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1078 CRAIGVILLE BEACH ROAD
/ Dr7$ �rgv� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �� Parcel__40 Application # � Health Division Date Issued lo� Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Stre dres I � Villa e `� � 9 Owner Address Telephone t� Per equest Square feet: 1 st floor existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio Q Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing b new >-w, C) Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor3Room Count � F Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No . Fireplaces: Existing New Existing wood/coal stove: 0 Yes ❑ No Detached garage: ❑existing 0 new size Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ew size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �_ Telephone Number 60W2' �� Address License # ex�,q aee� Home Improvement Contractor# /9 Worker's Compensation # ALL CO UCTIO E IS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNALURE DATE L� 4. FOR OFFICIAL USE ONLY ' i ' APPLICATION# DATE ISSUED MAP/PARCEL NO. i ADDRESS VILLAGE i OWNER r ' i DATE OF INSPECTION: ' FOUNDATION FRAME INSULATION 1 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH ! FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 3 , Depmftment of ndustrial accidents Office of Investigations 600 Washington Street _ Bostoi;'MA 02111 www.mass.gov/dia, Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectricians/plunibers . Applicant Information Please Print Leggibly' Name(Business/Organization/lndividuai): -Address: City/State/Zip: (�• y`-��c� Phone.#: --=r Are you an employer?Check-the appropriate.box. I I am a employer-with �_ am a g ' Type of project(required). 4. I eneral contractor and I * have hired the sub=contractors `6 New construction . employees(full and/or pnrt-time). ❑ 2.❑ I am a'sole proprietor or partner_ listed on the-attached sheet 7. Remodeling ship and have no employees These sub-cofactors have 8. M Demolition � working for me in any capacity. employees,and have workers' [No workers'comp.insurance comp:Msurance.t 9: Building addition required.] 5 .0 We are i corporation and its ME �Electrical airs'• rep or additions 3.❑ I am a homeowner doing in work officers have exercised their 11(],Phunbing repairs or additions rtiysel£ [No workers'comp. _ right of exemption per MCIL 4 insurance required.]t c. 152, §1(4), and we have no 12. Roof repairs r : employees. [No.workers' 13. Other comp.msurance regWred.] Any applicant that checks box#1 most 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 cunt wtors must submit a new affidivitindicatrng such. $Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or na those entifies have employees. If the sub-contractars have employees,trey must providt their workers'comp,policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site. P information. Insurance Company Name: Policy#or Self ins.Lic.# Xpiration Date: lob Site Address: `- Fonilcy � city/State/Zip:Attach°a copy of the workPss'compensa declarafion"gage'(showing the`pokicy number and eipiration date). Failure•to se coverage.as quired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine vp/ 15 00 and/or one ear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ` of up 50.00 a da against violator. Be advised that a copy-of this statement may be forwarded to the Office of Inv ons of IA for' e covers a verification I do ereby c fy under the ains•and penalties:of perjury fhat the information provi5dabovis true d correct:Date: ( :;e Phone#: . Offzcial.use only. Do not write in this area,to be completed by city or town official City or Town: IPermitUcense# -Issuing Authority(circle one): J.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector 6. Other Contact Person: g #. _ one y �. Information and Instructions l Massaclmsetts General Laws chaplet 152 requires all employers to provide workers'compensation for their employees. Puzsuant to this stage,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 vPithhold 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," AdditionaIly,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 untu-acceptable evidence-of eon3plience with-the mi surpnre 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);addresses)and phone nnmber(s)along with their certificates)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 as LLC or LLP•does havd , employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be.returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents.-Should you have any questions regarding the law-or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line•, City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all7locations 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 nnist be filled out each year.Where a home owner or citizen IS obtain'a license or permit not related to any business or commercial venture (Le..a dog license or permit to bum leaves-etc.)said person,is NOT required to complete this affidavit The Office ofInvestigations 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 Cammazwealth of M=arhUSattS aepartmant of lades�Aaeic�amts Office of bzVes.tigaidalms 600 Washington Stma Boston,MA 02111 'I`e1.##61 7-727-4900 ext 446 or 1-977-MASSAFE Revised 11-22-06 Fax##61'-727-774.9 Wwwmass pv/dj ACORQ CERTIFICATE OF LIABILITY INSURANCE 7ATE(MM/DD/YYYY) 1/09/2011 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 terns 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:CONT C Karen Bernier Southeastern Insurance Agency, Inc. (A/CN No,E:t: (508)997-6061 aCNo.(508)990-2731 439 State Rd. E-MAIL P.O. BOX 79398 PRODUCER CUSTOMER ID#: N. Dartmouth, MA 02747 INSURER(S)AFFORDING COVERAGE NAIC0 INSURED INSURER A: Arbella Protection Insurance Tupper Construction Co LLC wsuRERe: AEIC INSURERC: CNA Surety 27 Roberta Drive INSURERD: West Yarmouth, MA 02673 INSURERE: INSURER F: COVERAGES CERTIFICATE.NUMBER:,11/12 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.- INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD/YYYY INM/DD/YYYY LIMITS GENERAL LIABILITY 8500008743 11/01/2011 11/01/2012 EACH OCCURRENCE $ 1,000,0( X COMMERCIAL GENERAL LIABILITY DAMAGE SET RE TED ence $ 100,0( CLAIMS MADE a OCCUR PREMMED EXP(Any one person) $ 5,0( A PERSONAL& VININJURY $ 1,000,0( GENERAL AGGREGATE $ 2,000,0( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP%OP'AGG _$:. .'