing the name of the sub-contraclors•and stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.'policy number. 1'ant an employer that is providing workers'compensation,insurance for my employees. Below is the policy and job site information. M Insurance Company Name: Policy#or Self-ins.Lie.#:_ Vb✓L- 1cy,-�O( 16-A .Expiration Date: 1a lrs 11 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c:152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify undrIa* s enalties ofperjury that the information provided above is true and correct Si ature: Date: Phone#: (5b01 D�u—G f 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: A4CoR,aa CERTIFICATE OF LIABILITY INSURANCE DATE TE(M DDIY 2016 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). ACT PRODUCER 01962-001 NAME= Bryden&Sullivan Ins Agcy of Dennis Inc E (508)398-6060 ,N,,; (508)394-2267 PO Box 1497 ADDRESS: So Dennis,MA 02660 INSURER(S)AFFRD N VERA NAIC S INSURER A.I.M.Mutual Insurance Company33758 INSURED 114SURER B: Michael McCarthy Construction Inc INSURER P O Box 52 RE West Dennis, MA 02670 NSURER INSURER F, COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY.THAT THE.POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE I SR POLICY NUMBER MMIDD % (989syr,% LIMITS GENERAL LIABILITY EACH OCCURRENCE $ AMACOMMERCIAL GENERAL LIABILITY PREMI TO (Ee RENTED e $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ OLICY t E O_ OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ c' e ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA L1AS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ 4 DED RETENTION $ yy�g�q TH $ AoMMOMALI X TORY LS OER YIN E.L.EACH ACCIDENT $ 1,000,000.00 A 69IMMUl �MEWCUTIVE FY] NIA VVVC-100-6017656-2016A 12/15/2015 12/15/2016 (Mandatory In NH) �r E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 69eSCRIP N OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 T . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Cape Light Compact PO Box 427 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable,MA 02630 THE EXPIRATION DATE THEREOF,` NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD c a)6 � sTti Town.of Barnstable *Permit# P Expires 6 months A issue date Regulatory Services Fee t mxxsrnsr nrAss. Richard V.Scali,Director i639 �$ ACED MAC A 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,/ /�, Property Address 'mot U 6 6l e (1 : �/V17 A f 4 vt'Ut ❑Residential Value of Work$ y, 'Z� Q 0_� Minimum fee of$3S.00 for work under$6000.00 --...- .......... - - - .J._. _._.... _ __.... _ Owner's Name&Address `4,_ /') d.r- h 't Z-QO��r Contractor's Name / �fi I �� fly Telephone Number �� 2 ` z7�j Home Improvement Contractor License#(if applicable) 1 7 Z-5 2— Email: ,V,0p -('e Construction Supervisor's License#(if applicable) L� J r �., eaax�n • c & � n ❑Workman's Compensation Insurance Check one: 014 I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE ' Insurance Company Name '1 Workman's Comp.Policy# C'' 31 S'O 6 1 3 0 _0 1 Copy of Insurance Compliance Certificate must accompany each.permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side C)�3� Replacement Windows/doors/sliders.U-Value (maximum.35)#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 ` require . T SIGNATURE: - - Q:\WPFILES\FORMS\building permit forms\E S8,A c Revised 061313 CIA Hie Ct1mtf1EJ9IiEteFlaM of-Vas-sachilmetts .�e�rez�t r�f�`;frrl�s '�4eczden�s - Office trrtgaiiorrs 600�%Yrr�s agton meet Bostw,•MA 02111 wa liv.MaSmgoi'ldl Workers' Compensation Insmanre Affidavit Bi:iilders/Contractors/MecfriciansMumbers AppIkant Infarmation Please Print Legibly Name(fie slOrgsnizafronllndivi�alj: �a.y �/'�� A&iress_ 7 fir' y n F��P 1 �� City/Stat�z�= ® tp/- vr" 0- r9' d�6 � f or 7 z 6' —z 9� Are yian aar employer?Check th±«aplxropriafo bumTypo g#paojet-t(rgmre k❑ I am a employer with 4_ ❑ I atna:ge�al confmcfor and I ti ❑Newa r�„ct„rc#ion . employees{full and/or part�ime�* have hired the suactors. 2-[� listed on t I am a sole proprietor or partner- . the at#aclied sheet; 7_ ❑Rrmndeling ship and hare:no employees Zhese sn6 coofracteis have S_ ❑Ikmralifion crorlfing forme in any capaci£3c �plxayees and have vrorlcers' _ ❑BnildFng addififln �6 Tilt'OI�CPSS'c[fmp;in�rranre COfl2p_trt�_Lrarx-¢ require ] 5-❑ '%Te area corporation and its 10.0 Electrical repairs or additions 3'_❑ I am a homemmer doing all work officets ha:m exercised their 1 E_❑Plumbing repairs or additions myself [No workers'comp- right of esmmpfionper MGL 121-1 Rnof repairs iumnunce 1 c-15Z§1(�and weha%eno requin'�I D_.