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HomeMy WebLinkAbout0108 CEDRIC ROAD I (S.—.. Application numbe ® . ga Fee.......................... ........... ..... ...... KAM APR 2 3 2019 Building Inspectors Initials........ .. ... .................. BARNS-1-ABLEDate Issued Z �qq ................:.......... ...........;�,1............ 16 rOWN 0 Map/Parcel......... ....�. ....................... . TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION . PROPERTY INFORMATION Address of Project: ��n C cl�t c AW G e,�_ _r NA NUMBER STREET VILLAGE Owner's Name: &!LJ-.V-,e ZR;k,J Phone Number Email Address: Cell Phone 4Number Project cost$ / J�D, �' Check one Residential / Commercial J I OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK � Siding Windows (no header change)# c? 13 Insulation/Weatherization ©Doors (no header change)# 0 Commercial Doors require an inspector's review Q Roof(not applying more than 1 layer of shingles) Construction Debris will be going to o�,✓ �r CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# n (attach copy) Email of Contracto 2Co-&r�. Phone number •f�oo j?c cT 147t ALL PROPERTIES THAT HAVE STRUCTLIRES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece'of paper: Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a'site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No ,if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION r Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with.780 CMR the Massachusetts State Building Code. I understand the construction inspection'procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. ; Signature Date APPLICANT'S SIGNATUREtl Signature Date All permit applications are subject to a building official's approval prior to issuance. a' The Commonwealth of Massachusetts ment De art `of ts IndustrialAcciden P O f g ` ffice o Inpesti ations 600 Washington Street- Boston;AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit:;Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): l�n/iS �-��J yw �0/1 uC Address: City/State/Zip: 6V Phone#: AYama employer?Check the ppropriate box: Type of protect(required): 1. employer with 4. ❑ I.am a general contractor and I * have hired the sub-contractors 6. ❑•New construction employees(full and/or part-time):. - 2.❑ I am a sole proprietor or partner- listed on the attached.sheet. 7.. emodeling F. These sub-contractors have ship and have no employees 8. ❑Demolition working forme in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. # 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 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 employees. [No workers' 13.[:1 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. / �°- Insurance Company Name: Policy#or Self-ins.Lic.#: ACX1/ .h-J Expiration Date: -Job Site Address: ltf b� Gp(--c' Qa City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number.and expi6tion 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 pa' and penalties of perjury that the information provided above is true and correct Si ature: Date: Phone#: $ 2ze Aff Official use only. Do not write in this area,to be completed by city or town offcial 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 applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate 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 nuinber. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that'a valid affidavit is on file for future permits or licenses. A.new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts t Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www,mass.gav/dia 4 JgU0j s s[tUwO 0 bW n U N33 Wb IJIV1JJON 666 0a1 ozoz�swo:say dq3 CL66 60'-I ssO sP:tepue1'S Puel sueoV S`Lt�c dartt s oO amsua3i a6ulossal rpr;n8lo pJe o8ssoeSs od to uorsiAllien to1 4eamuotuuto. 