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0054 EBEN SMITH ROAD
���� ,. a : ,. '�. � Y � � „ . ./ G �� „y •� .. .. �, ,, a ', ,e _ � ,. _. �, a � _,; ,. -� a y ... ,,, . - � w �. _ _; ,r L �, o ,.. ,, �� � � v_' . —.� a , >. r ,� ; ,. .. � d. s „� .. .-. �, .� _ � ., ,a �. '. �� .. �, t s,, ,. ,, ,. 4 � v � � _ _. _ ." _" ; ,,, .. ?: .. .: f .' ..> � � -. .. .. ': ,: • G .. ., .., .� - - �. y:. _ �. �. _ a o '.. - � '. fi � .. a :.. �. � i. i [�' �. - c - [' . - .. ., ., 3' - - - �. n ... - ... ., ,.. _ .. �. i . _ ', ,. rt � .: .. .. :. ,,> � - , � y Application number.......................................... A Date Issued........ RAMNSTABM1:.�.�. ..�.!..WAS& 4-PIRESS PrAMPI 16,39. �0 Building Inspectors Initials............ Map/Parcel...... ... . . ................................... TOWN OF BARNSTABLE TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ING/W ROOF/SIDINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY MORMA'TION Address of Project: _jy fl � &ter NITIVIBE STREET VILLAGE Owner's,Name: ���. Q � �'/4 �, ,, Phone Number Email Address: r�(�c r IC @ e►�ca s n e-{' Cell Phone Number Project cost$ R I 1 7 _ Check one Residential Commercial + OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Se, .44,a,\a C'c,4ci-,� Date: TYPE OF WORK Eiding Windows (no header change)# L Insulation/Weatherization Doors (no header change) g )#.�_ Commercial Doors require an inspector Is review u Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 141&s4e-1r?4o/r COl`➢H RAC Y OWS INFORMATION O161V'LATION Contractor's name i�r u,, `7�n.�;so r, - Sov 2�� AfPAJ F,, Iev4 kfi'n jow S Home Improvement Contractors Registration(if applicable)# 17 3 2-q S (attach copy) Construction Supervisor's License# 0� S-7 07 (attach copy) Email of Contractor SL,Jea q5 ; (• C M Phone number l/01- z z R -9 RCo ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. n APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4:30pnL Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMTTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures;specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT9S SIGNATURE Signature Date /O / All permit applications are subject to a building official's approval prior to issuance. Renewal Agreement Document and Payment Terms 'byAndersen. dba:Renewal By Andersen of Southern New England Mary Pat&Rick Clayton ' ALACIEMIENT Legal Name:Southern New England Windows,LLC 54 Eben Smith Rd. Centerville MA 02632 Rl# 07 MA#173245 CT#0634555 Lead Firm#1237 36 9WINDO 1.0 Reservoir Rd I Smithfield,RI 02917 H:(508)681-8018 - - Phone:866-563-2235 1 Fax:401-633-6602 1 sales®renewalshe.com C:(508)280-2133 Buyer(s)Name: Mary'Pat &Rick Clayton -` Contract Dater 10/05/18 Buyer(s)Street Address: 54 Eben Smith Rd., Centerville, MA 02632 Primary Telephone Number: (508)681-8018 Secondary Telephone Number..(508)280-2133 Primary Email: mperle@comeast.net: Secondary Email: Buyer(s)hereby jointly and severally agrees to.purchase the products and/or,services of Southern New England Windows,LLC d/b/a. Renewal By Andersen of Southern New England("Contractor"),in"accordance with the terms and conditions described in this Agreement Document and Payment.Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms.of which are all agreed"to'b ...the parties and'incorporated herein by reference-(collectively, this"Agreement`): Buyer(s)hereby agrees to sign a corripletion certificate after Contractor has completed all work under.this Agreement. Total Job Amount: $90557. By signing this Agreement;you acknowledge that the:Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,,or cash. Deposit Received: $41778 Balance Due: $4,779 Estimated Start: Estimated Completion: Amount Financed: 6-10 weeks. 6=10 weeks $9,557' Method of Payment Financing : We schedule installations based on the date:of the signed contract and secondarily on. the date in which we complete the technical measurements.The installation date'that, we are providing at this time is only an estimate..We will communicate an official date and time at a later date:Rain and extreme,weather are the most common causes for `delay- Notes: 50%deposit-GREEN SKY;" 50% balance due upon completion-GREEN SKY Buyer(s)agrees and"understands that this Agreement constitutes'the entire understandings between the,parties and that.there"are no verbal undersiandings changing or modifying any of the.terms of this Agreement.No alterations to or deviations from this Agreement will be valid withou.t the signed,.written consent of both the Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1)has.read this Agreement, understands the terms of this Agreement,and has received a completed,signed;and dated copy of this Agreement,including the two attached Notices of Cancellation,:on the date first'written above and 2)was orally informed of Buyer's right to cancel this Agreement: NOTICE.TO BUYER. Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY.CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 10/10/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION; WHICHEVER DATE IS LATER.SEETHE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC ' dbai Renewal By An of Southern New England Buyer(s) -02 Signature of Sales Person: Signature. Signature' Chris Hutson Mary Pat Clayton Rick Clayton'. Print Name of Sales Person. Print Name: Print Name.." f• UPDATED:.10/05/18 Page'.2 / 11 :'. ZZ ram'llweweve�-W/ Office of Consumer Affairs and .Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement;=Contractor Registration - Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS, Expiration: 09/18/2020 10 RESERVOIR ROAD - SMITHFIELD,RI 02917 = - iCA 7 Ca 20M-05/17 Update Address and Return Card. � + .%`in. �cvninniu�w,a,�l✓�o-�.i%�m�-:�io�el.G: Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation IZ3243 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW7ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 10 RESERVOIR ROAD" SMITHFIELD,RI 02917 Undersecretary iv .a� WithOUt Signature i r Commonwealth of Massachusett-s h: Division of Professional Licensure Beard of Building. Regulations and Standards Constr� is `S ,prvsor /0 /20 0 CS-095707 Epp d res : 09 8 2 BRIAN C DENNISON 8 BLACKWELL-DRIVE r; CHARLTON MA.;0 1507 _ - Commissioner The Commonwealth of Massachusetts Department oflndustrialAccidents (f 1 Congress.Street,Suite 100 ' Boston,K4 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERINlITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): �S„y/�,Qrn ,f fj1G.�GI✓7,Y �it�nr/oa/f Address: 10 /fie Ser l/o,'r- Rcl . City/State/Zip: -1 4,;e_f 2 Z 2,,1 17 Phone#: Lf 0 l—Z2 k--q J•OO Are you an employer?Check the appropriate box: Type Of project(required): 1.r1 am a employer with eR 04, employees(full and/or part-time).* 7. New construction IM I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.[—]I am a homeowner doing all work myself 9. ❑Demolition y (No workers'comp.insurance required.)T 4. I am a homeowner and will be hiring contractors to conduct all work on m ]0 Building addition ❑ !' Y Property. I will ensure that all contractors either have workers'compensation insurance or are sole I LM Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.eO f repairs These sub-contractors have employees and have workers'comp.insurance.' 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. er (,t),Lh ja CIO 152,§1(4),and we have no employees.[No workers'comp.insurance required.] /Cc r -0`5 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. }Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatine such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: '',f e M QJl S 14 C. CDP, -n y Policy#or Self-ins.Lic.#: (^/CA 3 J S S 72—CI Expiration Date: Job Site Address: /f 6 Rc• City/,Mate/Zip: C&?7WV,'f1,e , m t4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties,in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pai . and penalties of perjury that the information provided above is true and correct Signatur Date: 10 — Phone#: y 0 1 —L 2 9_':T KQ Q Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACC)RV CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CoBiz Insurance, Inc.