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HomeMy WebLinkAbout0008 DONEGAL CIRCLE , . t• .. •p .. ,. v _, t ., .. .. � �: � .. c' . .. c . . � � ,. n ,. _ .� t ,. - � s '# ` '. e �t ^r� ,. o 4 . .. � 4. . � �. .. . a, _ .. x . - . ,. _ � - -. . . _ .. �' � ., i .. :. .� n � r - .. � . ' a o. � - r U - �' :.. � • �.. _ ,. � _ '� .� ,. ' n - '0 o . t a _ _ - • A •� Y • c ' .. }. n •� o � i i. � .. n � � ., 4 0 _ — ._._ a �. ., e— esr .t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �/ V Permit# � _ Health Division , ! � �Ud - //� Date Issued Conservation Division Application Fee l / Tax Collector / Permit Fee Treasurer SEPTIC SYSTEM MUST SC Planning Dept. IX STALL.E®IN COMPLIAt�°"'� Date Definitive Plan Approved by Planning Board VWTH TITLE 5 1ENVIROWENTAL CODE ANE Historic-OKH Preservation/Hyannis T004 REGULALTIC ES Project Street Address u►eaA���ior.1 Village _1 g%b Ala. Owner 1,,34\ G f rJ &,evs&, Address 130-0 HAW 5D.29- Telephone Permit Request 4w- RoWeOells Of hawk- _SQ�Ts &sag Sue:.LQ0f2- i Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation tPoo.oy Construction Type Lot Size Grandfathered: 0 Yes .❑No If yes, attach supporting documentation. , Dwelling Type: Single Family 4P Two Family 0 Multi-Family(#units) Age of Existing Structure 33 Historic House: ❑Yes VNo On Old King's Highway: ❑Yes ?DNo Basement Type: IfiFull ❑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 0 Electric ❑Other Central Air: 0 Yes *o Fireplaces: Existing New Existing wood/coal stove: 0 Yes 0 No Detached garage:0 existing 0 new size Pool:0 existing ❑new size Barn: 0 existing 0 new size Attached garage: ❑existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes I No If yes,site plan review# Current Use %A 16C —�Qsjb►N 94 Proposed Use BUILDER INFORMATION Name FIL'ws C. e-ki' Telephone Number s- 36 a- LAoZ> ` Address ? 0• l3ox -7 7a License# _LS ®& �® i�• 076°i Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE iZ.1910 3 } FOR OFFICIAL USE ONLY $PERMIT NO; -.1 / DATE ISSUED - r i MAP/PARCEL NO. J) ADDRESS ,I _ VILLAGE ' OWNER _ DATE OF INSPECTION: FOUNDATION FRAME _ INSULATION ems' FIREPLACE } ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL; I GAS: ROUGH FINAL ' `1 FINAL BUILDING 1 -t ti DATE CLOSED OUT " 4 ' ASSOCIATION PLAN NO. x The Commonwealth of Massachusetts u�)3 P Department of Industrial Accidents 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit-General Businesses name: �L1 .n1 ri l_t3v.1� N�4 TN C_ address: . city `(1c ) � state: (1 zip: O 2L7 phone# sy6"01 S',� CX) work site location(full address): t4eA ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑Restaurant/Bar/Eating Establishment working in any capacity. ❑Office❑ Sales(including Real Estate,Autos etc.) am an em loyer with em loyees(full& art time). ❑Other I am an employer providing workers'compensation for my employees working on this job. company name: 101$ C address- =40 • jga city: �fl O b f phone#. . .��� "t� . '�, fj(J .insurance-eot. . ROlicj# MEN /. �/ El I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: company name. addressd city phone#. insurance co. olic :# company name: address city::. . phone#. insurance Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certi and r he pain nd penalties of perjury that the information provided above is true and correct Signature Date 1 1(7 Print name tit a ,��Q f�� Phone# 1L3'08 4 9f;7a=(,Rao officiA use only do not write in this area to be completed by city or town official city or town: permittlicense# -[]Building Department ❑check if immediate d uire response is re ❑Licensing Board P 9 ❑Selectmen s Office i ❑Health Department contact person: phone#; ❑Other (mvised Sept.2003) ' 1 ` � s 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 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. Please supply company name,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 permit/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. 