3 Jac�nu�cXn�zraerc�t�:f�n��l�cruac�r%rft '• •/ Office of Cousumer-Affairs&Business Regulation License or registratsou valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration.'date jf found return to. RegiStrafion::� gsg22 Type: Office of Consumer Affairs and Business Regulation �J Expir"I ort la`f91201$ LLC 10,Park Plaza-Suite 5170 Boston,MA Q2116 TROY THOMAS HOME iiVIPF:OV MINTS,LLC TROY THOMAS 499 NOTTINGHAM DR CENTERVILLE,MA 02632` Undersecretary Not valid w' ut signature =DATEE(MMIDDNYYY) CERTIFICATE OF L1ABfLITY INSURANCE � � . 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 have ADDITIONAL INSURED provisions or 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). CON ' - PRODUCER NAME:TACT Donna OstroWskl Mark Sylvia Insurance Agency,LLC PHONE : 508 957-2781 Ic o Ext 508 957-2125 FAX No . 404 Main Street E-MAIL Centerville,MA 02632 ADDRESS:mark@marksylviai nsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:Farm Family Casualty insurance INSURED _ INSURERBt _ . . Thomas Home Improvements LLC INSURER C> PO Box 177 - - - .INSURER D Centerville,.MA 02632 INSURERE: ' _ - 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 13Y 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 SUBR POLICY EFF 7OMILDCD LIMITS = - LTR' TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY 20O'IX1416 5/01/2018 EACH OCCURRENCE $ 1000000 DAMAGE TO RENTED 100.,000 CLAIMS-MADE F0 OCCUR PREMISES Ea occurrence $ person) $ 5,000 MED EXP(Any one p ) - INJURY $ .1,000;000 PE RSONAL AL&A DV GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000;000 X POLICY❑JE 0 LOC $ OTHER: COMBINED SINGLE LIMIT - $AUTOMOBILE LIABILITY Es accident - BODILY INJURY(Per person) .$; ANY AUTO OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE $ HIRED N.ON-OWNED Per accident AUTOS ONLY AUTOS ONLY $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR - - - EXCESS LIAB CLAIMS-MADE *EACH EGATE $ $ DED RETENTION$ PER A WORKERS COMPENSATION 200IW8053 5/01/2101$ 5/O1/2019ERH AND EMPLOYERS'LIABILITY YIN T $ANYPROPRIETORIPARTNER/EXECUTIVE NIAOFFICERIMEMBEREXCLUDED? MPLOYEE $ ` (Mandatory in NH) 1,000,000'. If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additlonal Remarks Schedule,inay be attached If more space is required) Carpentry <". Insurance Coverage is limited to the,terrrms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Troy Thomas ACCORDANCE WITH THE POLICY PROVISIONS. 499 Nottingham Drive Centerville,MA 02$32 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(201.6/03) The ACORD name and logo are registered marks of ACORD THOMAS HOME IMPROVEMENTS PROPOSES TO PERFORM THE FOLLOWING WORK: Location of proposed work: Bonnie Zahn 108 Cedric Road Centerville, MA 02632 Date on which construction should begin: Winter 2019 The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that cannot be avoided by the contractor shall not be considered as a violation of this contract. The contractor agrees that when such delays become known to the contractor,the contractor will advise the homeowner as soon as possible. The homeowner hereby acknowledges that in certain remodeling work,the demolition process may reveal defects in the existing structure which must be repaired, creating additional work which may need to be carried out in order to complete the work described in this contract. In such case the homeowner agrees that the duration of the work and the schedule date of completion may differ,and that such variation is not to be considered a violation of this contract. Cost for labor and materials under this contract: $14,570.00 Proposal to install 6 Wood-Ultrex Integrity casement windows&2 Wood-Ultrex awning windows Front windows to be black on white with a cottage style simulated checkrail in the glass Side& back widows to be white on white as discussed -Energy Star certified, new construction windows, Low E2/with Argon -All windows to include interior trim primed ready for paint - 10 yard dump trailer will be needed on site;and will be removed at completion of the job -Contractor will be responsible for all building permits needed at