-CO NAME: 1401 Lawrence St., Ste. 1200 PHONE .303-988-0446 FAX Denver CO 80202 E�OAIL C No:303-988-0804 DD ss: COMail@_cobizinsurance.com INSURER(S)AFFORDING COVERAGE NAIC @ INSURER A:Acadia insurance Com an 31325 INSURED ESLERCO-01 Southern New England Windows, LLC. INSURER B:Firemen Insurance Company of WA,D.C. 21784 dba Renewal b Andersen of INSURER C:Homeland Insurance Company f y Southern New England o New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: —A INSURER F COVERAGES CERTIFICATE NUMBER:1252851165 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 WVDPOLICY NUMBER MM/DD MWDD LIMITS A X COMMERCIAL GENERAL LUU31LnY CPA3158728 1/1P2018 1/112019 EACH OCCURRENCE $1.000,000 GrWMS MADE FRIOCCUR ED PRE�M SES Ea occurrence) $30D,DW MED EXP(Any one person) $10,D00 PERSONAL&ADV INJURY $1,000,0DD GEN'L AGGREGATE LIMIT APPLIES PER: X GENER POLICY❑ ❑ AL AGGREGATE $2.000.000 JJEE� LOC - PRODUCTS-COMP/OP AGG $2,000,000 OTHER: A AUTOMOBILE LIABILITY N CPA3158728 1/1/2018 1/1/2019 COMBINED SINGLE LIMIT Ee accident $1 000 000 X ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ A X UMBRELLA LIAR X OCCUR CPA 1/12018 1/1/2019 EACH OCCURRENCE $10,0D0.000 EXCESS LIAR CLAIMS-MADE AGGREGATE $10,000.000 DED I X I RETENTION $ B WORKERS COMPENSATION WCA3158729-20 1/12018 1/1/2019 X 'PER OTH AND EMPLOYERS'LIABILI Y YIN STgTtJTE ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) If yes EL DISEASE-EA EMPLOYE $1.000.000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB $1,000,000 C PoOution Liabl% 7930073340000 1112018 1/1/2019 Each Occurrence $1.000,000 Claims Made Policy Me a $1,000.000 Retroactive Date 06202013 Deductible $10.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD �3 t„E x a .Town of,"Barnstable *Permit 0 l o 3(q 3 r Expires 6 months from issue date _Regulatory Services Fee as N, X-PRESS PERMIT 7 MA88 `Thomas F.Geiler,Director Building Division ' MAY 16 2013_ Tom Perry,CBO, Building Commissioner- ZOO Main Street;Hyannis,MA 02601,` www.town.barnstable ma.us TON.QF F<$ARN'STABLE ~ Office:•508 862-4038 ax; 508-790=6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY' 4 'Not,Valid without Red X-Press Imprint Map/parcel Number { w Property Address y� /U /'1/�li i�l) �PPfex U,(/m EiResidential _ Value Minimum of Work `j Oa fee of$35.00 for work under,$6000.00 " � Owner's Name&Address , g4/Zo C/f� 4- le G z 3z w s Tele hone Number !O a qSl�. V Contractor's Name, Of J h �/LU/!/S/l% p - C!¢�j 22i a e M E/UIIINC Home Improvement Contractor,License.#(if applicable) Construction Supervisor's License#(if.applicable) ;f a CS �O 7 [ (Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner, E have Wo ker,'s Compensation Insurance _ J a c e�. h? r'a e yr IVJ Insurance Company Name M r - - Workman's'Comp .,hl Policy# � ' Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof{hurricane nailed)(stripping old_shingles):_All construction debris will be taken-to Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) 0 Re-side -. i#;of doors (Replacement Windows/doors/sliders U-Value' : 3�" (maximum.35)#of windows *Where required: Issuance of this permit does not exemptcompliance with other townidepartment regulations,i.e.Historic,Conservation;etc. ***Note: Property Owner must sign Property Owner Letter;of Permission. A copy of the Home Improvement Contractors License-&Construction Supervisors.License is" re aired. SIGNATURE -- - �I y/a U 13 C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Contenf.0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 , f Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT (� /L Ei✓ - I, OWN THE PROPERTY LOCATED AT yr, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT: TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH:780 CMR,THE MASSACHUSETTS STATE _.BUILDING CODE. I GIVE MY PERMISSION TO - LESSEE TO APPLY FOR A:BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. 1 SIGNATURE OF OWNER:: OWNER'S:ADDRESS`. OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS LESSEE'S TELEPHONE: ..': APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS _ 1645 Newtown Rd.; Cotuit, MA 02635_,: APPLICANT'S TELEPHONE:' : 508-428-9518::: RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: i I RewgulailllorFana Standards f 171 Jaf -rtUhIspis ALDLN AVE M-W ass, x iiwar&lei-Nt-f 02-V 06/1812044 a°""'a Vn3C8~tt2 L:AIISt3fli@7"AI3.A2t'S at'c JSitSttleS5 H�gtuauun J brew of regtUr'auwl.vauu IVY AUUIYtuut Mc uuty OME-IMPROVEMENT CONTRACTOR before the expiration date. tf found reuarn to: Office of Consumer Affairs and Business Regulatia Registration;��0'740 TYPO, 10 Park Pl#a-Suite 5170 Ftpira �a1� Supplement Card -- Boston,MA t1211G .� .u WE CAP=H6l;1fEi- .kc. JOHN STRUMS 1645 NeM n Rol. '" :. Catty,MA yz Utderserretar3 Not v d wi out sx 4ture / Department oflndustrialAccidents -:- Office ofln-pestigations 1 Congress Street,.Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information PIease Print LWLbIy Name(business/Organization/Individual):Capizzi Home improvement Address:1645 Newfown Road City/State/Zip:Cotuit, MA-02648 Phone#:508-428-9518 . Are you an employer?Check the appropriate box: FE roject(required): 1. I am a employer with 40+ 4. ❑ I am a general contractor and I employees(full and/or.part time).* have hired the sub-contractors w construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. modeling ship and have no employees These sub-contractors have molition working forme in any capacity. employees and have workers'[No workers' comp.insurance comp.insurance. 9• ]Building addition required.] 5. ❑ We are a corporation and its 10.❑Blectrical repairs or additions 3.❑ I am a homeowner doing all work. officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.].t -c. 152, §1(4),and we have no 12.0 Roof repairs employees.. 13.�� Other- [No workers . comp.insurance required.] *Any applicant that cheep box#I must also fill out the section below shov&g their workers'compensation policy information\" t Homeownpts who submit this affidavit indicating they are doing all work,aad then hire outsi&e contractors Tal.-A submit anew affidavit indicating such. tConfri&ors that check this box must attached au addition sheet showing the name of the sub-contractors•and state whether or llot those entities have employees. If the sub-contractors have employees,they must provide their wdrkersI 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:Associated Employers Insurance Company Policy.#or Self-ins.Lic.#:WCC5010 547012011 12/25/2n12 Expiration.Date: Job Site Address: City/State/Zip: C e,r/Ge_y U.J` 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. fate up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un the pains and penatties ofperjury that Mhe information provided above is true and correct .Si ature: Date: Phone#: 508-428- 518 - Official no use only. Do t write in this area,to be completed by city or town official City or Town: PermitMeense# Issuing Authority(circle one): Y:Board of Health 2.Building Department 3.City/Town Clerk -4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: ` Client#:47298 CAPIHOM DATE WMDWYYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 12/26/2012 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:lithe certificate holder is an ADDITIONAL INSURED,the policy(les)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 oerdlicate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER COMENTACT Karen Walther Rogers&Gray Ins.-So.Dennis ► ro NI,877-816-2156 434 Route 134 E South Dennis,MA 02660-1609 INSURE AFFORDING COVERAGE NAIC# 508 398-7980 MISURERA:Main Street America Assurance C INSURED INSURERB:Associated Employers Insurance Capizzi Home Improvement,Inc. INSURER C: Capizzi Enterprises,Inc. INSURERD: 1645 Newtown Road • INSURER E•Cotuit,AMA 02MS INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 POLICES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOL BR PO EFF POLICY EXP "Am - LTR TYPE OF INSURANCE NSR POLICY NUMBER M MM1D A GENERAL LIABILITY MPB1075H 6/08/2012 0610812013 EAmoccumwimE $1,000000 X COMMERCIAL GENERA.LIABILITY DATE° 8500,000 CLAIMS-MADE QX OCCUR MED EW we per) $10 000 PERSWOL A ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENL AGGREGATE LIMIT APPLIES PEt PRoDums-cow/oPAGG s2,000,000 PRO- LOC _ sC�6 WINED . A AUTOMOBILE LIABILITY M1M28044 6/08/2012 06108/201 (F,,dd„INN OAeT $500,000 ANY AUTO B�AYBNAJRY(PerP ) $ ALI.OWNED X SCHEDULED _.. oWLYIN,NIRY(eraoddenoOS $ AUTOS /UrrNONIaWNED PROPEMY DAMAGE S Axx H1AUTOS ,rive Oth Car $ A X LWELRULALIAB OCCUR CUB1076H DW0812012 06108IM3 EAcHoccuRREmm $5 000 000 EXCESSLWB CIAIMS-I�AApE ,�, - _ AGGREGATE $5 000 000 DED I X1 RETENnw s10000 $ B WORKERS COMPENSATION WCC5010547012012 1212512012121251201 X WcsTATLL OTFi- - AND EMPLOYERS'LIABILITY ANY PROPRIETORlPl1TIVEa EL EACH ACCIDENT $1000000 OFFICER/MEMBEREXCLUDE07 N NIA - (MandatorylnNH) E.L.DISEASE-EA EMPLOYEE$1 000,000 Byesdesa�e One DE SCRO'TION OF oPERATtOms below F-LDnEAsE-PoLx;YuMrr 0,000,000 DESCRIPTION OF OPERATIONS I LOCATWMI YENICLES(AUaeh ACORD t01,AddWcmd Romargs Sdio&b.B mere space is regtdmiQ - Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION Towrl'of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IH 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE F 0196 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD 11S91859/M91856 TI-H Town of Barnstable ,Permit# p EVIres 6 nn date Regulatory Services Fee BAMSTABLE, NAM Thomas F.Geiler,Director '°tfn ram" l O f 2bll Z Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number d r 1 Property Address 1 Al S 111 h kCj,4 e n-t e v 1// [ZResidential Value of Work 2- r Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address_ �,i G U 4/Z O d�- M A 1z y C 1.