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 owe of invesugatlmns 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 Ar 1 x: 1 y i I lee 1°anvaw�zcuea/ �'aaoac`euoe�la B'QARD Op,BOIL©ING REG;ULATIQ;NS r License. CONSTRUCTION SUP-'-RVISOR ; I I ' Mum,, 08'5887 s Tr..no: 85887 Re,sfc JAY 'MILLER 450 SOMEFtS'ET r TAUNTON MA 02743 5 e i I' Adrrttinistrator I: � 1 l ' DEC-30-2003 01 :44 AM P. 01i91 VJ,/iViia77V Va.a.a 7.t.Jt:+Al7goL�YJ "HUk ql Town of Barnstable t , t Regnlatory Services Tliamw F.0411m,Dirutar Building Z+ WOU To=Tamil DnU" CommUdoxv Zoo Drxatn ft+eat HY&QU,UA 02601 Dace: 508.862 4028 Paz. 501-MOM Prop" Own" Must Complete and Sign This 9ecti,ora TfM4 A Baader ., , `' !!.._v 'awrMwwFa"�11�iRXiCtD�t�A�lb��3u��xQ�C�'t�, • ", .., ,' bat4b�•t�t�ipt�Sl��s t : �,to;cct OIL=J,boh&,, to wu pZtt�r�O►tivm to�000r7c�uthc�mt3•bg tie bv3�lpasxeiGt�ip.�ca�ics�for, . f�i�rew of,jobl • , NO As,e sor.'s map and lot- number ........L..�. .:. ...................., r0-S--.7G SEPTIC SYSTEM MUST BE 7G INSTALLED IN COMPLIANCE Sewage;?Permit number 'I�••..•�r•• WITH ARTICLE it STATE S, NITARY CODE.A AD TOWN CFTHETG� ;. TOWN` Off' BARl L vQy Y t . BASHSTAIME, o 39 NUI"AING ; INSPECTOR O '�0 YP a' z639 � J 1v 7 APPLICATION, FOR PERMIT TO .. .,. 4W1.. ............................ ............. TYPE OF CONSTRUCTION lsl/. (./!/�t'•....<.... . I .......- ...... ...... ....... �cr, sa?.. .......1 �.........19 ..� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... ........ �JN.. C�' Off!. ........�/. . "..r......... .( .�.1Ile............................................. Proposed Use .:./....... ell::4P./Yl........... f.��...........la....`.zd...... ..... Zoning District Fire District.........:. ....................................................... ..........................:.............................:.....,.... � ' � Aress � :> .G I ............................Name of Owner -awe 40-- - (` KSame of Builder �'✓!v ..:� ���rS ........Address .. .�- 1 � ,� :...... 1 'v0 ..!?Z(e0t Nameof Architect ........................................r........................Address ....................................................`............................... Foundation , p Number of Rooms .... ............ Q......... .........�...+0......v7... � Exterior .. + 1....:..........................:...........................Roofing ...X-9?11.A..f�(r .......... .................................... Floors .. .... % /�....... ........ Interior ...G°��-�t2.e. ................................................... /sy�il'+ L":a74.......... t dr. 4. Heating ....�.1....�!� ....�.YNA...,.:..... ....Plumbing 6 1�..................,........ .......................................... Fireplace ...a�6�.0.N..: .......................................................Approximate Cost ......Psn;?o!.n p . .�. Definitive Plan Approved by Planning Board -------__-----------------__----19________ . Area ..(e............ .,. .�...................... Diagram of Lot and Building with Dimensions .� � Fee ........-............................ SUBJECT TO APPROVAL OF BOARD OF HEALTH �Vj J At I her by agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam G*� . ... Feldstein, Dr. & Mrs. Robert single V No .....Wqi.4eik* for .... d to.�� .................. ................................................. Location ....... ........................ .............. gr.vil.IA................................ Dr. & Mrs. Robert Feldstein Owner ..