.2,000.,0( POLICY PRO- JECT LOC $ _AUTOMOBILE LIABILITY 56662400002 12/01/2011 12/01/2012- COMBINED SINGLE LIMIT -ANY AUTO (Ea accident)._ . $.. 1,000,0( BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ IN( X NON-OWNED AUTOS $ $ UMBRELLA LU\B OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION -S $ WORKERS COMPENSATION WCCSOOSS9.301200.710/03/2011 10/03/2012 sX WCSTA U- OTH- AND EMPLOYERS'-LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE RICHARD TUPPER IS E.L.EACH ACCIDENT $ 5OO•B OFFICERIMEMBER EXCLUDED? N/A ,00 (Mandatory In NH) I LUDED FOR WC COVERAGE E.L.DISEASE-EA EMPLOYEE $ SOO OO H yes,describe under r DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ S00,00 C and or theft of money & r 71068813 02/28/2011 02/28/2012 Limit of $10,000 roperty. DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE"'DELIVERED. IN.. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE "F r Information Only" Karen Be I ©1988-20 ACORD C RPO TION. Al rights reserved. ACORD 26(2009/09) The ACORD name and logo are registered marks of ACORD- Massachusetts- Department of Public Safet, Board Hof Buildim-Re!_ulations and Standards Construction Supervisor License License: CS 69M RICHARD'S TUPPER 79 B MID-TECH DR;:, WEST YARMOUTK MA 02673 Expiration: 12/31/2012 (ommissioner Tr#: 8340 l O>flice'TY�ANVIF*ffi*1 06b(ee0 ffN License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 121845 Type: Office of Consumer Affairs and Business Regulation Expiration: 61IW2012 Individual 10 Par l a 5170 'B-ost ,MA 02116 VID TUPPER rt TUPPER 29 Robe 29 Roberta Drive � W.YARMOUTH,MA 02613 Undersecretary Not valid witho signature foOMT`:JPPER CONSTRUCTION CO..LLc 79B Mid-Tech Drive West Yarmouth, MA 02673 Phone 508-778-0111 Fax 508-77&5010 Registration#121845 License#069058 Date: 1/5/2012 Attn:Building Department _ I hereby authorize Tupper Construction Co.,LLC to pull the permits necessary to complete the project described on the attached permit application form Thank you, Owners' Signatures Print Owners'Names: ��1 V�c�l.(,� Street Address: to79 C,rz - vie TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Cl Health Division Date Issued L Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Stree ddress IU7e W - AC4 0-'' Village Owner i L Address Telephone `1 .m� Permit Request 9 �ZfL �Z�t�",` gVh` a ,, !l ' � bra 6 �vbP ofia wal Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type_t JAMIahn' Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family,.d Two Family ❑" Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other k' Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 0 If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ` Name //� �'� ��i�t����, ��,� Telephone Number Address �,%2i° �� �/ License # Home Improvement Contractor# Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO dig�/ SIGNATURE DATE` { J FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCELNO. i; ADDRESS VILLAGE ' s OWNER 'r DATE OF INSPECTION: FOUNDATION FRAME ti INSULATION FIREPLACE s ELECTRICAL: ROUGH FINAL :x PLUMBING: ROUGH FINAL 4 F GAS: ROUGH FINAL ' FINAL BUILDING '.: DATE CLOSED OUT ASSOCIATION PLAN NO. r - s � t r �-. Massachusetts -Department of Public Safety i^ Board of Building Regulations and Standards ' Construction Supervisor License: CS-100988 HENRY E CASSII}' 'r 8 SHED ROW WEST YARMOLFTH Expiration Commissioner 11/11/2015 Vz"G, r; II CJ Oice ol`ComumerAffairs and Business ReguLition 10 Park Plaza - Suite 170 Boston, Massachwetts 02116 1-1.o III e Improvement Cotitraotor' registration Registration: '153567 type: i'rivate Corcwiatioii Expiration: 12/15/Zb14 'I'rli 23,1631 COD INSULATION, INC I IE"NRY CASSIDY _.__..._......................_.__. _ 1'J f�1-AI-R D 0 N CIRCLE -....._. YARMOUTH, MA 02664 -- .. ..._._...._.. .. . ._ upllatc Address and I clurn card. Mark ieasuu litr ch;mgr. Address LI Renewal ._I E1111.1lo}•niaut I I Lu.+l 61111 .. �, (i't�af ul,N/•!!c4flrfC c`1,,.1(1C.1Jt It fY(tail<"�J .. .. . Colo AII'llir ti "k Ltus,n4ss llegulatio„ l.icenie or regutratiou vAid for individul use. uilly 1 ti� ipUmr IMNttC.)VEMe:N'I- CON fRACI OR I)etU1C the expiration date. 11'FOUlld Irctur a tli; c lr"Ij5uy,>Irutivi,. 153567 Type: Office of Consumer Affairs and Business Regrrliitiou 12115/2014 Pnvate Corporaticii 10 I'.lrk Plaza-Suite 5170 1lustun,MA 02116 L)ndcrsccrcU,r) l)t\•i11 WIt110 t 11At 'I"e i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Connlpensation Insurance Affidavit: Builders/Contractors/Electricians/I'ill tubers p2licalat Infor>iiati®n P'l�]Prinit I.,e ibiy N 1Illc (easiness/Organization/Indi/vidual): Fr� r City/State/Zip: Phone#: �� 2- / .44 t you an.earphny r2 Check the appropriate boz: 1. 1 am a employer with. .,1 4. ❑ I am a general contractor and I Type of project.(regnired): employees (full an4,rpr part-time).* have hired the sub-contractors 6• ❑ New construction 2.❑ 1 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' [No workers' comp. insurance comp. insurance.t 9. ❑ Building addition o required:] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.E] l am a homeowner doingall work officers have exercised their _ :11:❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required] t c. 152, §1(4),and we have no 3a.❑ I am a homeowner acting as a employees. [No workers' 13.UOthe'r_Z 1r J � 717_'�� general contractor(refer to#4) comp,insurance required.] 'A11Y applicant that checks box 1#1 must also fill out the section below showing their workers'compensadodf oucy 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. 