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1620 FALMOUTH ROAD/RTE 28 (4)
-- r � e a ' 0 t w 1 Y a Application number..... ....�Q....................... DateIssued................................................................. JU � D �/�� Building Inspectors Initials..............................:........ �1 c2d ®lo.................... Map/Parcel...................................... TOWN OF BARNSTABLE \L . EXPEDITED PERMIT.APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION r 1664-70 Address of Project: v UMBER/ S REET VILLAGE Owner's Name. G-✓C l'( 'I Phone Number 508-775-0079 Marcel R. Poyant Email Address: poyantl@verizon.net Cell Phone Number 508=776-4417 Project.cost$ ( �, Check one Residential Commercial OWNER'S AUTHORIZATION �j As owner of the above property I hereby authorize /�/"�� Zea0 1q / `- to make application for a b J ng pe c rdance ith 780 CMR 6`*n Owner Signature: Date: -� Marcel R. Poyant 6/2 /18 TYPE F WORK D Siding T'D Windows(no header change)# ED Insulation/Weatherization Doors(no header change)# Commercial Doors require an inspector's review Woof(not applying more than I layer of shingles)Construction Debris will be going to r-wcO �4 CONTRACTOR'S INFORMATION o p Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# / o U "' (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X I 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-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION 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 CAM and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. 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 lease Print Legibly Name(Business/Organization/Individual); c ti/I-,f Address: U� City/State/Zip: ��� ll/ Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with _ 4 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance. $ 9. ❑Building addition. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself: [No workers'comp. right of exemption per MGL 12.❑Roof repa' insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other P d, comp.insurance required.] rz v � *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. . I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certify under the pains d penalties f— -- ry that the information provided above is true and correct Signature: 4� Date: c)vo -e Phone#: 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer,is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment-be deemed to be an employer." MGL chapter 152, §25C(6)also'states that"every state or local licensing agency shall withhold the issuance or r 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 commonwealtfi 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 numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town),"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for firture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massacchusetts Depmtnent of Ea6sirial Accideuts office of Investigations 600 Washington Street Bostan,MA 02111 TeL#617-727-4900 ext 406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 4-24-07 win govrdia '4�b CERTIFICATE OF LIABILITY INSURANCE D-M( 2 ) 18 THIS CER7IFICATE IS ISSUED AS A NA EK OF RFORMATM ONLY AND CONFERS NO RIGHTS UPON THE CFRnRCAXE HOLDER THIS CERTIFICATE DOES NOT AFFIRIiIIATIVELY OR NBGATNELY-AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IMS CERTIRCATE OF INSURANCE DOES NOT CONSTOUIE A CONTRACT BETWEEN THE TANG INBURER(S),AUTFWRIZED : REPRESENTATIVE OR PRODUCM AND 7W(SCAT E HOLM. PORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicoes)must be endorsed. 9 SUBROGATION4S WAIVE,subject to the terms and conditions ofthe POD&%certain policies my require.an endorsenmt. A staftment on this certificate does not Confer nights to the certificate holder in lieu of such endorsements). FRODIOCER JIM HIIMMAN Schlegel 34 Main Street Schlegel Tans Broker PAL S508 791-8381 �@ ��m(508) 771-0663 chl JnSUc= Rest Yarmouth, Ida 02673 INGUREIMAFFOTmINc oovOIAGE NAME IMWP6tA•TRAVELERS PROPERTY AND CAS INSURED INSURERS: JINTAM CABOON m>SlmErtc: DBA CAHOON CONSTRUCTION INSUREP D- 16 Wi3QUAQUBT AVE 1 E_ M& 02023 INSURERF, COVERAGES CERTIFICATE NUOlIBER: 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 NOTVNTHSTANDING ANY REQUIREMENT.TERM OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE 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 POUCFS.L.IUI'T5 SHOWN MAY HAVE BEEN Rf3DUcED BY PAID CLAAIM& LTR TYPEOFINSURANCE POUCV NBER BDlICY ffiggym