�................................................................. frame Type of Construction ........................................... .............................. .............................................. Plot ............................... Lot ................................ Permit Granted October 12 76 ...............19 Date of Inspection/C. Date Completed ..... .... ........19 ;PERMIT REFUSED . ................................................................. 19 0 ............. ......—............. Ir .............. ....................................................... ............................................................................... ........... . ........................................................ Approved. .......................................... 19 ........................................................................... ................................................................................ p,.-.• -�.ra,....r ..^��.•. ... ..4... ..- 6. -.«F.•:1.......o•_.. �. �- ..,a...v.�....,..rrws- + .-,.. � , 1 ,z As essor's rriap�and"lot number ........./�.°. .�``••0�••.'•.•p.••• f 0 - ^7 y Sewage Permit number QyoFT"Er°�� TOWN OF BARNSTABLE BABBSTeBLE. C, "6 9 .•�� : BUILDING INSPECTOR iAPPLICATION FOR PERMIT TO ...................../...................,...............:...................!.............................. ............. TYPE OF CONSTRUCTION /*f�P"P/ . . ".... fs�1. n.C.: ..t�:.eti-e? .✓;.. r............................. t�� r.........19. ..-� PTO THE INSPECTOR OF BUILDINGS: jhe -undersigned hereby applies for a permit according to the following information: Location ... '`.................................' rG 's' �5?.G....... ���`. ! ........... 1.+/a'�;l-.'./%�•'.............................................. Proposed Use ... '�''.'!. �'.4 _17......... ! . .. .........f!'7 .1' . ......... ...t ................................., . �!.' .... a � y ZoningDistrict ........................................................................Fire District .............................................................................. r t f /ff'� i �'r Jam',rrf ,`r' / /.s.......:r2 A l J'�/. " 1 Name of Owner ,...:... ................ . ....... Address ,......._ .:...... ..i................. olf �. Name of Builder JY /l/d/�°// - +.................Address ...,,:.................... ,. . ......... r i , Nameof Architect ...........................%......................................Address .....................,..........................:.................................... ..................................Foundation .�.." 1 0��- ... �' '�' �/.. Number of Rooms .... ................... -.-............,,...... .....:........ Exterior //li� ..................................Roofing l�'1rfi ,./1 ,,............................................... .................................... .,.... G. t � Floors •................................ ......:... .........................................Interior ......... ,.......... ..............G......................... ! C iyAm Y�OYc h ' Heating �!r�...f !'tom`..` G ... • .121....'.! ....Plumbing i ............................................. .................................. Fireplace ...:...�.... � .. . � Approximate Cost r� 5��� ... ..! .... ` .................... :..................................... Definitive Plan Approved by Planning Board ________________________________19________. Area ...................� , ....................... Diagram of Lot and Building with Dimensions Fee ...........`-�...j" ".... "................. SUBJECT TO APPROVAL OF BOARD OF5 HEALTH C?1P r; '1 0 i Aga �t •�� At m I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. . r���.... Feldstein, Dr. & Mrs. Robert A=169~/0 -^, � / . ' � 18709 add �q �w���� � '`" : rennnrp, ~ ` ' ----'' 0 l Cl ' Locot�n'-----.