'Couunctors that check this box must attached an additional sheet showing the name of the sub-eonmicnon and state whether or not those entities have cutployces. If the sub-contractor have employees,they must provide their workers'comp.policy number. MMMUMMMUMMUMM I am an employer that is providing workers'compensatiion insurance for my employees. Below is the policy and job site informuYian, Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: m Job Site Address: City/State/Zip:C �'h% I��Lllf�a �' Attach a copy of the workerV cornpeasatiou 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 tine up to S 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.maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby eerd# nder the nd penalties of perjury that the information provided above is tare and correct Dat • Phot t `0A'i4l use only. Do not write in this area,to be completed by city or town official 'City or Town: Perrdit/LIcense# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. Cityll'own Clerk 4.Electrical Inspector S. Plumbing Inspector `6.Other Contact Perot: Phone#: CAPECOD-27 MYOUNG D(MMIO i IYYW) d,_._ CERTIFICATE OF LIABILITY INSURANCE DAT (MM/D N 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 terns 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 e_ndorsement_(s). _ PRODUCER License#PC-514062 NAME: Margaret Young Rogers&Gray Insurance Agency,Inc. -PHONE FAX ----- 434 Rte 134 South Dennis,MA 02660 AoDRIESS:myoung@rogersgray.com INSURERS AFFORDING COVERAGE -^ NAIC li _---------------------_._._..___.._ . _. INSURER A:PEERLESS INSURANCE COMPANY NSURED INSURERS:COMMERCE INSURANCE COMPANY Cape Cod Insulation,Inc. w INSURER C:Evanston Insurance Company _ _ _- 18 Reardon Circle INSURERo:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 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. NOTVVITHSTAN DING 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. MR TINS -SUBR POLICY EFF POLICY EXP _ TYPE OF INSURANCE R V POLICY NUMBER MMIDOIYYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -D�GErO RENTED A X COMMERCIAL GENERAL LIABILITY CBP8263063 4/1/2013 4/1/2014 -REMISES Eaocadrence $ 100,000 _I CLAIMS-MADE I_I OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 _ GENERAL AGGREGATE -- $ �2,000,000 GEN-L AGGREGATE LIMIT APPLIES PER:A PRODUCTS-COMP/OP AGG $ 2,000,000 - POLICY P-R^O_- I LOC $ - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 000,000 Ea accident $ _ _, B ANY AUTO 13MMBCKVMK 411/2013, 4/1/2014 BODILY INJURY(Per person) $ ALL OWNED X UT SCHEDULED AUTOS BODILY INJURY(Peracddent) $ _ A X HIREDAUTOS X N N-OWNED ? (PERAC�NMAGE $ X UMBRELLA LIAR X OCCUR - - EACH OCCURRENCE $ 1,000,000 C EXCESsuAS CLAIMS-MADE XONJ453512 4/1/2013 4/1/2014 _..._...--.-- _ _ADE AGGREGATE 1;000,000 DIED X RETENTION$ 10,000 $ WORKERS COMPENSATION VVC STATU- OThi- AND EMPLOYERS'LIABILITY - - l Y L MI ` D ANY PROPRIETORIPARTNER/EXECUTIVE Y/N WCA00525904 6/30/2013 6/30/2014 E.L.EACH ACCIDENT _ $ 1,000,000 OFFICERIMEMBER EXCLUDED? ❑ NIA - " (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 lips,describe under DCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Compensation includes Officers or Proprietors. Addtional Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD s OWNER AUTHORIZATION FORM, &&dcL 74-a�eac,-e4 I, (Owner's Name) owner of the property located at , (Property Address) Ile, (Property Address) hereby authorize (Subcontract r) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property: Owner's Sig ature Date E or) Map ��- �y Parcel " I�� 0 Permit# House#,� Date Issued Board of Health(3rd floor)(8:15 -`9:30/1:00- PM Fee; 9 ( Conservation Office(4th floor)(8:30-9:30/1:00-,2:00) Planning Dept.(1st floor/School Admin. Bldg.) Definitive PfAv,ed by Planning Board 19 MRNMASS.039. TOWN OF,BARNSTABLEBuilding Permit Application Proje tre : j Cl Vo.h t E.u I L L t 0 (-U p' ' Village Owner ' I u a k (. r i&"U Lam' Address Telephone Permit Request CL tb C> D � , G First Floor D 0 square feet Second Floor tl 11 square feet I Construction Type�� g"�8�pQ ' Estimated Project Cost $ 2 Lila 0,G'p Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family #units) Age of Existing Structure Historic House ❑Yes i@No On Old King's Highway ❑Yes�o Basement Type: ❑Full Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) N-1 A Basement Unfinished Area(sq.ft) U�C� Number of Baths: Full: Existing_ t� New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not i luding baths): Existing n New First Floor Room Count Heat Type and Fuel: G ❑Oil ❑Electric ❑Other Central Air ❑Yes 'Z7No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑ tached(size) ❑Barn(size) one ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Voo P3 LU t>t•,)T Telephone Number Address i �, y� t i, �,T� License# � S �•. ��/n f2 Lit��".� f-�, Home Improvement Contractor# Z Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Le U SIGNATURE DATE -L BUILDING PE 9 ENIED FOR E OLL NG R ON(S) ., Ile _ FOR OFFICIAL USE ONLY .PERMIT NO. s DATE ISSUED. MAP/PARCEL NO. t: l.... i _ F - ADD RESS G s VILLA_ GE: OWNER DATE OF•INSPECTION: FOUNDATION FRAME - r ! t ! �Y # .� • � � t '* ¢ F ^ ,^. } ! � s r p '`�• r � s f•. y e•'M1 � ' �' - INSULATION . FIREPLACE �, 4 ELECTRICAL: ROUGH t. FINAL PLUMBING: ROUGH FINAL .. GAS: ROUGH FINAL• ' FINAL BUILDING F # � i ry r- -� '• L -q• .. ,. ` a. P t DATE CLOSED OUT ;ASSOCIATION PLAN NO. The Town of Barnstable • �aHsrAst� • Department of Health Safety and Environmental Services 4''�Ec ►`° Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commission: For office tine only Permit no.�_ Date , t► t AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION a MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization. conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Wock- Y\ ��0�� Est. Costo"� D o O Address of Work• l)--7 LI /au4i LLC- LIMCN ► D, &01 L Owner's Name f. i h d c . T i eat u G 7- Date of Permit Application: I herefiy certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDE PE ALTIES OF PE I hereby apply f r ermit the tot owne Date ontractor Name Registration No. OR Date Owners Name 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office 91111 9911ONS 600 Washington Street Boston,Mass. 02111 O������/�� Worker]C� ensation Insurance Affidavit name: f 1J U location: j'1 (�� lr 04 2O �, 1 b U ? LE city bhone# ❑ am a homeowner performing all work myself am a sole proprietor and have no one working in a ca acity ❑ I am an employer providing workers compensation for my employees working on this job. tom nnv name: _ . address: city phone#: insurance co. Volicv# ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensauon polices: ........... company name: address: phone dtr. #:. insurance co. company name- address: phone cih #: oliev# . .... .......... . . .. Insurance co Failure to seavtz,coverage s,requtred under Section 25A of GL 152 can lead to the imposition of criminal penalties of a One up to 51,500.00 and/or prisonment as well as civil penaltles in the fo o a STOP WORK ORDER and a One of 5100.00 a day against me. I understand that a one years'fin r coverage verification. copy of this statement may [o ed to the Oftice oC a tigations of the DIverification. I do herebv certify the p d penalties perju that the information provided above is trap d rreci Signature Date _ Print name / Al, Phone# official use only do not write in this area to be completed by city or town otIIcial city or tow n: permit/llcense# (]Building Department ❑Licensing Board ❑checkf immediate response is required.