•_1 y-1 d 5'y C Jiver s revill A4 U26 .32 Contractor's Name YC1 G1 N S t{ 11,lfl l Telephone Number r 4l%2 2/' I'-If1/fitt EAj c Home Improvement Contractor License#(if applicable) I d 4 y Construction Supervisor's License#(if applicable) C s y !T ❑Workman's Compensation Insurance •Check one: 2012 ❑ I am a sole proprietor W 2 2 ❑ I am the Homeowner I have Worker's Compensation Insurance A $Ja(igI-e'0 figp he/ lJ�+evj LMS OSuMAf NpFBARNSTABLE Insurance Company Name I V►��C 1 zv P! Workman's Comp.Policy# �)/0 Y7e: - Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles)Y All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping..Going.over existing layers of roof) ❑ Re=side t 0 C #of doors Replacement Windows/doors/sliders.U-Value 0 (maximum.35)#of windows 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission: copy of the Home provement tractors License&Construction Supervisors License is equi SIGNATURE: C:\Users\decollik A ta\Local\Microsoft\Windows\Temporary Internet Files\Content Outlook\DDV87AAZ\FMRESS.doc Revised 072110 7 �.: , • ., • E���EnrE£��rxv���tl��.��a��e�user 6a Was)flltgETti yj�`eE't` �Q SE`Oft • s o�rkers CQm er adail lnsuraace Aff Zdagt:R.Rde- lC afract�i l Iec ieia f 'I berg APi�aat itifcrnzafica t �2z]I$ BusiuessfQ J1 � , w _ .. � �at?oIIlTadividua!)- � •� ��f •'t7 f3�� " -�-F'?? 1�'r7t��E�c�i� ��J€, Aadr s-k- ire fah 2af=P1uyerz Cu—the a ra•rrate bos. M. �F F. t�Yi anz a 6009Yer i ffyO 'r' 4: [l r nun a gweial contractor and 1 �yge a��raject(required}: s eazpIogees($xii andtor dart time}. frame Irizsd fire sub confiaetdrs R. Q New COI s Trc#oa. �.Q I aFa a sole grdPndtar Oparta=4 I►s�an&a attaciled Sbqsheet, 7 uci st 'aave irQ employees 'F�i's suh�coniractars have }g Q 1?eaio&tiou rya for in nay ca£rty., plogees and have workers' jN4 vraiiCeis coax instrranC'0 COlup Incrsranre 4; (�Build ng'acrditic is 5 Q.Gee are a corporation and its m[J EIectri caI repair or additiogs gIIr ff horireoirrdauig aI� ocer haYb cJ:eFCiSed their Ia wo I L�] IimGuig ieaits or arfcIitioas" Y rFcexs'ciirsp. f�rezemptioaper It GL 12. ias�icaaeq regiLised j ?S2,¢t{` ,sad We havt ad Q Roof • : • , ' •e�Ioyees.[No wdrT�s' � , ��:[�t�"dier :�.CJ 6 * Y??Pr mat sh:t~e saxe aysc msura tFSoc�rteownas�vFi¢svbmnih •vitindi oatdtes- ha¢Eiclawshdtumgtheiitiac -Fs'so pIIPojtG}'a ocmariou • 'CacEa�tlfat chtcf g ttisY an all work and area orttside a0ritmcfos Quist submits a^w afndavit trt�tcatrag svcIL t boiGVgsca 5 {4'addi�nnais$r�cs r Y I€rfic sv Caa(xac�is�av� 0y, .th_ must `vsd s. �c etas 9rd,sub coil adnis aed staft ivfiez or noc ii i have: . r. P� R UL1ZS• cY m�,,,i; Q7F[arc eMgEvger thdt ts-ravrdrrla y T.- rn arritaYiait tcrrxr�Cers caasgensatrun�rrsurrznce far rxg enrptayees $ed cs fhe v_ - — ` _ 41 d1ab ate • IiTsu�ance.Coax�saa��7- :�Sf©et/�:�t'l� �e���e���S ��,�. f�1�j ,�.- ; - •PoRCy .orSel�ins.Lrc.#;_ / 7 Q Ceps rrh`aa Date:. /m2 Xddi�: ry /34'1 ' • °AEtacFt a cg- of tiie �� �/ . . . C:tt�/7�'.p: - -� . . • satian gaecy Crecfirat n sFaateI rire t€ov Sse icx5istr3e�tQa(3v aennrn$g(oar qae-Year isrsprtesorrtm a as we1I P p rcuial 4tiite ds iotfe)as efarcundeca25AfMG c 152 can Ieadafi othm i p �rxc as civil penalties in tTie foim of a STf}YDK OR JD a fne of aP0 SZSD.OQ a tta y a�ramsf tiie vigiat Be adczs.�d tfrat a copy Qf�st#er eat any be foi wardec(��e Qf�ce of Iavestigatiqas o die I1IA€qr ice coverage vet icandit' �fo JierefiJr uicifer ; '• ..... . ..: F izisd frerraf` ' fg Y that the Fxcfarmatinrr iiirviifed of ave is frue zbvd aQr e-Af Bate- P[ioife; }: O 0 Z�&('cse�rtlp,•�o�rrt svFrta tic fhis at ea,fa Ee'carrf�rfed by arcrsvrr ttjcz�: - -• at-��� ••Per�rtlLic�gae� . . • . - • •• - : Q$rd Q gall�rm& Deparl e 3:.CRyaawi Qerf Efeeirzcar �gectar s"":Ph=b'ug 6�� �r: cpoF `Coal et Persaa: Client#:47298 CAPIHOM ACORD,. CERTIFICATE OF LIABILITY INSURANCE .DATE 6/08/20/2 YY' /o8012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES. BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Karen Walther Rogers&Gray Ins.-So.Dennis PHONE FAX 877-816-2156 A/C No Ext: A/c,No 434 Route 134 E-MAIL ADDRESS:. South Dennis,MA 02660-1601 SOS 398-7980 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Grange Insurance CO. INSURED INSURER B:ASSOclated Employers Insurance Capizzi Home Improvement,Inc. Capizzi Enterprises,Inc. .INSURER C 1645 Newtown Road INSURER D: COtuit,MA 02635 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 MM/DD/YYYY LIMITS A GENERAL LIABILITY MPB1075H 6/08/2012 06/08/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY - PREMISESOEa occTurrence $500,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO LOC - $ .1— A AUTOMOBILE LIABILITY M1 M28O44 . 6/O8/2012 06/08I201 COMBINED SINGLE LIMIT Ea accident $500,000- ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS - BODILY INJURY(Per accident) $ - NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Peraccident $ X Drive Oth Car $ A X UMBRELLA LIAB OCCUR CUB1076H 6/08/2012 06/08/2013 EACH OCCURRENCE s5,000,000 EXCESS LIAB HCLAIMS-MADE - AGGREGATE s5,000,000 DED I X RETENTION$10000 $- - B WORKERS COMPENSATION WCC5010547012011 12/25/2011 12/25/201 X WC srnru- orH- AND EMPLOYERS'LIABILITY - - - ANY PROPRIETOR/PARTNER/EXECUTIVE Y I-1 - k E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? � N/A , (Mandatory in NH) " E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD101,Additional Remarks Schedule,if more space is required) Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE - ©198 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S82889/M82857 TLH 'Aassach sm-as -Department of Kus wsc Sates Srard of Building Regulattons and Standards Lwemse tp IS ALDEN AVE Buzzards Bay K"* 0611812044 Umee of consumerAuua=,&tsunness liegmauuu i,tcbuva ter rc usi iuu,riuui uao uuiy OME IMPROVEMENT CONTRACTOR before the ex0ration date. If found return to: Office of Consumer Affhirs and Business Reguiation Registrationr4' p`t{40 Type: 10 Park Playa-Si:ite 5190 Expl `Y �9. Supplement Card Boston,MA Q211G CAFiZZ#HOME ZECrJ Newton Rtl...•� Undersecretary VOW,rout sigaature Sy £13?A/ FID#80-0014011 : 4; Z CSL#7454 HIC#100740 Home Improvement 508-428-9518 1645 Newwwn Road 800-262-5060(Toll Free) Cotuit,Massachusetts 02635 508-428-1547(Fax) www.capizzihome.com Established in 1976 P POSAL Date _ _ _ -- ... . - -- -........... - j _ Name. Job Address i Address: f City/Town i City/Town 1 , Home Phone State i ....: L __ Cell Phone 2. -- ZIP —. --- I Estimator - - --� 3 -yy E Mail 2 I ! � � � Job Number - ..........-. _.._... - _ . We hereby submit specifications and estimates to furnish.and install-a new door system as follows: �L a Remove exterior and interior casings. Operation Diagram a Remove existing door slab,doorjamb and threshold. Remove storm door system if applicable. In a Dispose of all debris,including disposal fees:: C Install new pan flashing. • Install new door system. _ • Install new exterior and interior casings. Out e Permit included: 7 Style ( ) c� !�� l '��C. ✓�`� S le of Door s Size: Interior Trim Style: Size: l�C Exterior Trim Style: x, Size Wall Thickness: 2)' �ot 2"x 6„0 Location of Door(s): .' Note. If rot is found in boor area,additional costs will be incurred. Labor&Mated -- ---- --- OPTION; Painting of door,jamb frame, and exterior&interior casings to complete installation, two[21 coats, one[11 color. Labor&Materials:. $ `� NOTE: If units being worked on have alarms,customer is to contact Alarm Company and be billed direct for any associated alarm expenses. OPTIONAL FEATURES - 1.. Hardware: Brass $ . 2. Aluminum Trim,Coverage on Exterior Casings: $ . 