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Home My WebLink About0013 ELIJAH CHILDS LANE 1 ! �ja.. Ids Lhe . v n n v - yCA- i2J)12- CAPE COD roe N OF 11,RIN TAB INSULATION FIRER GLASS SEAMLESS SPRAT FOAM SUSPRNOEO .. RATTS GUTTERS INSULATION CEILINGS _ 1-800-696-6611 DI►J °� -. Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 C Date: fl/o p Dear Building/ Inspector Please accept this Affidavit as documentation that Cape,Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Villa e , �c��v►�- t�iof-� f 3 �'), _ �� Chi "leis. L��.� . C�n,J�� l�.e.. J Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) (X ) Slopes Floors Walls Sincerely He y E C sidy' ,.President- L. Cape Cod ns'ulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ;•3IV Application # 001Co dwo 6Z3 Health Division Date Issued l Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village e"—.4e zZgd4�� Owner il4Z,6 '11_ Address Telephone c_ W Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 60 , e7 Construction Type Lot Size / Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) o Age of Existing Structure Historic House: ❑Yes .a-No On Old King'4Highway: Yew o#`, Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)� :'*? Number of Baths: Full: existing new Half: existing V neV Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name !'�j�1i �� lrsi/ �G� Telephone Number Address e/ Z&YCez c-o,a License # 115zoe Home Improvement Contractor#/S��`'�� Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO DATE SIGNATURE �7�� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP PARCEL NO. f ADDRESS VILLAGE -'` OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ,= FINAL BUILDING _. DATE CLOSED OUT ASSOCIATION PLAN NO. i OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at J-/j Property Address) (Prope y�ss) hereby authorize Ca C o rLs ula l d 1 v (Subcontr tor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature a Date FCERVE D OCT _ 92012 i i 1 f b` 617/ 11 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2012 Tr# 206433 . CAPE COD INSULATION, INC HENRY CASSIDY -- 455 YARMOUTH RD. HYANNIS, MAi02601 ..Update Address and return card. Mark reason for change. [,I Address I Renewal l I.Employment I... I Lost Card :A� �i SUhI-041U4-G1U IL Iti UI'I'ice.� of Sumer Afl•aii 13us`ue_•Reguljrtu i Licriue or registration valid for i::aii idu! :orl,� r10ME"11VIpRb(% fflfl�iSlOhjl`p a � before the expiration date. If found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation a 1 Expiration: 12/15/2012 Private Corporation l U Park Plaza-Suite 5170 i../ Boston,MA 02116 f?ir;00D INSULATION, INC x ENRY CASSIDY 55 YARMOUTH RD. YANNIS,MA 02601 Undersecretary t alid ith t'si Lure �ln,,a�tutsctts-:Dcpartntenl ()f Public Safch Bo., ii ,If 86il'din�g Ir Rc�ulations anti 1t:uul:u ils' Construction Supervisor License _ Liven CS 100988 _ HENRY CASSIDY , 8 SHED ROW t WEST�ARMOUTH, MA 02673 Expiration: 11/11/2013 ( luunll.,,n.'• Tr#: 7620 , Clientrx:4597 CCINSUL ACORD,,, CERTIFICATE OF LiABILITY INSURANCE C DAT7(mmiowYyy_-Y*I THIS CERTIFICATE iS ISSUED A5 A MATTER OF INFORMATION ONLY AND CONFERS NO RlGHT8 UPON TGERTIFICATE HOLDER HIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOY CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the c,arllNcate holder iB an ADDITIONAL)NSURFu,the policy(ies)must be endorsed,if SU9ROGATION IS WAIVED,xub)ect to the terms and conditions of the policy,certain p611cles rrray ruyube an andorsarnenl.A Btatemeht pn lhie cerliijpyte doer not currier rights to the certlilcalB holder in lieu of such endarsemenl(s). 