ww UINTS GENERALLJABOM EACH OCCURRENCE $ CCIb$tERCiAL GENE RALLIABIUTY DAWkGE TO RENTED $ CtAM4AADE OCCUR eEDEV rVonepavm) $ PERSONAL&ADV INJURY $ c GENERAL AGGREGATE $ GEN'LAGGREGATELIMITAPPUESPER PRODUCTS-CONPIOPAGO $ POLICY PRO LOC $ AUTOUOGILELU 31UTY -MISINGL iM17 $ ANYAUTO SWILY INJURY(Per per-on) $ ALLOWNED AUTOS AUTOS BODILY ENJUR Mw a=went) $ H(REDAUTOS _AAUTNOS�� P a $ $ UH3REUALIA8 FOCCUR EACH OCCURRENCE $ EXCESSUAS CLAM4&4 M AGGREGATE S DED RETE TTION$ $ A WORKERS � JWC-11S50,do 2/3-3/18 2/13/19 WC STATU OTH- WLIABILITY YIN ANYFROPRIETOMPARiNERE)ECUTNE MIA EL MNACU NT S ZOO 000 OFFICERNfELIMRO( LUDED? YJ peanea"to NH) E DI EA 100,000 tf desonbaunder PnIONOFOPERq-noNSbdlow I EL DI LSFASE-POUCYLIMIT $ 500,000 I ASCRIPTION OF OPERATIONS I L1=71ONS I VENCLPS(ACa b AXM ter.Add,'AOwl tt mft 9ded&,HmoresTace aee�ile� .7I MANa CJWOON HAS ]3 ZC= NOT TO BS C DVBRSD MWIM )WR CURR>= WOI MM ColeWSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAN CEI LED BEFORE THE EXIgRATTON DATE THEREOF, NOTICE wiL.L BE DELIVERED IN RICSARD CAZEAULT ACCORDANCE YYITH THE POLICY PItOVISIONS. MA 02632 AURKN WD Sam 1 -2010 ACORD CORPORATION. All rights reserved. ACORD 25(201 OW The ACORD name and Iogo are registered of ACORD Phone: Fare E-MI: O:AZRA1ULT7 @CCbMAST.14ET eodfa o��'o��n CS, °tB��n of�pd/th Of 100393 Cdnsa�n9RP tes$Massa , 9�tat� atlhnse 10, k-10?4D ��S0 Stanch, Rb s cbh�fif� Office of Consumers k'&rs�ness �E HOME IMPRt3iTL'€}NTRAGTOR _. fg�•trahon va►id far al andyidual use only - 3 - 6eforr the ex0 rate die. If found return to: ' �� bona tfficq`of consumer A1121rs and,Business ReVation F 68�7 7119 _ _113 Pais Pl 5170 + r r Bastrtry.jUlA 02i76 RICHARD P D/B/A R Cmeauft Roafd J RICH ARD CAZBAU�TJR Corners f� - .- ' -Fn Centeru►de,MA-02632°-` r� -- _ Und ersecretary ��, nature t r' r Town of Barnstable Building , Post This Card So That rt is.Visible From the Street Approved;Plans Must be Retained on Job and this Card Must be Kept Posted Unt11,LL Final Inspection Has`Been Made , ;, • ,639 t m r3 Where a Certificate'of Occupancy�s Required such Building shall Not`be Occupied until a Final lnspection.has,been made Permit Permit NO. B-17-4207 Applicant Name: Christopher Gacicia Approvals Date Issued: 12/12/2017 Current Use: Structure Permit Type: Building-Smoke Detector-Fire Alarm Dection Expiration Date: 06/12/2018 Foundation: ' System Map/Lot: 209-013 Zoning District: SPLIT Sheathing: Location: 1620 FALMOUTH ROAD/RTE 28,CENTERVILLE Contractor. Name: Christopher P. Gacicia Framing: 1 Owner on Record: POYANT,MARCEL R Contractor License: 105072 # 2 Address: 20F CAMP OPECHEE RD Est Project Cost: $8,000.00 Chimney: - CENTERVILLE, MA 02632 Permit Fee: 4 $ 172.80 Description: Work associated with upgrading and repairing fire suppression Insulation: Fee Paid: $ 172.80 system in the deli area.Work includes relocating mechanical pull _ Final: station,installation of commercial c02 detector,and hooking up to Date 12/12/2017 current building alarm system. Upgrade griddle gas shut off to an electric shutoff to shut down the system {` 7, Plumbing/Gas AE M' Ra 1 Project Review Req: - � ' _ �'� y q Rough Plumbing: `' =,, Building Official Final Plumbing: k This permit shall be deemed abandoned and invalid unless the work authorized bythis permit is commenced within six months"after'issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the'approved construction documentsfor which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be dis la ed in a location clearly visible from access street bcroad and shall be maintained o en for ublic i'ns ection for the entire duration of the P Y P P P work until the completion of the same. " ^ Electrical .. J The Certificate of Occupancy will not be issued until all applicable signatures bythe Building and.Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough:. 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT PA �tt�t�&J 1� Town of BarnstableRFECEIPT 0 SAWWAOM 200 Main Street, Hyannis MA 02601 508-862-4038 it Application for Building Permit Application No: TB-17-4207 Date Recieved: 12/5/2017 Job Location: 1620 FALMOUTH ROAD/RTE 28,CENTERVILLE Permit For: Building-Smoke Detector-Fire Alarm Dection System Contractor's Name: Christopher P. Gacicia State Lic. No: 105072 Address: 9 Totman Street, Quincy, MA 02169 Applicant Phone: (617)479-6035 (Home)Owner's Name: POYANT,MARCEL R Phone: (508)775-0079 (Home)Owner's Address: 20F CAMP OPECHEE RD, CENTERVILLE,MA 02632 Work Description: Work associated with upgrading and repairing fire suppression system in the deli area. Work includes relocating mechanical pull station, installation of commercial c02 detector,and hooking up to current building alarm system. Upgrade griddle gas shut off to an electric shutoff to shut down the system ZE Total Value Of Work To Be Performed: $8,000.00 -c� Structure Size: 0.00 0.00 I 0.00 } w Width Depth Total Area I her swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568): I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. 