��--�------ --. ' ` . � . Centerv�lla .-------------------------.. . - Dr. & Mrs. Robert Fmldotabm ' Owner ----------,----------- Type or Construction ' ' ' ' Plot . . ' � ~ . Permit` Granted— --' ---------'' ' 76 � . Date of Inspection D~'~ Completed ' . . rERmmo . . ' . - .............................................. . - ~ ' . . ............................................ -'-- -'' ' ' ----' K w" . " � � � --.`�...�- ---............................ ...................... � '-----^---^^-'' '-^---'^-^-----' Approved ................................................ lV � ^ . � -----------------.--..--.---. , _ . ---------------------^~---'' . ^ ' TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL ID 169 070 GEOBASE ID 9556 ADDRESS 8 DONEGAL CIRCLE PHONE (401)663-6300 Centerville ZIP - LOT 53 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CO PERMIT 16679 DESCRIPTION BUILDING PERMIT #13335 PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BOND 1t1E CONSTRUCTION COSTS $.00 Qi► 753 MISC. NOT CODED ELSEWHERE 1 PRIVATE P, 1 , * BARNSTABLE, • MASS. OWNER ATTLEBORO ENTERPRISES, AQUIVEST GROUPi67� ADDRESS Epl 2 BAYVIEW AVENUE PORTSMOUTH, R.I . BUIL SAT is DATE ISSUED 07/19/1996 EXPIRATION DATE BY __ Y Department of Health, Safety and Environmental Services 4► * a�xwsrABt.E, MAS& �039. ED MA'S A BUILDING DIVISION BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRELl.q. APPROVED PLANS MUST BE RETAINED ON JOB AND FOR ALL CONSTRUCTION WORK: INSPECTION WHERE APPLICABLE, SEPARATE THIS CARD KEPT POSTED UNTIL FINAL IN 1.FOUNDATIONS OR FOOTINGS HAS BEEN MADE.WHERE A CERTIFICATE SP CTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERSOCCU ELECTRICAL,'PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS - ' `2b� K�• ' �G-off �Zs=9c .Car�►or � Y 2 2 f 2 3 1 HEATING INSPECTIO APPROVALS ENGINEERING DEPARTMENT IAJ 2 ARD O EALTH OTHER: SITE dN REVIEW APPROVAL fi*t , I 57f [Uv il 1A WORK SHALL NOT PROCEED UNTIL PER IT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION.` NOTED ABOVE. TION. Assessor's Office(1st floor) Map Parcel # Conservation Office(4th floor)(8.30- 9:30/1:00-2.00) Date' Issued 9G Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) Engineering Dept.(3rd floor) House# '4 : aj'S UST B ANCE AND rmTrniuvu fanove y amm� d - .19 `}, ": E Ns TOWN OF BARNSTABLE Building Permit Application Project.. t A ress �1 r Village G6-Nn -Owner _ W,.3 Address k aA�1/1 /�- 6L8.7/ Telephone (a8 3.-(g,-3 00 Permit Request ZJU ST/�LL- ' Nei U �+�i//� �jA'Ti�jjl/G o _ G01V t/it_j2T �i llol -D�IT� ��/�ND/ i° R/�i►-��, kt � Sf ��v-> ia� keyu,2�y/S4 "First Floor � Lj' 3 � � square feet e4 , Second Floor square`feet Estimated Project Cost $ Zoning District PL:S . G Flood Plain Water Protection Lot Size a 0/ q00 O q Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use S 1,N G LC J_-(k NA t'Ly H-g,w'--e— Proposed Use Construction Type WOO r---/e/}-M `Q. Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure S(p Basement Type: Finished Historic House IV D Unfinished Old King's Highway Number of Baths ' .2-- No.of Bedrooms Total Room Count(not including baths) S First Floor Heat Type and Fuel C) I (-- Central Air S Fireplaces (ey-[STJ N G Garage: Detached Other Detached Structures: Pool N� Attached Barn N cy None (�— Sheds ~' [12 Other �- Builder Information Name I M O i U Q_�> i'/��oS,._ y -(G .Telephone Numbers-L�O/-•fo f3 3 - ?b 0 Address 3v�5 �lh�P <L G �� License# 9e 7 2% Home Improvement Contractor# A/a i /?C-!5?. 