4'R000CER - Roflers&Gray Ins--So.Dennis NAMIc: Mar aret Youn -- 434 Route 134 PRONE _ _ A1C Nd Ext:508-760-0602 A/C No 877-816. .156 Suuth Dennis, MA 02650-1601 E-MAIL ----_----- 508 398-7980 INBURER(8)AFFORDING COVERAGE '~`-- __..._.___ ' WSURF:RA;Peerless Insurance NAll.k wsUREo'y — - [18333 Cape Cod Insulatlorl Inc INSURERS:Evanston Insurance Company 455 Yarmouth Road INSURERC:Atlantic Charter InsLirence Hyannis, MA 02601 INsuRERD .Commerce Insurance Company —34754 INSURER E: - LOVEHAGES maotwR F: — CERTIFICATE NUMBER: PHIS IS TO CERI IFY TWAT 'fHE IoOLIC1ES OF INSURANCE 1.15TED f.+ELpW HAVE BEEN ISSUED to THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOIWITHSYANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY C014TRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AI'FOPOEO BY 711E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. sEXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY' HAVP BEEN REDUCED BY PAID CLAIMS. FIT— TYPE OF INSURANCE ADDL SUBR POLICY OFF 1-6LICY EX A GENERAL LIABILITY POLICY NUMBER- MM1DDlYYYY MMIODJI'YYY CSP8263063 LlMlrs 4101l2012 04/01 J201 EACH X COMMERCIAL GENERAL LIABILITY pA�q E'r OCCURRENCE $1000 000 Pamll§ES ENT CLAIMS-MADEER OCCUR 3 accu'rD $100 UUU ,r .MED EXP(Any one pereon) s5,000 _ PER60NAL&AOV INJURY S 1 000 000 GEN'LAGGREGATELIMIT;APPLI63PER: GENERALAQr3REGATE 52,000,000 — POLICY PRO• LOC PRODUCTS.00MPIOPAGG $2 000 OLIO p Aur6Moe1leuABwTY 12MMBCKVmK 4/01/2012 04101/201' COMBINED SINGLE LIMIT --" ANY AUTO - E21accident 1,004,400 ALL OWNED BODILY INJURY(PnPe.on) _._ AUTOS }( SCHEDULED AUTOS r 130DILY INJURY(Per aw-:danl) X HIRED AUTOS }( NU ED - AUTOSTOS S PROPERTY .B X UMBRELLA LIAR -- S El(C�Sy LIg6 OCCUR XONJ453512 4/01/2012 04/01/201 EACH OCCURRENCE _- - ( CLAIMS-MADE - $1.000 000 OED X RETENTION '10000 AGGREGATE $1 000 000 C WORKERS CQMPEN8ATION — ANDEMPLOYERS'LIABILITY WGA00525902 6/30/2012 06/30/201 X WCSTATU OTIi. ANYCER/ aEYO/�pq(yrNEf�1 1iECUTIV&Y f N DFFICER/MEMNER ES(OI UDC 7 ] N 1 A G.L.EACH ACCIDkN1' '.1000000 Ir(Mnnrleiory in NM) _ - DES IPTIONunder E.L.DISEASE_EAeMpLOYEE $1'044404 DESCRIPTION OF OPERATIONS bcldw j, ^---- E.L.DISEASE_POLICY LIMIT $1 000 OLIO • - DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(AUaah ACORb 101,Addltlonal Rdmarks aghedW9,N more apRe 10 rerrufre(p "Workers Comp Information " Included Officers or Proprietors Certificate Holder is included as an additional insured undGr.Ganaral Liability when required by written contract or agreement. ' g , CERTIFICATP HOLDER — CANCELLATION } Cape Cod In'sulation,lnc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DB CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOYIcE WILL BE DELIVERED IN ACCORDANC E WITH THE POLICY PROVISIONS. . AUTHORIZED REPRESENTATIVE - ACORD 25(2010105) 11 0)198 -2010 ACORD CORPORATION,All rights mgerYed. #S83949IM83848 i of, The ACORD name and I090 are reglslered marks of ACORD MEY f F The CornMot;1, , !1h of Massachusetts -_ =T Depctrtme' m t•; oidustrial llccidcrtts w O stigcltivnsf�tcc' i,ti r , .boo_n . . 'rr11V0n Street ; Bos/ L, 2111 _ f Wurl:cl''s Cl►llll)C.I1Jilti011 IllSlll'i1111'C AhlYii.: r," I lllltl@l'$/C OY1C1'ilCl41'SL� I'.l'l1'll'littYS/.l'�lllll.11►41'1 11;pliraullnfc►►'Yuatiuu 1Pleilse Prim Legibly `,uu, Ist!:;iuc;.�.�/Orani�.tttiutl/lrldiyii u�ll): t 1�412_ r� — 4 ' _: 1+e tuu an t•luhlvycrY C'IWCI,c the Ilppropriale box: Type OfprojCCt (rrtitlired): n 1 I ,uu a r• lt)l�ryca' With ~ _... `l• � l cuntrataur and l haveE.' �r New cons'u ut'tiun ult.i u)Q:V:.S (full arld/o hart-tune) "' hired Il u1111ctors listed oil 7. Reuloclelim,, the ana,i, I i .l.