- ❑Selectmen's Office ❑Health Department contact person• phone#• ❑Other (crnam 9195 P1A) •.o Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal', d 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit.for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the perinit/license number which will be used as a reference-number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. j. The Office of Investigations would like to thank you in advance for you 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 Oftice of Investigations 600 Washington Street Boston,Ma. 02111 ` fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 DEPARTIB11T OF Pt=JC SAFETY h COMMONWEALTH /0/0 COMMONWEALTH AVE z OF ` r P "' . MASSACFWSETT8 BO8TbK MASS.02215 �J EXPIRATION DATE I. C O N S T RL I S-U F E R V I S O R x RESTRICT(ON5 9 3 6 'EFFECTIVE DATE UC-NO. r NONE o 05i01/1990 0517a9 'i " KENhETH A LUDWIC 33 FIANINER CIRCLE t SS A 261-59-1215 COTUIT NA 02635 PHOTO(BLASTING OPR ONLY) FEE: 0.00 HEIGHT: NOT VALID UNTIL SIGNED BY LICENSEE AND ICN _ - - STAM D -SIG+ TURE THE CO _ DOB: 0612511958 THIS DOCUMENT MUST BE NATURE ' - CARRIED ON THE PERSON OF THE HOLDER WHEN ENGAG- OTHERS-RIGHT THUMB PRINT ED IN THIS OCCUPATION. . + ER _ I HOME IMPROVEMENT CONTRACTORS REGISTRATION Board of Building Regulations and Standardsi One Ashburton Place - Room 1301 Boston, Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 123675 Expiration 03/25/99 Type - INDIVIDUAL— HOME IMPROVEMENT CONTRACTOR Registration 123675 j Type INDIVIDUAL Kenneth D . Ludwig I Expiration 03/25199" 1595 Main St W. Barnstable MA 02668 i ` Kenneth D. Ludwig ` G� �o'�&�t595 Main St ADMINISTRATOR W• Barnstable MA 02666 - J Y 'R �. 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"�e".`^as"���a +yi 4^r t� �"�rir''3.:��� t ti. � �.. � '�J. ?�3',A.+t(:�?:iF'�,' ,:i,�'-' 2'.._.l�`'x.��++7'.U*-'i•k -.�..,..3?�-�+.+�.2�11F-�'�" .+." �'bk....M�',':1..2.,3i•.iC?'�.V'ei�a?c-.�3ti�,b'"w',";�Y^,?�.NY.r�s::. 7""`��a d. yT!TRr°,w.5�.: �d£.+c'i. '��`rad..� ��i"€63��ii4�'✓ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION q0 Map Parcel Application # L / Health Division Date Issued J 29r1Y Conservation Division Application Planning Dept. ` Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis 1 Project Street Address ,a,Z Village Owner 4t- r- %2ezelle-s 6 Address S Telephone ��9 l E y Z 9 7 - Permit Request ew!aye- 4_1 4Ze 01 tep :Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay _ Project Valuation -�#y2d4 d Construction Type .�✓%�6.� `� y�E Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documech-Ltion. Dwelling Type: Single Family 21 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes >&No On Old King's Hi hway: Oyes No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other a}, Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name e IAI�d ��� r� Telephone Number Evy 5/2 /q- Address 1204a d f��'T,d License # XZ) G al&a 12T4 Home Improvement Contractor# Email Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE //er// E G p FOR OFFICIAL USE ONLY �7 APPLICATION# DATE ISSUED MAP/PARCEL NO. s ADDRESS VILLAGE f i f OWNER DATE OF INSPECTION: FOUNDATION FRAME } INSULATION C FIREPLACE Y. ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL { GAS: ROUGH FINAL I FINAL BUILDING ffATECLOSED OUT ASSOION PLAN NO. i t .Massachusetts -Deppl tm nt of Pjiblic Safety <�bard of Building Regula#ons jand Standards - Construction Supervisor _ License: CS-100988 `0- o,� HENRY E CASSID ' - �• 8 SHED ROW s WEST YARMOUM A / ,i Expiration Commissioner 11/11/2015 a G� Office of Consumer Affairs and Buslness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 j Type: Private Corporation t,j,`i Expiration: 12/15/2014 Tr# 233831 CAPE COD INSULATION, INC 1,41, x 'yy'� HENRY. CASSIDY , � � 18 REARDON CIRCLE � { SO. YARMOUTH, MA 02664 , pdate Address and return card.Mark reason for change. —.�scn i 0 20M•05i11 eAddress Renewal Employment ;E Lost Card - cJ�ze�arrrinaararvea�i b�C>�cc�a�ceaeCla. - �L\__'Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration 153567 Type: Office.of Consumer Affairs and Business Regulation . . xpiration 12/15/2014 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATIQN;INCj ; - T HENRY CASSIDY A e 1--!4 - 18 REARDON CIRCLE — SO,YARMOUTH,MA 02664�'t ! Undersecretary of val witho t nat re The Commonwealth of Massachusetts Department of IndustrialAccidents W Office of Investigations y d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: k 1/l C�4 V G I�i City/State/Zip: �bA M r n Phone#: _6A - 71 r?�c 2 l Are you an employer? Check the a propriate box: Type of project(required): .❑ I am a employer with 2'�2 4. ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ 1 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. El Building addition [No workers' comp. insurance comp. insurance.$ required.] -5. ❑ We area corporation and its 10.❑ Electrical repairs or additions ' officers have exercised their 11. Plumbing repairs or additions 3.❑ [am a homeowner doing all work ❑ g p myself. [No workers' comp. right of exemption per MGL 12.0'Roof repairs insurance required.] t c. 152, §1(4),and we have no t W � („� employees:[No workers' 13.XOther_ dV` 7� comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must'submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site. information. II'n Insurance Company Name: k[ 06, Policy#or Self-ins. Lic. >�1.�0 I Expiration Date: Job Site Address:&Y G� /��� / 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 cer,ify the pains and penalties of perjury that the information provided.above is true and correct Signature: Date: Phone#: 2 -<Z 2 Official use only. Do not write in this area,to.be completed by city or town official: City or Town: Permit/License# Issuing Authority(circle one): 1, 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ti 6.Other f" i Contact Person: Phone#: i t CAPECOD-27 CVANGELDER DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/1/2014 tTHIS 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 IBELOW. 