1 understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State.Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Christopher Gacicia 12/5/2017 (617)479-6035 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $8,000.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $172.80 ...... .?................................................................................._.._........................................_........................i....._........................................................_............. Total Permit Fee Paid: $0.00 3-1 n 62-3 11 12: 0 4 p P. 1 COMMERCIAL REAL ESTATE POST OFFICE SQUARE•20F CAMP OPECHEE ROAD,CENTERVILLE, MA 02632 TEL 508.775.0079 RENE L.POYANT 19M2000 FAX 508.778.5688 MARCEL R.POYANT,President&Treasurer EMAIL poyantl@verizon.net RENE M.POYANT,Senior Vice President MA Corp.Brokers Lic.#337 MARY J.POYANT,Vice President FACSIMILE TRANSMISSION COVER PAGE TO THOMAS PERRY, BUILDING COMMISSIONER, TOB 508-790-6230 FROM: MARCEL POYANT,CENTERVILLE SHOPPINGCENTER {AM} DATE: 6 / 3 / 11 TIME: 2 40 / x {PM} NUMBER OF PAGES: {Including this page} TRANSMITTAL COMMENTS: I HAVE A ONE THOUSAND SQUARE FOOT SPACE AT THE CENTERVILLE SHOPPING CENTER WHICH WAS RECENTLY VACATED BY A TENANT-SELLING COMPUTER PRODUCTS AND PROVIDING COMPUTER SERVICES. I HAVE A PROSPECTIVE TENANT WHO PROVIDES ''MESSAGE THERAPY-"':"COULD YOU PLEASE ADVISE AS TO WHETHER THIS USE WOULD BE "PERMITTED" OR WHETHER THE PROSPECTIVE TENANT WOULD NEED TO SEEK A SPECIAL PERMIT? 0 THANK YOU FOR YOUR ATTENTION. 0 C� I --n N C r-- L C "SERVING CAPE COD SINCE 1947" COMMERCIAL PROPERTY MANAGEMENT • REAL ESTATE APPRAISING&CONSULTING • n 03 ll 12:04p p_1 COMMERCIAL REAL ESTATE POST OFFICE SQUARE•2DF CAMP OPECHEE ROAD,CENTERVILLE.IN.62632 TEL S08.7T8BD79 RENE L.POYANT UW2000 FAX SM7785088 MARCH R.POYANT.PndQAd L TwAmtr EMAILPVDaASl�m4wn+ RENEM.FOYART.Sen01T Vl00 POB9ident MACo.Bmk—Li dW - MARY A POYANT.VI-�WA FACSDIME TRANSMISSION COVERPAGE TO moms I=, BUILDING COIBIISSIORER, TUB 508-790-6230 RObL MARCEL POYANT, CffifERV17Tx SEOPPIHG CENYTR - (AM) DATE: 6 / 3 1 11 TIME: 2 :40/ x(pm) NUMBER OF PAGES: {Including tbiz DagaJ TRANSMITTAL COMWNTS: I HAVE A ONE TPWSAND SQUARE PWT SPACE AT THE CENTERVILLE SHOPPING CITTM WBICH WAS RECEMY VACATED BY A TERANT,SBLLING CO1D'OTER PRODUCTS AND PEOVIDIWC COMP0'TIM SERVICES. I RAVH A PROSPECTIVE TENART WHO PROVIDES'DRESSAGE THERAPY.. COULD YOU PLEASE AWLSR AS TO HHE MA THIS USE WOULD BE"PBRHITTEU^OR VIMPRER THE PROSPECTIVE TERANT WOULD NERD 70 SEEK A SPECIAL PM" � ~O THANK YOU POR TOUR ATTESTION. a � rn 'SERVING WE COD SNCE 1947' III COmMESMLPROP6UYMANiMUS09 PEAL ESTATE AWFAISWO SCOna1LMHG azis I !vw_3 •xPw PaPaaox3 (S -3. uoi }zauuoo atiw! "P} ON (ti '3 Jaa.suP ON (5 '3 Asn8 (Z '3 au i t 1 o do 2UPH (L '3 A A a a0} uosPay ---------------------------------------------------------------------------------------------------- Bs9SELL M 6 Xl AaowaW 16LO 1uaS ION ; lnsad (s) 2d uo1 }eu1jsa0 ;PON 'ON a��d al ! d Wd1E 1 1IN '9 'unr : aw!j/a}?q (Z (L ( ME : [ 1106 '9 'unr ) }aoda� jpsq uoij?3iunwwoD . 1 •d TOWN OF BARNSTABLE BUILIYNG PERMI APPLICATION Map Parcel Application #o ld X �3 3 Hea F lth Division Date Issued o 1 Conservation Division Application Fee o co Planning Dept. Permit Fee / 7o 0c;L Date Definitive Plan Approved by Planning Board 2112-)10 Historic - OKH _ Preservation / Hyannis V Project Street Address l 6 . Village P Owner e,r r t O a,, Address F" r 'NC)'J_41 Telephone 0c6 - 1131 3 3 to (� �I �l �Z&3� Permit Request QAeA;-I:on X1I A kev,..) l s Lt 2 -`2 1�,>2on ce Z dl v d Square feet: 1st floor: existing ip proposed "j"kAe2nd floor: existing proposed A11A Total new Zoning District Flood Plain Groundwater Overlay Project Valuation &0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ® No On Old King's Highway: ❑Yes 8 No Basement Type: ❑ Full ❑ Crawl ❑Walkout Q Other nE)A e- Basement Finished Area(sq.ft.) t 0AP Basement Unfinished Area (sq.ft) (10n P_ Number of