[ '.-.� I ani x,lc t:n't.lpricaor 11 or partncrsflip These•;in 8• El Dernolururl.�I,aCCOr'S have ,,,id h;:tvc: M.)cult:llOYecS wock-M8 for employ:',•'. .I it;tve workers' comp. 9. Building addition lilt:ui ,My capacity. [No wo1'kr..rs' insulunt (--� ruuyl unulant.r. rr.iluirCtt ] 5. ❑ We arc u'ation and its 10, El .Blcc;triCid rcpnirs of udtlttluns Ofhctb it,,, , ,cicised their right of 1 1• ElPILM,lbirig t-epairs Ur ddditioas - I hUIIICUWIICt d0111b all work exemptl,,�l l,t NIGL c. 152§(4),and . 12. Roll`re anti I M t wUrkefs' ci�mp. •we havt ;,iylluyees. [No workers' .* y, ut;uraulrc rr.c ulrcd. I3. Othcr��yL�?C�CI �lf'1�1 yL��1 i 1 I 'I comp. ur,A,i. ,1,.;:required.] `lG .T F y,i,I,.;int ttla[checks b( tkI must also fill iult the section below shin r,- i;u'workers'compensation policy inforn'latioil. `--------_..._._— "'i this id1iduva mdicating thry arc doing ell ww 1.,:,,i,i,;n hire oulsidc convectors must submit a new affidavit iruliauiltg such. „,i•,.t„„lh<it rnu:k thts bi,> [oust attach an additional sheet showing u, of the sub-contractors and state whether or nut those entities have.euy,lui.:r.i It employees, tlwy must provide their workcts' I ton col employer that i.r pr6vidirig workers'cornpensalioll i1r,,:,;1itCe for my employees. Below is the rube}'arld joG site ^— Lnt,i:,nt','('ilntp:uly NittrlC: 6 . i', ,�:. �; ,ti .�c'II.n1s. I.,ic. Ff t•!1./��_��/ .• _ J"_Xpl1'ation,Date.. .� --- Ci ly/S fate/"Lip: ut,,h u ropy ul Ule worl�ers' COI 1pensaIiuu.Policy deelurltlon p;lg, i,i,. uu16 the policy number and t:xpiration(late). - -- ""to • uic uvctuoc us rcduitcd udder Section 25A of MGL'c. I?.' w I,'lld 101110 IIl1pOSl110f1 Of Calillllal pernllliCS Of a f111C tlp LU �t,�UU.I)ll,,ntL'ul c:u nupi nuntutau, as Well as civil pcnalues in the form Of a STOP 1. )k k ORDER and a tine of updo$250.00 a flay agaitlst tllC vtt larur. lit'athtsrtl py „(du,slutculcitt 1114 c t`orwat'iied to the Office of InvC5li ,.ui••u,.,I the DIA foe Instwance coveyue'e vocii�IOiUWII, 1 du here c if under the 1 iris artd penalties of i t tilt v that the informalion provided above true artd,currect. '1r_'uullart': _ G Date._. 4 Z 1 •� tr (1/(i(-w1 n.)e only, 1)v 11w 1vrite in this area, to be completea lit r.tt ortown official; t,;il} ol-Towu: # . lasuiuh Alithority (cart leEone): i I-ll(lard of►lealll► 2. Buildi►►g'Del.artttletlt 3.Cit);'It,tt it (;Jerk 4.Electrical Inspector' S. FULAIllbilig jnspce'lul b.Other IL (•Vold('(I'l rSUll: 1 • #: — T ' Town of Barnstable (/ 7� � X-PRESc �� *Permit# v7 Expires 6 months from issue date JUL 17 2007 Regulatory Services 41-4 OO Thomas F.Geiler,Director TOWN OF BARNSTABLE Building Division 7119JO-7 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 /72-L,93V Property Address l� ^/ C�/flt�O3' �71`v2�G'ZGGt� .i 2,6 L Residential Value of Work � �— Minimum fee of$25.00 for work under$6000.00, Owner's Name&Address Ao&14I.L4 ,f�uo7f, r a�L1,;,r7U4 Cc+Ic...IDS LANs C�T F�zviC. r , &ZL 3 Z Contractor's Name- &72Z0t6a _,2?t C ) Telephone Number �G =3-� ' 7Z'7 7 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) [ orkman's Compensation Insurance Check one: ' ❑ I am a sole proprietor F ❑ I am the Homeowner [i]I have Worker's Compensation Innssurance Insurance Company Name Workman's Comp.Policy# t� C1(G�G t✓2— Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side r M'Replacement Windows. U-Value Jam) (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg NV'A� P Revise071405 � - Board of BuildingReoula Mons and tandat One Ashburton Place - Room 1 '01 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 103926 Type: Private Corporation Expiration: 7/10/2008 THERMCO, INC. WILLIAM MCCLUSKEY 7D Huntington Ave. S. Yarmouth, MA 02664 ----------._- -. . _ . L•pd:ite;Address and return card. Mark reason for change. --- :address Renewal Employment Lost Card Guard or Guildin; Regulation;and Standard; License or registration N alid for indiv idul`use onk HOME IMPROVEMENT CONTRACTOR Before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 103076 One Ashburton Place Rm 1301 Expiration: 7/1012008 Boston, Ma. 03105 Type: Private Corporation ;._P,i.ICO, INC. 'LUAiNI MCCI.USKEY ?Hunting•on Ave. Yarmout h, NIA 02664 Ucputy Administrator ,Not valid ithout signatr ¢ q t Z THERMCO HOME IMPROVEMENT 7-D Huntington Avenue South Yarmouth, MA. 02664 (508) 398-7277 Fax (508-398-7866 July 16,2007 T To Whom It May Concern, I,Adelma Knott, as owner of the property at 13 Elijah Childs Lane, Centerville, hereby authorize Thermco Home Improvement to act as my agent in all matters to do with any and all renovations and repairs at the above named property. Adelma Knott AO/3D CERTIFICATE OF LIABILITY INSURANCE ��L26%�a0o PRODUCER (781)986-4400 FAX: - (781)P63-4420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rx3k. 5 sa�aa:es Company HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 400 North Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. F.ardol is MA 02368 INSURERS AFFORDING COVERAGE _ NAIC 2 INSURED INISUReRA AmGuard The_'mco Inc;. INSURER E: 7 1) Nuntington f voriva INSURER C INSURER 0: Sgutt': .4a =out.1-: M.& 02664 INSVRERE THE POLL I� OF INS'JR4NCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA"r!D,NOTWITHSTANDING ANY REQUIREMENT,TERM Oft CONOITfON OF ANY CONTRACT OR OTHER OCCUM_NT\MTH RESPECT TO'711HICH THIS CERTIFICATE V 1Y 9E ISSUED OR MAY PERTAIN• TF!E INSURANCE AFFORDED BY T1IE POLICIES DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERM$, EXCLU$10":S AND CONDITIONS OF SUCH POLICIES. A "+ L jMI. SHOb%N-MAY HA'✓E - �Fn ED 6Y?AID lA 8 �N311 Ab0'L POLICY=FFHC nvE POLIS.^f EXFiRATION T q c TYPE OF INSURANCE I POLICY NUM9ER DATE M(Aioo,PDA IHtDOM__!1 I _ _ LIMITS CENEPVLLIAVILi7Y , I D.4GIApE rC P.ENTED CONIMERC'IAL G21,jERAL LIA.BiL(Tl' CIA11`11y waE El GCCUl MED EXP(An cne o3rsa) 1 I (F,-Fsorw,&.AarIN,I,RY G=N''RA. AGO- P Q AT° I S I rcfYl AGGFEC,ATE LIMIT FrPLIEb PER i �FRO I. pOl?, cr- LD" AUTOMOBILE LIABILITY j M'.5 NEC SINGtF VAT c 771 AN-i AUTO' ALL QtbPJGO AU r03 I EOOiLY IN:URY $ SCH60VL30AUTOs � IFe'?arscnl HIRED A!,IrCS i BCDMLY IN:LP.T" Y r ire ac d.ni; f HOtI-0tN1\pAUTCS I ?rOPcnT(DA."dAGE .� !F-e acndenli i GARAGE LIALILIT'Y AUTO ONLY.eA ACCIDENT I I I ANY AU TG 7THER THAN I%A AC I c AUTO ONLY: AG Is I i FXi•E:SNMeRF1LA L!A9IL I TY I t �f OGrup.. EI CLAINQ MADE I TE 5 GFGUCTISL'c. i RETEtv'"f'•CN 5 _ If S 17.E A<)RY,fRSC0,10ENSATICNAND � I I. N^,S',ArJ- I TOTh-. _0PLOYER3'LLAEILI`Y - ' A:VYP,q.PRIETOR'P.42?i:E vEkcJU71'✓6 I I E LEACH rM aCC DENT 5 _ 500,000 O'FIC=RFnF1IBEFEt'=LIiDEO'.• I1}P��BG99fi2 2/4/2007 2/4/2C08 c P 500 000 L OISE,,,-.•cA EA4 _OYES Y r I 1 Y:s, lestrteuGar 100 000 L I$?FCU L?ROV!910N�belay I ! IL 01S_c>S F_)_t(.7 :LU LT 2 .� r OTMer fI t DESCRI?';ION OF OAEPA'qoN:J'_01,ATIONaNEHICLEZIEACLV51d11$ADDED DY EK:)ORSEk1EHT/S-ECIAL PRCr-ASIONS a3 ov4-cba 3C® O�! iZ9L1r-ance I` CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ASOVE CECCrjSEO FOLICIES BE CANCELLED CEFORE THE 1 EXPIRATON DATE THEREOF, THE i:5'JIMG IIJSURE.4 HALL ENCEAVOR TO M41. 