®Qt#Ler 2OI44-< y"l,r►4)41 comp_insm-a•ce regaired,j !Aw appriomt that checks bm-11 nmst also fM out the section belaw showing ilea vD&U!s'compensation poii[y iaf� l EGameowners who submit this affidavit iuffcstiug they are dying aR wcxk and then hie outside contmcmm nmsi submit anew sdTidsrit inrh-tm s rll Cant oactoa dvd cbeck at this bo mast sttdhed as sdditionA sheet shommg the name of the sa€t-caatacb"and state vrhether oruot timse have asplayees. Ifthe,sab-contractors hale empIcrgees,they trrast provide their workers'-comp.policy number I am an e►ripPryeF#Jirrt isgrfr►�ici it�orkers'colit >?srrfian aiisurrrrzc far tR1K empl�yee� BeTais is the poTic,1*rurrI}ob s& . infirmalfan- Insurance GompanyName: Policy 4 or S-S€irrs Lic-4` PxPiratiauI?ate: Job Site Address: Cify1`StafE�Zip: Attsch a copy of the workers'compensation policy declaration page(showing the poliq,number. and expiration.'date). Failure to secure coverage as requiredunder Section 25A of MUL c. 152 can lead to the imposition ofcrimival pmalfies of a firm up to$1,500.0a and/or o eyearimpri as well as civil pees m the fvmi of a STOP WORK ORDER and a fine ofup to$250_00 a,day against the violator_ Be advised that a copy of this stg�maybe forwarded to the Office of Immsfigations.of the DIA€or instwanco coverage verification_ I do hereby aetl fy t nder eke palm annd penattie fpejYmy i#atflae iri,{orraalian prm�d abaue is�6lua and correct S1ffiatQrE: �%' �///� Bate: PTA#: iW ciat u-w only. Ikr not sprite fa this area,to be completed byr do ax town officiaL City or Town- PermitUcense# - Essuing Autharky(circle ane) 1.Board of Health 2.Buff-ding Department 3.Citylfoyi Clerk 4_Electrical E mpector 5.Plumbing ELTmtor 6.Ctthcr Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursnan'tto this statute,an employee is defined as"_._every person in the service of another under any contract of hire,. express or implied, oral or written_" An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,-or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also stains that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to constract buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage re-quired." 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 beeu presented to the contracting authority." Applicants — Please fill out the workers' compensation affidavit completely,by checkiag the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cerbficait(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 'I1re affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out izt the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant . that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations uz (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be.provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e,a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidaYrit 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 Commoawean of Massachusetts Departmmt cif hidustdal AGckd-e,T Q-fll�e of kvestig4txowi 600 Washhom Strom Boston:IAA 02111 Tel.A 617-727-4900 W 4-06 or I-�• MASSA' Revised 4-24-07 Fax#6 1 7-727-7-149 v .ma-.ss go ddia oFn+e r + BARNsxABL E « �$ HASS. Town. of Barnstable ArFD MA't� Regulatory Services . Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section -If Using A Builder I, /✓M as Owner of the subject property herebyauthorize �� t/1 � / e j w to act on m behalf, y in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner. Date • Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPHLESTORMS\building permit fonns\EXPRESSAC Revised 061313 Town of Barnstable Regulatory Services P�oFniE TO Richard V.Scali,Director Building Division * saRxsrnsrs *` Tom Perry,Building Commissioner 9Q� 16 �$� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.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: cityhown 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) ti 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. 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 persons)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 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 Iast page of this issue is a form currently used by several towns. You may care t amend and adopt such a formlcertification for use in your community. Q:\WPFILFS\FORMS\building permit fomu\EXPRESS.doc Revised 061313 ' �/ae�oo�vrno�zcueaCC/z o�C�///Laa�aclic�eGY�- �� , Office of Consumer Affairs&Business Regulation License or registration valid for individul use only • before the expiration date: If found return to: ME IMPROVEMENT CONTRACTOR a egistration: ;;178232 Type: Office of Consumer Affairs and Business Regulation xpiration:;::3/26/2016 Individual 10 Park Plaza-Suite 5170l - Boston,MA 02116 PAUL J. PERFETUO PAUL PERFETUO k n 87 BRIGANTINE AVE �' Jf OSTERVILLE, MA 02655 Undersecretary Not valid without signature i Massachusetts - Department of Public Safety Board of Building Regulations and Standards ' `Construction Supervisor License: CS-097541 PAUL J PERFETUb 87 BRIGANTINE=AVE OSTERVILLE AfA 026551..