411y c,C- 2-64-1 .y jkz,� kye- Worker's Compensation#SuO -Io S'uPP X /00 o u 77-Y-; AT':_ 6;>2 6 7/ s1413 J"E c T ?';=� . NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE L�- — DATE I 1 2_3 ' BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) )� l FOR OFFICIAL USE ONLY PERMIT NO. 33 -3 - DATE ISSUED ' MAP[PARCEL NO. ' ADDRESS. VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE. ! ELECTRICAL: ROUGH FINAL PLUMBING , ROUGH FINAL t t GAS: , ROUGH FINAL - FINAL BUILDING DATE CLOSED1&RJ '•' ` " 'f t ASSOCIATIOXPEAN NO" . The Town .of Barnstable Departmentof;Health Safety and Environmental Services Building Division 367 Main Shock Hyaanis MA 0=1 Offrcm 508-790-6227 Ra Hu"idp/h�QCdtag�tv/�W1Y u S i•• u1i. F= 508-775-33" 'For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENTCONTRACrORLAW SUPPLEMENT TO PERWr APPLICATION MGL c. 142A requires that the"reconstruction,alterations;renovation,repair,modernization,=rV Si0u, improvement,.removal, demolition. or construction of an addition to any pre-odsting owner occupied building containing at least one but not more than four dwdling units or to sGrw=r-s which are adlacezu to such redden=or building be done by registered eoatr =rs,with certain ego PdOns, along with other requirements Type of Work:C��� �S4�34 Est.CostoaeEif/�8 Address of work: f3 D,?) i r 6a L C-A re4V/a—& i v �, Oaner.Name: Acc�tei l)c S% 6wae ° Date of Permit Application: 2 3 I (� I hercbr certify that: Registration is not required for the following remn(s): Work excluded by law Job under SI,000 wOj3uilding not owner-0ocapied wner Pulling oars Permit Notice is hereby gh=that: OWNERS PULLING INEIR OWN PERMIT OR DEALING WITHDNREGISIMED CONTRACTORS FOR APPLICABLE HOVE %eROVE?AENi' WORK DO NOT HAVE .ACCESS M THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERSURY I hereby apply for a permit as the agent of the owner. Date �--- nttactor name Regisuatian No. OR .. .. . .. .. .'.-- ., . . ... ......ul., .1'.. A ✓ The Commonwealth of Atassachusetts Department of Industrial Accidents - �, Of//ceO/AYest/layoffs �;� `ti!a_: i•,�` 600 11•ashington Street Boston,Mass. 02111 Workers' Compensation Insurance.AMdavit ;AnDhcant Information: Please 01IiNT'1'w�]���� �� _�n��� .• � .S name: AG 4)V/V E ST G2n C.0 0 /9r�IAV I,?6 location: e`L g r y VI � l� city ��1Q1�v�10t�t�Tl-} f� - D28 - l ohone 0/-&g3 'b300 I am a homeowner performing all work myself. 0 1.am a sole proprietor and have no one working in any capacity L..1an... .: . ...�;,,iaaiir�iu,n " _..._ ,, •.... .. ;.....,.-c... y}!' •r+�anvr lam an emplover providing workers' compensation for my employees working on this job. comnanv name- address: �h'• phone#• insurance co. .� polio.# L' .r: _ •r. -iwr......far..+•-• ►..,A'!O^..""r*�!.�!n!�o►.f1"" i r..........tee.. '1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: YET To 136 D6�T2e&M1NE- address: A2i5 cLl �% ;/0 v112 /&At W j' -C-Or4 ► city: /27- T/�i u/L�� insurnnce co. policy# -', L��� *J�TJ�i' =R: 'fA°S ?F7•_�Rs! comnanv name: address: city: phone • insurance co. Attach addiddhal'sheetiflieeessary� :•:�7: '•r ;t;'�-srr+ Y r;- ��+. ���•. failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. ' l do herehr cerriALuntler the pains and penalties of pcduq•that the info►nwdon provided above is true d correct Signature Date Z 3 Print name ��1 i ��`� 1Ll 1 � NOT ro G�n- Phone# &e 3`�� official use only do not write in this area to be completed by city or town official city or to permit/license q riBuilding Department C3Ircensing Board ' D check if immediate response is required 0Seleetmen's Office [3Ilc211b Department contact person: phone#; r iOther o (revised 3,195 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers t'o provide workers° compensation for thei, -emplovees. As quoted from the "law", an empinree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An enrpin>>er is defined as an individual, partnership,association, corporation