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HomeMy WebLinkAbout0347 GREAT MARSH ROAD ep of 9 '!+ (� I;tPlyf1!!j!t r 1dr i. .. U. ,.. � ..., {,. .. .F .. .. ., ,,..E _...«i t' ,,., � :. : �'rr �.,., :: _ ., .F, •`�{ _ 11 e 1 �M .. _i � �3f 111. f:� c {' ! , ff I Will a, ]I ;1- il- ., tl I + f a tt 1 I "n`��. .,f ,� p e u t „ ,, i. , 1. .. .�. .. 6 ° ° .11 o ' i a i 'wig ar., - ,� 11 . , v I r a,. s. , 0 y n ,' a .O a e �t YI 4 Al h ,�. F tl a dt.a 'R,' ' ��W ,. 9 If. ,1 s 111 •y Y 1°: i f ,o W gg .� •'�" {I 4 e ' F � ° N gyp° g a;,+ 1•5 g /' b SL4. 4 .A 13 di �. , { n qa '1. Is q A: Y,. .. t •� s �� ,. �'� a ,F� `5 $ �,, i R E 4 '3 1� t Div t p .7• 11: f 1 , l R. E $`q l < ,�_r ni '; s'' 4 d d q, ;. i y ° r i ', 0� } a9 N. 9 n ,p ' ,z' - a, �� r. M a•.« A 4 y ,1 "� �� � n <, d s �• r .. i11 a „H ,,a �op F { P M= A ... u, i:. 1. ., . 1. A b , < t w +: y , _ o B F 1 e 9 y n " R e,; t n , M , aQ , e r - - 1. - I 5 .. ° 4 ¢ y ,'f i No P .I, 4 °u v a.aI Ir �, ,., •_— ,, r .. u - - Town of Barnsis11 a *Permit." Regulatory Services E�ires6morrtLsfronzissuedate °' SABNSfABr.F., e' �$ ee 163 . �� Richard V.•Scali,Interim Director p�DlwA'i� Building Division Tom Perry,CBO,Building Com ft 200 Main Street;Hyannis,MA 026E SS Nvnlrw.town.barnstable.ma.us Office: 508-862-4038 _ DEC 0 9 2015 Fax=508-�90-6230 MRESS PERMIT APPLICATION Not Valid without Red X--Press I Print E lvlap/parcel dumber oZ/o n Q(„ PropertyAddress -ma/''S ,pa-7 V j 11 YResidentiai Value of Work S _3 Minimum fee of S35.00 for work under$6000.00 , Owner's Name&Address_ n'(p�,p/1 e l n e Z '3'�7 [act I/��/�c� �?_�fig(✓i(�e l� 0 Z& 3 2_ Contractor's Name�rlA� Telephone NumberaO tl�i2 R-9 k'ao Home Improvement Contractor License_(if applicable) /7 3?-q 5-- Email: Construction Supervisor's License 4(if applicable) p ci 5 7 0-7 gf Workman's Compensation Insurance Check one: ❑ I am a sole proprietor " ❑ I-am the Homeowner , 1 have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy r �tlC�11.8D `$3 ES2 3 y Copy of Insurance Compliance Certificate must accompany each permit. - Permit Request(check box) - ❑ Re-roof(hurricane nailed)(stripping old shin.les) All construction debris will betaken to ❑ Re-roof(hurricane nailed)(not stripping Going over existing layers ofroof) ❑�R -side Ly'�teplacement Windows/doors/sliders.U Value . 30 (maximum 36)s of windows S I 4 of doors: - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,ete '"'Note: PropertyPwner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required.' SIGNATURE: % QMVPFILESIFOUMbuilding permit fornAWRESS.doe Revised 061313 t Renewal _ .byAndersmm' :EL SE\T. WIN"r[nuncr{Ui r �6 7F�`Ubtr>io;R�s,t •,'Lim�bint k.E C328Er5 i:wrnrnr n�28 .ry s 9oafhea I�ri Y.aglaaui!W� L�Lt:,!/�►%o, -, .. - &em�ty;�l ibry Aadrwen of Sov,ffieia Naw$ gel O[SWA-4 W1 0 WAM WORtREiti6OIDMM0�'l�EME" 5�jrtr{gF Sarett,�W���iry s��d T.sp.Codr.d R�Dac -' Mh!5-, Ua}�ertQl tiercby inily:arod sus.,i IIN 4r ®to pn,clia,e Ilrep t4e�ea rrrd�Isx se�vuxa of Su3a91ierrl I�revt+:E'',qpd 1'1P.r,rbo�rr�;'. ti/tbfa IZe�cweil. 