10 DAYS YM TTnN NQTICE TO TFE CERTIFICATE HOLDER NAUEC TO T''11 LOFT,BUT FAILURE TO DO SO SHALL IMPOST NO CBUGATICN OR LIABILITY OFANY kIND UPON THE I WN UR!!R,ITS AOnPM. OR P,EPRE92NTATTJC9.,_.___�.___._...____ _.._ AUTHORIZED RFF'RESF-N7hllY, _ Micaa2l C ZiEtian/Mj .� �..:.. . c..-.1 ACORD 25(2001/08) (PACORD CORPORATION 1"a 1N5025(0'C5).t3a Pap I ol. 3�• Department of Industrial Accidents Office of Investigations s a 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): Address:'7 OL�� • City/State/ � Phone#: _�O Q 7.2,,7 "] Are you an employer? Check the-appropriate box:., Type of project(required): 1.® I�am a employer with >y 4• ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for mein any capacity. workers' comp:insurance. 9, ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 10.❑ Electrical repairs or.additions required-] officers have exercised their eP 3.❑ I am a homeowner doing all work right of exemption per MGL 1.1.❑ 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.�Othe �' >�f `7 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: �F t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such lContractors that check this box must attached an additional sheet showing the name of the sub-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. Insurance Company Name: Policy#or Self-ins.Lic.#: `?��1e }��Z Expiration Date: - 09 Job Site Address: &4AIC-1 City/State/Zip:��/W,iIle, !� 02-&3 Z_ 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 caii 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 maybe 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 and correct Sipmature.. Date: _ LGo '7 Phone#: �G�'� . �'�-72,3 7 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical In 6.Other spector 5.Plumbing Inspector - . Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as:" dual,:partaerslup,.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. How 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 workbn such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the msur LP does have insur ance. If an LLC or L compensation t r uired to c workers , members or partners; are no required carry . policy is required. Be advised that this affidavit may be submitted to the Department of Industrial employees,a p y Q Accidents for confirmation of insurance coverage. Also be sure to sign and date the afrrdavrt. The affidavit should t be returned to the city or town that the application for the permit or license is being re Quested, not the Departmen of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference member. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"'the applicant should write"all locations m. (city or town)."A copy of the.affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for.future permits or licenses..Anew affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts . Department of Industrial.Accidents Office of Jhvestigations r 600 Washington Street . Boston,MA.02111. Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.m.ass.gov/dia V }, ti `It 1y1�� Assessor's map and lot number Sewage Permit number . /.... .. .Q.............0/.�..1� SEPTIC SYSTEM House number ...................... ........................ s�LE /. INSTALLED IN CO ,� WITH TITLE o MPS . TOWN OF �BARNS�� AL�WDa A�. x BUILDING" INSPECTOR 1:51YIL�P. APPLICATIONFOR PERMIT TO ..:........ ...............:.....:.::........................................................................................ ,!�' �` .........................:.... TYPE OF- CONSTRUCTION ........ ........ .... .....:...e; .........19.. TO THE INSPECTOR OF BUILDINGS: r The undersigned hereby applies for a permit according to theNol.ong information•,J l yLocation ....... G............ ...............--:...... .... -..... . ................ . ................................... y,...................................� Proposed Use ....... ' -/`..!..,. ........ Zoning District ............. ....,............... ..........:..........................Fire District ,,v Name of Owner ..�. ..................................Address ...... ` . '.:...... .......................... Name of Builder ./-, ./ r......................Address ...... ... ..... .................. Nameof Architect .......................................:............................Address .........................:......:..:................................................ 611.�'.�.. Number of Rooms ...................................................................Foundation .... / ............................................ Exterior ... .. Roofing f ........... .................................................. ............................................................ Floors .......................................................Interior ...............................'......... Heating ...................:......:....................Plumbing .....:.............................................................................. Fireplace ..� L ...,....'......... .... Approximate Cost ...... P:. :. ..... ` ................... .. .... Definitive Plan Approved by Pla g Board ----------------------_---------19________. Area Z1. .........5: .....:.. 01 Diagram of Lot and Building with Dimensions Fee (� .................... SUBJECT SUBJECT TO APPROVAL OF BOARD OF HEALTHY IJ'� } I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regardin the above construction. Name ............................................. I - "SMALL, ALAN No .... Permit for ...OTIP......S.t;Q.-rY....... . Single Family..Dwelling ................................... .................. Location ....Lot...#.5.2....1.3...Elijah Childs Lane . .. ..... .. Centerville . ............................................................................... Owner ......Alan....Small....................... .. ............ .... .. Type of Construction ......F.....ra...m.e......................... .. ................................................................................ Plot ............................ Lot ................................. January 9f......19 81 Permit Granted ................................... Date of Inspection ......19 / Date Completed 199 a PERMIT REFUSED ................................................................ .19 ............jl-�:.... .f-.................................................. .............. ............................................................... ............. ............................................... ..................... .......................................................... Approved ....................................... .......... 19 ............................................................................... ............................................................................... Assessor's map and lot number ................ f.. j� . J�.- ,� P��f TH E Sewage Permit number'/ /�......••• ....:.....,.........,.. .... ..-:.........