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0017 CAP'N LIJAH'S ROAD
Jn r �� .. v _ - ,: ' ! �... .,.i eir fit.s * a C} �,. nf' a.. r a i 3 w n a .r ,,�,; � 3 c Sa e -, ,. .. �� - ' - .. tr" . F. ,�,'� a a �� kY ��k? �s' �� `;.'t"� � .. - - o _ .. o � - �.. � � � �� ` o � � - � .. U e � � � - �, Y .. — � k p t o e - = p�e�r�5 Town of Barnstable �r ' 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB47-835 Date Recieved: 3/27/2011 Job Location: 17 CAPIN LIJAH'S ROAD,CENTERVILLE Permit For: Building-Shed-Residential-200 sf and under Contractor's Name: State Lic. No: Address: Applicant Phone: (704) 735-2954 (Home)Owner's Name: COX,GREGORY J Phone: (865)599-2722 (Home)Owner's Address: 72 CAPIN LIJAH'S ROAD, CENTERVILLE,MA 02632. Work Description: Installing prebuilt yard shed Total Value Of Work To Be Performed: $5;000.00 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). I 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: Charlotte Cox 3/27/2017 (704)735-2954 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $5,000.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $35.00 3/27/2017 $35.00 XXXX-X)M-XXXX- Credit Card 0891 ..................................................................................................................................................................................................,........................................................................................ ................... ........:.... Total Permit Fee Paid: $35.00 } aS,xl.+�xur�'3»' ••s.a E »aww.sa ,A.w.�'. ..,.w,S;>F ;a»x"a�w"slxde:` Town of Barnstable Permits 'j, C) pt`fNE r .yO Expires 6 months from issue date Regulatory Services °A 4 Fee � :9 � g y MASS, >; t a ..> •. 9�A 039. s $ Richard V.Scali,Interim Director Building Division / /� 6 201, Tom Perry,CBO,Building Commissioner t/ 200 Main Street,Hyannis,MA 02601 8Ajs/-' www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Z s—7 Not Valid with Red X-Press Imprint Map/parcel Number // Property`Address /l� Gl' ,S rtY P &;;- V�`` Residential Value of Work$ -7Lf 6 Minimum fee of S35.00 for work under$6000.00 , Owner's Name&Address �"(Or%f ICJ l 'N 1 s8;�4N i `P_- 0 oz63� Contractor's Name / LIX04/` Telephone Number 000 7 1 Y -6 5'11 Home Improvement Contractor License T(if applicable) /,2 Email: Construction Supervisor's License 4(if applicable) �Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 71 have Worker's Compensation Insurance �" Insurance Company Name �k/ ,1/,j,4W 5Aire Workman's Comp.Policy V L? 0/S'"S/9 2. /S� 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) ❑ 3y Re-side `/ Replacement Windows/doors/sliders.U Value - ' (maximum 35)4 of windo s l of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *4Vheie required_ Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prope er must sign Property Owner Letter of Permission. A cop of t e Home Improvement Contractors License&Construction Supervisors License is requ' ed. SIGNATURE: Q:\WPFILES\FORMS\building permi tms XPRESS.doc Revised 061313 Name Depot Contractor License Numbers: MA Hoene Improvement Contractor Rog. # 126893 Salesperson Name and Registration Number. Janice Campbell : R-1-073A13-00016 Horne Improvement Agreement THD AT- HOME SERVICES, INC ("Home Depot")or Service Provider named below will furnish, install and/or Service the equipment listed below at the price, terms and, conditions as outlined on this form. GPu+am»r l�fd�rmpllan: Gregory Cox .A. 113oston North €974811 F. .N.. a tiL` d(D'{ft .. - 4:b;4it ild a ,-.,-w,.vs.,M..«..--..;...,.,.,.,..,,,.w..,....� t. v �3PY VS ti7'itwp, 14�t4 17 C p'n LlJahS Rd CHATHAM MAy7 €02633 (704) 735 29a3 v„-a�3 fiitttif}q'aP1.� .......,$ .., @yahoo com-, >,«« ,.,:..:. w-..H :.,.w..... ..,,.,.�>. ....w..:w..,.-...,.,...F.a.....:..,w,:.:.. 4..«..w.�e4»....a,..,...,,.::...... ,...,..•»n.--,r.,.....,.,...,.......:.,.,»»_.. .,<....�...-...»....,....,....,...s.nt..« ( bcox8 Iq a 6,�$54134'�P 6'•4FteN e2i7Leli}SC NOTICE QF RtGJ4T T4 CANIC YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 or Email CustomerCaancellationNQrthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different .CANCELLATION PERIOD.. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR. STATE. YOUR.. PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME' DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU, OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOTS EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL< PLEASE. SIGN BELOW TO ACKNOWLEDGE-EDGE-THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF Y' MT TO CANCEL. Acknt wi"tg X 12J11/2,016 Distfibutiori White Home 0opot Yellow-Customer Copy f^ ��w} gip: Office of Consumer Affairs and Business:Regulation 10 Park Plaza - .Suite 5170 Boston, Massachusetts .021.16 Home IrnprovenmentwContraetor Registration ` Registration; 126893 Type: Supplement,Card t Expiration: .8/3/2018 THD AT HOME SERVICES, INC ANDREW SWEET - -. 