or other icgal entity, or an,,,two or more of the forcuoing engaged in a joint enterprise, and including the legal representatives of a deceased emplover, or the receiver or trustee of an individual , partnership, association or other legal entity, employing,employees. However the o%vner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwellino 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 1.52 section:25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or hermit 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. j`w�.:a:. 'y�,•S'7 •.1:1 7. - .la w.... .,� c`.w:.C, v.•.:. R�:•'� � .'t•i •r 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 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. Tile affidavit should be returri.01o.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. 7.1 ,�.. �. .... .. '. -;r' .ii�•L -ti _ia.��«...:�v..�..-• 7jL� f'���A� •r�..SGi,.lL? ¢�'��� YwuF�''..h.� �v _. .... 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 permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX uniess other arrangements have been made. Tlie 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. t T' !!1_!�'!'^;"�.f•+:.e► .�!7vs�t. ...••:rr.w .•rR;�: •.f:)t:+si_ i «• .�w:'«`..i+ ...7 ie :e:'. .�. 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 fax#: (617) 727-7749 phone#: (617) 72,74900 ext. 406, 409 or 375 DEPART01 OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Restrt�tedxTd OU .., iIMOTNY M FORD '. •nr� 339 PINENILL RD 02190 t --IfE5TPORi, MA p ` :VIOENC OF PROPERTY INSURANCE THIS IS EVIDENCE THAT THE INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND RCONVEYS AL /2? 9 5 THE RIGN,TS AND PRIVILEGES AFFORDED UNDER THE POLICY ' °■usstssaasltmaowmmcaiamssasaasssasssassaas:as�smaaassssaasscmcsasssSaammsamaasamsaassaacgaaaaamsssmseasaaaaasmsam�sbssssmsasss I PRODUCER COMPANY CONTRACTORS INS. SERVICES INC. GOLDIN-INSURANCE AGENCY INC. MARYLAND INSURANCE GROUP VASTAPROVIDENCE,JERI . PHONE CODEZ 3 0 8 .....•.•.:••.••••.•�.•.•••••.••.....•..•.•..•. .a..:.... s • SUB. POLICY NUMBER CODE •LOAN NUMBER • Ma• .:. ........4. "' 8R90797565 INSURED' I AQUIV.. ........................... EST GROUP INC. .................................... BRISTOL FERRY .'WHARF EFF: DATE (MM/DD/YY) EXP. DATE (MM/DD/YY) continuous until 2 BAYVIEW AVENUE OS/04/95 ( terminated if PORTS.*' OUTH RI checked I I .................:........................................... O 2 8 7 1: ..THIS REPLACES PRIOR EVIDENCE DATED: aammassa{ii�aamsmsmmmasssasasmmssssassssaassasasaassamsasssssaas�aasaamoasasasamamaaaessmmasaaaoammamasaaaaaaassaasssaasmsaasass PROPERTY JWFORMATION samass�sais�assssammmsaaassasummaimsa Banana aana Run anasasaaaaaacma=aa0aaaaasaaammasamsanm=alas=axsaosamsxsa===spa=aaesaasa:saazas LOCATION(DESCRIPTION 001 a:. SEE DESCRIPTION BELOW LOCATIO4 DESCRIPTION 1, ry1 i COVERAaa�s*sORMATI■o mss■■aasu■•■um■assmmmsssst�smsmmsas:asagamaaaaamsomaamas:aaamaaaasmaaaaeaaaasasaaamsamesmmaasaaumtsascaa COVERAGE;I�l��ORMATLON- e ssrmuui�omassspwusanolumaasmsassmsaasmasssssasaassssmaaamsssaassasssmssaaaaasaaamaasaaasa■asmssaaamsassaasaasmasaaasaaa Coverages/Perils/Forms Amount of Insurance BUILDERS RISK "SPECIAL FORM,, SUBJECT TO Deductible STANDARD EXCLUSIONS 8 DONEIAL 'CIRCLE, CENTERVILLE, MA $224 640 $500. 