�• -- - � row �� „+ Z SARNSTADLE, i House number r. M ................................................., 90O b 9 0� ,sue 7 • �0 ' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...:� �'1��" ....................................................................................... .................. TYPEOF CONSTRUCTION ................ / i................ ............................................................................................ ....7............ TO THE INSPECTOR OF BUILDINGS: The undersigned 7heby applies for a permit according to the follo ing infor at11 Location .... 1.... �... ........... ......... .............: .' �. � ��%�!J...::................... .."`. ... ..... Proposed Use ...............,..n`! ............ .. ZoningDistrict .................. ............... .....................................Fire District ...... ..................................... .... . ........................ r Name of Owner ... .. '7i° Address / ......... Nameof Builder .............. :.................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... f Numberof Rooms ..................................................................Foundation ...:. .... ... ......'C:.................................. Exterior ... .. ...... ....".".. ..........Roofing ......... .......'........- .......................................... Floors - '�. Interior....... ...................................................... .........''7 ...r- ......... ............................................. .....Plumbing Heating r......... g .......................................:.......................................... 11 Fireplace✓r:............... ..../yl Z. Approximate Cost ...... Q... ..�........ ..................................... ........ Definitive Plan Approved by Plana g Board __-------------_---------------19--------. Area �. ':.: ..........—.).....: Diagram of Lot and Building with Dimensions t. Fee ?.. SUBJECT TO APPROVAL OF BOARD OF HEALTH v� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. el Name ........... ...... . ................................................. - � ' SMALL, ALAN - V1 7;�2=--�3 DW Lane PERMIT REFUSED ........... .. ' ' ' — ... . . lg ' -----------^^^—'^^^^---' � —.---....,------~---.... . � ^ k y> e,6 Iry TOWN OF"BARNSTABLE� permit No. __ a. ---- --- V Building Inspector-. tD� Cash !•WAY OCCUPANCY 'PERMIT -Bona ___ '' 1• - ".No. building nor .structure shall`be- erected, and no land, building or structure shall be. used fora new-,' different, changed, or.enlarged .use without a Building Permit therefor . . first-having been obtained from Ahe Building-Inspector.No building shall be occupied until,a certificate of occupancy has been issued by the Building Iiispect or. Issued to_' Alan &mll Address Centerville 3.0t # 2 13 Eliiahi Childs -Road. Centerville Wiring Inspector. _ P Inspection. date Plumbing Inspector r �zL Inspection date a (xas Inspector, Inspection date Engineering Department co! '� f,f � 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. f �� .�1 � �.'3.`.� 19 � .......... �C!?� d */dam .__- ii - /' Building Inspector ; I ti St�.1�1-t. �anntt_.�! - 3 �5>_nrzac7M Flow : lto 0 la.p.D -ra�t< = 330� t�i0 % • �5 6.Po. I(o2 (3 ' icn+o U S t OOGG 6At_. A� Per usE. i ooc� AL.. 2.S + 3 /S G.P.D. rx • � ra at •o Z . To-rA L �ES16W = .42r� /7 I � ToTA t_ vat�� F'c.vw z 33D 6�t?D. f �_ - •2G 40 `� 8� rs ? SAXTER -rim ST oF• ruo.=loo.o '_= ICE' • �g ........,,.,a►• ,.P� 4. e ; . �uu• o L tS d PPe i ooc Wv. A 01. •box CIO•L SEvT iC l o ;? 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