3. Grid Type: Grids Between Glass Color: $ 4. _Grid Type: Interior Snap In Color: $ S. Grid Type: Exterior Applied Muntins Color: $ y Accepted B�:' p J Date: 0 —;2, THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL#3gcPF6 Page 2 of 2 Capizzi Home Improvement Inc. Specifications and Estimates NOTE: For all Great Lakes Premier sliders,HiR Plus single Low E argon gas-filled,4.2 R-value 1" Thermopane-tempered glass,multipoint locking systems and white powder-coat handles are standard features. Great Lakes Premier sliders come with'a lifetime non-prorated transferable"warranty including glass breakage. GREAT LAKES PREMIER DOOR OPTIONS: Maxuus Double Low-E Argon Gas-Filled 7.6 R-Value Triple-Pane Glass $ Maxuus Double Low-E Krypton Gas-Filled R-10 Triple Pane Tempered $ Glass OPTIONAL GRID TYPES(All in Glass) 1. Classic Grids: Color: $ 2. Williamsburg Grids: Color:. $ 3. Georgian Grids: Color: $ 4. Regal V-Groove Grid: Color: $ Door Color: Interior; Exterior: NOTE. All doors come white inside and outside unless otherwise noted. ® Classic Brass Handle: $ Satin Chrome Handle: $ Euroglide Operating System(Includes Classic Brass Handle w/Lockset): $ SOLAR.BLINDS AND SOLAR SHADE OPTIONS: t Lift and Tilt Solar Blinds: Color of Slats: $ Solar Shades(Pleated Shades): Color: $ Prefinished Infinitrim for Matching Interior Casings: $ NOTE: ALL OPTIONS MUST BE EITHER CROSSED OUT OR FILLED IN Job Total to Date $ We look forward to working with you;please call if you have any questions. Sincerely, e� �r CAPIZZI HO IMPROVEMENT, VEMENT; �— All - f_v�5 �� � d 1� � s 5t !,be -'*-ej �y ISC P(:5!f6A,__ Accepted By: P( ��'D �l� z. � 1 Date: ,�"— THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL# 343`�� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued o�C� Conservation Division Application Fee Planning Dept. f Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 5,Ll e B E/u Slnj�N -1Z DAD Village C et4T-eV1ed 11 _ Owner ��"L h A IZII h N p N►A Ry' P C 14 �TOA Address P1 EEC M f'f�?i�Gj �?v Telephone - °I r Cetr- et-Vl el ,OA 02,6 3v Permit Request ` !f1at.c exisTmi 0 .ec_ o,i hemp- y+ jA s4 dn@. •eyA' -[-- �0 c u.e�j al 0,j ,ey-i dT�v��i - �4 py"'o F_ 11An/ A W4 t h,4 0 e-c16 e x�d�i � <✓ ` l y x l .� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District R G Flood Plain Groundwater Overlay Project Valuation `�i ���°Pd Construction Type W O a D r Lot Size 4 ` ' Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family M/ Two Family ❑ Multi-Family (# units) Age of Existing Structure �0 Historic House: ❑Yes LtAo On Old King's Highway: ❑Yes tQ�Rlo Basement Type: ®'Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing .2 new D Half: existing new Number of Bedrooms: -3 existing d new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: q(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: ,J — Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 34 If yes, site plan review # Current Use S 1 a 16 l;4 a j y Proposed Use SA MA- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name :TohAJ �' �fiVU� C� Telephone Number 5dd` Y C11'p2£'Utae, .2rn f -Elves Address License # 1 Home Improvement Contractor# Y Worker's Compensation # 1 ALL!CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO uh +; a WA 0 fe, leVI/oI A!10Wit N SIGNATURE DATE U he 12.0 1 Z- FOR OFFICIAL USE ONLY ` APPLICATION# DATE ISSUED MAP/PARCEL N0. ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: 1 FOUNDATION °f�Sasos 1� ��)) �IZ FRAME INSULATION FIREPLACE - t ELECTRICAL: ROUGH 'FINAL.- r PLUMBING: ROUGH FINAL F GAS: ROUGH FINAL FINAL BUILDING Zft i 1 at, � DATE CLOSED OUT ; ASSOCIATION PLAN NO. � S �Ort TNF� � �'owh- of R arnsia ble y ; y�P Regulatory Services . • i • �aRrrsraaL� Thomas F. Geller;Director, „ 9 XASS. ,g `bp,Ea;9,. Bulding'Divisiop ,. Thomas Perry, CBO,Building Conamisslo ier 200 Main Street, Hyannis,MA 02601 " �ww.town..barnstable:ma:us • Office: 508-86203 8 r Fax: 508-790-6230 PLAN RE VIEW. Owner: Nfap/1'areel 7 �S Project Address-54 E� 5Ou-t11f AD Builder: .The following items')-,vere noted on reviewing: O .10V �MAY- 'SPAtJ � ZJc� l� 0C, ;Tcs 'TS y Reviewed bv:' Date: 4t �.5 #E to4 a •� `�� � ' ;�e�rzen�Q�`,��zr�u<s�ic���€eei�et��`' E cas ingET12. f ree ^� "t fi a WTV , aexersgam �r� al��Iagsuraeedazt: Pgil �rs� Irrcar IcIefQulI. er AD�r�icar���r�€�rmaii�tt� ' �:� Ptiat Le_�&4v },� �] 1 E ar12 (Susine�ssfQrd�2izattoti!-Tndzuidua() r`+2�1•' b�` ' ": Ytt L'�yr t'6tc�n '"`. � f c u Val CityfSfat�fZip: Ara kod an emplayer?Check&e appropriate box � + Iam a etiaglayer tvi h : f f? .j[] I am;a geherat cautrat for and I Type of gral ect(required) zr euigIoy es(fait agdlo rpa2t dine); ❑l Jf fared the sat corilractars 1t CC�rIstITIGfIo72 2 Iiste[ 7 am a solegraprietar orparine ` as the attaefed sheet -A 7 emod Iut slug and Save tia employees ': These sub contractors have 8 [71?emQLtioa fi uFarktExg'�r mo in aIIy capacity employees nud have'workers` jNo woikers'Gomts insurance carrmg.Mst anc X iu,acFdtttort add Q �] 5 Ej Tie ire a caiporatioa mdx' tts i 6.0 Efectncal icpaus r addidaFzs 3 I gin ff hoeac�ruwrdoiag"a>£war3�f officers baye:exercised tbelr A , I I �]PIiimbrn ib A pans or additions m�s IF o urorl�ets comp . right of ezemptza perGL t k c.l52 14 .lZ koof i airs uistxcaffc�required {.};"agd we have ua . 6 Aecy aDp tcznt teat ch Mks Sax trl a�st ais6 fits Out the xtba bcIaw ghd cng tfrsir x c��s' on POIicy-Zko out r'cforrt �vtts wncs submit ttvs zr"davtt indicating tL-y ax-doer all work and then hire out Lc conttact6n rots it 6au[a a.^w atn avet utdi.,ating sz= tConaactoStEit Iik tfus bas tri�tst ate h�as additcottaf slit sl�rsvig tlt nacre of th subs ant�acta;s and star✓wh or aot this_ ^ate favo mFs[ayc . IE the su6„on�senics have eun(oy :they mcssE g nviac.thmr w�-is':e{r�a.po-?scy miml3 s I rrm tin errzgtayer that rs pracdus .warlers'carrspersait.cns aF¢nce far rzt empfayees &etcrw is fhe prrEicgr¢nd jah srte" K Clt�art[fatilJll. Insurance ComgauyName_�5J-t�Z1 41?0 e�s? ���gs ��1�a f :Al Policy or Self tIIs LiC. V lob."`Szte Address j' City/sty rz�F: �'..�P"G� �Gta Ile" � 4 ttac€r a copy of fhb ar t s'cacripegsaf q pa ct'decl rattan page(shnwtttd.fie palrcy r�rrtrtfxer�rrd lratiatt d te): ' Fatlur to secure covera;R as ttgvtFeci under Sectton 25A orm c`-!52 cap Ipad to the inpQ sition of crt rnai penatttes of a' fux�up to i,SQQ.Q�:'andlor:one-ye,r imprijcjnm at;as 1 reIl as civil penalties iii the form gf a:STQP QRK©KDEff anda fin' of up x S250(}(!a day against the viglator Be advised that$copy a€ Lis sPatem nt may he forwarded to tfie 4f ice of, Investtgati its of the Did€or ttssunnc coverage"wetificatio I do hetehy it der the parrs Gird eisaf� fF� ¢rY that the infarmatran praided rrbave is true¢icd cartee€. . Date flficFalscse aalyTa trot write rn fhrs areas toe cans�eterf�y�rz ar twr c� :cia!t Clty ar'FaZI �� e EtL(�iltQtE C r I45IIIIT ty,( trcle QFLB I I card of Health Z but l eparf eitt 3 Cis rl a `Y �i'Clerk° Eleatr�cab Tus ecturY Flu K h a G`Elmer F ui�Iiispectt c Caat$cE Persoa. i R. wPlie. . v:� � .:. � any, F "r c 4 p; q 2 �m •a y ry., � � "1 �' Y ,- g i s Client#:47298 CAPIHOM DATE(MMIDDIYM ACORD. CERTIFICATE OF LIABILITY INSURANCE 12128/2011 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 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 CONTACT Karen A Walther,CISR Rogers 8;Gray Ins.-So.Dennis PHONE 508.760.4630 FAX 877.816.2156 A/C No Ext: AIC,No 434 Route 134 E-MAIL ADDRESS: South Dennis,MA 02660-1601 - INSURER(S)AFFORDING COVERAGE NAIC# 508 398-7980 NSURERA:National Grange Insurance Co. INSURED INSURERB:Associated Employers Insurance Capizzi Home Improvement,Inc. CNA Insurance Companies INSURER C: p Capizzi Enterprises,Inc. INSURER D 1645 Newtown Road Cotult,MA 02635 INSURER E: INSURER F: COVERAGES CERTIFICATE,NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MMIDD A GENERAL LIABILITY MPB1075H 6-/0812011 06108/2012 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $500,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY1:1 PRO LOC $ JECT A AUTOMOBILE LIABILITY M1 M28044' 06/08/2011 06/08/201 (CEO,acccid.n SINGLE LIMIT SOO;000 ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ A X UMBRELLA LIAB X OCCUR CUB1076H 6/08/2611 06/08/2012 EACH OCCURRENCE $5 00O 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5 000 000 DIED I X RETENTION$$10 000 $ B WORKERS COMPENSATION QQ130221321 12/25/2011 12125/2012 X WC STATU- OTH- AND EMPLOYERS'LIABILITY RY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $1 00O 000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1.000 000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $1 000,000 C Surety Bond 70011607 11/28/2011 11/28/201 $25,000 DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry. CERTIFICATE HOLDER CANCELLATION Town Of.BarnStable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE, WILL BE DELIVERED IN- 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©198 .2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S75543/M75539 KW a 1 IS HOME IMPROVEMENT CONTRACTOR be lore a expiration a e. oun return o. k Office of Consumer Affairs and-Business Regulation d� � egistration:_-:400740 Type 10 Park PIaza-,Suite 5170 e ` txpirafion 612 312 0 1 2 *Supplement Card Boston,MA 02116 CAPIZZI HOME`IMFROVEMENT,INC JACK STRUNSKL_ - 1645 Newton Rd. Cotuit,MA 02635 Undersecretary Not valid without signature le Massachusett.s- 13e()artanent of Public Safer}' Board of Suildinu Re!4iatians acid Standar6 q. Cnrrstruct»Supervi�ar Licenses License: CS 64817 JOHN TSTRUMSKI �F _ 9/f ;,PO BOX 861 G�'l BUZZARDS BAN. A 02532 .