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 CONTANAME., Cape Cod Commercial - Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 AIc No Ext: 'VAX' No:(877)816-2156 South Dennis,MA 02660 E-MAIL - ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Peerless Insurance Company INSURED INSURERB:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURER c i Evanston Insurance Company 18 Reardon Circle INSURER D:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 INSURER E:. INSURERF: 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. IL7R TYPE OF INSURANCE D POLICY EFF POLICY EXP - In vivo POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS - A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR CBP8263063 04/01/2014 04/01/2015 PREMIMaSESOEaoacurrenE cD e $ 100,00 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY PRO- ❑ JECT LOC' PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY - _ COMBINED SINGLE LIMIT $ _8 Ea accident _ B ANY AUTO 14MMBCKVMK 04/01/2014 04/01/2015 BODILY INJURY(Per person) $ ALL OS X SCHEDULED BODILY INJURY Per accident) $ 1,000,000 _ AUTOS AUTOS ( NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 C EXCESSLIAB CLAIMS-MADE RIOXONJ453512 04/01/2014 04/01/2015 AGGREGATE $ DED X RETENTION 10,000 Aggregate' $ 1,000,00 WORKERS COMPENSATION - - - - _ PER - OTH- AND EMPLOYERS'LIABILITY - STATUTE ER _ Y 1 N D ANY PROPRIETOR/PARTNER/EXECUTIVE CA00525904 06/30/2013 06/30/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yas•describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE., THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 4 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i 1 . ©1988-2014 ACORD CORPORATION. All rights reserved. IACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD OWNER AUTHORIZATION FORM Owner's Name). owner of the property located at Property.Address) (Property-Address) i. hereby authorize (sub a r) an authorized subcontractor for RI E Engineering,to act on my behalf to obtain a building permit and lo perform work on my property. owner's rre Date oFtHE ram, Town of Barnstable *Permit# o? V 1 OL ti�P� ti� Expires 6 months from issue_date • Regulatory Services Fee _ ,) BARNSrABLE. yQ- MASS. Thomas vAl F. Geiler, Director 1 1639 A10 ED MP'� Building Division �� � �� PP rry,CBO, Building Commissioner OrMain Street, Hyannis;MA 02601 MAY 1 2 2009 www.town,barnstable.ma.us Office: 508i8A?r-4038 r Fax: 508-790-6230 ' 'i�*I &4jTWj_T APPLICATION - RESIDENTIAL ONLY � �f�v l Not Valid without Red X-Press Imprint Map/parcel Number__�C_`-to/ 30 ��yy Property Address OV F Cea Vt ik ,Residential Value of Work'46_ff 0Q Minimum fee of$25.00 for work under$6000.00 Owncr's Name & Address i/7C,�ct / �t ,eci u1 P O f.,K 7 9 y OS-Trevt/C( ,-119• Contractor's Name ��,��ir'7 l.� IrPS'�c'�� Telephone Number V � � � 7 �� t,7er I tome Improvement Contractor License# (if applicable) ! Construction Supervisor's License # (if applicable) .7 6�_316 [KWorkman's Compensation Insurance Check one: ❑ 1 am a sole proprietor ❑ I am the Homeowner FA. I have Worker's Compensation Insurance y �'7v n 1nsurance Company Narn Workman's Comp. Policy # Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing'layers of roof) Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum .44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is.required. SIGNATURE Q. "PI-ILLS\P01ZIAMbuilding permit forms\EXPRESS.doc Revised 100608 License or registration valid for individul use only before the expiration date. If found return to: hoard of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,Ma.02108 Not valid without signature Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regjstrabon; 160627 ! ` vie _8/812010 �: k� r, Tr# 272337Wf I # Type Incliv'idual l STEPHEN W.C#RESINELL j G \rth STEPHEN.CRESWELL- 1:1` t t95 PINE ST � ,• � � / ' I � CENTERVILLE MA 026 2 �~ �f Administrator +:`: Jam:-& �- o� . Board of Building Reg latiobs and Standards Construction Supervisor License i License• CS 36 765 Expiration=6/27/2009• Tr# 16946 rE Restriction 00 �s f STEPHEN W C RESWELL 195 PINE STREET CENTERVILLE,MA 02632' i ; Commissioner 1 i Y. The Commonwealth of Massachusetts Department of Industrial Accidents rp Office of lnvestigations- ' 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): C1_e1L_M( Address: 57 Ci /State/Zi �to�-`T��v// ,�'�� Phone.#: �� FS� ty p Are you an employer? Check the appropriate box: Type of project(required): 1AI am a employer with. 4. ❑ 1 am a general contractor and I 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 workingfor me in an capacity. employees and have workers' Y P tY• $ 9. ❑Building addition [No workers--amp.-insurance comp.insurance. 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 1 LE]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.❑ Other .�l�. comp.insurance required.] *Any applicant that checks box#1 rnust also fill out the section below showing their workers'compensation policy infomnation. t Homeowners who submit this affidavit indicating they are doing 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-contractars and state whether m not those entities have employees. If the sub-contractors haveFnployers,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure fo secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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. .1 do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct. Si¢nir„r Date: Phone Official use only. Do not write in this area,1b 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 CIerk 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 foregomg-engag in a jom e- rpzis�e,-anc TnZudffig a leg represenuative�Fuf -decxased-en4duyer,,w_-the- receiver or tiustee 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)stafcs"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 in.