Baths: Full: existing new yxP_ Half: existing new Number of Bedrooms: no(N le existing —new Total Room Count (not including baths): existing 61 new Fo First Floor Room Count Heat Type and Fuel: 5d Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes b No Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new. ; size_ F c Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Y~ Commercial ®Yes ❑ No If yes, site plan review# ;? = Current Use kjoAQ. i As A 0 S Leo Proposed Use Zoa( Estee <�r( (' = APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name —MlAael Telephone Number (-50 \ 'T �5' 6 36 s Address 5.7 Eim e of License# /0'Z 26 y !j J I Y:1�5 1 1,11.5 K Home Improvement Contractor# 14; ar'3 F Worker's Compensation # Y'S20 6 3 o ALL CONSTRUCTION D�E (E�SU FROM THIS PROJECT WILL BETAKEN TO /<g du;c�/ SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER f� F DATE OF INSPECTION: FOUNDATION FRAMEZy�l o INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL "= PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT -9, ASSOCIATION PLAN NO. " r a• The Corn o Afassachusetts ,yam .f \ Department of Industrial Accidents Office of Investigations 600 Washington Street Bostott, MA 02111 • �• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Budd ers/Contractors/Electricians/PIumbers Applicant Information Please Print LeOblY Name (Business/Organizationflndividual): - Address: q7 r P_d W I -, u� City/State/Zip: 2s6L5 0!1,1\s6A Are you an employer? Check'the appropriate bog: Type of project(required): 1.© I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-tirn.e).* have hired the sab-contractors 2.❑ I am a sole proprietor or'par6aer-' listed on the attached sheet. T.&:Remodeling ship and have no employees These sub-contractors have 8. '❑ Demolition s and have workers'loyee working for me in any capacity. emp 9. ❑Building addition . [No worker's'.comp.•insurance comp. insurance.$ required.] S. ❑ We are a corporation and its 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12_❑Roof repairs insurance required_] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ 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. tContraetors that check this box must attached an additional sheet showing the name of the sub-contractors and.state whether or not those entities have cmployecs. tf the sub-contractors have cmployecs,they must provide their workers'comp.policy number. lam an employer that is providing-workers'compensation insurance for my employees. Below is the policy and job site info rntatio n. Insurance Company Name: �(1-fw�i l�aTVNS _ Policy#or Self-ins. Lic. M 0 61 39 Expiration Date: Job Site Address: Y(o k) City/State/Zip:�ey�ha Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as quired under Section 25A of MGL c. 152 can lead to the imposition of crimi ial penalties of a fine tip to $1,500.00 and/o one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine• of up to$250.00 a day ainst the ' lator. Be advised that a copy m of thus statement may be forwarded to the•Office of Investi ations of th for rice coverage verification. I do hereby cerf' ruder Al ins jTnd penalties ofper/ury that the information provided above is true and correcr Si afore: Date: Phone#: Offtctal use.only. Do not write in this area, to be compleled by city or town official .City or Town: Permit/License# Issuing Authority(circle.one): `- • 1. Board of Health '2.Building Department 3. Cityrf own Clerk 4.Electrical Inspector S. Plumbing Inspector 6. Other. ions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute, an ernployee.is defined as "...every person in,the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership,association, corporation or other Legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a$eceased employer, or the receiver or trustee of an-individual,partnership, association or other legal entity, employing employees. however the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or Iocal 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 pro duced-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 v6th 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-contiactor(s),name(s), address(es) and phone aumber(s) along with their certificates) of insurance. Limited Liability Companies(LLC) or Limited Liability h Partnerships(LLP)with no employees other than te members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the_city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions.regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials .Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in:the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pernutliicense 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 La (city or town).".A copy of the affidavit that has been officially'stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be 61led out each year. Where a home owner or citizen,is obtaining a license or permit not.related fo any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone-and_fax number: The Commonwealth of Massachusetts Depaztmont of Industrial Accidents Office of rn.vesuptim. 600 Washington Street Boston, MA 02111 Tcl. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7744 • Revised 11-22-06 • www.mass.gov/dia 07®144 03;13poi rov-AiG + +073 331 88a9 T•483 P.00f/002 F-816 �_ 7. - ` i. *, ---•.,',. ,.pppq j(�� iy f ypA yv�n Q i� •r d 1 ¢qa r+a.����'/��'b�._Yo.�� ��„`� � .id 3 Ts� {y r. _ r di � �,; .: 11 rRibV®:7 t F .{, r a •P.`- c a. t a ,`t ! _ J-i ....--=._.w. � ii _ �� �1`��C'.ut- �0'tt1 raps^iG8':!tSLr�ti[. ncy Ina TO�t �� iy V .i'�/y .�t � ,�.�� . � G 0.LJ! ep.A i�:lv�a^e a.r p• i 296"JVIf5K+1 st l•Yf. � ,�� .'�; r (S •C 1 r'.t.,i�7'1 fJ Hy'�ir*MA=601 � �! 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THIS l s'PO mF iFy?THAT TVE;<O1J00 OF INSURANCE 11MO MOW MA415 M.N..GIrUFD 7tx-s H1:1t36tIRED[+ D ABOVE FOR f THE POLii✓Y PERIOD i ADICA S",NO f',�" ��7A vCa:46l:�l1'FtE�tlf�lan f- OR(:�ONDMi�t 1 OF ANY CONTRACT CH OAS 1ER � ;3C3�.(:fetiEN T W i�H P�z:;Rk+�T�'O;t��T;SCH'T�►S li:�F:d;, ,t::�ti'1�Y�aY i3E 15511E_®_���4AY::aeZ.�1N�i`r1a 1A35�`iAP1Clr AFP9R[23i0 THE � f't iCiE a�SCFtt�Ei`F1E sitit 13 1 tL1 A1.s t TgtitdS,�X�LtiSiC Ali: s'�Pf:y!�f9A1S�i :S'.dN tattLB—UF L!A$fT�SH:rif1fM I MAY iiAVE MEN RJE.DJMD I?- P,410 CW" V;- �.�� ---.—.,.___.�,..._ ----,•-_,,�_____.�.._�..�.. ._-..1.�.--• �..�.�-.tea.----� 'TR Ty"op i068nllt v �A r o gypy rar b" nr WAITS 1 IpAmel�ibrEXbCffrrv>' S � I ' { r}r •, i 3 MOM A'ti; Y6it,'i 8Y6 r9i*N2..:_ to MA QWWWV 01�Y, ' � �A '���R,t 41=.+:�tl -C-.Lv`:�� .,L-tF.:'\' i�r�'..�N� ,__�aor±maw_..• '� r M Re:THE WORKERS CowsoWINTION POLICY[TOES MOT v RtPJftOjg Gi,7 P kA F MVW.. . f TOWN OF BARN ETABLE � s4;e.w-W of Tee A8;A eeacie .-OLetss a axxr=euou THE 4 BLDG DEPT i ExPo3A7 ET1& ,TilE��iJivacca+�e Ymet A+ra�Taemkt lr2 1.730 SOUT'rf%f K'hY.Yak i±Ed;0-1 vm I a T:6S tiEMIMATE HOLDER"M TO TH@ LEFT,%ff HYAN N IS,MA 0=1 1 FAILM Te W.L SUCH naTa aw�a s�slk OR ra;aa'-qy Of � AWY vvio13 CN VE ccwi+.NY,Ms laoNra onTapR6$f t t , i Nlassachusctts - Dcparlmcnt of Public Safcrh Board of Building Regulations and St;uulards Construction Supervisor License License: CS 102260 Restricted to: 00 MICHAEL MEAGHER JR 97 EMERALD LANE ` MARSTONS MILLS, MA 02648 Expiration: 11/5/2012 t' fill] issionea Tr#: 102260 . ,, ✓fie '��rirraoaursfaf� o��/C�aaaulzacaet Board of Building Regulations and Standards . HOME IMPROVEMENT CONTRACTOR 'a Registratlow 162938 Expiration:_,4/27/2011 Tr# 283438 Type DBA • ,�I i j MEAGHER BROTHERS CONSTRUCTION MICHAEL MEAGHER JR' - 97 EMERALD LN -, MARSTONSMILL, MA 02648 Administrator I I ��— Massachusetts Department of Environmental Protection Bureau of Waste Prevention • Air Quality 1100100803 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition General Statement.If B. General Project Description (cont.) asbestos is found during a Construction or 4. General Contractor: Demolition MICHAEL MEAGHER operation,all responsible parties a.Name must comply with 197 EMERALD LN 310 CMR 7.00, b.Address 7.15 Chapter erg1 E of the and Chapter 2 MARSTONS MILLS IMA 02648 -� General Laws of c.City/Town d.State e.Zip Code the commonwealth. 5089896363 mike@meagherinc.com This would include,but would not be f.Telephone Number area code and extension .E-mail Address optional " limited to,filing an IMICHAEL MEAGHER asbestos removal h.On-site Manager Name notification with the Department and/or a notice of release/threat of release of a C. General Construction or Demolition Description hazardous substance to the Department,if 1. Construction or demolition contractor: applicable. MICHAEL MEAGHER a.Name 97 EMERALD LN b.Address _ MARSTONS MILLS MA 02648. j c.Cityrrown d.State e.Zip Code 5089896363 1 imike@meagherinc.com f.Telephone Number(area code and extension) g.E-mail Address(optional) MIKE MEAGHER h.On-site Manager Name 2. On-Site Supervisor: MIKE MEAGHER On-Site Supervisor Name 3. Is the entire facility to be demolished?