� Exn3ratiarit 6/18l2012 C'or6rnislnafer= "Tr,: 10573 S� t M id 4. i a + ` P - e r� • z F t - r Page 7 of 7 Capizzi Home Improvement Inc; Specifications and Estimates STATE OF MASSACHUSETTS LETTER-OF AUTHORIZATION TO APPLY FORA BUILDING PERMIT Jt'C,J 1 I,. N//IS �•��?�` 1. 1 QWN THE LOCATED:AT MASSACHUSETTS: I HAVE AUTHORIZED.'' CAPIZZI HOME IMPROVEMENT` TO ACT AS MY,AGENT TO APPLY FOR A BUILDING PERMIT 1N:ACCORDANCE::WITH�780 CMR :THE MASSACHUSETTS STATE BUILDING CODE. ' I GIVE MY PERMISSION TO: _ LESSEE TO APPLY FORA BUILDING PERMIT IN.ACCORDANCE WITH 780'CMR, THE' MASSACHUSETTS STATE:BUILDING CODE. SIGNATURE OF OWNER OWNER'S ADDRESS. OWNER'S TELEPHONE:, LESSEE'S SIGNATURE` . LESSEE'S;ADDRESS: ;. LESSEE'S TELEPHONE: APLLICANT'S:SIGNATURE:. F APPLICANT'S ADDRESS: ": 1645 Newtown Rd.,;'Cotuit,lVlA 02635 APPLICANT'S TELEPHONE:' 508 428-9518 =j RESPONSIBLE OFFICER r ` RESPONSIBLE OFFICER ADDRESS:t: RESPONSIBLE:OFFICER TELEPHONE: . . No /I/Z-2Es:Z: ) l�l P675"1�� RAS : _ � Gr (SA/ V / 75 'Sc IVA %�." e .w GRAA��, -AlKIS 7 11V6 IS Z- HA A G lQ1411 yp C � yBC Jv � k Y w r(vp . l 02 e7 �3 ✓� la �30IVA" L� t try - 3 �3 t-.O c> I � . _ t I t V. -e- _S - S,5.o -6.�•U. . ter!G TA+-t tC = 3`Q\i t5 Go = 4 �.1✓D: /�20� ,{rl�+[7 i u 54E-- t 00o CiI5.P�5At- PIT - USt= t'C�oa SAL. 5 �� .. 4 T,'u $t�T'i 27N1 ATz °SO C�P.D., To TA L t16l;i = 425 T.P.D. Pl_--f2GDl.dT10L.1 . SZATE t. tN 2.ulu• atZ ASS. 30 En 0. a r - F+I TESTLow C3� Tort' v _ ,Poi I o� ►u�. ',; ` �l -Box1000 ,L Sync. to a1 L • � LAN 't 2A t/t3j,, Fi T a V41 T'14 1 STO W fc IPAo 1 L-� L dGAT y"ov t C G t�'"i t.F=.� T t-1 A"T' THE C"'O L)WW-710,Q 5 t�otiu t�l 4�Ek(=L�t�l Cc�rtilt�lL�(S V./ ITN Tt-li= �jiD�.LI/_l� r f ZI.,07L �d w cF. A 2�JST'A . t;� Ci+uT ` C [f E U.ATG ILA , o .'" 't""'�„'�' 8/S.KTCGZ Rc.G t S rICLa D LA, 5u`2u�Y1��S. Vt.� A oSTE��/t rl� o MA t-115 _P t A►-� F --- ---- -,._.r_•._�r�./__L_TU._--�l.C_C�rT:.__�it_tGlJ�3� e 1 r:P I 1 f-/S ►-I--r, .. /_.. € .i. M Town of Barnstable 'T"E' ,,� Regulatory Services Thomas F.Geiler,Direetor AM ' Building Division 1619 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038. Fax: 508-790-6230 PERMIT# '�O l � FEE: $ SHED REGISTRATION 200 square feet or less Location of shed(address) Village 9�i�1�»�a ,=i /�2 /''�T C �✓ CSC ' -duo l 8 Property owner's name Telephone number ? p iD -n CD Size of Shed Map/Parce # cr7 w m 3/Z0 2- Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Conunission•(signature_is_required) rSign-,off.hours=forConservation-8;00-9:30&33 30'=4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS,FORM MUST BE ACCOMPANIED BY A f PLOT PLAN , Q-forms-shedreg REV:05201. , LJO &ACZ78441--e 6;4ZI 061EEG.' U _ Q F Lit �L.DV/ _ tIO '3 3o G.P �- ' T'Ic T'p., 1F� _ 3`DJ trG `70 ctq� .1=ra: Py r u5� t o0o Ear: Per ���,4e.�,ef � �� •`,w� r{] c�AL1. jaeE_A - l5D y t ToTA L -p ESiG1J = -425 •ToTA.L �ca1��f Fc�4c./ = 33Q.�.a?'a. •3Z.' `��'` : S� ��- �� Pr--fdCOL6TIC)LJ aX d `1- ST "1 ' Top F6, Low Pp� v►sr- fox to ll IboO ►- SD . IWv. �►rvA S� LAN Sat ¢ 'A RT Ap WAS►aE.p • CaVTIV-t�ID -- _ i GG{ZTt.i=`l, TF-(AT TNT FOV+JUQ�106 SFao.�!►J 1 Fkt=t5i-1 Cc 4lPL�lS WIT" "i°F-1= �jlDt~.L���� or A�.lv SC-'<<��1C1` �'C-CAL) c6l/�i-i.ljr� of TNT. �. r -Z'oww ot=FAQ-h1STA . t � tr�+ t � 1 PA,Tc UA ! A" OSTE��/1L X o t4t1ASS• -_ _� i. _ -./ _1 TUt"_ tlG !,F—`�•i....�il•1G1:./L�� At��71 1 !'�#_1'T'� � .� !f`. d e Town of Barnstable *Permit# a IT Erpire rS morn/rsjronr issue dare Regulatory Services r Thomas F. Geiler, Director t i J WN �BLE Building Division -` (Liz Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.towh.bamstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRE S PERMIT APPLICATION - RESIDENTIAL ONLY INot Valid 14111out Red X-Press Imprint Map/parcel Number Prop rty Address C �L� �rn q Cho ty'vi"A f Residential Value of Work Q Minimum fee ofS35.00 for work under.�6000.00 Owner's Nam e cC Address Contractor's Name �-- 'A-M-eS { ' 001V Telephone Number Gf_16 Home Improvement Contractor License#(if applicable) ��O �3J Con uction Supervisor's License#(if applicable) 9� Cj. Ta Workman's Compensation Insurance Check one: Vthe❑ I a I a sole proprietor ❑ m Homeowner. I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers ofroof7 Re-s[de #of doors Replacement Windows/doors/sliders.U-Value (maximum .35)#of window *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 Leiter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is required, IGNATURE: 1137 Park East Orive C�"� T 8! &T V > RL set s 122M/3oa39(wtoon rtssoc aces a—l Woonsocket Rhode Island 02895 cam.341C OW725(Moon AtsoCiatn in6) n [a011�975-6666 ' ®.Mass.w a 119535 0"oo Asncrates i+xJAW _ J Purchaser(s)Name: &L F L -I-W d , installation Address: � �i e 5.a J ff . c -l'rCet�l z lklaiRttg Address: ';ry 4'/7 iC�J Home Phoroe.�&hg _CeB Phone:„ A09)$b 2/33 E rrsall:�3eC*f G[�+sC,a� t`�S�11 tie Year Home BuBt £s,�..._Customer initiets-YIXw— Taxes Paid In Tavm i/We,the above purchasers)('Purchaser(s)")and the owners)of the property located at the above installation address,hereby jointly and severally agree to contract with Moon Associates,Inc:('Moonworks")to furnish,deliver,and Install of all materials as described in this agreement("Agreement'),the attached Spec Sheet(s)and diagrams)which are incorporated herein by reference and made a part hereof.A Caaepletion Certificate will be executed for aii jobs at the end of the Installation. ` Order Number: Order Number: Order Number: Project Type: J Project Type: Project Type: Agreement Amount $��� Agreement Amount $ Agreement Amour S' Less Deposit$ S •Q less Depositt $ - less Depositt $ F_ Balance Due On Completion $Jr�� Balance Due On Completion $ Balance Due On Completion S tblinimum 33%or Agreement Amoum due upon execution, tMinirrmum 33%of Agreement Amount due upon execution. rMlNmum 33%of Agreement Amour due upon aaacutien. Indicate Payment Method For Babuce tndiah Payment Method For Bafana Indiate Pesonent Method For Balance Due at Time of Installation Due at Time of Installaiton: Due at Time of inctallatlon: Est,St D e: Est.C pletio Date: Est.Start Date: Est.Completion Date: Est.Start Date: Est Completion Date: DE 1T/PAYMENT OPTIQ)iS(subrtect to fund vertEeauon and/or Qedsa approvall 4asldees Check or Money Order Ck a,, <Z 3.Financing (Matte payable to Moonworks) Acct R Approval Code 2.Credit Card"(cfrde) visa MasterCard .Discover Actt p Approval Code •i/we apse w sum Maen"M to cherp the referew-W credit card for the deposit amour ACCt# Exp Date Security Code indicated.emance to be cMrged to credit card upon camoetion or rn0,14,64ion it notedgb My it is agreed by and between the parties that this Agreement mnstbukes the endre understanding between the parties,and there are no we" understandings changing or modifying any of the terms of this Agreement.Purchaser(%)hereby acknowledges that Purchasar(s)11 has read the from altd reverse of this AgmemeM and has received a completed,signed,and dated copy of this Agreement bulluding the two aaompanying Notice of Cancellation forms,on the date first written above and 2)was orally Informed of his/her right to cancel this transaction.Do MY SIGN THIS CONTRACT IF THERE ARE ANY FRANK SPANS. Pur baser "LAt-Y PurchaseriiA naturSignature Stgnature PAT Print Name Print Name Nutt Name YOU,THE BUYER($),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD 8USiNESS DAY AFTER THE DATE OF THiS TRANSACTION:SEE THE NOTICE OF CANCELWTiON FORM BELOW FOR AN EXPLANATION OF THIS RIGHT. FLAN NOTICE OFCAmi Date of Transaction 3 Date of Transaction You may cancel this transaction,without any penalty or obligation, You may raises(this tiansacklOn, whh"anY Penalty or oblation, within three business days from the above date. If You cancel,any within three business days from the above date.If you cancel, any Property traded in,any payments made by you under the Contract or property traded in,arty paymerft made by You tphder the Contract Of Safe,and any negotiable instrument executed by you will be returned Sale,and arty negotiable Instrument executed by You vM be returned within 10 days following receipt by the Seiler of your cancellation within 20 days following receipt by the Seller of your cancellation notice,and any severity Interest arising out of the transaction will be rwtioe,and any severity interest aring Out of the transaction will be canceled.It you sues(,you must make available to the Seller at your canceled.If you cancel,you must make available to the seller at your residence,to tubstantiaBy as good coneftn as when received,arty resMarics, In substantially as good condition as when re eived, any goods delivered to you under this Contract or Sale,or you may,If You. goods delivered to you under this Contract at Sale;or you may,if you wish,comply wkh the Netructions of the seller regarding the return