2455 PACES`FERRY ROAD, HSC`C 1�1 + y L ATLANTA, GA 30339 .7 k Update Address and return card.Mark reason for change. Renewal Em to ment. Lost Card (�Address [� ❑ P .Y 0 S:A i •:i 2QM-05!1T r - C/�c 'fC �u�riaf2a<ci�%�,-��^jt�zadu��res��l1 Rice of Consumer Affairs.8�Business Reguiadon License or registration valid for ndividual use only before the expiration date,If found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation 7` Registration 126893 Type: lO Park•Plaza-Suite 5170 ExpireUort 8/_/2018 Supplement.Card B60on,.1VIA 02116 THD AT HOME SERVICES INC: THE HOME.DEPOT AT•,HOME SERVICES ANDREW SWEET 2455 PACES FERRY ROAD HSC nature ATIANTA,GA 30339 Undersecretary -- Not,v with ut sig The Commonwealth of Massachusetts Department of Industrial Accidents 1= Office of Investigations ta ti ^� 1 Congress Street Suite 100 Boston,MA 0211 4-2017 -� www.massgov/dIa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A ticant Information Please Print Legibly Name(BtisineSs/prganization/lndividual): The Home Depot At Home Services Address:908 BostDn Tpk City/State/Zip: Shrewsbury,MA 01545 Phone#:5os-962.8942 FA� employer?Check the appropriate bog: Type of project{required). Toyer with 200+ 4. I am a general contractor and I emp - 6. ❑New construction * have hired the sub-contractors [remodeling yees(full and/or part time)• listed on the attached sheet. . sole proprietor or partner- These sub-contractors have g- ❑Demolition ship and have no employees employees and.have workers' working' for me.in any capacity. 9: Building addition comp.insurance.= [No workers' comp.insurance 10.�Electrical repairs or additions required"] 5. 0 We are a corporation and its 3.❑ I am a homeowner doing all work officers have.exercised their 11.0 Plumbing repairs or additions right of exemption per MGL .12.0 Roof repairs myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.]t . 13 1Other employees. [No workers' 1E comp.insurance required.] / *Any applicant that checks bos-41 must also till out the section below showing their workers'compensation policy intuffiation: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit iiuli ti such =Conttacton that check this'box must attached an additional sheet showing the name of the s-ub-contractors and state whether or not those entities have employees- V the sub-contractors have emplo)ces,they must provide their workers'comp-policy number. co ensation insurance for my employees. Below is the policy and job site I am an employer that is proving inorkers'Compensation information. Insurance Company Name: New Hampshire insurance Company ,p 3itnot7. Policy#.or Self _ins.Lic.#.WC 015519215 - Expiration Date: f L✓' `Y'y1 ( 7 � n� City/State/Zip: Job Site Address: f Attach a copy of the workers' compensation policy declaration page{showing the policy number and egpira�ti of a Failure to secure coverage a. required under Section 25A of MIGL c.152 can lead to the imposition of criminal pen fine up to$1,500.00 and/or one-year inipnsonment, 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 DA r nsurance coverage verification" I do hereby certify u pains and penalties of perjury that the information provided aye is a and correct Date: Si afore Phone# 401-714-6 E only. Do not write in this area,to be completed by city or town o al. Town: permit/License# hority(circle one): Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing InspectorPhone#son- _ ® DATE(MMIDD/YYYY) ACO CERTIFICATE OF LIABILITY INSURANCE 0211812016 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). CONTACT _ - - PRODUCER NAME: MARSH USA,INC. PHONE FAX AIC.No), TWO ALLIANCE CENTER E-MAIL 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIL# 100492-HomeD-GAW`-16-17 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Cc 16535 THD AT-HOME SERVICES,INC. New Hampshire Ins Cc 23841 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C: P 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339. INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 REVISION NUMBER:8 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE.POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL UBR POLICY EFF POLICY EXP -- LIMITS - TYPE OF INSURANCE I POLICY NUMBER MM/DD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY GLO4887714-06 03/01/2016 03101/2017 EACH OCCURRENCE $ 9,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE- OCCUR - PREMISES Ea occurrence $ LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 JECPRO- PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY PRO- LOC $ OTHER: B AUTOMOBILE LIABILITY BAP2938863-13 03/01/2016 03/01/2017 COMBINED SINGLE LIMIT _ $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED Per accident $ HIREDAUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ $ DED RETENTION$ _ C WORKERS COMPENSATION WC01 5519215(AOS) 0310112016 0310112017 X STATUTE ER" C AND EMPLOYERS'LIABILITY YIN WC015519217(AK,KY,NH,NJ,VT) 03/01/2016 03101/2017 E.L.EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE EflN I A D OFFICERIMEMBEREXCLUDED? WC015519216.(FL) - 03/01/2016 03/01/2017 E.L.DISEASE-EA.EMPLOYE $. 1,000,000 (Mandatory In NH) 1,000,000 If yes,describe under Conitnued on Additional Page E.L.DISEASE—POLICY LIMIT $ DESCRIPTION OF OPERATIONS below- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE' THEREOF, NOTICE WILL BE.'DELIVERED IN 1111 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee I: ©1988-2014.ACORD CORPORATION. All rights reserved. ` ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1. I x The Conrnt®nwealth of Massachuseus Department of Indurstrud Accidents Office of lnvesdgadons 1 Congress Street,Suite 100 Boston,ALL '02114--2017 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): f_/ �//CJ(o Address: 0 City/State/Zip: ! 