the property NOTICE REQUIRED BY LAW With the agreement of the contract$500.00 of estimate is due. Further payments under this contract are as follows: 1/2 of the estimate due at the start; and remainder due at completion of the job. Balance of all materials and labor shall be payable in full upon completion of work described in this contract. Payment as agreed upon shall be made when due. Any payments which are delayed shall be subject to a finance charge of 1.5% per month. The contractor warranties the workmanship completed under this contract for a period of ten years from the date of completion. During the stated warranty period the contractor shall be responsible for the service of the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair due to abuse, misuse, and or normal wear and tear,which shall be the responsibility of the homeowner. All warranties for the materials supplied by the contractor shall be passed directly to the homeowner. The homeowner may be required to register or mail in such warranty card or evidence of ownership in order to activate such warranties. Homeowner failure shall not create any responsibility for the contractor under the warranty provisions;the choice of repair of replacement shall be at the discretion of the contractor. The homeowner acknowledges that the form, content, and notices contained in this contract are intended to comply with the applicable portions of the Mass. General Law Chapter 142A, and regulations promulgated there under. In the event of any instance of non-compliance, only such portion shall be invalid and the remainder of this contract shall be in full force effect. In addition,any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the maximum extent allowed under such law and regulation. Signed as a sealed instrument on this date: Date: Homeowner C 7tractor • 'MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(800)851.8424 . 10/4/2016 Form of Notice of Casualty Loss to.Building Under Mass:-Gen. Laws,Ch.139,Se6.3B :. BARNSTABLE BUILDING COMMISSIONER -+ 36.7 MAIN STREET ' HYANNIS:.MA.' 02601 : t. - -ca. Re: Insured: BONNIE ZAHN Property Address: 108 CEDRIC ROAD,CENTERVILLE;MA 02632 Policy Number: z 1335330 Type Loss: All Other Section 1 Losses Date of Loss: 10/03/2016 Claim Number: 409423 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed 100 .OOOor$ c ause Massachusetts General Laws Chapter 14 3 section ec on 6 t o be applicable. cable. If an o Pp Y. notice under Massachusetts General Laws Chapter 139 Section 36 is appropriate,,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,.date of loss and claim or file number. MPIUA Claims Division x CMA00021 a, R ffi. rtY .r.'{ `�.i-•� J--v3 b, f � "3"h ` 4�i.'� t.. �Y�hi__ , �m. Town of Barnstable Final Inspection Affidavit Dates 0c1_ l Thomas Perry,,CBO Building Division 200 Main Street Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed at: Street: 10S QUD6C ejQaD V llage: C1LL21FP_Uft 11 L' has been inspected by a certified Building Performance Institute(BPI) Inspector.All work performed meets or exceeds federal and state requirements. Permit application.number: Q0IS-1 Issue date: Sincerely, Francis Sheehan President' Frontier Energy Solutions, Inc. 502 Harwich Road, Brewster, MA 02631 Office: 774-237-0410 Email: fssfrontierenergy@gmail.com J TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION V,Ali�! OFBAR! STAB LE Map � Parcel Application #�� � n n PF Ip: Health Division Date Issued TF51) Conservation Division Application Fee Planning Dept. };, Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address �� cac( C, &4A Village Ce14(5 rU t Owner &i44 I Q- �ZG� Address 4 Q�l Cost t t-c- RarAA Telephone <^n,4 1�r-yi MA 42 2 .Permit Request ,���r V <. ��g (C��c. K ' U 'l EE 2 o,- e44!b*"L �Yl o®l-. tALL� �l� 25 (A l tk,r` 2` '-- r w 1e 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 vl Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure �7 Historic House: ❑Yes 9 No On Old King's Highway: ❑Yes ❑ No Basement Type: 2 Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing ez new Half: existing new Number of Bedrooms: 1; existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: M'ncGas ❑Oil ❑ Electric ❑ Other Central Air: SYes ❑ 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 ❑ No If es site Ian review# Y P Current Use 9 ,e S 7 !