wish,comply with the instructions of the Selkv regarding the return shipment of the goods at the sellers expense and risk:if you do make shipment of the goods at the SORen expense avid risk,It You do make the goods available to the Seiler and the Seller does not pick them up the goods available to the Seller and the Seilur does not pick them tip within 20 days of the date of your Notice of Cancellation,You may within 20 days of the date of Your Notice of Cancellation,You may retain or dispose of the goods without any further obligation,if you retain or dispose of the gook without any farther abtigation,If Yeu fail to make the goods available to the Seller,or If you agree to return fag to,make the gaols available to the Seiler,or if you agree to return the goods to the seller and fall to do so,then you remain Pable for the goods to the Seiler Wild fall to do so,then you remain We for performance of 90 obligations under the Contract To cancel this perfonnallm of all obligatlorts under the Contract. To cancel this transaction, mail or deliver a signed and dated copy of this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice,or send a telegram to cmweL%tfon notice or any other written notice,or send a telegram to MOONWORICS S1E7 Park East Drive. WcJ%PcJkt, Rhode island Moorttr Am U37 Park East Drive, Woonsocket Rhode Island 02995.NOT LATERTHAN MIDNIGHT OF l 1• 0235%NOT LATERTHANMLDtiilSWOF 1 HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date Consumers SUM Date ? mat _ S4 n .- � � On •�` --art _,���- 'MOONa � JAN 'Ea.-MOON Yt✓.'�{'s s$+ +'�. �F4t - �R.Yt("p��j:: j �- yaik9Cm'!�" e"�9LZ`..ti"..Y'3:?Laa" `C'bi�'iJ3•.Sa.�.+' '�' 'ii�v',3C.� ��'`a�Hv�./w'^"#+T,� .. '.R � °,.maw.Zia ,'.3tr� �e'eke$� �a.. �R4 '; 4�'.F� - pnwdl of on tim sa c.�.:ri,x't`-"reed f?.:Fe ROAD Cl of D. Rl 028-34 .123= CERTIFICATES'OF,LIABILITY INSURANCE. op ID - EDATE(MM/DDIMOONA-21Qj05/1Q PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, ,Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box. 1 . .,,.ALTER THE COVERAGE AFFORDED BY'THE POLICIES BELOW. Manville RI. 02838-0001 .3,., Phone:401-769-9500. Fax:401=769-9502 INSURERS AFFORDING COVERAGE : INSURED Moon Associates^ Inc INSURER A: uati,onal Grange Insurance co 14788 DBA Gutter Helmet DBA Renewal by A.ndersea' of RI _ INSURERB: Beacon Mutual ,DBA Gutter Helmet Roofing` DBA Moon Works INSURERC; 1137. Park East .Drive irlsuRERD Woonsocket RI` 02a95 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH.RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH. - PQLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ..: POLICY NUMBER _.. -rULIUY _ '... `. LIMITS ,- LTR NSR TYPE OF INSURANCE ' - DATE.(MMIDDlYYYY) :DATE(MM1DD/YYW) _ .. GENERAL LIABILITY - EACH OCCURRENCE :. -$ 1,0 0 0 0 0 0 rU A X COMMERCIAL GENERAL LIABILITY MPS26619 0'9j16/1'0 - .0 9 11 6111- PREMISEES E dccurence) $500000 CLAIMS MADE, OCCUR MED EXP(Any one person) $1000Q, PERSONAL&ADV INJURY ; $100 0 0 0 0 . .GENERAL AGGREGATE-. .$200Q00.0. . GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2 0A 0 0 0 0 POLICY SR0.. LOC - JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $'100.0.000 : A X ANY AUTO B1526619 09116110 09/16/11 (Eaaccident) i ALL OWNED AUTOS BODILY INJURY $ ` (Per person) SCHEDULED AUTOS HIRED AUTOS _. BODILY INJURY $ „ NON-OWNED AUTOS {Per accident} PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY .' - AUTO ONLY-.EA ACCIDENT, $ .. ANY AUTO.. EAACC $ OTHER THAN - AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE .$ 1000000 . $ X OCCUR CLAIMS MADE, CUS26619.. 09 j16 j10 - 09 j16 j11 AGGREGATE... $ ., HDEDUCTIBLE _ $ RETENTION $10000 $ WORKERS COMPENSATION X` TORY.LIMITS ER AND EMPLOYERS'LIABILITY Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ 28586: 10j01j1Q: ` 10j01j11 E.L,EACH ACCIDENT $500000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH). E.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under SPECIAL PROVISIONS below.. E.L.DISEASE-POLICY LIMIT $500000:. OTHER_ DESCRIPTION OF OPERATIONS-1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ' 'CERTIFICATE HOLDER a CANCELLATION , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES'BE CANCELLED BEFORE THE EXPIRATION MOQNASs DATE,THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1:0 DAYS WRITTEN NOTICETO TFiE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL' IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS,OR'. REPRESENTATIVES. AUTHORIZED REPRESENTATIVES L� ACORD 25(2009(01}: ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of-ACORD The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/I ividual): �O SSoG NC Address: 32. W City/S to/Zip: Phone # OCT Are ou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑N construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right ofexemption per MGL 12.❑ Roof repairs, insurance required.]t cr 152; §1(4),and we have no employees. [No workers' 13.❑;Other , comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check.this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation,insurance for my employees. Below is the policy and job site ` information. Insurance Company Name: RMCGAI Policy#or Self-ins.Lic.#: �` (ij Expiration Date: f O{•,Y/ ^// Job Site Address:. � � ✓ � City/State/Zip:� yVI �3 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 agairist.the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true d correc Signature: .-- '7V /' //�,� Date: _ Phone#: LT2z_ 6 21,, C`�r� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town of Barnstable *Permit eho(y �� �� Fx 'es 6 mo.the from issue date RAWgulatory Services l Mass. Thomas F.Geiler,Director 43� .�' UG 2 3 Zoos Building Division OF SMNSTAIX Tom Perry,CBO, Building Commissioner 20 ain Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ! —7 / i - Property Address 54 EbPlD 5 mrf1 R �C c� , Ce f1 kr V 1 it � V --(6 2-- Residential Value of Work "7, KOO, 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address dC'>ri Tl(li i R , Y ETC' V ; t I c t- Contractor's Name L'pe can RcAic j' F- Telephone Number 11 —�43 6 Home Improvement Contractor License#(if applicable) 1 y cZ oZ Construction Supervisor's License#(if applicable) C:S Ug 3 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ am the Homeowner ( I have Worker's Compensation Insurance Insurance Company Name t fir[oo j 4 s5 f l-c 3:6 jL,,t f aCi cQ Comp YJ r / Workman's Comp.Policy# 1/yG If yy 3`7 22 , !� Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) [O"Re-roof(stripping old shingles) All construction debris will be taken to s ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. 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 ust sign Property Owner Letter of Permission. ' me p e t Contractors License is required. SIGNATURE: Q:Forms:expmtr Revise071405 - snaxsrns Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Tom Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, C)a c,:u S [3 Cr(--c)k-1 ,as Owner of the subject property hereby authorize (en c ROv r.-rc) If- to act on my behalf, in all matters relative to work authorized by this building permit application for: rni-►-P-, 2oc tcL Ce n-1-Cro l (Address of Job) Signature of Owner Date 1-AD V_ 2&a ON Print Name Q:Forms:expmtrg Revise071405 The Commonwealth of Massachusetts .r Department of Industrial Accidents Office of Investigations kvi 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): (Se ��1 in Ro\/c rC.JF--" — Address: (,EEh{y) Srn—tin Roa.CL City/State/Zip:C�'-P�r6 ilk, 4A 02632 Phone #: �� - 3�— (v 2q Are you an employer? Check the appropriate box: Type of project(required): 1.ElTam a employer with I 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees - These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' ❑. comp. insurance required.] 13 Other P- rb *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. 1 Insurance Company Name: G ra f l i TC . sS�ak 170 S 0 ra Vl C-c- C14 Policy#or Self-ins.Lic.#: t+ W 3 Cl G Expiration Date: - J-00-7 Job Site Address:,- F eyl cSt I i-ty1 QQ a— C City/State/Zip: Gera er l UA U 2J,�3 2-- 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 ce Jy nd the^p in 7a_ndpenalties of perjury that the information provided above is true and correcte: e Date: ? , Phone#:. 7 7 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: . p ���uCOGLG4 .