—.ice 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-contiactor(s)name(s),-address(es)and phone number(s) along with their certificates)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials .Please be sure that the affidavit is complete and printed legibly..The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in'the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 tnwn).".A copy of the aff davit that has been officially stamped or marked by the city or town may be provided to the - ach 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 fo any business or commercial venture (i.e.a dog license or permit to brim leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to.dank 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: Tho Commonwealth of Ma=chuse#s Department of Iadustrial Accidents 4ffce of Investigations 600 Washington Street Boston,MA, 02111 Tel. # 617-727-4900 ext-406 or 1-977-MAS-SAFE Fax# 617=727-7749 Revised i 1-22-06 www.mass.gov(dia c ro,�ti Town of Barnstable Regulatory Services • Ri R,JCri R(� • KAM $ Thomas F.Geiler,Director 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town-barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder I, /"/tV 1 J4- 9�/J ,4-1 , as Owner of the subject property hereby,authorize C4-,-& to act on my behalf, in all matters relative to work authorized by this bdding permit application for. (Address of job) � 0 e of Owner Da Print Name If Property Owner is applying.for permit please complete the Homeo�mers License Exemption Form on the reverse side. ,. 0:FO R.Ir15:0 WNERPERMISSIOt1 'THE r . Town of Barnstable ` Regulatory Services Tbomas F. Geiler,Director sxxrasrwsr..e. - MA2c g . �Plfo; 16 Bnilding Division Tom Perry,Building Commissioner wWw.to wn.b arrtstable-rna.us Office: 50 8-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE-- JOB LOCATION: number street village "HOMEOWNER" name home phone# work phone# CURRENT MAILING ADDRESS: city/town state rip code The cent exemption for"homeowners"was extended to include owner-occupied dwellinKs of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. D'EFINMON OF HOMMOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to' be, a one or two-family dwelling, attached or detached siructures accessory to such use and/or farm structur6s. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall_be responsible for all such work performed under the building permit. (Section 109.1.1) -Me undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner"certifies that-he/she understands the Town of Barpstable.Buildiug Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Budding Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any borneowner perfnrmmg work for which&-building permit is rsqufird shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of eonsttruetiod Supervisors);provided that if the homeowner rngages a pa sons)far hire to do such work,that such Homeowner shall ad as supervisor." Many homeowners who use this exen>ption are unaware that they am assuming the responsibilities of a supervisor(see Appendix Q, Section 2.1 rncs This lack of awars often results in serious problem,particularly Rules&Regulations for Lieeruing Cmutuctiear Supervisors, when the homeowner hirrs unlicensed persons. In this case,our Board cannot proceed against the unlicensed person,as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsj'blr- To ensure that the homeowner is fully aware of hiArr responarinlitirs,many communities require,as part of the permit application, that the homeowner certify thatlydshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt sucb a fo¢rrVc rtiSeatirnr.for use in your community. Q:fonns:homccxcmpt. To: KERRY INSURANCE AGENCY INC: SCO From: Deb Derochemont 4-28-09 7:21am p. 2 of 4 AC Rv® CERTIFICATE OF LIABILITY INSURANCE DATE YYYY) 09 PRODUCER KERRY INSURANCE AGENCY INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EASTHAM COMMON RTE 6 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NORTH EASTHAM,MA 02651 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (508)255-8000 INSURERS AFFORDING COVERAGE NAIC# INSURED CRESWELL CONSTRUCTION CO INC - INSURER A:Liberty Mutual Groun 195 PINE STREET INSURER B: CENTERVILLE MA 02632 INSURER C: INSURER D: NSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR OkODIL POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYYYYI DATE(MMIDD)YYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY REMISES a ,"q',ee $ CLAIMS MADE OCCUR MED EXP(Any one person $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGG $ POLICY RO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE ` (Per accident) $ GARAGELIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO FA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION WC1-31S-342421-029 4/19/2009 4/19/2010 WCSTATU- OR AND EMPLOYERS'LIABILITY Y/NLIM, ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-FA EMPLOYE $ 500000If SPEC describe under IAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 ' OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF BARNSTABLE BUILDING DEPARTMENT DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 7 DAYS WRITTEN 230 SOUTH.STREET NOTICETOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUTFALURE TODD SOSHALL HYANN IS MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. '. AUTHORIZED REPRESENTATIVE Jeff Eldridge C v ACORD 25(2009/01) C 1988.2009 ACORD CORPORATION. All rights reserved. CERT NC.: 4885191 CLIENT CCD2: 1342421 Deb CecOCYemont 9/28/2009 7:14:08 AM Page 1 of 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # (o Health Division Date Issued' J Z(oh Conservation Division Application Fee Planning Dept. Permit Fee l Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street A dress 0142A� f Village fj//14 Owner QQve Address � AlZy_aP_.e e,4, Telephone , - Permit Request r }-- s• i/0r.,- 1 - kmlgee Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type W Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure 0 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full 66rawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full-.existing new Half: existing new Number of Bedrooms: K9 existing _ne Total Room Count (not incl ding baths): existing new BU+Lsv�a °u�F��'FY t:ftJ om Count Heat Type and Fuel: Ga .. ❑ Oil ❑ Electric ❑ Other (�� Central Air: ❑Yes No Fireplaces: Existing New MAEx`�t n3ogod/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ n5*Q%Ipzle)F BAB�rn D4xFisting ❑ 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 l ` rV Telephone Number Address LM License# 0(45' Home Improvement Contractor# Email )-o r06 Worker's Compensation # ALL CONSTRUCTI DEBRIS gSULTING FROM THIS PROJEC WILL BE TAKEN TO 0 tlw`r' Uwi Ste/' SIGNATURE DATE S I� n; FOR OFFICIAL USE ONLY c APPLICATION # 'i DATE ISSUED MAP/ PARCEL NO. — ADDRESS VILLAGE OWNER DATE OF INSPECTION: 4l, FOUNDATION i FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL -GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i \\\ 37 Amos Landing Ruad Near Scabttry. Alassachusetts 026.19 Remocle ieag Phone/Fax 51)K.477.1522 - Email: SCS HOME SCe'cnmcust.nct P1a4Sleek Inc. Remodeling Specleliet S.G. , Scntt Goldstein CUSTOM Klass Lic.