� �-� OF Expiration Commissioner 05/17/2015 K '7/,7h y I,ll,e Town�of Barnstable *Permit# Expires 6 mondis froni issue date Regulatory Services Fee ,3 S = BARN$rABM MASS.1639. Richard V.Scali,interim Director �m Building Division Tom Perry,CBO,Building CommissionerxPRESS PERRMT 200 Main Street,Hyannis,MA 02601 4 waw.town.barnstable.ma.us JUL — 7 201 Office: 508-862-4038 Fax: 508- 90-6230 EXPRESS PERMIT APPLICATION - RESIDE AL ONLY No Valid without Red X-Press Imprint 6"CT•1 NSTABLE Map/parcel Number/ Property Address /Residential Value of Work S ,�j, C(W Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A& it Ilam-440ow ljoe'lefleal oval-Z j jo�I- e W 19 IqA,9 f / Contractor's Name R u F o C—'U t1 514 2[Et Telephone Number Home Improvement Contractor License#(if applicable) 15q $t!p Email: Construction Superviso'r's License#(if applicable) CS 9Workman's Compensation Insurance Ch [1 ck one: I am a sole proprietor ' ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance y / Insurance Company Name �j e4164 !�1/r�,e,/�OL l Workman'sComp.Policy# WC•,p) a'99 Copy of Insurance Compliance Certificate must accompany each permit. '! Permit Re est(check box) Y6 ir✓VI O u-r r/ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to kmd Fi It ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maxiinum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections'required. Separate Electrical&Fire Permits required. -W- here rcouired: Issuance of this pennit does not exempt compliance with other foam department regulations,i.e.Histmc,Conservation,ctc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License Is, required. ' 1 SIGNATURE: G TAKEVIN MBuilding Changes\EXPRESS PE XPRESS.doe Revised 061313 _ The Commonwealth of Massachusetts Departnnent 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 D Please Print Legibly Name (Business/Organization/Individual): lhulU 1�'T� �VA 1W� w✓1 5�i(c.��j0/� Address:To 3t,4 S City/State/Zip:Gv, h 0 19 Wl 067� Phone#: 77LI Are you an employer?Check the appropriate box: Type of project(required): 1.91 am a employer with ez� 4. ❑ I am a general contractor and I employees(full and/or art-time .* have hired the sub-contractors 6. ❑New construction ?.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y p tY• 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions self. Y m ' right of exemption per MGL �o workers comp. 12.❑ Root repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation:insurance for my employees. Below is the policy and job site information. Insurance Company Name: W1'�• Policy#or Self-ins. Lic.#: W G a- 3 I S-3 K42_,q e'G 1 y' Expiration Date: 3 l 11 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to.$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si an c: �C.c-�✓Lf�> Date: Phone#: 72 Lf- 7),) - II Z 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 .aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD,YYYY) 3/4/2014 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 O'BRIEN'S CENTERVILLE INS AGCY INC wa°MEA� - 259 PINE STREET PHONE FAX No• PO BOX 610 E-MAIL CENTERVILLE, MA 02632 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: Liberty Mutual Fire Insurance 23035 INSURED _ INSURER B. PAUL RUFO DBA RUFO CONSTRUCTION COMPANY INsueERc: PO BOX 648 INSURER0: WEST HYANNISPORT MA 02672 INSURERE: INSURER F COVERAGES_ __. - _-__._ CERTIFICATE NUMBER: 19411546 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. INSR1 -TYPE OF INSURANCE ADD SUER POLIPOLICY NUMBER MMIDDY EFF POLICY MIDDIYYYY LIMITS LT LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S kGE TO CLAIMS-MADE _ OCCUR PREMISES E RENTED aocaurence S MED EXP(Any one person) S PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S POLICY PRO- LOC PRODUCTS-COMPlOPAGG $ JE OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ _ Ea acadent AN'Y AUTO BODILY INJURY(Per person) S i ALL OWNED !—!SCHEDULED BODILY INJURY(Per acedem) S AUTOS i AUTOS I — I^NON-0WNED 1 PROPERTY DAMAGE GE $ HIRED AUTOS I ;AUTOS 1 UMBRELLA LIAR !