60 U M-d Phone#: 7 71 764--Z3 25 Are you an employer?Check the appropriate box: Type of project(required): 1.El am a employer with 4. I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. n Building addition (No workers' comp.insurance comp.insurance. required.] ' 5. F1 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' comp. insurance required.] "Any applicant that checks box##t must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are domg all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 employee& Below is the policy and job site ' information. Insurance Company Name: �(1�: Z !J �IV S • 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 cerfify4nder the pajps and en 'es o er'u that the in ormation provided above is true and correct Si ature: ! Date Phone#: '77�' 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#: Wells Fargo Bank,N.A. 1 Home Campus MAC: F2303-04J Des Moines,IA 50328 Ph:.877-617-5274 8/12/2016 Town of Barnstable Attn: Robert McKechnie Building Department 200 Main Street Hyannis, MA 02601' Regarding Property Registration at: Address: 17 CAPN LIJAHS RD CENTERVILLE MA' 02632 zz Tax ID/Parcel#: 192-157 011 Dear Sir/Madam: The property above was sold to a third party as of 8/04/16; therefore Wells Fargo no longer has interest in the property and is no longer the responsible party. Please update your registration records. Thank you for your assistance in this matter. Sincerely, Paige Gebel o`�L Wells Faro Home Mortgage e� g a gg Paige.Gebel@wellsfargo.com a i i Assessor's map and lot number ..... 71- SEPTIC SYSTEM MI Sewage Permit number IN S TALLER IN C ST TE ' �i ►-A A;�TIC1-E E AND •SOWN �Q�oFfNE tp�I TOWN OF B ' ` TABLE i BAUSTUL i BUILDING INSPECTOR APPLICATION FOR PERMIT TO ................r—'1 ........................................................................................... TYPEOF CONSTRUCTION .... .. 4 ..ti........ . ... .....:............................................................... �. G .... ......19i� TO THE INSPECTOR OF BUILDINGS: The undersigned h reby applies for a permit according to ,thhee following information: Location .. ... ..... .¢.........L .............. �rW-................ ..? :... .................................................................. ProposedUse .../...r�r. ........................................................................................................................................... S Zoning District ........................................................................Fire District .......1 .f.-..... ... .....j`............................. Name of Owner-`�1r `.J... Address .......... Name of Builder ..— '� ...............Address Nameof Architect .......�1, ...........................................Address . ....... ....... ....................:.................................. 4 l4 /�. Number of Rooms ..................................................................Foun tion ......................... CT�3.,r^. �Y......<..�?...C....... Exterior ...................... �� ftr. f: . `........................Roofin �� �� rr• - Floors /f.'. .....................................................Interior .........�� ^ / 4' Heating ........ ............ ..................................Plumbing ....... .1W- ................................ Fireplace ........ .......�l�AWv- �,X......................Approximate Cost ti! o y` Lmaa ?.S� Definitive Plan Approved by Planning Board -----------------------------19--------• Are a ........ S........... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH / 0 0 1y a � J Q Q � I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ......... ......, T ...`�.... ' � %. ~-8� ~ ~ 00���� � - �� m�mr�v No ---�-- Permit �v --------...--- 0 singlefamily Location ---------------------' Centerville ---^^----^—'---------------- Ovvner ---..Ie.1.1ag.e.n~Ferrmn.e... Type ofConstruction .........z.r.mme...................... ----'-----^-------------'--'' plot ---------. Lot ..........#2................... November 18 Permit Granted ....... lV 76 � . 70 ' Date of Inspection ..�..l� ~ Date Completed --..I.............................1p PERMIT REFUSED -----_---------------. lQ -------------'------^------ -''—^'----'--'—'^--^'----------- ~^--'--'--'---^'-----~--^^--^—' --'----'—'-----------'—'-----' Approved ---------------- 19 ' '--------------^^—~—^—`—^'—^—^ ----'-------------'----'^—^^—' � � � Assessor's map and lot 'number ....................... ,Sewage-Permit number .......................................................... 'THE TOWN OF BARNSTABLE III LE 039. BULDING INSPECTOR APPLICATION FOR PERMIT TO ......... .... ..................................................................................................... TYPEOF CONSTRUCTION .... ........................................................................................................;................ ............. ........................19........ .... .. ... ... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......... ................... .............. ..................................................................................... Proposed Use ... .......................................................................................................................................... I .... .......... .... .. Zoning District ......I........................................................I..........Fire, District ....... ........................... Name of Owner ................... ............ �!1�7��.*Address` ..................7�= ................................................. Name of Builder .......................... ..............................:..........Address ............/................................................................... Name of Architect ......................... dress 1,n....................................Ad ............................. 611 F <. ...... Number of Rooms ................................ ouncl-,5_�ion . Ae 11" ..................................................................... E x I e r i a r 1, /5"1...................Roofing ............................................... ........ ...... ............. ........ ....................... Floors -0 - Interior ........ ..........;�;.,.......................I................... ................. . ................................................................ Heating ..... ....................I..........................................................Plumbing ...... e -- ...,..............::...................................................... Fireplace ...... .......__01�;�:Olxe_,� I.................... c:'.' -G- ................ pproximate Cost ..............��ee A ................................................... Definitive Plan Approved by Planning Board --------------------------------19--------- Area ......... ........... ............ Diagram of Lot and Building with Dimensions Fee .........v��....... SUBJECT TO APPROVAL OF BOARD OF HEALTH 4_1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .............:-�,......................................... Tellegen-Ferrone A=192-157 r j • m s 18822 1 1 2 story, No ................. Permit for .................................... t � . single family dwelling ........................................................................ r LocationVICapt. Li jah Road ..................................................... Centerville .......................................................... Tellegen-Ferrone Owner .................................................................. ' � Type of Construction ..................frame........................ k i '� .............................................. ............ 4 Plot ................ 04k2 . r r November 18 76 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ......................................19 f Z PERMIT REFUSED ................................ 19 ........ ... ..................................................... 3../... il ..... 1. `�" . ........... ' r ......................... .... .................................. : - � ............. ` fApproved ,............................................... 19 I k ....................................... f .................... ......................................................... 'r ti Town of Barnstable, 367 Main Street, Hyannis, MA 02601 REGISTRATION AND CERTIFICATION FORM FOR FORECLOSING/FORECLOSED PROPERTY Thank you for registering in accordance with Town of Barnstable Code chapter 224 sections 224-3 and 224-4. Please complete one form for each property in foreclosure (section 224-3)or already foreclosed for which possession has been taken(section 224- 4). Please file the original with the Building Commissioner and a copy with the Chief of the Fire District in which the property is located. If you claim you are exempt from registering under Massachusetts law,please state the reason(s) and complete section 1 (property information)and the first paragraph of section 2 (foreclosing party, court, etc. and foreclosing party representative,but not other representatives and attorney) so that the Town can review the exemption and update its records: N/A Section 1 —Propelly Information Property Address: 17 CAPN LIJAHS RD CENTERVILLE MA 02632-1615 Assessors Map#: n/a Parcel#: 192-157 Land area and description lot of 16,117 sqft (or 0.37 acres) Building(s)description and contents - single family home of 1008 sqft Occupied: Y �Occupant(s)(if borrowers so state and include name(s)) N/A Phone: 877-617-5274 email: codeviolations@weiisfargo.com other: N/A Vacant: n 'Date: .10/27/2015 Anticipated Length of Vacancy: n/a Last occupant(s))(if borrowers so state and include name(s)) Pamela Smith c/o Wells Fargo Bank, N.A. Phone: 877-617-5274 email: codevioiations@weusfargo.com other: N/A Has possession been taken no If so,please explain and complete and file the v maintenance and security plan form(unless exempt as stated above) see attached Section 2—Foreclosing Pally Information Foreclosing Party(full name/title) Wells Fargo Bank, N.A. Foreclosure Case Court: N/A Docket# N/A Date filed: N/A Current Status: active Foreclosing Party's representative(s) for property (entry, management,repair, etc.)