�,_n<R— Proposed Use Ke_5-i'dePI,CA APPLICANT INFORMATION (BUILDER OR HOMEOWNER) _ Name1�40,J;d_< 1, R_r d 5Telephone Number - Z� C "6 Address`J 0? a r Gv a G 0 ��cv� License# l 1 Home Improvement Contractor# 1 (0 O Worker's Compensation #VWWe, -[60 - 401 Sal S -266R ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I I t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. �S ADDRESS VILLAGE ' OWNER x DATE OF INSPECTION: w !.FO,UNDATJON a.{, 1,,, r,. ,,*u,=�sd}t—.,. yz - FRAME INSULATION,L_k i-�:4.,z I FIREPLACE a, w ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ., GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t Please Print.Legibly Name(Business/Organization/Individual): ,ro 4- f t' LA(Z,-Ay ( ®:Aj-1dnS , ;7-A C . Address: S62 ( .0c r w G�y Q_06J� City/State/Zip: e-e- 02-1 S k Phone#: -1 Li" 2 " 6ti 10 Are ou an employer?Check the appropriate boa: 4. I am a general contractor and I Type of project(required): 1. I am a employer with 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers 9. ❑Building addition [No workers'comp.insurance comp.insurance) re uired. 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions q ] 3.❑ I am a homeowner doing all work officers have exercised their 11.[I 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:YOther W�4?4 d el employees.[No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infotmation. 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 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. _ i Insurance Company Name:A M .J�R, ` .�-. u(� C© Policy#or Self-ins.Lic. #:\/ J C-(DQ•-U(5 91 S 2f-)EA Expiration Date: ,4 !-01 Job Site Address: 110 City/State/Zip: e r\rt ((, .A- 0201- 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�un ains and penalties of perjury that the information provided above is true and correct Signature: Date: V(S-65 Phone#: z 0 Q Offlcial use only. Do not write in this area,to be completed by city or town official City or Town: PermitiLicense# Issuing Authority(circle one): L 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 applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The D4.Partment 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia { y Town.of Barnstable Repdatory Services -��rwfi4`;eIB, RicliArd V.S614.�Director z TOrn ferry;l#uit li s�;f:va�tnt si�?ccc 200 IvJa u Riiee'ijIytuwd,;,_4A.02601 Office. 508A862-038 pax: 509- 9t0-6?3Q , roperLy Owmer. Must p p �tt- id Sign: This' Sep: lo". I, 0 Ryl {� , � '�'1 � �.. _:�m.{?wner or" he subject pl-ol-crye,° hc k aiid to;r L.nP.P37}t:SE lal , im mamrs.-M(ativc to wonk authonized b rh s h-d&ng.. v= ppIic M-QD E01 ka. r- S and alp zue �e r-e pt�x�ik�lit,y of It applicant.. Pools are naT rc,be ffled or u,-ILtd ttefow knc z; iasaaeJ,mjd Fib Si;ratj es1 f cxia;za .nl7lic Ott jj I'nnt N:me r _ t t C:FQRMS`Qr.?tl£EFr_I 'tf$51O JPooUS 3/ 1,� 2015 12 : 35 : 39 PM 8626 2 02/02 CERTIFICATE OF LIABILITY INSURANCE [:!03M M121YYYY) s/2o15 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 00509_001 i5cT Jeffrey Ford _ Rogers&Gray Insurance Agency A/C.No.Ext (800)553-1801, FAX (508)398-0246 434 Route 134 EMAIL South Dennis,MA 02660 I ADDIZEss: _ . �_INSURER(S)AFFORDING COVERAGE NAIC INSURERA: A.I.M.Mutual insurance Company J3758 INSURED INSURER B: - Frontier Energy Solutions Inc INSURER C 502 Harwich Road INSURERD: Brewster, MA 02631 INSURER E: 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. IINMR I TYPE OF INSURANCE DDLISUBR. POLICY NUMBER POLICY EFF POLICY EXP LIMrrS LTR, INSR:YWD _ (MMIDDIYYYY (MMIDDIYYY't) GENERAL