_ ❑ Yes R] No �N �0 4. Describe the area(s)to be demolished �0 3 PARTITION WALLS �0 �0 5. If this is a construction project,describe the building(s)or addition(s)to be constructed: NEW PARTITION WALLS o ag06.doc 10/02 BWP AQ 06•Page 2 of 3 T—k Massachusetts Department of Environmental Protection ■ Bureau of Waste Prevention . Air Quality 1100100803 BW P A 06 Decal Number Notification Prior to Construction or Demolition C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project, were the structure(s) surveyed for the presence of asbestos containing material (ACM)? ❑ Yes ❑✓ No If yes, who conducted the survey? b.Survevor Name c.Division of Occupational Safety Certification Number 7. Construction or Demolition: 2/1/2010 2/1/2010 —� a.Start Date(mm/dd/yyyy) b.End Date(mmldd/yyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: ❑ seeding ❑ paving❑ wetting shrouding b. If other, please specify: ❑ ✓❑ covering ❑ other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? NA a,Name of DEP Official NA b.Title 1/28/2010 c.Date mm/dd of Authorization NA d.DEP Waiver Number. D. Certification I certify that I have examined the IMICHAEL MEAGHER �o above and that to the best of my a.Print Name _o knowledge it is true and complete. JMichael Meagher The signature below subjects the b.Authorized Signature �N signer to the.general statutes OWNER �o regarding a false and misleading c.PositionfTitle oo statement(s). MEAGHER CONSTRUCTION d.Representing 1/28/2010 e.Date(mm/ddlyyyy) �O �d ■ ag06.doc•10/02 BWP AQ 06•Page 3 of 3■ i Massachusetts Department of Environmental Protection ■ t Bureau of Waste Prevention•Air Quality 1100100803 � BWP AQ 06 Decal Number i Notification Prior to Construction or Demolition Important: A. Applicability When filling out pp `7 forms on the computer,use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building, or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor-do not use the return (DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09(2)ten (10)days prior to any work being performed. The following information is required pursuant to 310 CMR 7.09. B. General Project Description 1. a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied Instructions residence of four units or less?❑Yes ❑✓ No 1.All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order 2 Facilit Information: to comply with the y Department of Environmental KALSTAR REALTY SERVICES Protection a.Name notification 1620 FALMOUTH RD. requirements of b.Address 310 CMR 7.09 Barnstable MA 02601 c.Ci /Town d.State e.Zip Code 5087753333 1 INile@soldcapecod.com f.Telephone Number area code and extension E-mail Address(optional). 950 1 h.Size of Facility in Square Feet i.Number of floors j. Was the facility built prior to 1980? ❑✓ Yes, ❑ No k. Describe the current or prior use of the facility: PHOTOGRAPHY STUDIO I. Is the facility a residential facility? ❑ Yes ❑✓ No �0 m. If yes, how many units? Number of Units. 0 3. Facility Owner: =N IMARCEL POYANT �o a.Name �0 1686 FALMOUTH RD. b.Address _ BARNSTABLE MA I. 02632 �cp c.Citv/Town d.State e.Zio Code 0 5087784240 f.Telephone Number area code and extension .E-mail Address(optional) _a MARCELPOYANT �Q h.Onsite Manager Name ag06.do.c•10/02 BWP AQ 06•Page 1 of 3 ,.,......�," ., .y ..,Y., .., r ` , I MassDEP Home I Contact I Feedback i Tour I Privacy Policy MassDEP's Online Filing System Usemame:MIKEMEAGHER Nickname:MEAGHER123 GEM My eDEP Forms 00 My Profile cO Help My eDEP Show;Filter_:; . Last Download Trans# 1D Transaction Private Note Status Update to Print 286591 100100803 AQ 06- Add Note SUBMITTED Ot/28/201-U Download Construction/Demolition Notification Number of records found.- 1 First Prev t of 1 Next Last MassDEP Home 'I Contact i Feedback I Tour i Privacy Policy MassDEP's Online Filing System ver.9.1.7.0©2010 MassDEP h}Fr�n•'/:/niJnn rinn mnnn n�.i/Rnnnn/�AvLJnrv�nDnnn nnrw 41001I)nI n — ? `QED THE 1 OOP a', -- . Bath WeetirrD room -` to tNK Sf-id�LD BE-ON THIS r ,e WALL i f _< l t 1 1 1 { t 1 ) i i -6wallv351'e 't ! ) mC6 1 t' FLOOR PLAN APPROVED THIS 26TH DAY OF UARY 2010 — 261Aalf lts Yr !— ls 3b"openings �;; . R. Poyant ; ` I Full wall .: full wall' 3 0" CII-�°�' _ o 4 S' f � i TOWN OF BARNSTABLE �rkt FEB � d ! ,. dui=! a 13 Isl f 1 I � I I t i r 1 t i t I 1 I j T � i i ZONE: HB Business District Legend: Min. Lot Area: 40,000 SF Setbacks: p Ce/DH Min. Lot Frontage: 20' Front 100' ® wee°.cm°(,°v"d) Min. Lot Width: 760' Side 30'in total 7' Not less than 10'on any one side O unntyP- Rear 20' © a°e Dete OWNER: o °°PIP, h Marcel R. Poyant OQ coem ee,m(„1) •,,�96 ® c.ten eem°(a.aige9e) ti ti ASSESSORS REF.: T,..