��?i OCCUR EACH OCCURRENCE S EXCESS LIAB ' ;CLAIMS-MADE AGGREGATE S j DED i E RETENTIONS $ A WORKERS COMPENSATION WC2-31S-385298-014 3/7/2014 3f7/2015 ,/ STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN NIA E.L.EACH ACCIDENT $ 100000 OFFICERIMEMBER EXCLUDED? ❑Y (Mandatory in NH) E L DISEASE-EA EMPLOYEE S 100000 If yes.de scribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500000 DESCRIPTION OF OPERATIONS r LOCATIONS r VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PAUL RUFO Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Liberty Mutual Fire Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD _ i N Massachusetts Department of Public Safety �< f$.. ° o , Board of Building Regulations and Standards { u 75 :-Construction Supervisor �' T. . . € � � Js .r ,� k a 9 U S De artment of Labor License: CS-094062 �' 1 14Occupational Safety and Healih Administrahoh f PAUL A RUFO =r ", 4 b * a I Paul Rufo t�. , r P O BOX 648 I s w q .,� t WEST HYANrTIS OR672, t-;has successfully completed a 10 hour Occupational Safety an ealth I,A. Coursein 3 3k"jT` $� .l Constn01 Safie &•HeaRh`, ,. Expiration l (� Commissioner 12/01/2015 I i r�tnerr .. - z.5q.. _ .._ _��a -.ten ar�.�v"�- d:� a . •. . o�Caa�ccdeCra Office of ConsuMtr Affairs&Business Re ulaho I tense or registration valid for individuUme only . ME IMPROVEMENT CONTRACTOR 'before the expiration date. If found return to: Wei istration: 154$62 Type :Office of Consumer Affairs and Business Regulationxpi ration ,1110/2015; DBA 1.0 Park Plaza-Suite 5170 z Boston,MA 02116 RUFO CONSTRUCTION 0Y ` PAUL RUFO t�n 10 OLD TOWN ROAD HYANNIS,MA 02601 t e. Undersecretary -Not valid without.si turtle _ 1..f � . • tARN.STABU MASS. Town of Barnstable Regulatory Services Richard V.Scali,Interim Director Building Division Thomas,Perry,CBO Building Commissioner 200 Main Sheet, 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 . as Owner of the pro subject perg I _ .. hereby authorize 40 to act on my behalf, in all matters relative to work authorized by this building permit application for: 61e5� 0 V Ile-" (Address of Job) IV Signature of Owner Date ha Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAEVIN D\Building Changes\EXPRESS PERMITTXPRESS.doc Revised 061313 " `- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1 Parcel Application # ©� 48o ?43� Health Division Date Issued A �t Conservation Division ANN lication Fee Planning Dept. Permit Fee �A6 3T Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address _ 6 W v t_qj i pi � '1 Village Geri+tr v,r(fe- Owner A- h it e e M "ha it Address 6 C 1 Sk,'n 124 �41 Telephone Permit Request t/P 4qk 6 q A zv Y\ flcn,� , A-,.eP �l,ee.1 .� � �gl�S` �o L�ang0-5 fiv �j�'yc v � y��pe- firms �n d ct F�` avt o�ufrcl �ue� K ro (Aan �z ®�'�n �► fi Square feet: 1 st floor: existing/q o® proposed D 2nd floor: existing a proposed o Total new Zoning District Flood Plain Groundwater Overlay g Project Valuation 6, 5-°G Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup orting `'Sumer tation. Dwelling Type: Single Family ff Two Family ❑ Multi-Family (# units) =' Age of Existing Structure 3 7 Historic House: ❑Yes 0 No On Old King's Highway: `( Yeses No Basement Type: act Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) 0 Basement Unfinished Area (sq.ft) (°Ga Number of Baths: Full: existing new © Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing 6 new U First Floor Room Count Heat Type and Fuel: 0 Gas ❑ Gil ❑ Electric ❑ Other Central Air: ❑Yes ® No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ha No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: Wexisting ❑ 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 ��� Per-f, Telephone Number 7 Z6 2�- 7 Address License# 6S 7f�J a5r�� ��e v►'� O '�� Home Improvement Contractor# 1 7 g Z-/ 2 Email DPz r- Worker's Compensation # u/GZ 1 —Gc'!Yr3-o«f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 3�31 /*/V ' FOR OFFICIAL USE ONLY 1 APPLICATION-4 DATE ISSUED d K MAP/PARCEL NO. k , ADDRESS VILLAGE OWNER ., y DATE OF INSPECTION: FOUNDATION r ` FRAME r ,r INSULATION ® L41Z-q Iy M FIREPLACE f , ELECTRICAL: ROUGH FINAL e PLUMBING: ROUGH FINAL GAS: ROUGH L' FINAL FINAL BUILDING S q , r DATE CLOSED OUT ASSOCIATION PLAN NO. Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , 600 Washington Street Boston,MA 02111 www.mass gov/dia T Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information 1 _ Please Print Legibly Name(Business/Organization/Individual): AL_ I per Address: ? �� 5�✓� e �� City/State/Zip: �� E'��i' ��f / 4 02-si-f— Phone 7Z6- ZT_3 Are you an employer?'Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction - employees(full and/or part-time).* have hired the sub-contractors 2.R I am a sole proprietor or partner- listed on the attached sheet. 7. ®,Remodeling' ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y aP t3' # 9. ❑Building addition [No workers'comp. insurance comp.insurance. required-] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions ,109 officers have exercised their 11. Plumbing repairs or additions I am a homeowner doing all work ' g P myself. [No workers right of exemption per MGL comp. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy'#or Self-ins.Lic'#: Expiration Date: Job Site Address: City/State/Zip: , Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a�np ndd`e"nalties of perjury that the information providedt e above is true and correct. Signature: /4N4 '� Date: Phone#: J -7 2 7-7 3 Of use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): Health 2 Build ing Department 3.City/Town/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 1.Board of Heal g p tY p g p 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." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(17 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 perfoffiance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call.the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submif 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 (Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would lice 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 kvestigations 600 Washington Street. Boston,MA 02111 TeL#f 17-727-4900 ext 406 or 1-877-MAS8L F Revised 4-24-07 Fax#617-727-7749. www mass.govf dia Office of Consumer Affairs and Business Regulation 10-Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - ,�-•-•-� _` Registration: 178232 Type:. Individual t.i ' a . ; ;' Expiration: 3/26/2016 Tr# 250268 PAUL J. PERFETUO :� -, „ s PAUL PERFETUO �, 87 BRIGANTINE AVE. OSTERVILLE, MA02655 Update Address and return card.Mark reason for change. ❑ Address Q Renewal Employment ❑ Lost Card SCA 1 Co 20M-05/11 - - -— - - �,�� � - - �e Wovn4nConsumer Bus nessRfirulati c4eG�. : License or registration valid for individul use only Office of Consumer Affairs,&Business Regulation g ' ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 178232 Type: Office of Consumer Affairs and Business Regulation xpiration -_.3/26/2016.:, Individual 10 Park Plaza-Suite 5170 r , Boston,MA 02116 PAUL J.PERFETUO' I 1 € i .PAUL PERFETUO 87,BRIGANTINE AVE. OSTERVILLE,MA 02655`" + Undersecretary Not valid without signature Massachusetts -Department of Public Safety j� Board of Building Regulations and Standards Construction Supervisor. License: CS-097541 PAUL J PERFETUb 87 BRIGANTINEAVE OSTERVILLE AfA- 02�655 Expiration Commissioner 05/17/2015 I 0 THE rO ti Town of Barnstable Regulatory Services 9��$ Thomas F.Geiler,Director 1639 Alm ► .Blulding.nivision Tom Perry,Building.Commissioner' 200 Main Street,Hyaunis,MA 02601 www.town-barnstable-ma.us Office: 508-862-4038 Fax: .508-790-6230 Property Owner Must Complete and Sign This Section •If Usinw A Builder •as Owner of the ro subject l property - hereby authorize C(_t I t' F> 1-1 to act on my behalf, in all rnattets relative to work.authorize*dby this building permit. (v U 1l'4 b,n &Ylkry I Ilc (Address of fob) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant rtr f Cr+ �1 C� t✓� � w � f� Print Name Print Name. a. &31-14. Date ; WORMS:OWNERPERMISSIONPOOLS 612012 �THe r Ibwn. of Barnstable t Regulatory Services r3tixxsx�sr.� Thomas F.Geiler,Director . MASS A,.�� Building Division. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma:ns Office: 508-862-403 8 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 Barnstable Building Department rrrinirrrrr m inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner L Approval of Building Official Note: Tbree-family dwellings coni•a�35,000 cubic feet or larger will be required to comply with the State Building Code.Section 127.0 Construction.Controt 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 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 fuUy aware of his/her responsibilities,many communities r cquire,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 cornmunity. Q:fom}s:bomeexempt l 1r e v� r .I : , e w1 �-IAIG x MEN MOONS moommomm MMUMMENOMMEEMONSM moloommommom iiiiiiiie�iiiiiii=iii ■mmMM qM■Mm�MM mmmmmmmmmmmmmmmmmmmmmmmmm�immmmmmmmmmmmosom mommommmoommommommommmmom ommommommolommmm mmmommmmmommmmmommmmmmmm OEM mmimmm ME mmmimmmmmmmmmmmmm ................ ... . mmmmmm ME mmmmmmmmmommmmmmmmmmmmmmmmimmmmmimmmmmmmmo MSMMMMMMMMMMMMOIMMOOIMMMSM mmmmimm mmmmmmm .... ............. .................................. ....... i r� Town of Barnstable ,ofTME�a ,SA Regulatory Services- Thomas F.Geiler,Director Building Division 1639- Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Qffice: 508-862-4038 Fax: 508-790-6230. PERMIT l /� FEE: $ SHED RE TION y - 20 re feet or less Location of shed(address) lage 1vr-H Property owner's name Telephone number Size of Shed Map/Parcel# S j71 X/ i Signature Date . ? s Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) _ Sign off hours for Conservation 8:00-9:30&3:30-4:30 _ . 1 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION . FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg ' REV:042911 it � 1 V1 �r �r T o�T G A G� V,J l p.C.r C.L d PLAN t el APPLICANT:. MARSHALL TOWN: CENTERVILLE LOT 54 ��[` iii'" TMO �fgfSf:ffJfliSfl�?ASS' -f _ �j SS'SSSSSSSSS7`:?;frrrrtSS' .rS??SS f'.if:firr.: i?'s Irm . LOT 53A ,His??s?i??%?:.�s:r••sr.:: - ,rsrs rr.,;rs;rr LOT 55 61,g2' 44.20 r+a to ZOT 538�_ LOT 52A ��°2• `` a�a LOT 5ZB Mr411t1u 4 - dP��(Y1 Df QfsS4�,O ' T r� STEPIJ.'lp T. D 5.00 DOYLE ¢ ', t7 i FL000 PANEL: 250001 0015 C FLOOQ ZONE: "C" DATE MAP REVISED: �?8/19/1985 A HHEREBY CERTRFY THAT THRS MORTCACE INSPECTION fkAni Has BEFTI PREPARED FOR: DATE . OS/za/aa11 � � SCALE: 1 $p'" � CAPE COD FIVE CENTS SAVINGS BANK : DEED .REF: 18225-1 PLAN REF: 281=59 THE TAPED m THE DWELLING SMOWM DOES NOT PALL cTIGiYATF6tf A SPgCuq FLppD HAZARD ZONE PER TEPED INSPCM4 THE OWELIA0 AVPEaRS TO CDNFGtM TO THE=AL ZOA�ZNG BYLAWS IN EFFECT THE STRUCTURES SHOWN ON TNI5 MORTGAGE INSPECTION PLAN ARE LOCATED BY TAPE SURVEY AT THE AME OF FROM TRUCTION WITH RESPECT TO kGRIZONTAL 009MONAL SETBACK REOWREMp�S ONLY. ND INSmkmT SURVEY WAS PLIWORYEp aND LOCATIONS SHOWN ARE UYYAK OR I5 FIAEMPT FkbM VIOLAYTON ENFORCEMENY ACY10N UNDER MA GENERAL LAWS CHAPTER 40A . AN INSTRUMENT SURVEY RS N@cEssgRY FpR PRECISE LOCATIONS SHOWN WN ARr6 APPROXIMATE LOCATIONS SECTION 7- REPMENCE DEED SUBJECT TO AND MAIN THE BENEFIT OP ALL MOM RIGHTS OF WAY. AND ENCROaOHMENTS:IF ANr EXIST,EITHER WAY ACROSS PROPERTY LINES DINGLE LAND EASELHENYS.RESERVATIONS AND RESTRICTIONS DF REM"-IF ANY THERE SMALL BE AND I.9; SURVEY COMPANY ANC SMALL NOT BE FIELD LIABLE FORSDAMAGES.PROPROPERTY Lf E% AWE ANY USE IA5 THE SAME ARE Of LEGAL FORCE AND EFFECT, OF 1145 PLAN FOR PURPOSES OTHER THAN MORTOACFINSPECTIOw. FROM TELEPHONE: 508-428-0055 YANKEE LAND .SURREY COMPANY, " INC FAX: 508-4.20-5553 .119 ROUTE 149, Marstans MiUS, MA 02648 yonkeesurveyOcomcost.net. www.yankeesurvey.com. 81575 SHI TO/TO 39Vd Z GGOOOZb805 8b:0Z TTOZ/EZ/80 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Mai- Parcel l i Application# �•� ® 7;2, Health Division Conservation Division Permit# Tax Collector Date Issued Treasurer Application Fee i Planning Dept. Permit Feed Date Definitive Plan Approved by Planning Board o 7131�0 Historic-OKH Preservation/Hyannis Project Street Address q �tre,k S,��n PCv Village C e�c v6 Owner Address 2)U A1_1A" TY- Telephone d-�l, 61 �v�� ? lAl99_�S� � 353 fk Permit Request To C«l u i,il/V ,? se�J-c l ,� ic, <;�, fiC,Y -- /�% !'�y„Zjv� <� f/l s U t �i S��P�y ��.c.�,(— C.l.rL�. '����•� �'iJfrcaC' .S�Cki...'` +��:'1'1 Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size I �c 7 s;Fr Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 21� Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes Alo On Old King's Highway: ❑Yes two Basement Type: @ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing_ new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric 0 Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:0 existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization_O_Appeal#. Recorded-0 -- - �-- ---- - -- Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION f 3 Y-7 Y5 Name ► a'J �vf Telephone Number � 77Y- 2f2 Address 3 7 t�"Pe2 6 License# CS O'72zl37 S• Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �Iar'mjj-A oo.