LIABILITY - EACH OCCURRENCE - $ COMMERCIAL GENERAL LIABILITY DAMAGETO RENTED PRE N11SES Ea occurrerIce CLAIMS-MADE F-]OCCUR MED EXP(Any one person). '$ PERSONAL&ADV INJURY \ GENERAL AGGREGATE EN'L A.GGREGA.TE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGES F OLIC'Y FCC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I tE3 2cadera ANY AUTO BODILY INJURY(Per person) ($ - 1 ALL O�TdED SCHEDULED BODILY INJURY(Per attidentj AUTO AUTOS HIRED AUTOS NON-OWNED PROPER 'DAMAGE AUTOS •Per accidenit UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ EXCESS LIAB CLAIMSMAD17 AGGREGATE 3 _ DEG RETENTION $ )$ y�pR��R Cp PEPJSpTyON X I, ' �,;q l �TR Ah'D Ebt.LOYL�RS'LIABILITYf^ ANY;PROPRIETOR/PART"JERJ a CUTIVE�Y/N I E EACHACCIDENT 1,000,000.00 A OR 10ER/MEMBER EXCLUDED' Y I NIA VWC-100-60153i5-2015A 3/14/2015 3M412016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 I.yDr,descriibe under ,� E L.DISEASE-POLICY LIMIT € 1 000,000.00; DE..�RIPTION OF OPERATIONS beWn _ _ , , DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Sandwich 16 Jan Sebastian Drive _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sandwich,MA 02563 THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 2630 c�trre.r cCavictul use. f#tiiee of� 'for in ' Coasunzer Affairs& l�egulatioa I;u�se or,reg'�rateaa valid , �AtfRROV F E7 C �pR bdoTethe irsitstentf If found f arm tc 160854 Types offim f Caasuaner Affairs and Badness Ic on FRONTIER ENERGY SQIUifOi�S` FRANC 13 SHEEHAN _ 5M HARWIC-H R1? r`r - BREtRtS ,lUfA02634 Dad€iserrrtary with tsipatm. I J �. Resbi ed To-CSSWC-lnsutathm Con'tradw Ma ssachusefs-i ep2g:rmerxi df Plib3:l--Safety Beard of BWdling Rmgulig(dans and Standards [ESL-105 0 . BmwAor FYure to possess a edition of the Whosadwsetts, Sty Bwlftg Gate is causefRi'tmoodon oftWioenm "'�$t���' � if fir_•. , °: fori�Slic�ingu�rr�onv� �.6PS r Ces ssir3 er, MUMS r ' Citizen Web Request Page 1 of 3 �THE yJiL<M07 � �. . Logged In s: Citizen Request Management Monday, Jut TOWN\sheas Route to Users Search Requests Create Requests Reports Request Information Request ID: 21056 Created: 6/18/2007 3:35:26 PM Status: Assigned To Assigned To: Nobody Department Health Office Anonymous: No Request Category: Estimated 6/20/2007 Change Estimated May June 2007 Jul Completion Completion Date, Date: Sun Mon Tue Wed Thu Fri Sat 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 1 3 4 5 6 1 7 Created By: Shea, Sally Priority: Medium Building Dept Citation Numbers: Requestor Information Requestor KUMJIAN BART RequCON: DETAILS: 18 CYRUS DRIVE LOCH 108 CEDRIC ROAD Centerville Ma 02632 Centerville 508-428-6118 Request Parcel Number 172 +Block: 135 Lot: 000 i CALLER STATES THE GRASS IS 2' Map. HIGH THE PLACE IS A MESS LANDSCAPING WISE, LIGHT ON THE Parcel Lookup HOUSE DANGLES. NOT OCCUPIED SINCE FEBRUARY. THE CALLER STATES THIS HOUSE IS A RENTAL PROPERTY. THE CALLER STATES THE OWNER IS MARCIO NATASO FROM http://issgl2/internalwrs/WRequest.aspx?ID=21056 6/18/2007 Citizen Web Request Page 2 of 3 36 DEVON LN. MARSTONS MILLS. Email: Track Request Progress Request Work History: Internal Note History: Entered on 6/18/2007 3:35:26 PM by Shea, Sally I INFORMED THE CALLER THAT WE DO NOT ENFORCE ISSUES RELATIVE TO ESTHETICS,THAT I WOULD PASS THE INFORMATION ON TO HEALTH IF THIS IS NOT A REGISTERED RENTAL. HE STATED THAT HE WOULD ATTEMPT TO CONTACT THE HOME OWNER update delete Add document or image link: � rowse * You can also type in a folder name to see everything in the folder Current Links: Time worked on request: Response time: * Time entries are in hours. Examples of time entries: 1.25, 0.5, 0.75, 1, 3.5, 0.25, 0.10 * Response time: Measured from the creation date to your first actions on the request. * Do not include nights, weekends, and holidays in response time for most departments. .Public Use: _PrinterFriendj Version Internal Use: Printer Friendly Version http://issgl2/intemalwrs/WRequest.aspx?ID=21056 6/18/2007 i _. E ALL'LED "TELECOMMUNICATION .