35 AN,CiELA ROAD, BRAINTREE, MA w $247,594. w�F � a sasaaama�.mriimsassa■msmmsssasssssssssaoastmamassass;aassaas�aemsacaassaasesaaaassaasaaasaaaesaaassaaaameaaassasmsaasamssaasmsamasa REMARKS'Q' lading Special Conditions) THIS .,EVIDENCE OF INSURANCE REPLACES EVIDENCE ISSUED ON 9/25/95 ADDITIONAL INSURED RE �tESPECTS ABOVE LOCATIONSi ' I . ATTLEBORO PNTERPRIESES PROPERTIES; I*1C. I EXPIRATION DATE OF I; .; POLICY: CONTINUOUS ' amsssma CANCELLATION T'ION s�mamaamsssssmssssammsssstsssssssssatsssssss��asaamaassasssssaosaamsmamsaaaaaamsasemamsssasmssaamamamsascsasamaasssl ' smssassmuaas�ssamasmssm�oasasYsass�aassasaeaassaassaaasaseas aaosSeassemaasamsaaamasasesascseeaamsamacasaamabasaamssaaaaaaassl THE PO41GY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE POLICY BE TERMINATED, THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 10 DAYS WRITTEN NOTICE, AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW: sasmassamamssmsaasamsas•amamsssamamniaaaassaseaaaaaocaaeassmasacaeaaaaaaammaaascaaaaaasaacacscasaaasasasaasaasasasssasasssaseassc ADDIT101t�tJ INTEREST NATURE OF INTEREST NAME AND{l►flORESS ( I Mortgagee I I Addi-tional Insured ` 'A f I Loss.Payee ( ) Other .. A•URE•OF.AUTHORIZE'•AGENT•OF• OMPANY.............................. .•..•. .•• ACORD 27'S2/88) 1 i I • MI WIlOr4 AGENT : NCE nod 1 HOME BUILDERS INSURANCE PROGRAM Post Office Boxio197 Contractors .Ins Services, Inc. Jacksonville,FL 32247-0197 73 TAunton Avenue East Providence, R. I. 02914 CERTIFICATE OF INSURANCE This Certificate Is provided as evidence of insurance under Policy# RRan7.97�h.; of the Company named herein. MORTGAGEE INSURED Name and Address Name and Address j:. • Bristol County Savings Bank Aquivest Group, Inc. 130 Pleasant Street Attleboro, MA Bristol Ferry Wharf, 2 .Bayview Avenue Portsmouth, R. I . 02871 Amount o overage Per Bldg, Premium Effective Date(Date (Completed Value) $ � $ owl Construction Began)• Term Description and Location of Proper YAO tie Insureds 12 Months rantnr WA CQwP!QUW , 35 An ela Road Braintree MA - Completed VAlue 247 594, - Premium: $495.00 This into certify that the above is insured under a Builder's Risk policy issued by a Maryland_Casualty Company, covering property identified above from the Inception date shown,subject to all terms and conditions contained in the policy. Insurance as provided under the aforementioned oiicy is subject to all terms, conditions and limitations thereof and shall in no event extend beyond date of termination oft d's interest in the articles described herein: Dat�ci oZ 19 ized Agent Or WARNING This Certificate is issued to protect the mortgagee only, Under the terms of the insured's policy, insured agrees to report all starts and pay the appropriate premium to the Home Builders Insurance Program, P.O. Box 10197, Jacksonville, FL. 3224.7.0197. Insured must report all starts shown on this certificate prior to the end of the next month. If insured does noV-r�port within this time period, the insured will not be covered. ?I:r In.sU,Ocl should check with his HBIP agent to make sure he understands his•raporting requirements: MARYLANDvCASUALTY COMPANIES THIS ENDORSEMENT, EFFECTIVE 12s01 A.M. , SEPTEMBER 1, 1995 FORMS A PART OF POLICY NO. BR90797565 ISSUED TO ACQUIVEST GROUP, INC. AND ISSUED BY THE HOME BUILDERS INSURANCE PROGRAM . IS AMENDED AS FOLLOWS: IT IS HEREBY UNDERSTOOD AND AGREED THAT THE FOLLOWING IS NAMED AS SECOND MORTGAGEE AR RESPECTS PROPERTY LOCATED AT: 8 DONEGAL CIRCLE, CENTERVILLE, MA. MASSACHUSETTS HOUSING FINANCE AGENCY, 1 BEACON STREET, BOSTON, MAI 02108. ALL OTHER TERMS AND, CONDITIONS. OF THE POLICY REMAIN UNCHANGED. AUTHORIZED SIGNATURE INFORMATION FOR LOCAL .OFFICIALS Proof of Licensure" Pursuant to 780 CMR 63.8A .and 104 CMR 22 .55-22 . 58 the dwelling unit located at 8 Domegal Circle. Centerville shall be. certified '(N.B. the Department .of Mental Retardation issues a- certification which is equivalent to a license) .and operated by the Department of Mental, Retardation. In addition, the attached Affidava t shall be. completed prior to application for Certificate of Occupancy pursuant, to 638 . 1. 