-/) SIGNATURE ' "/"� DATE 7772 S` CSC r C FOR OFFICIAL USE ONLY �PEl;vMT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: p LM�.J FOUNDATION d �g� FRAME y 9)1ZJ�� ov�PLE7E Sia=,JG.sffi�"'� Avc arP*� -rxEs INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t ne t ommunweatin uJ lrlu3;a;ucnuz;eu2f Department oflndustrial Accidents 93 Office of Investigations ' ' a 600 Washington Street Boston, M4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print 1Legibly Name (Business/Organization/Individual): 1C\,A,r� Address: 2 L`7 City/Stat Phone #: UFt-_ico_ Are youan employer? Check the appropriate box: 'Type of project(required): 1.L"I 1 am a employer with f 4• ❑ I am a general contractor and I 6 ❑ ew construction employees (Cil -and/or part-time).* have hired the sub-contractors 2. P P ro r I am a sole ietoror partner- listed on the attached sheet lJ 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers' comp._ c. 152, §1(4),and we have no 12.0 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,pob site information. Insurance Company Name: ATM Policy#or Self-ins.Lie. #: V W C: Expiration Date: 10 ,7 Job Site Address:_ �f?� (����Jkii! p6A City/State/Zip: rf/� 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 der the pains and penalties of perjury that the information provided above iiss.true and correct. Signature: ` [!� Date: 712,Y Phone#: t-35 >7 0 z 6o& 77Y- 2 l 2- 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#: 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 defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152;§25C(6)also states that"every state or local licensing agency shall withhold the issuance or . renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any produced acceptable evidence of compliance with the insurance coverage required." applicant who has not pr p p g q i political Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of is poh subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/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 bush 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 faxx number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. _ 617-727-4900 ext 406 or 1-877-MASSAFE a- F 617-727-7749 Revised 5-26-05 w-w--w.mass.2ov/ma f °FINE�° Town of Barnstable ~°^ Regulatory Services BAMSTABL, ` Thomas F.Geiler,Director 9 MASS. �jAIF 6,39. Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction, alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: 2QM /,1,J7,K3eJ sew-CA aa1 Estimated Cost 1�, Address of Work: 4% 'Ru—S Li Owner's Name: ePA AYCV1 Date of Application: I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of th er: 7/zs-A Date Contractor Signature Registration No. OR Date Owner's Signature Q:wpfiles.forms:homeaffidav Rev: 060606 FISE Town of Barnstable Regulatory Services s�MASS, � Thomas F.Geller Director ' r ns�ss, g � Building Division.. Tom Perry, Bunding Commissioner 200 Main Street; Ijyannis,MA`02601 www.town.b arnstable.ma.us gftee: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign'TWs Scction. If Using A Builder as.Owner of the subject property hereby authorize ���� C to act on my behalf, in all matters relative to work authorized bythis building permit application for, Y 1 \O (Address of fob) Signature of Owner Date Print blame • Q:FORMS:OWIIERPERMISSIDN (� /� / y .Jlty -�n7ltinda�L7oa.�7.�Clt. C� 1�7,17.dJgI,'�/LJP ✓�C -V/0977/I7tO�I7.[IIP.[LGI� d����QJJ¢C1LUJ6U.J 7 \ � BOARD OF BUILDING REGULATIONS + Board of Building Regulations and Standards License: CON UCTION SUPERVISOR MOVEMENT CONTRACTOR f Number: CS 0 37. Registration: z f . #. Birthd 962 Expiration: 8/5/2007 i Expires: 05/19/2008 Tr. no. 21860 Ex i e f ' Type: Individual p ` i Restric ted:ted: 00 � DAVID COX I DAVID G C DAVID COX 367 UPPER COU / c, 367 UPPER COUNTY RD. S DENNIS, MA 02660 Commissioner S.DENNIS, MA 02660 Administrator ! :i NOTICE NOTICE TO _ TO EMPLOYEES EMPLOYEES The Commonwealth ®f Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the.above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL. IiyS!JRANC;'_COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC 6010812012006 03/07/2006 - 03/07/2007 POLICY NUMBER EFFECTIVE DATES HUB International New England 437 Station Avenue LLC South Yarmouth, MA 02664 (508)394-0946 NAME OF INSURANCE AGENT ADDRESS PHONE David Cox dba New England Carpentry 367 Upper County Road South Dennis, MA 02660 EMPLOYER ADDRESS 03/21/2006 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation.Act. 4A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.