- BOARD OF BUILDI G REGULATIONS x License: CONSTRUCTION SUPERVISOR ' Number: CS 083280 Birthdate: 11/29/1964 Expires: 11/29/2 006 Tr.no: 83280 Restricted: 00 SEAN J ROYCROFT 65 EBEN SMITH RD ( � CENTERVILLE, MA 02632 Administrator s ✓fie V�rvnaaruueall�. a�✓��ivauvna lug Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 141225 Expiration: 1/22/2008 Type: Private Corporation ROYCROFT&KUEHNE BUILDERS, INC. Sean Roycroft 65 Eben Smith Ros Centerville,MA 02632 Administrator 08-08-06 10:04am From-SOUTHEASTERN INSURANCE AGENCY 508-7900557 T-996 P.01/01 F-834 >� --"�Tm vwc a e ao e�� • e ae.. w• �•• •rear■ i o Be T•V VY,O/-1��V4r U31/Uli/LUUtT PRODUCER (S08)997-6061 FAX (SO8)991-3283 THIS CERTIFICATE 18 ISSUED AS A MA rrER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIG14TS UPOI I THE CERTIFICATE 662 State Rd. HOLDER.THIS CERTIFICATE DOES NO r AMEND,EXTEND OR P.O. Boa. 79398 ALTER THE COVERAGE AFFORDED B THE POLICIES BELOW. N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC 0 INSt1AED Roycro t & Kuehne Builders Inc, INSIIRERA. Arbella Protection Insurance 6S Eben Smith Road INSURERS. Merchants Ins Group Cetitervi l l e, MA 02632 INSURER C: Granite State Ins INSURER D: INSURER E: COVERAGIS THE POLICIES OF INSURANCE USTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I 4DICATED.NOTWITHSTANDING ANY REOU.REMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICM THIS CERTIF CATE MAY BE ISSUED OR MAY PERT.JN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIOO S AND CONDITIONS OF SUCH POLICIES.,%GGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTN£ POLICY EXPIRATI N LIMITS GEIERALLIABILITY 9500022739 07/03/2006 07/03/2007 EACHOCCURR" CE s 2,000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RE TED S SO 000 CLAIMS MADE ®OCCUR MEO EXP(Arty a PaMt)) s 5 000 A PERSONAL 6 AD INJURY S j a 000.000 GENERAL AGGR GATE S 2.000.000 GEIFL AGGREGATE LIMIT APPLIES PER PRODUCTS-CO APIOP AGG 4 j QDO 000 POLICY 1ECT LOG i AU':OMOBILE LIABILITY COMBINED SING.E LIMIT ANY AUTO (Faawderd) L 11000,000 X ALL OWNED AUTOS 7AM027701409S 10/18/200S 10/18/2006 BODILYINJURY 0 sCHEOULED AUTOS (Per weep) S HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (For mdowl) S PROPERTY DAMAGE _ (Per ewwant) incl. GAI(AGE LIABILITY AUTO ONLY-EA\CCIOENT d ANY AUTO FA ACC $ OTHER THAN AUTO ONLY. AGG a F-X(ESSIUMBRELLA LIABILITY EACH OCCURREI ICE S OCCUR D CLAIMS MADE AGGREGATE 3 DEDUCTIBLE S RETENTION S S WORKERX COMIPENGATION AND W STATI} I IOTH- FMPLOYSAW LIABILITY C ANV PROI RIETORIPARTNERIEXECUTIVE E.L.EACH ACCIO ENT $ 100.00 OFFtCERneEMBEREXCLUDED9 WC4W392269 08/01/2006 09/01/2007 E.L.OISEASE- EMPLOYE 5 lOO,000 Ir yea,des,Idle uPder SPECIAL I ROVISIONS ovow E.L DISEASE-PC LICY LIMIT Is 500100 OTHER _T DESCRIPTION OI:OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEM ENT I SPECIAL PROVISIONS For any and all operations performed during the policy period. CERTIE1961-9 HOLDER CANCELLATION SHOULD ANY OF THE A80VE DESCRIBED POLICIES 8 CANC8LLE0 BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER I OLL ENDEAVOR TO AWL Towa of Barnstable 10 DAYS WRITTEN NOTICE TO TOM CGRTIFICA-11 MOLDER NAMED ToTH£LEFT, Atta: Bldg Dept BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE1 0 OBLIGATION OR LIABILITY Mal al St OF ANY KIND UPON THE INSURER ITS AGENTS OR RE FRIEUNTATNES. HyaAnl s a MA 02602 AUTHORIZED REPRESeNTATIVE Joan Martin ACORD 2512001108) @A CORD CORPORATION 1988 A„ssesso?s Office(1st floor) Map Parcel AS -2 — Permit# Conservation Office 4th floor)(830-9:30/1:00- 2:00). Date Issued / oZ (O .,,Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) 1J7, Engineering Dept. 3�fr)loo House# PT1� VS im DAUST BE iN IALLE PUANCE 'a L $ D 19 ENVIRON DE AND s 'TOWN TOWN OF BARNSTABLE > Building Permit Applica n ✓Project t dd J ,e � illage I. /-6wner address <1 �elephone 'Kermit Request X First Floor square feet Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family , Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway AI /� Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name Telephone Number Address License# Home Improvement Contractor# 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 SIGNATURE DATE✓ � � 3 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY _, PERMIT NO. i L- DATE ISSUED ' MAP/PARCEL NO. } ADDRESS < VILLAGE OWNERf DATE OF INSPECTION: t i FOUNDATION FRAME INSULATION — FIREPLACE 3 ELECTRICAL: ROUGH FINAL PLUMBING: _ ROUGH FINAL -_ GAS: ROUGH FINAL cl FINAL BUILDINGS DATE CLOSED OUTJ, ASSOCIATIONP,AN NCO: • 1 < s .� t E f n _ The Town of Barnstable,� �P Department of Health Safety and Environmental Servi ces Binding Division 367 Main Street Hyannis MA 0=1 Ralph Cmssaa Off cc S08-790-6w Bmading Commi: Fat 508-775 33" For office use only Permit no. Date AFFIDAVIT HOME n"ROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT AMICATION MGL c. 142 A requires that the"reconstruction,Ateerati= excavation,repair;moon,won' imprvve:nent..N=cn-1, demolition. or wnsuuction of an addition to nay ptz-a �a vww Cc-UP building con=ining at least one but not more than four dandling units or to MUCOM which are adjacent to such residence or building be done by registered coatsacxors.with certain c pdons► along with other of Woric Cost Address of Work 6 4 �6wner.Nam :/Date of Permit Applic Lion: I herd)-certify that: Registration is not required for the following rrason(s): Work cxduded by law Job Hades SI.000 Building not w... o=*cd Owner pniling oaa permit . Notice is hcmby gn'ea that: OWNERS PULLING THEIR OWN PERMrr OR DEALING Wrrff �CONTRACTORS FOR APPLICABLE HONM M'ROVE�Ni DO N� CESS O THE ARBI'1 RATION PROGRAM OR GUARANTY FUND UNDER MGL c'14ZA SIGNED UNDER PENALTIES OF PERM" I h apply for a permit as the agent of the owner: Registration No. Conuacaor name OR w ' `4 �"�• Tile CummunN'calt I q Atassachwetts W l _: Department o Industrial Accident . , ! oficeolloyest/9alloos 3 �;! 600 11 a.vitiogtan Street 0 111 workers' Compensation Insurance AMdavitlocation,-4�D _ name: glo a O citt I am a homeowner performing all work myself. I am,a sole proprietor and have no one working in any capacity I am an employer providing wori:ers' compensation for my em loyees working on this ob. p1 4�0&U ' AL cir s 110 W N 12 �` �• i=�ld1 sits , L�✓l i�5 iM ,A- "hone . i sur�n AI� � 3 ce MI am a sole ro netor, eneral contractor homeowne circle one and have hired the contractors listed below who hav' the following workers' compensation polic v m n •n� c• insurnnee ro "efiev# �..:.-.+:•.- ....- -.;�.-•.- -- wen any....rt�e�r•err'r'r•-�+r-e•�'".y�s � ,�J�J�4l�j►'�i7:++�/7A°S'�,.ti..r�r�- mminanv name, address: cih "hone#• insurance co "offer# »5 •--- :Attach aJditional'shee!if accesses .:'`^`" •ram^°°�<-+'-'^'�' '""—� """ `""'`"'' �'"� ""'""" i"IHM to secure coverage as required under Section 25A of A1GL 152 an lend to the imposition of criminal penalties of a fine up to S1.500.00 and/or une years'imprisonment as ivell as civil penalties in the form of a STOP WORK ORDER and a line of S100.00 a day against me. 1 understand that a cop} of this slat a mad be forward eZ a OlTic rr c of Investigations of the D1A for coverage veriffatiom I lurch• uarli r , a' s ataities ojpe ' th t the infonnation pm-ided above is tnre and correM p ;PAn i_snat rc Dan am 64 V►1 l�S I� y _ 1`- t n l T / � � �Phon_e r ofriciai use on1v do not write in this area to be completed by city or town official city or town: permit/license# r9Buildiag Department Licensing Board check if immediate response is required Oet Selemea's Orrice (311eaitb Department phone ilt "other �conm ct person• - Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the employees. As quoted from the -law", an emplgree is defined as every person in the service ofanother under anv contract of hire, express or implied, oral or written. An emplurer is defined as an individual. partnership, association. corporation or other legal entity, or any two or mor the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the rcceiver or trustee of an individual , partnership, association or other legal entity, employing employees. However tltc 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 hot 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 even, state or local licensing agency shall withhold the issuance or rencival 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 h, been presented to the contracting authority. I . .. � ... • ._ i• . : - .. tit' _• _�.�".7 tiny;.e;..r .y :wr,:r '-'• '-""'?�'""". Applicants Please 'I'll 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. 77re 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 full out in the event the Office of Investigations has to contact you regarding the applicant. Plez be sure to full in the permit/license number which will be used as a reference number. The at may be returned t,', 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 question please do not hesitate to ;,Live us a call. «.w �:.s: ..',".a. :fir. :w:•s.. The Department's address. telephone and fax number. The Commonwealth Of Massachusetts 4w Department of Industrial Accidents r° office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 nhnne #- (617) 727-4900 ext. 406, 409 or 375 / x 1 � , Imo' !r ` {� ��'► i�`�` • `� -'.a"''`� t '` ,ems � -,• `� 1 ► �`�.,: l • �� �:� 1 r � - -,,_ � - ,► a � /T(,i4 , ! I AFL Wou.O is � ULL '�,r»ENslurvL hINE �FT y .