(name,title,): Wells Fargo Bank, N.A. Company(if different from foreclosing party): Wells Fargo Bank, N.A. Address: One Home Campus, MAC F2303-04J, Des Moines, IA 50328 Phone: (877)-617-5274 email: Codevioiations@weiisFargo.com other: N/A If an exemption is claimed,please do not complete the remainder. Other representative(s) (if foregoing representative is primarily responsible for property and/or foreclosure and is most likely to be able to address town matters ` concerning the property and/or foreclosure,please so state and do not complete contact information(i. e. "none"or"see above")). Name,title, other: N/A Company(if different from foreclosing parry). N/A Address: N/A Phone(s): N/A email(s): N/A other: N/A Name,title, other: N/A Company(if different from foreclosing parry): N/A Address: N/A Phone: N/A email: N/A other: N/A Attorney representing foreclosing parry ORLANS MORAN PLLC Firm name(if different from attorney's name): ORLANS MORAN PLLC Address: P.O. Box 540540, Waltham , MA 02452 Phone(s): (781)790-7800 email(s): info@orlansmoran.com other: N/A I acknowledge that the information provided is accurate and correct. I also understand that any inaccurate information will result in non-compliance with section 224-3 of chapter 224 of the Code of the Town of Barnstable. { Digally ngea Pryor Angela P ryo r'Date:20115.10.27 1gned byA 57 I16-05'00' Date: 10/27/2015 Name:Angela Pryor Title: Research/Remediation Associate I hereby certify that the above-named foreclosing parry is in compliance with the provisions of section 224-3 of chapter 224'of the Code of the Town of Barnstable. Date: Building Commissioner, Town of Barnstable i MAINTENANCE AND SECURITY PLAN FORM FOR FORECLOSING/FORECLOSED PROPERTY Town of Barnstable General Ordinances,Code section 224-4,requires a mortgagee taking possession of a property before or during foreclosure, or after foreclosure if the mortgagee becomes the owner,to bring the property into compliance with the maintenance and security standards contained in Code subsection 224-4(B)within thirty (30) days of a notice from the Building Commissioner. Please either complete and file this form or another containing the same information with the Building Commissioner within thirty(30)days of the notice. If a mortgagee claims an exemption from the provisions of Code sections 224-3 and 224- 4,please explain, leave the remainder blank, sign at the end and file this form or letter of explanation and also complete and file the applicable sections of the registration form for foreclosing/foreclosed property N/A Town of Barnstable, 367 Main Street, Hvannis, MA 02601 (1) Registration date: 10/27/2015 If not registered, please complete the registration form and state date of filing or anticipated filing N/A (2)If commercial property, describe space utilization floor plans required by the Fire Chief and filing date (actual or anticipated)N/A (if in possession or ownership must be certified as accurate twice annually in January and July). (3)Describe any hazardous materials on the property as that term is defined in MGL c.2 1 K and the date(s)and method(s)for removal as approved by the Fire Chief UNKNOWN (4)Method(s) and date(s) all windows and door openings secured(or will be secured) UNKNOWN If left secured,name, address, and contact information of security personnel providing twenty-four-hour on-site security personnel on the property WELLS FARGO BANK,N.A. F2303-04J, 1 HOME CAMPUS, DES MOINES to 50328, 877-617-5274 (5)Location(s) and date(s) "No Trespassing" signs posted or to be posted on the property UNKNOWN (6)Name(s), address(es) and contact information of person(s)responsible for maintaining: structures, lawns and shrubs in sound condition free from excessive growth and the property generally in accordance with the Barnstable Zoning Ordinances the definition of"maintenance"in this Ordinance; any other provision of this Ordinance; and for disposing of trash, debris and pools of stagnant water as provided in Chapter 54 of the Town of Barnstable General Ordinances WELLS FARGo BANK,N.A. MAC F2303-04J, ONE HOME CAMPUS, DES MOINES, IA 50328 (7) If the Fire Chief of the Fire District in which the property is located has approved turning off the water or electricity,please state: Date of approval UNKNOWN Date(s) electricity turned off UNKNOWN on if applicable UNKNOWN Date(s)water turned off UNKNOWN on if applicable UNKNOWN' (8)Name(s), address(es) and contact information pf person(s)responsible for maintaining all existing fences around swimming pools and spas or installing fences as required by Chapter 210 of the Town of Barnstable General Ordinances WELLS FARGO BANK,N.A.,F2303-04J,ONE HOME CAMPUS,DES MOINES IA 50328 (9)Name, address, telephone number and email address of person who can be contacted in case of emergency if different from the person named above or in the registration under section 224-3(A) (name and contact number to be posted on the front of the property if required by the Fire Chief or Building Commissioner WELLS FARGO BANK,N.A,F2303-04J,ONE HOME CAMPUS,DES MOINES IA 50328,877-617-5274 (10)Date(s) certificate of liability insurance on the property filed with the Building Commissioner SEE