` 6173323865 P. 02, UNREGISTERED LANp S221a f PME NUM8EIt• DEED BOOK: 2024 PAGE: 47 ATTORNEY: DAVIS & 6000N, P.C. PLAN/DEED BOOK, 257^.^. PAQEt' 94 LOT(S) 14 } LENDER: PLAN NUM99R: OF { WILLIAM R. AND MIRIAM F. KUNKEL OWNER: GI BALD $NEFFELC REGISTERED LAND APPLICANT, - 03/13/92 I'-34' RE018TRATION Doo1i: pACN;: DATE; SCALE CERTIFICATE OF TITLE: FLOOD HAZARD INFORMATION PLAN NUMBERS t.oTtsJ= FLOOD MAP COMMUNITY NO,1 x50001 ZONE: ASSESSORS ,MAP, PANEL• 0015C DATED= Ot/l4/85 M�,P: BLOCKi PARCEL:_,___ MORTGAGE INSPECTION PLAN IN BARNS TABLE N/F James'.. Iron . 100.0' pipe t • � Shed: � t t ; Lot 14 15,040 SF Lot: 15 � scIL a Lot 13 r Ln 1 Oec e- 1 Story House 3 1,•31* No. 10 45' a. k Sd 1 9 y xg U Ly C E D R C R0 Jv . �THIs__tS�THE.RESULT_OF TAPE-KEASU_REMENT. NOT THE RESULT OF HAM INSTRUMENT SURVEY AND is C�_RTIFiED TO THE TITLE INSURANCE COMPANY AND ABOVE LISTED ATTORNEY AND LENDER. w THERE ARE NO DEEDED EASEMENTS OR ENCROACHMENTS WITH RESPECT TO BUILDINGS SITUATED ON THIS LOT EXCEPT AS DES LAURIERS & ASSOCIATES. INC SHOWN. 161 , WASHINGTON STREET THE LOCATION OF THE DWELLING.SHOWN DOES NOT FALL WITHIN EAST'.-.WALPOLE. MA 02032 (800) (508) 668-5010 A SPECIAL FLOOD HAZARD ZONE.. THE LOCATION OF THE D*LLING AS SHOWN HEREON EITHER WAS o I:oBERT. � IN COMPLIANCE WITH THE LOCAL ZONING BY-LAWS IN EFFECT EN WHEN CONSTRUCTED (WITH RESPECT TO STRUCTURAL. SETBACK No.31300 REQUIREMENTS ONLY) . OR IS EXEMPT FROM VIOLATION EN- FORCEMENT ACTION UNDER MASS. G.L. TITLE VI1. CHAPTER ' 40A. SECTION 7. uRv Li GENERAL NOTES: (1) The declar000at Bade above are 66 the basic of my knoe el g , iefo►rtatloa, and be6of at:the resetl of a mortgage p101 Flap tape surrey intpectioa Dods to the normal staadord of core of registered lad serveyors practicing in Hattachosetts. 12) Declaratloas are made to the above anted client only as of this 4414. (3) This plea *ac not made for record- is per posts. for use is re aria deed descri tioas or for construttions. 14) Verifications of ro ort (ire ditetsi s. 9ppP P � 9 P PP .y on 1 beildiag offsets, teeces, or of conflgeratios may be aecompli:hod only Lyon accerotoi iastrutent tervey, i i { ((1 r� i Assessor's dice(1st Floor): T r°" 6� �a�II�3�) ri!Aj� Assessors map and lot num S ED IN COMPLIANCE Conservation WITH TITLE 5 Board of Health(3rd floor): ENVIRONMENTAL CODE AND Sewage Permit number �S - ( t sesasTtnti • 3 Engineering Department(3rd floor): TOWN REGULATIONS ° oa�9.``�d° House number Y1r Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE ' BUILDING INSPECTOR APPLICATION FOR PERMIT TO 2- TYPE OF CONSTRUCTION e—lop 19 f TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies four a permit according to the following information: Location l©F 04!54al- t/ / Proposed Use _�'Co?-,6&-A.4;-/sti. ✓�o Zoning District k 1, —)N,- /L C— Fire District ' R,/-/ Name of Owner r -,o 6P" -:5X 1o� Address Ill 4 cr Name of Builder �.��/'� ��a� /s� Address Z 7 U'l5gP" /Owai Cr/�ici�Lry. Name of Architect .G1 9Tm�����w B�1isc Address Number of Rooms CJ Foundation i Exterior �'y��A�� -�����<.f Roofing Floors Interior Heating Plumbing Fireplaces Approximate Cost �� d Area 9� a� 1 Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ��'��� �� Construction Supervisor's License ' ; SHEFFIELD, GERALD 1, �o 35013 Permit For ADD PORCH a Single Family Dwelling Location- 108 Cedric Road Centerville , 'r. Owner, . Gerald Sheffield 1 } Type of Construction Frame ) i Plot Lot F Permit Granted April 28 , 19 92 Date,of In 19 Date.CoQpleted 19 a a" Yj i E .` ti AS W d ' s•d' dY� • � , 'y � e. A 1 • • ICo-a UNPE RtAYFIEFJT a 2�1 IorrJofgT 2xl�o�IBP�at�1 4�4 0 7T I 2><l0 Jo15T� I 2x IoJoI--:,T \ I R(nr _ s 0 \ z JOIST/POST CONNECTION - SCALE 1.1/2=1-0' I 2-2��10 C-11F;pE�' c, I . 5 \ 4:2. 2 spa R (sEm-VV-TD FL �\ FOUNDATIQN PIER PLAN /16 S�EE-T *a-)' CONSTRUCTION SCALE 3/8'=1-0 SELF—JEALIF1 SNIr�C,ILES �,i 15��trx,FFll,Jc FELT 0,.'F-f- T cG 4F?