�RS, 2 d of 2x4 Qi i I � ! fiLL 6NEDS :MAV9 64&E . BOAR VS N�r S►�o w N ' yj 4 Pe.�4TEs i i PuRk.�►Js v� f4ch Assessors map and lot THE Sewage Permit number . .: ..:..... � 'SEPTIC SYSTEM MUST a ��P� ♦� INSTALL ED IN COMPLIAN H ; House number ..... c 9 E.AHB 9T11DL `� ...... ....... WITH TITLE.J o ' ENVIRONMENTAL COG -. .� a ypr°�e :M T O W N' ' O F BARN 9TABL Re.;} f - BUILDIHG INSPECTOR APPLICATION FOR PERMIT TO . `e ` TYPE OF CONSTRUCTION .......: . ........ ......... .................... ......... ...:..:............. ......... ............:. CA ....................... .............19..Q. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following informs ion: Location ....1 !.... ..... : ..... .� ...........�...........0 ProposedUse ... .. ........ ... .. . . . ........................... .............................. ............ ......... ........................ Zoning District ............................... ......... ..... .Fireo'DistHgt .... ..... .. ............................................... ... Name of Owner ....... .... ........................................Address .......... ...... .(......................................................... Nameof Builder ........................1 .....................................Address .......................................................................... Name of Architect .:..Address: .............. ......................................................... ............ ...........,,................ ........................... Number of Roo s ...............................................................:.:Foundation ................ Exiei .. ..............`....... .... .................................................Roofing ... ...... . ........... ..................... Floors ............ .................Interior .... .................:............................. C% �f%�C .......................... . Heating ..:�......�.....................................................Plumbing .......... ... . . Fireplace .... . ........... ............ ................................................Approximate Cost .......4 ......................... Definitive Plan Approved b Planning Board _______________________________19________. Area ......1. . Diagram of Lot and Building with Dimensions Fee ..... 1.....1.....1..�....... SUBJECT TO APPROVAL OF BOARD OF HEALTHQ� �. r f , I hereby agree to conform to all the Rules and Regulations of the Town of BarnstablLregang the aboveconstruction: Name .. ........� .^ . ' ' ' ~ ' SMALL, ALAN E. 22432 OneStm� No -----.. Pe,mh for ------..�y.......... Single }7amil D�elIi ^ ----..:------��.-----.���----- � ' �� ' Locohon .Lmt_#272_54_Eben_Souit]b..I�o�� ^ ' ~ Centerville ----.----.----------------- Owner Alan E. Small .................... Type of Construction ...������--------. ---------------.�-----~.---- ' Plot ............................ Lot ................................ - ^ ' Permit Granted ...S ^P,�—��V 80 . ._ . . . Dote of Inspection --..............................lP `^ � °_ .. . . Dote Comp|eto6 .............. | UU , . - REFUSED S SPERMIT � lV-...—.� . —.. '�--..�--------. ~~ ; -- ~_ . --' -----------------'' ^ ` ' - - '' . —.— . .��—.. '-- -------- .� . . �� v~ .... --.�—_�-.—.-'.-'~—'~.—^--^'~^' . � -^ Cr. -----~—'~^^'^---'r--~^—'' �C^*� —*--------------.. lV ' _ - . . . ...—..�,-�.-�---------.-------.---.. ...................... ........................................................... . ' . . do- Assessors map and lot number ......../ }%\..:..... r.. ypF TH E ' Q r :sewage Permit number ,'.........�1+�.� ................... Y . , -' � Z BBHBSTADLE, i House number ....... .`......:.................................................... 90�,0�MAGI L 00� am p TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......... : ..................... ...................................................................... :�.'W.. TYPE OF CONSTRUCTION ........................................................................................:............................................ ................................................19.. ? TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .....L�1- .. �' ...... 6 '- dr: � �r��;✓c c - y� � '� ...�,�> .. f c. ........�'/.`....... d...... ?. ProposedUse ........ ......... .......... .................... ..................... ...................................I......................... ZoningDistrict ..................................;....................................Fire District ..................................................... Name of Owner ....::." ...c'..........'� ....................Address ........('� ............................................ Name of Builder .......... : ...................Address Nameof Architect ..................................................................Address .............................�..................................................... Number of Rooms Foundation .. ��-�-�" ``......................................... ................................................... r � Exterior `�' ..(� g....... .. .......................................................Roofi n ..... �:•.:?> Floors .: ' fit_ ...Interior Heating ......' ....! .. .` `�.`.................................................Plumbing ......... .:..... .`.:a'.".: .:r....................................... .... Fireplace t 11 2=..................................................Approximate Cost ....... � ..r ~'................................... Definitive Plan Approved by Planning Board ________________________________19________ Area ......� .................. �.7`� cJ Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name 1:...�:'! ................ SMALL, ALAN E. A=171-157 No .22.49.2... Permit for .OTXQ...Story........... ........Single...F.amil.y...DVe.11 A.9............. Location ...Lot...#.2.7.2...5.4...Ehea...$mith„Rd- I ..................Oenterv.41 e................................ Owner Alan E. Small ...../Frame Type of Construction ................................ ......................................... Plot ...................... Lot ................................ tube 8 Permit Granted .....SePte„.,.,.,..r,.„_,,,..,1 q 80 Date of InspectioO................................19 Date Completed ... .................................19 PERMIT REFUSED ............................... 19 . ............................ .. ............................. ........................... ................................................... ............................................................................... Approved ................................................ 19 TOWN OF B'ARNSTABLE Perm 2 it-No. -----224 • -Btnlding••TIlspector a,nsrr.aa - Cash • �orpre� OCCUPANCY PERMIT sond ' _XX__/l f "No' building nor structure':shall'be erected','-and no land, building or structure shall:,be used for a new, different changed,,or. enlarged .use without a Building Permit therefor first having_been'obtained.from"the.Building Inspector: No building•shall be occupied until a" certificate of occupancy has been issued" by.-the Building Inspector." Issued to Nlan -E. SinalA Address - Tani- #2]2 rill: F:ki',--n Smi-"f--h RnInd.�' cpni-Pr, �Ti 1 Wiring'inspe'ctor' ^�^ Inspection date' 7 ,! t.L- fAn fi Plumbing Inspector ' a� a.. Inspection date G"as Inspector. ' Inspection date " Engineering Department' r ; _•_._ Inspection date THIS PERMIT WILL-NOT BE VALID, AND THE.BUILDING SHALL NOT; BE OCCUPIED .UNTIL . SIGNED BY THE BUILDING INSPECTOR' UPON SATISFACTORY COMPLIANCE WITH TOWN . REQUIREMENTS. t...... .., 19 . _ ......... fBuilding...Inspeetor, .... l/ ��'F't c T�-.t iC - �30,� t5 G % • ,ct..y c�.t=t7. P,¢op� ,�er�v�._G,�P U5�- to0o Per �•�i4"4 . 'U6 WA,LL. A2E.A,�= (5p i�v SF �c 2..5,,,,�••��`'�S G.P.U. � , - Sd PAJ& A) 1.0 TOTAL. 'L)8S16W = 42S A,.R1--> I �•"• �.j T-oTA t_ a.t 1_�-f FL-DV./ = 3'30.6 p 5 4, Pr_tZGDLQTIOLI V&TE CIQ L mIw, oiz ASS. 4 "ate _�, oz�I2 '. rr ' x `p tits 2404 Se- Tu -rtsT -1 l $p FL.= Tor 1 uv Lopti1 �'Poc I o iuv »► + 4'�P� UtST iw• 6AL. so.8 SJ3601L_ -Box SD.G Sepnc iuv. l to Z l T'A�t►� 1000 E-'So IW. ! ✓tom, PIT ' w i-MA G, WAf►ICID E4.-U 449 HIC, -i L/101 Le�rt ez-V C t;..•L - lZ w o 5.;.d.t: - c.A L k� l 11 -�3-1�=`C' _ � } ( GGiz-rti=.-{ TWAT T1. G_ FOOO_04TjOQ 5tA0%AJQ PLL>,�1 V_t=V'1c a i-1E�t=t5t�3 GcrWlPL.�lS• W IT1-� `t"►-ti - �jl D�.Li�-.1� � t SC�� �, -'oww vc= A2h1S1'l .l. � ��uz C tG4 L.0i.� RcGlSrc..l,i�o i1�.i••iJ ;u2��`(ut'-S •(-l-1 l�, t�t_A t-! l L1 UT �,-;irta U l--i A" o 11JyfC':7.tnC�W �iUt;�/t=�{ Ti4L C_i: r t t_ u', , rb V) ►�M►