#(142629 HOMES Reg# 1(H)O14 Tim Revellese April 18,201.6 1078 Craigville Beach Rd Centerville Ma. PROPOSAL FOR RENOVATIONS TO 1078 C.RAIGVILLE BEACH RD -All necessary building permits -Remove wall separating kitchen from living room up to cabinet including the 2 cased openings by kitchen and living room. Save all pine for new%wall -Remove chimney down to below floor joist el�is -Dispose of all demo -e- AwoT�cT —�S_71' ✓ I-10rirEr/��,v��•.��� Add -Patch in roof rafters and roofing(roofing to math as close as possible) -Patch in floor joist and subfloor. -Insulate new attic and floor areas -Build new V2 wall at separation of kitchen to living room -Electrical to include the relocation of thermostat, oil burner switch and 2 light switches to 1 location.Add 2 outlets to new'/a wail. -Frame header to separate kitchen from living'room. Wrap header in pre primed pine -Install existing pine boards to living room side of/z wall -Patch in drywall and plaster at%wall and ceilings -New granite counter installed on 3 brackets. Allowance$850 installed -Patch in hardwood floor at chimney area. Stain to match existing as close as possible OPTION-Sand and refinish living room floor with 3 coals of polyurethane-Additional-' $850 including moving furniture -New kitchen floor-Floating vinyl click floor installed over existing.Allowance.$1300 installed NOTE-Price does not include and painting.Price does not include the upgrade to any insufficient framing uncovered during construction TOTAL PRICE: TWELVE THOUSAND FIVE HUNDRED.DOLLARS$1.2 500 00 PAYMENT SCHEDULE Deposit at start $3000 Upon completion of all demo and interior framing $4000 Upon completion of interior work $4000 Upon completion of all work and sign off from the town $1500 Sco Go stein (President) Tim a elles Date of acceptance GVD2K fTY�/G�BI� I U J /rJYlt d't! !i'"/ONE/ s��y�� May 3, 2016 Scott Goldstein SG Custom Homes 37 Amos Landing Rd. New Seabury,MA. 02649 Dear Scott, This letter authorizes you to apply for and obtain all required permits to complete renovation work on my cottage located at 1078 Craigville Beach Rd. in Centerville,MA. Thanks, Ti vw Reti�:U.P.yP� Tim Revellese 339-987-8297 I 37ie Comrl:orrrreakh of- assadiusetts ., Department of r4dzfsh ial Acciderds 600 Was hzgtonx Street _ Baton,CIA 02112 mm-mc gorldia 'Workers' Campensaffun Insurance Affidavit Builders/CantractursfEIec6riciansfPlumhers Armlicant Information Please Print Legibly Name aemP�eA[�rg�b ��� 11,P Addre-s L NO'� CitgfStatef Y V tD Phone `' AK u an employer?Che the appropriate bow Type of project(regmi9eti): 4. I am a en�eral contractor and I Iam a employes with ❑ g G. ❑New construction • employees(fall andfor part-time).* have hired the sulr-contractors 2.❑ I am a sole proprietor oz-partner- listed on the attached sheet, I`- Remodeling ship and have no employees These smb-comractors have g_ Nemolition -woAdng far rrae in any capacity employ amdbave wod:ers' ca P§a-W-0doen Mmp.fragrance comp.mcnrat�tp l 9. ❑Building eddifi required-] 5. ❑ We are a corpozatilm and its 14❑Electrcal repairs er additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbiagrepairs or additions myssdf[No workers'camp- right of exemption per MGL. 12.❑Roofrepaim insurance reqired-]i C.I52,§1(4k and we have no employees.[NO Workers' 13.0 Other comp-insuranm squired_] $AnyVPHCS=d,atemcis box P1mastalsoffiaolthgsectinabgawslawiagtheaworkezeco3pensaii npaHUinF0nM2ia3 I Hamemuers who submit dais af#i n d hulicztmp they are&m.-O wa l sad thm bite outside cantram—st submit anew affidarlt ind'�sacb- ZCauactmstbgr clieckthis boat must attached=2dditian22 sheet shouingthe n—of the sob►-comtasetats.zad staiewhether armt18ose enfidesbzm eatployem I€thesab-tontaictnrsbaveempleyee%tf y=xsepmuidethek uarkelewmp.policynumbm lam an ,Beleiv is the policy and job site inforrrrrrtion. - - Insurance Company Name: � Pflfiey#or self--ins_Lit^.4 Vl� V FxpiratioaI?ate: Job Site Addr� QtY1Stafell7.tp: e/U'.C Attach a copy of the workers'comipensarionpolicy declaration page(showing the poRry number and expiration date). Failure to secure coverage as requiredunder Section 25A of MQ.c�152 can lead to the imposition of criminal penalties of a fine up to$1,500OD andlor one-year imprisonmerd as well as civil peualties.in the form of a STOP WORK ORDERand a fine of up to$25(LOO a day again&the violator- Be adsdsed that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for imsmance coverage verification I do hersby csrWfy a nder L*e pains and p&naMn ofperjWy that fie&informagwi prm ded abm�&is bare and correct Sitrattfre: Date: Phone#: ada'cird use only. Da not write in dds area,tct be cmapTeted by diy ortntrn offidal City or Town: Permhf kense# Issuing A thority(lade onf): 1.Board of Health 2.Building Department 3.Cty-fFown Clerk d.Electrical Inspector 5.Plumbing Inspector ti.other Contact Person: Phone#: - ormation and lastructions 7M&scacJ=eds Geheral Laws chapter l52 requires all employers In provide woik='compensation for their employees. , Pm-giant to this stare,an mnpIayee is defined as."every person in the sm-vice of another under any contract of bae, express or implied,oral or writCnu_" An eTIayer is defined as"an individual,pant arms,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 t ustee of an individual,partnerhip,association or other legal entity,employing employees- However the owner of a dw-ecl.ing house having not more than tbrw apartments and who resides therein,or the occupant of the - dweIling house of another who employs persons to do maintenance,consfxuction or repair worir on such