ATTACHED EVIDENCE OF INSURANCE (11)Date(s)cash or surety bond of at least$10,000.00 filed with Building Commissioner to remunerate the Town for any expenses incurred in inspecting, securing and making the premises comply and continue to comply, a portion of which shall be retained by the Town as an administrative fee n/a (12)Date(s) scheduled for inspections with the Building Commissioner and Health Director,who may at his or her discretion include the Fire Chief, in order to confirm that the land and structures comply with the provisions,of this Ordinance UNKNOWN or to identify the provisions with which the property does not comply and establish a program to bring the property into full compliance UNKNOWN (13) Date(s) when the property was sold, or is anticipated to be sold, to the foreclosing party. If neither,please explain UNKNOWN I acknowledge that the information provided is accurate and correct. I also understand that any inaccurate information will result in non-compliance with section 224-3 of chapter 224 of the Code of the Town of Barnstable. Digitally Pryor Angela Pryor j;'`'Date:015.10.27y11:59:I12-05'00' Date: 10/27/2015 Name: Anqela Pryor Title: Research/Remediation Associate i I hereby certify that the above-named foreclosing party is in compliance with the provisions of section 224-4 of chapter 224 of the Code of the Town of Barnstable. Date: Building Commissioner, Town of Barnstable i WELLS FARGO HOME MORTGAGE CONTACT INFORMATION For questions or concerns regarding a property registration issue please contact the Property Registration Department. Property Registration Department Registrations@wellsfargo.com For other inquiries please route applicable requests to: Building and Code Compliance Department CodeViolations@welisfareo.com Utility Bills ConvUtilitvPmt@wellsfareo.com HOA or Condominium Dues or Fees HOAPmtRequestFH@wellsfargo.com Tax Related Requests: TaxGatekeeper@wellsfargo.com REO property inquiries PASAPinguiries@wellsfsargo.com ' Insurance Claims HazardClaims@wellsfargo.com General Property Preservation Property.Preservation@welIsfargo.com For questions regarding purchasing a Wells Fargo property please contact 1-877-617- 5274. You may also contact our dedicated property preservation call center at 1-8777617-5274 Monday— Friday from 8:00 AM —9:00 PM EST. Please note all legal documents should be sent to our legal mailing address below: Wells Fargo Home Mortgage 1 Home Campus MAC# F2303-04J Des Moines, IA 50328 21174 O DATE(MMIDDM/YY) A C4 .. CERTIFICATE OF LIABILITY INSURANCE 3/25/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:CONTACT Wells Fargo Certificate Service Center Wells Fargo Insurance Services USA,Inc. PHONE_ 404-923 3719 FAX 1-877-362-9069 C o xt• AIC No): 3475 Piedmont Rd E-MAIL wfis.certificaere uest wesfar ADDRESS: t ll o.com q @ g Suite 800 INSURERS AFFORDING COVERAGE 'NAIC tl Atlanta,GA 30305 INSURER A: Old Republic Insurance Company 24147 INSURED INSURER B: Wells Fargo Home Mortgage INSURER C a division of Wells Fargo Bank,N.A. INSURER D: 90 South 7th Street, 14th Floor INSURER E: Minneapolis,MN 55402 INSURERF: COVERAGES CERTIFICATE NUMBER: 8901677 REVISION NUMBER: See below THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. , INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY Y MM/DD/YYYY XP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY MWZY 304056 04/01/2015 04/01/2020 EACH OCCURRENCE $ 10,000,000 DAMAGE CLAIMS-MADE �OCCUR PREMISES aEoccu RENTED $ 10,000,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 JECT X POLICY MPRO ❑ LOC PRODUCTS-COMP/OP AGG $ 10,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED . PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident . $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ PER A WORKERS COMPENSATION MWC 302638 04/01/2015 04/01/2020 X STATUTE OERH AND EMPLOYERS'LIABILITY 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑N NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If as,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Proof of Insurance CERTIFICATE HOLDER CANCELLATION Wells Fargo Home Mortgage, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE a division of Wells Fargo Bank,N.A. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 90 South 7th Street, 14th Floor Minneapolis,MN 55402 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) Wells Fargo Bank,N.A. MAC F2303-04J One Home Campus Des Moines,IA 50328 Ph:877-617-5274 October 27,2015 .. i fs tZ R Town of Barnstable Attn: Robert McKechnie Building Department 200 Main Street Hyannis,MA 026oi Completed Property Registration for: 17 CAPN LIJAHS Rl "CENTERVITLE MA 02632 161577 TAX ID: 192-157 Dear Sir/Madam: Please see the attached property registration form and use the below contacts to expedite any future requests. Code Violations: CodeViolations@WellsFargo.com Property Registrations: Registrations@WellsFargo.com General Property Preservation: Property.Preservation@WellsFargo.com Call Toll Free: 1-877-617-5274 For questions regarding purchasing a Wells Fargo property please contact 1-877-617-5274• Sincerely, Angela Pryor Wells Fargo Bank,N.A. MAC F2303-04J One Home Campus Des Moines,IA 50328 Angela l Pryorwellsfargo com, TOWN O 'M G"', 28 AN 8: t19 CA I PE SAW We ar her izaitt®n i1x 508-398-0398 December 14,2011 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#201101655, Status A, Parcel 192157 at 17 Captain Lijah's Road, Centerville,Permit type: RADD, and issued on 4/12/2011 has been inspected by a certified Building Performance Institute(BPI)Inspector. R-18 Cellulose insulation was added to the attic. Basement sill was insulated with R-19 fiberglass batts. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey o►� //3h> Cape Save 7 Huntington Avenue Suite C, South Yarmouth,MA 02664 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map i �` Parcel Application # Health Division Date Issued '4 Conservation Division Application Fee' Planning Dept. Permit Fee " Date Definitive Plan Approved by Planning Board 2J/l Ae- Historic - OKH _ Preservation / Hyannis Project Street Address G fdot i r� �--`Jo o Village ceci*rurj& p Owner 1 a,tri S'`n 14 Address S'a-M =a � Telephone �.In - Permit Request tE ,01 .<I+le n gCJn+5 �-- �aSir' i'�- ape— � S' ,yes+.��1 R-S` �'��Co ass d e . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation G,06- Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family X Two Family ❑ Multi-Family (# units) Age of Existing Structure _51 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: W Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing i new s Number of Bedrooms: 3 existing -new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: W Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes 91 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 i�� �i t%A Telephone Number 5 ` 3 g U_ Q Address -7 1afofi � License # TG t0lIb pr �� rdT d- "I Home Improvement Contractor# Worker's Compensation # 7 / 3 0 l J I ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO YU.(- M Q U`I"k r - SIGNATURE DATE� ' �� `" 41 FOR OFFICIAL USE ONLY APPLICATION# _y u I r DATE ISSUED s MAP PARCEL NO. 4 ` ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION i _ J FIREPLACE ELECTRICAL: ROUGH y FINAL ' P PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 1 r FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. 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'' _ _ ::: : .11 �10 �. cat s ey' ernp ov,. plb,e Save. a Ns a are to h fi1.ats con1. tracts and 6' 'I' r it5 car our 11:11,cap Y• : . � I M::�*.. �l:::::::::�:! ..'- -.1— '�'1; .-. t.—Ill Icha cCI' ll6u1.skey Cape Save miner 919- 3- 9 cell . -11 .. . : . .. ......._ _ . . --.. _... 7C H nt gtgn Avenc i.III Oc th YI... -but a, t 2 6 .. .. ...... ..... ... _ . _. ... .._ __ „,x+ �• `,,fir. ,�J' ''�,{,/��y g t 3�i,p y�,� l.� Office of Consumer Affairs and Business Regulation - 10 Park Plaza- Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164432 Type: Supplement Card CAPE SAVE Expiration: 10/6/2011 WILLIAM MUCCLUSLEY 8201 S. HOURD CT CHAPEL HILL, NC 27516 __.:--------_-__.._..._._......_......---_______:......... .:.... _ Update Address and return card.!!lark reason for change. Address '- ? Renewal T ; Employment i.._ Lost Card lC'S^vI•: .2 7nf rt^�F 1-.: .../.clJ�' / S ,:., .,//%ti C!'L'If<.}.�- ?a(ICf7-'ll.iL Y:�..'f•�(•:i�3�Y/'�tdl;}�ilf Office of Consumer Affairs&Business Regulation License or registration valid for individut use only before the expiration date. If found returns tw. R HOAAE IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 164432 Type: 10 Park.Plaza-Suite 5170 `"..s' Expirations. 10/6/2011 Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM MUCCLUSLEY .7C HUNTING AVE..S.YARMOUTH,MA 02664 Undersecretary ” Not valid wit ou signature ,- pat•iit►rnt lit'f?ttt'114: s:aftl,� t3a+:it it s:fi tltiddim—, fin<tat iti Sri+ :tiff) �gmltl:zi•al,i L;ce se: vJ SL 102776 .. Restricted to. IC ss %nLuAM MC GLUSKY .�t 37 NAUSET ROAD !NEST YARMOUTH, MA 02673 - E1.i3:,,lhsw "12013 T'. 102776 :i � A9 f LL ^• 460 ` y p e3t Main StrHyannis, MAA eet e�g4 J �L 7 ay 98 HOME RI-TMI ENERGY 8C ASSISTANCE CORPORATION TTY on all tines www-lia-concapeCod-or HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER Isti a� *. hereby consent to and agree that weatherization work may be done by.the Weatherization Program of Housing Assistance Corporation ( herein after referred as "Agency") on the property located at: The weatherization work done will be based on programmatic priorities and availability of funding and it may include all,or some of the following measures: Weather-stripping &caulking of windows and doors, insulation of attics, sidewalls & basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (S)years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. `—Home Owner: (Signature) ``.Date: e 'k 7 Agent: (signature) Date: HAC approved Weatherization Company : a- c, say \t Caliber Building&Remodeling Cape Cod Insulation ap:eS ave Creswell Construction Frontier Energy Solutions Lohr& Sons Peter Smith Resolution Energy Rock Solid Construction All Cape Insulation 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): mic"I e ALc14%s iC lk CIF= 'i SA Address: ax co it ru Gab ti �� City/State/Zip: S 1amagT k .A 6ZOWOne#: Are you an employer?Check t e appropriate box: ` Type of project(required): 1.0 I am a employer with 4: ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors . 6. ❑ New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. .❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Builduig 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 I I.❑ Plumbing repairs or additions No workers myself. ' right of exemption per MGL Y [ comp. 12.❑ Roof repairs insurance required.]' c. 152, §1(4).and.we Have no 1 employees. [No workers' 13 Other SnStJ la- (0(1 conip.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check.this box must attached an additional sheet showing the name of the subcontractors 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: S iA t CC Policy#or Self-ins.Lic.#: G '3 Q(��] Expiration Date: I t Job Site Address: C0..(�`1-OL,o L l�k h s City/State/Zip: ��' �►<<e l �/� �� 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. Invcstigatioils of the DIA for insurance coverage verification. I do hereby certify under.the pains nd enalties o erjury that the information.provided above is true and correct. Signature: 1. `' Date: Phone#: Official use,onlp. Do not►mite 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#: �C0R�'® CERTIFICATE OF LIABILITY INSURANCE °A11120io- �' 31/1/20Y0 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 iieu'of such endorsement(s). PRODUCER I NO FACT Shannon Sperrazza Risk Strategies Company PHONE (781)986-4400 �F N :(781)963-8420-_.__._._. 15 Pacella Park Drive ADDRESS:ssperrazza@risk-strategies.com �— Suite 240 PRODUCER p0018476 Randolph MA 02368 INSURERS AFFORDING COVERAGE INSURED IINSURERA:Seneca $ ecialty Insurance CO INSURER B:Keatin Group Ins Services Michael McCluskey, DBA: Cape Save INSURERC:Chartis Insurance _- 7 CHuntington Ave INSURER D: South Yarmouth MA 02644 INSURER E: ---� - -�-� INSURER F: COVERAGES CERTIFICATE NUMBER-CL1011132675 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 t INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 1 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; j i POLICY EFF I POLICY EXP L_ , TYPE OF INSURANCE i POLICY NUMBER ' MM1D0 MMlODlYYYY : LIMITS GENERAL LIABILITY +—; j EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY i PREMISES cur a ocrence} $_ 5_O,000 A ;_ ;CLAIMS MADE X OCCUR AAG1002608 10/16/2010{IOJl6/2011 MED.EXP(Any one person) !$ 10,000 1 i PEr RSONAL&ADV INJURY ;$ 1,000,000 I GENERAL AGGREGATE Is 1,_000,000 �EN'L AGGREGATE P SIT APPLIES PER: ` PRODUCTS-COMPIOP AGG S 1,000,000 X ; POLICY C LOC I $ - --- ; AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 6208200 111/6/2010 '11/6/2011 (Ea accident) ANY AUTO BODILY INJURY(Per person) j$ -;ALL OWNED AUTOS I {BODILY INJURY(Petaccidant) $-~ X j SCHEDULED AUTOSi 1 II-PRROPERTY DAMAGE -�--- Xi HIRED AUTOS I (Per accident) `$ i i X 'NON-OWNED AUTOS L_ $ I $ (X UMBRELLA UUIB OCCUR j EACH OCCURRENCE — $ 1,000,()00 EXCESS LIAR i CLAIMS MADE —--- I i AGGREGATE $ 1,000,000 DEDUCTIBLE B i RETENTION $ j j 1023578601 10/16/201010/16/2011j $ WORKERSCOAIPENSATION Michael McCluskey ; WCSTATU- ,OTH- AND EMPLOYERS'LIABILITY Y I N I if X TORY LIMITS G ER i r ANY PROPRIETOMPARTNER/EXECUTIVE I I excluded from coverage'1 E.L.EACH ACCIDENT $ j OFFICERIMEMBER EXCLUDED? i N!A l .. t 500,000 1(Mandatory in NMI I (9930951 10/21/2010 I`10/21/2011 I yas,desc ibe under j 1 E.L.DISEASE-EA EMPLOYEE$ 5fl L000 DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT $ 500,000, 1 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Issued as evidence of insurance. Contractors-Executive Supervisors or Executive Superintendents. CERTIFICATE HOLDER CANCELLATION, (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Ruth 460 West: Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601-3698 Michael Christian/SMS �'"" ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS026(2oowq) The ACORD name and logo are.registered marks of ACORD VHWE Town of Barnstable o *Permit# * * Expires 6 months from issue date BARN szABM Regulatory Services Fee Z� MASS. �b i6s9• �0�' Thomas F.Geiler,Director ArfD�rA , Building Division Elbert C Ulshoeffer,Jr. Building Commissioner Office: 508-862-4038 367 Main Street, Hyannis,MA 02601w �� 41�02 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION BPRNS Not Valid without Red X--Press Imprint oWN OF Map/parcel Number c� Property Address �� ,L / Ct J �tesidential OR ❑ Commercial Value of Work Owner's Name&Address a/ ve Z/ Contractor's Name . Z t ��' _I�IM�rCJIf{/}1 11� Telephone Number Home Improvement Contractor License#(if applicable) /Cw 71-1 Co nstruction Supervisor's License#(if applicable) 5- 7O 4� W - A Compensation Insurance Check one: ❑ I am a sole proprietor �❑ I am the Homeowner L!� l have Worker's Compensation Insurance Insurance Company Name �. r� Workman's Comp.Policy#C/4 1A) _ d sCaCo Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roofl ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) VOther(specify) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature ) 6taL;1! expmtrg LOT 3 • -fir � � ,, �.. 9� / E 6 7- 1-10 L r /-6 o;Q i`ovNis;��p,J i «aLa2o' -btsr 00 ` Prr AO /3U/1- D11VC, SETOACA:::- 2,F U/,2E.MF�I/TJ 20' F'20A/T /o ' Si DE /O' 72E.4 72 P2o,a0 SED 3 B ED/20_oA�15 SEP T/C 5 y5 TE_M CONS T2 UC T/OA/ SHALL GOA/F02M To MASS . L7E5/G�/. 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