8 , Use Group: Pursuant to 638 ..1.1 the. classification .of use for the above named , dwelling unit shall be. R-4 contained in. a single family dwelling. This dwelling unit shall house no more than four , r individuals Classification of Residents/Classification of Buildings The above named dwelling, ,unit shall be built/renovated to accommodate individual's viewed as impaired pursuant to 638 . 1.2 . This dwelling unit shall be eauinned with a fire suppression system in compliance with 638 .2 .1, Category A, Option. 1. IV Certification Specialist ' Department of Mental Retardation Lq .The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Mental Retardation Southeast Region 68' N. Main Street Carver, Massachusetts '02330` Philip Campbell Area Code (617) Commissioner 727-9088 Richard J. O'Meara Area Code (508) Regional Director 866-5000 Date ., A F F I D A V I T To, Whom It May Concern: I hereby certify that the residential program at operated by meets or exceeds all requirements stated in either. 104 CMR 22 . 55-22 .58 (Staffed. Apartment) ; or, 104 CMR 22 . 80-22 .84 (Limited Group Residence) pertaining to smoking regulations, staffing ratios, resident classification and resident restrictions (if any). by floor. . ' Resident classifications have been confirmed through a. fire drill in accordance with the procedure outlined in either 780 CMR 638 (Staffed .Apartment) ; or 780 CMR 636 (Limited Group Residence) . Certification will be issued to this program in accordance with Department of Mental Retardation protocols . Quality Enhancement Specialist Office of Quality Enhancement _, �`�`' Q`' �'� ♦�� ���q U/QP O SANS per' oo- CIR ` 3� 1=, H=►•off!'—a��++ �N l�4 . BRIDGETS> i ^l t�1 \ II opc `r1 DONEGAE PATH�� �QapO =�lLunrh�rr ti I �_CIR _/Q Q _J -, G A C.ri Ppn;l 1 �`l Q vIj l� r�� " = l Cc I ticI o to �. a•,r�, , BERr Loco, G, �1 MANNI W � c,R_ lJ `,cEBECCAL A ° C+fG!� •(, / O \ r o � 9 s PIUSSO �'� oc VERMEEi�I<1 r1 'o WESTMrNS � WPI LON CIR i U Q4 SA 2 ,Q � l001lo Vorrh y', Pond m'I D AU ?" L4rst Pond AIR OAKS .� � RD urn ytfa! N GOSLING A q�SChoo1 C C/ of '''s}, • � h%v l i of _0 ' l 7. X10 /Cva a� Q GENERAL INFOR!1 ATION \ i , onina Desivnation: Res. C /'- Min. Frontage: 100 ft. Min. Setback Dimensions: 1 � Front- M ft. 2�'... ' ?� n} i Side: 10 ft. Rear: 10 ft. Max. Bldg Heigh: 30 ft. or ?.5 stones rz=',C of ,� cam' , , Max. BldL. Lot Coverage- 15% or .'S00 s.f. /jcC\ e4` ! ( if ninoffdischar2ed on site I not more than 501/a INII Parking Requirements- None 17--tea : . Note: Site is within the Groundwater Protection District. no restrictions to the or000sed activity Plan Prepared For: Acquitech Group, Inc. r < .15 I 2 Bav View Avenue Portsmouth, RI Telephone- (401) 683-6300 iI Plan prepared by: Norman Levin, P.E. 7 8791 25 Lexington Drive Hyannis. MA 02601 Telephone: (508) 778-5110 PLAN O� LAND Fax.- (508) 778-6317 AT 8 DONEAGAL CIRCLE Scale: As Noted Date: July 27, 1995 CENTERVILLE, BARNSTABLE, MA C IT, 7- F7, 771:7,7 77 t7 -7- 4N -d 1 0 s V se c-dif n g t t e -O'Oflo'n Nu' n d, IL Ap al u p IN A Fzv--�H I 54 r-� p 1�4 e rAv CL �l 4 IU\ -C tu Q C7 ............. fitftItitttiftitIx Ittftttit47 AS p to fitifit-"Ov E, C'Zo t........................ titttitLA P titifftLx C LU tiitiltiftr-I ILt-I IIttF-IV I tIN F-Y 14 IIittitV4 NEI -'�I A-re-�4 0 iHf�4 IItitttttifiititittifit �A�4 05 It.011 ifittf412 iJ Iiitt 1� 71 e 7L7 T' A�4 0 41� 'Co _V JE L� �5 L4 F Ilt.,?ikjq F P-P 16 �OF A, L:T H 1,N '5 p C,4 7� P IZA I 1� p LI-U jo Fop F m 4U lQ: OL r. Ar' C, LA�<I��j .H : , _.A U p �,�j r.a w 0 J_ A L.L. H T J4 15 14 1.4 1'�4 $L%i 16 L a �4 'I" v it �4 r 0 U V4 N-1- r7- PH 0�4L V r7 po 5 v H 1,4 4 o oo► . CIO rA co cr CD n L.. R A U✓�J7R { oW F ce -"►� E. 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