+ The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER JUL-1'f-ZWb UJ;4:D Jubtt'hi t' I1JUI1ty'Lb ! I" .I)c FRANCIS J. FEDELE MORTGAGE INSPECTION PLAN ENGINEER " SURVEYOR This plan vies not based on :on 53 P®PPLE BOTTOM ROAD ov instrument survey, and is to be S,4NDWICF1, MA 02563 used for mortgage purposes only. Phone (508) 4,28-1706 - DATE ; 2--S-04 . SCALE: 1"-� I certify that this building is located approximately as shown and i ® ! conformed to the zoning bylaws of the .town/City of nc n IP �C�nfPrvi�IL 3 when constructed and is not located in a flood hazard zone. Deed S Plan Reference o 0 County Reg. of Deeds I' Book / Page Plan Book i Page ;OI o _ n o'n l • ter.:r :, 23 s.� V , y -2A 114 4075.Ft fl-j ,o->s LotS2A w i�! o ►' i -W►' f5 6 a' o R= W.r9 Sucks eat ,tiQ,��gl P °S I�` nn�L.ilrN 1�1 1I d fits1����y%! TOTAL• P.02' j 'i-'...C.i'��l t i�� IL{)� �X 4• (p '�Y!�"�K�{q" V r 6 � ,� `t6Pc )an. q 0 h'SC`�'✓t. � � �� -� ���'1.1� "f'��t�si (��r z�',+�a C.ws `Sr ',..���\? t r i o fie '°ter 9 is= A /1 0 e—)e �.-• i P Jr, �f.® ,� t�.�i � �i 1_ ����'' 4��'%Fif�°I G,� (,N�•� vas.";/;.'� C� ,�,.y+s7 :by' VV �-- I t�tiEs,. �C2ie..;i'�i$'1 s.,r•rz°'� ,�.t,:..�; ��,,.� � G. ,.�.•` S��R:.�J L'✓��c.:�' o9-m y 1L y r ti yAl�«J v"E i+ yy il4 b ,� ,. to a A/& 16 U.G i Ny ! — Dec* 1 es t n 2110 Bust, ! f ii uI I i _--. _ CIA r i; i � I J s n r IZ . d 1 I I 1 I i I 7 ( i , E i y -. ......a..._.�._...i».:...ti..........��.�.m-- .._._-_..._.,---;�...a. ..._.:.-.. .n ,..+....n,........ ....._..a...r.-�......�.—�.� sue. �:v,�e.e ...... ..Y .- - i • Or .. 1 VNAA If j 4 . 9S hqq f d N+ f 1 1. ��ff rn� Gib ( 4 N � E i QyOfINET0�1 TOWN OF BARNSTABLE BARNSTABLE, i O•�`p Y{1Y Or BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ........ ...: ...:...,................................................................................................... TYPE OF CONSTRUCTION ........... +t!/h .................................................... ...........................:.................... 17 ....................197 r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the, following information: Location / ......t.� . ........... ........ ... A :... Proposed Use ... c ,..............................:............................................................................................... y Zoning District ............................... .. ..............................Fire District .......... ................,...............,.....; Name of Owne�L✓ " �""� ,/ ` ' ...............Address � �..... . . ................. . ............. ......... ...................... It Name of Builder ..................................Address .............................. Nameof Architect ..................................................................Address .............. ..................................................................... Number of Rooms '�"" .....................................Foundation 'G ';� ... . ... ........ . ..... ... / Exterior .:....... _..........r:...........................................................Roofing ....................:..�.............. Floors ........ ..............................................................Interior ........ !........��7.., .+' !................................... Heating ........ •. .f.. ................................................Plumbing ....... ,.,...................................... Fireplace .:......,......_ .................................Approximate Cost s E"',1... ........................... Definitive Plan Approved by ZnZin`gBoarcl ---------------_--_----------- < S /I. Diagram of Lot and Building w Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH 00 a _z � U, o a � � 4, �T , �1 LL ,� a\ m /C f/ / 0 � 4 9 1 /Vd ` Z � _ acLw . Q - w z w� ;Ww � i x zz /tea z 0 o f � d a W *� z t. � � U5 ._ I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...................:-G......................................................... 1 &oalIv Alan `. �� No --���yu'' Permit for —.----..a --_ ~ ������ ( .—.—.. -----~..-__---.~-.----.-' ���' `� � �^ �~' --~ Locotionl--.. .�Atb_.-------.- ..............-'—'-'^~`~~^^~`~~ ................................. Owner ---..Al4n.. .................................... � ! � Type of Construction .......b74ng........................ � —^-~~^'-^~^'~—^—'—'-``^~^------^--^—' | � � Plot ------_--. Lot --..v��3................. � | �{D[x � , Julyl8 72 ' Permit Granted ----..---.-----.lA ' | / Date of Inspection lA \ Dote Completed . � PERMIT REFUSED | ,,....—....'-----.—.-'----.—...-- l9 \ - ~'- -'--^~'~'---'-~^^'~—'~—'---^—^'--`~^'— ! —..~,....--,.-.,-.....-_—.--^.—.---.._—.,' ..--'._..-.._---.--,-----.,.__..._,._. \ | ������ ---������--- � '—'--~-''------'--'-^^~'`~''~~`^^^--'-~^'' i � "pp'"~=" l� - ,^—'------'----^—'-- | , ----..--..-----..--.—..----.-....—., " ` ----.---.------...~...—...,,..' =� � | |