dwelling house or on the grounds or building appu�thereto shall notbmanse of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or IocaI Iiicensmg agency shall withhold ffie issnance ar renewal of a license or permit to operate a baseness or to construct bufldings is the coramoxxwealth for any applicant who has not produced acceptable evidence of complian=with the insurance coverage required." Additionally,MCH,chapter 152,§25C(7)stains¢Bleitherthe.eommcmwealth nor ray ofits political subdivisions shall enter inth any contract for the performance ofpublio work until acceptable evidence of compliance with the ins dance.. requirements of this cbapinr have been presented to the contracting ailho>ity." Applies - Please fill out the workers'compensation affidavit completely,by checlrmg the boxes that apply to your situation and,if necessary,supply sub-cont uctor(s)name(s), address(es)and Phone numbers)along with their certi-fdcate(s) of „m=ce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers' compensation insurance If an LLC'or LLP does have empIoyees,apolicyisrequu-ed. Be advised that this affidayrt maybe subm�-dto the Department ofIndustrial Accidents for continuation of insurance coverage Also he sure to sign and data the affidavit The affidavit should be retuned to the city or town that the application for the peanit or license is being requested,not the Department of Inrhagtrial_Accidents. Should you have any questions regardmg the law or ifyou are required to obtain a workers' compensation policy,please call the Department at the number lied below. Self-fimutd companies should enter their self-insurance license amber on the appropriate lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fil out in the event the Office of Investigations has to colfact you mgardmg the applicant Please be sure to fill in the pen it cease mmaber wbich will.be used as a reference number. In addition,an applicant that must submit multiple penmit/Hcense applications in any given year,need.only submit one affidavit indicating current policy int'oImation(if necessary)and under"job Site A_eidress"the applicant should write"all locations in (city or town)."A copy of the-affidavit that has been officially simnped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for fufnre permits or licenses_ A new affidavitmust be filed 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 orpmmit to bum leaves etc-)said person is NOT recpmred to complete this affidavit The Office of Investigations would hie to thank you in advance for your cooperation and should you have any gnesiions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CamloaWmItIr of Masachmeng , Degartneufi Gf Jndugtiak Accidents 604 vlawmgtoa - Tf,-1.4 617' --4900 cat 406 or 1477-MA-SS AFE Fax 617` 27 7749 Revised 424--07 maS.�-EPgIdia f AC4[>O° CERTIFICATE OF LIABILITY INSURANCE DATE (MM,DD,YYYY, Estate 1 05/0312016 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 pollcy(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 Phone: 5OB-540-6161 Fax 508-457-7660 CONTACT Bob Allietta ALMEIDA 8 CARLSON INSURANCE AGENCY INC. NAME:PHONE FAX P.O.BOX 554 A/C No Ext: 508 888-0207 No: (508)888-0550 FALMOUTH MA 02541 E-MAILss: railietta@almeidacarison.com AODRE INSURER(S) AFFORDING COVERAGE NAIC# INSURERA :Western World Insurance Company INSURED REMODELING PLUS INC. INSURERB :Amguard Insurance Co C/O SCOTT GOLDSTEIN INSURER C 37 AMOS LANDING ROAD INSURER D: - MASHPEE MA 02649 INSURER E INSURER F _ COVERAGES CERTIFICATE NUMBER: 33156 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD`- SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MMroO MMroD LIMITS A GENERAL LIABILITY NPP1427194 12/18/15 12/18/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SO,000 PREMISES(Ea occurence) $ CLAIMS MADE OCCUR MED.EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICYFI PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ ' Excess LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B AANDEMPLOYERS' LIABILITY R2WC655501 12/31/15 12/31/16 TIo YLIIMTS OTH ER $ ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) 1078 CRAIGVILLE BEACH RD CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: Bob Allietta ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. .The ACORD name and logo are registered marks of ACORD 711 C/Q!/13)1G'7l!/tPCl�tll Q� ;l'�lCi iCCC12C4iC J \ Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Type egistration: 100014 xpiration: 6/812016 Private Corporatio REMODELING PLUS,INC Scott Goldstein 37 Amos Landing 4 -- --- Mashpee,MA 02649 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards �5/A3li E:tt E9!t i9 gs$$li�'3ligfta" �"'s 2k4# License: CS-042629 � SCOTTAGOLDs 'E 37 AMOs LANDING MASIiPEE MA 62646' p Jam" Expiration Commissioner 12/29/2016 0'*APE COD INSULATION El N PIY6 Q-35 $ep.5511 "..V POAM SUSPSN050 - SATTS OUTTSYS MSY TION MUNOS - 1-800-696-6611 Town of Barnstable Regulatory Services X_ Building Division 200 Main St Hyannis, MA 02601 %AJ M Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation; Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a_certified Building Performance Institute (BPI) inspector. All work preformed meets or.exceeds Federal & State Requirements. Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose . R-Value. 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JOB ............. .................... .......................... .......... ....... .......... . ....:..... ....:......... ............ .......... ...................... ........... ................. .......... Rmodeling SHEET NO. WI le, AA ........... .......... . ..... .......................... .. ....................... ............. ........... .................. .. ........ .............. Plu$ lak .......... .......... CALCULATED BY DATE M&Shpee;MA 02649 ............ ............. ................... I -IRR, CHECKED BY DATE Am6L-4-N w L4 .......... ...... ............. ............................. ........... ............. ............................... ............. ............ ........... ............ ............................. ..................................... SCALE PRODUCTM-1(Padded PRODUCT206A-1(Padded 17-EDGE)/Ae—m7.Inc,Gmton,Mass 01471.To Order PHONE TOLL FREE mam-m B 111LD/VG D,�pT MAY 04 2016 TOWN OF BARNSTABL E