�1NI I�x4 TIZIM F., —' J±x 8 FASCI,c'•� izA�E 4,,4�1 Pos-f Iz ct cE� o0T WII,,ScR>✓E}.1—� FFAMt 0 T100AL .JAck KAF-Mjz, 54STEM FaR I-sTc F ' WougE Cod�JEC-TloP SCFEPN rAI-�EL CSEfi 9col= FRAMl�1cj PLAFJ SOT S) WJ I>< FAME 511PPr 2!: 4'pAlLipq 1 a nV-rArT,-T 6 / DF COLIC.PAD FO STAI D SUPPo 2 7, RIGHT .-SIDE LEFT SIDE SCALE 1/8-1-0 SCALE 1/8=1-0 3 f 4 �tv a S { ,y � o H � ua � EQ. 2 FRAMING PLAN 116' CONSTRUCTION o SCALE 3/8=1-0' a 3= c g 6 a = C a ° �yt 1-0 to x W Z r LV 2 0 tR L7 O CD LL LL I PROD. PLAN # X 6023 N DATE:8-18-89 w DRAWN:MR. I. SHEET NO. ' FRONT ELEVATION z SCALE 1/2'=1-0' 3 OF 9 /� //7�L �I 4nc�e1: Osterville SEPTIC SYSTEM MUST BE INSTALLED IN-rr 0" 'LlANCQ:.. WITH ARTICLE II STATE 13 J t, SANITARY CODE AND TOW144- THE t�� TI $ TOWN O` ' MARNSTABLE ii . i EAWSTA ILE, i '•1639. ,•� , BUILDING INSPECTOR o war° u J h AP APPLICATION FOR PERMIT TO .........Build One Family. Dwelling TYPE OF CONSTRUCTION .................4dOOd Frame......................................................................................... +. y Januar-v...7.....................19.27 . TO THE INSPECTOR OF BUILDINGS: i The undersigned hereby applies for a permit according to the following information: Location Lot... 14 Cedric....Road...... entervillq.,...Masp..... ........................:....... ProposedUse ............Residential................................................................................................................................... Zoning District ..........,, RD-1 Fire District Centerville-Osterville Name of Owner Norma-st Homes Ina" Address .,,,.Ashley..Drive. Centerville Name of Builder ....NOrmeS_t Home.s......Inc.•..............Address ........same ...... .................................................................... Name of Architect .......................................none ................Address .................................................................................... ...... Number of Rooms .........6......................................................Foundation Poured Concrete .. ............................................................... Exterior ►Sidin&......:..........:......................................Roofing Asphalt P��in&...... .................. . .........t................................................. Floors ..............0 a t................................... . ..................Interior ................Dwall................................................. Heating Warm-Air ..............Plumbing 2=. baths .................................................................... ................:................................................................. $23Fireplace y ................................................. ..Approximate Cost 1000 ................................... ..... Definitive Plan Approved by Planning Board -------------------_-----------19________. Diagram of Lot and Building with Dimensions / 9,75 SUBJECT TO APPROVAL OF BOARD OF HEALTH �8 5: , I hereby agree to conform to all the Rules and Regulations of the Town of rnstable re r ng the above construction. Nam .......... 0»zmeat Homes, Inc. ' | 16829 one storyNo —.� .. Permit for . . —. --. ~ � ^ single family dwelling ^ U" Cedric Road ---------'---'—'^—'---'—`----'- ' ---.----...��......e......����----.—.----' ' Owner --__ . �Ioc.____.. Type of Construction -----. ___._. �. c. —.---.--_----.—,.--_—~-...'---' Plot ............................ Lot ..............#1 ............. . � ~ ' . _ �. ^ o 11 Permit Granted — / ^ | Date of Inspection � . Dote Completed . .,��,//7...��������l9 ' -^ ! `| PERMIT ! ' ~ ' ` — ' ' ~- l� - ' — ' ----'^—^^^^----'—'—^ . ..—.—.—~--__----.---.^ c .�--..—._._--.-..~—.--.-..�. .—.--.—,—. r'----~—^^,'~^~--^^^`—'`~--^'—'~~~`'`^—' '—.--,.--.--_--.....--'--...-..---.—... ^^ | ' ' . Approved ................................................. lA -----.---.---.------,—,,.--.—.- � . ----------..---..~.~--.—.—.-,..., . � ,