(A•) Location Mao Map 209 Parcel 013 ° u9nt E".H' r s 000: Z.N„;:a FLOOD ZONE: Z Community Panel No. #250001 0015 C x e, '" August 19, 1985 d e Zone C OVERLAY DISTRICT: Z AP — Aquifer Protection District 0 ' w As Shown an Plan Entitled Revised Groundwater Protection Overlay Districts" — April, 1993 r T PARKING REQUIREMENTS: ]�02e3t 5P Retml/Consumer Service: 1 Space/200 SF .�� 5,00r1 SF/200—SF= 25 Spaces OT•p0�� .. �I.56 peso Totals Spaces Requirrate ed: 26 spaces � / ' Poet OMa s Total Spaces Required of Previous Use: 26 spaces. ,mom 203 Spaces Provided as Conditioned in Appeal#1984-84 S.000tSP N Rd. toe i='CVS peAe HC Parking Spaces: 11 Spaces Provided ., .. � Existing Building Footprint: 1OT - Phase 1: Existing Stores — 4950t SF a""' ,.•e+" ��„ > R �� Phase 2: Existing Stores. — 7,025t SF R \ Phase J., Existing'Stores — 7,000f SF Phase 4: Existing Addition — 1,043t SF pew R ti r Existing Bank Building: — 3,350t SF St d Post Office Building: — 4,704t SF `10 > ti ' Total Building Area: — 28,072t SF 747 Coverage 50.5 yq/a� -• V + "I6T0 > �® MAP 209 � >y # 1 76 \ ek S9. t S8630'25"w 8 / FALMOUTH ROAD NOTES. eNY e bf .tbn Rm o,tabed h°rr,ewBafde PREPARED FOR: REPARED eY.• RRE «ddP°Ra Relen.Ib Site Plan For The Z,�'P°w"gem fiye1981 B� .w�r°bes R The a°° Sullivan Engineering, Inc. °ndb9, wem..e°e r r bt°m„trw, MARCEL R. POYANT Y P° Rood P.0.9."559 Centerville Shopping Center .e,enrebedf�rn.eeeR°P9$a°etm.as ow) ._, ,.�,,,,m 1620-72 Falmouth Road e')�cel ttNeoma or Hi nrnt°;e ae.. ant°bee xw. 20F Camp Opechee Road Barnstable (Centerville) MOSS. S)M.d°tum used h'NOM•29.a RRed,ReeR,ee 11-i d°mn,. Centerville, MA 02632 nrs eThP°e areiy°.°ilaj'.an e�','aiybar°.�Rv�Re;,y^^ru�ono.o„ry, Re.ia�.PS w F ver2a oA� February 25, 2009 1"=30' ,t vi 's TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map_ Parcel 0/3 Application # Health Division Zb 158 — y ? Date Issued I it Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH Preservation / Hyannis Project Street Address Village Owner f'zAlLG9L 00YA"77 TR S. Address Z�� �'�•� ram/ C� �s Telephone_ dP " 7?3' 1/2079 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District -Flood Plain Groundwater Overlay Project Valuation bcO.vy Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Qv Zoning Board of Appeals Authorization ❑ .Appeal # Recorded ❑ Q Commercial ❑Yes ❑ No If yes, site plan review# ` 3 C) -3 -7- Current Use Proposed Use ' 9-1 APPLICANT INFORMATION N _ (BUILDER OR HOMEOWNER) v Name /i u 0a4meY /,VL/" Telephone Number s?y-3,,d Z- �77 o Address �G 60Y ��y License# 3010 �3 D Home Improvement Contractor# 1,6a&,Q Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ri h FOR OFFICIAL USE ONLY 'APPLICATION# r � DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: r FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING A l�tolj° DATE CLOSED-OUT ASSOCIATION PLAN NO. A The Cornrnonwealth of Massachusetts Department of.lndustrial 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 Naive (Business/Organizationflndividual). �j0,� XSS0C,1 QJ/`� Address: G 13o x City/State/Zip: & Diets JO,M PIA, Phone.#: .�rU �i '3a Z 2 -70 Are you an employer? Check the appropriate bog: Type of project(required): 1.N11 am a employer with t® 4. I am a general contractor and I • part-tiioo. * have hired the sub-contractors empl oyees (full and/or 6: ❑New construction 2" listed on the attached sheet. T. O Remodeling 0 I am a sole proprietor or'parttYer-' ship and have no employees These sub-contractors have g. 'O Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'.comp.-insurance comp. insurance.$ .] S. We are a corporation and its 10.� Electrical repairs or additions required 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ 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. XContractors 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. 1 Insurance Company Name:�6�g 1� a,2 V Policy#or Self-ins. Lic.#: /jCC 2,000159. 0 Z 0 0 9 Expiration Date: Job Site Address: 1,12,d City/State/Zip: (/J,0W9 W-6 0`Y 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 crimuial penalties of a fine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine,. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the MA for insurance coverage verification I do hereby certify It. er tI pains a .d penalties of perjury that the information provided above is true andcorrect Date: ��J Si afore: — Phone#: Official use only. Do not write in this area, to be completed by city or town of-cial City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3. City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6. Other ( nnf4rf"Pnrcnn- hllone#: _ Information and Instructions Massachusetts General Laws chapter I52 requires all employers to provide workers' compensation'for their.employees. Pursuant to this statute, an employee is defined as "...every person in.the service of another under any contract of hire, express'or implied, oral or,written." An employer is defined as "an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or tiie receiver or Buster,of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal 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 v6th 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-contiactor(s)name(s), address(es)and.phone number(s) along with their certificates) of insurance. Limited Liability Companies.(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be.sure to fill in the permit/license number which vrill be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address" Lhe applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone-and fax number: Thy Commonwealth of Massachusetts Degartmc nt of Industrial Accidents Office of favestigati.ans, 600 Washington Streat Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia "i Client#:43203 CAPEASS ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE( 9Dlym PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE.CERTIFICATE 434'Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,MA 026604601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER.A: National Grange Mutual Insurance Co. Cape Associates,Inc. INSURER B: A.I.M.Mutual Insurance P.O.Box 1858 INSURER c: North Eastham,MA 02651 INSURER D: - 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICYON LTR N8 TYPE OF INSURANCE POLICY NUMBER D DATEEXPIRAT LIMITS A GENERAL LIABILITY MSO41163 01/01109 01/01/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL.GENERAL LIABILITY DAMAGE TO RENTED _ AGES R NTED ncel $50 OOO- CLAIMS MADE Q OCCUR MED EXP(Arty one parson) $5 000 X PO Ded:250 PERSONAL&ADV INJURY $1 000 000 GENERALAGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG s2.000.000 POLICY E O LOC A AUTOMOBILE LIABILITY M9041163 01/01/09 01/01/10 COMBINED SINGLE LIMIT ANY AUTO (Ee accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per pe—) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ X Drive Other Car PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLALIABILITY CU041163 01/01/09 01/01/10 EACH OCCURRENCE s3.000.000 X OCCUR CLAIMS MADE AGGREGATE s3.000.000 $ DEDUCTIBLE $ X RETENTION $10000 $ B WORKERS COMPENSATION AND MCC2000186012009 08/24/09 08/24/10 X TWIRCY7A1.,% o E EMPLOYERS'LIABILITY E.L.EACH.ACCIDENT $W00 O00 ANY OFFICER/MEMBER EXCLUDED? EL EL:DISEASE-EA EMPLOYEE1$500 000' S yes,describeunder PRO SPECIAL PROVISIONS blow EL DISEASE-POLICY LIMIT $500 O00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS '*Workers Comp Information'* Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES`BE CANCELLED:BEFORE THE EXPIRATION Town of.-Bamstable. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MALL 'L n DAYS WRIT INII 200 Main Street:_ NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA,02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY gND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 15(2007108)1 'Of 2 #IIA45898` DD O ACORD CORPORATION 1988- Massachusetts- bepai-tmcnt of PUI)Ilc S.ifctj Board of Building Regulations;tnd Stand.uds Construction.Supervisor License License: CS 3010 Restricted to 00 . WILLIAM F SWIET r" PO BOX 108 .< BARNSTABLE, tM 02630 Expiration: IZQ 2011 c'umniisw.uni y Tr#,: 10870 f i1 i. j d r Dec 30 09 10:45a Dec 30 091,1:21 a wut bwm P. 2 Town of Barnstable Regulatory Services. Thomzsjr.Gdler.Diredor. Building)Division Tam Percy,Building Conaoissioaer 200 Mao1 Sftze%Hyeanis,MA 02601 Www.town.baYUtab fe.ma.us Fex: 508-790-62 Office: 508.862-4038 Property OwnerMust - - complete and Sign This Section if Us' A Builder j Marcel R. Poyant as Owner of the subjece.proPertY. to acr on mYbehalf, hereby authorrt i IlCfit a litlOa for in all mattes cr.Iad� work authorised by this building pe pp 1620 Falmouth Road Route .21 (Address of Job) 12/30/09 S' of Owner Marcel R. -Po ant ,Print I�Ianoe er is a Lying for pest please complete.the If Property PP Homeowners License Exemption Fo rm as the reverse side..