6y Altidersero eel Suuil rn Neai.SnitLa,iel 4 failerau irr"1,,n, <niamae mrh the f�ms anti w6rlrl'iuorte cleAeniae cart>!he fi4i�t anr�ailsyeru aP Ibt!'agrccft Y1r L]lil fi5o'lllt 3iilu it vf!CiGuaticia sla,��(sj(�t�L1tK�w lg i9rus.'�i ,'er,•i tc "Work'<[l C.tardzi�; HQIA7'' - - To�liJcbAaieFtadici� 7S�irchBC f�9etltadat�yriro�t �CN,eek I�C� �i�needh , `ui3,of '" cQ in Si�:ei1 J�li ���� � �� ralect ao;:t sic Caud il>k 3. 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S.wow+o.l�f lt3 tl d� 9W1r k,B�lB�ri .3� .�LL w �' —sit, t�t2rf5l; It'1P.rlILlG4R71 9° � st Ni'14T34� 1 tQ®olL�'.::.. . ^`er iiil,�"L' liQ7fII�{fiJy 14 1E 1' 1 i Tilllid A 1CI03�i SAT iA r J i `ICI f1It fi(f NMNIGHT-,'01?,`J�E��;i �I!$li�S$'DAYAIti�t:TREI)A�'�OT��I��T�T[ON_S�TfiB.�L�'7'a1GE�liilits'1`ICBf��A�T,C7 "i(3B!TF(lI#MS'',t . mi#TiM$Wt, s e� a t'..: .a •�_ .0 6 r�� .y s�� 'fie y� [15ssa o4.�am Ei�ors �} y(au'r7 oy;c el�' Gate afTr a s �' IAN may pneel tf+is tratrspe�an.�rtooitt br•o$kgaophYwtta► this trartsactiowf,wrtha pe�talijr or�ligotipt4 vrrtlr�rt; tfuee bueierass dad h 1 t tr. 'If jlou Qatrrmeb strlr>h;'three(urnn isx: s fl oe r the affiare ditmro;ll'tooi a el,Mw Oft p :traded rn,awry madie bir;>rbv utrder # i.pertjr kradei r�,a"9+.pittterelEs nRadb trl+Yoe under floe t ent or;ia�; rrd a lnstavtnerrt eauet4rte,l I: �Can�eee or Sa��,atYd#fir Mt4+Set"fi,-IrtstFarmr�t'cxeeuee ' i.y$u wtll 6e ratarned rrli- tembarsiness d �r]Ilowing l�by yaa'wiU1 Iiri.irvtrtrrted.Yrltlrin tam busipoo9s daps i<olhrvrrng:� reelpe 6lr tltc Seller of hour emoEelUi6e aeotros, snle d reosiptb the:Self of pour h�lian notice'anc! ' rfiy lnEerest arterorg a1 i#ae r trar►sastton wiUU ! lecurr�r arrteree! artTain,B auk et trtudon- %v bts ltlrou carr�iE r�sttst melts aaailabla oi?tlr Sir canceled.Klou.el, u r�ustnnake aalile t a tl4e SePle1•:a at_ptrtt ,rtishienor"M ubr rafly as good coii ddo ai;.xheti h alyaur;tesiderrt rrt stsrni r m gaod:satt eion aavi�harr,. eel d, 7 EI° #o fau"+snder hits ani k ow i' received,sr r get-Aeltviered tv 1 tt this Garttaaet of, for.Yau rr dyou:vrtrtli;e,r�tpllr'with insltilt epltof l afiKws`ltoi+ 4d avithrton rWMtbe lrr ii, of 2 "r"tA'e Seller drBi t'f�r-ka�thl"_..'Tt goods at t tho Bellow ie ng tip®r+ettrrn s.Ir,pntertt pf tUoe g4 st they 5elkeo'a aril matt IE da maI&the goods tii►ailabBe ;5rsllarS'e r a>td rim If yaci'dri rrotaber tfi� oodt'av�laNe" po flue�d doe Seller doe itat pads ftir.6 up wtt4tte tlwe.�eand floe Seller s rl4tpick trio up wrttJrin; ad flte'date nfesneeila #on prw'rNa�l RAW l tYnortt r otP;et�dace'o#caerelfstlrxt.rrru rultipr'taralro ttoe gosils witlr4rrt au r,tiirtlrer dl��gatioj!:fi r 1' �se`al the'goads wrtftawt ari firrt4wt:+ibwSatlan If Iron�� �trleAtB 3Maa able to the,gelUer,or if you agree 1 ti0 to tails.goods available eta tiro Seller.or d is rw gods to tho.Shcar alrod fl oQ:elm sa.ran yea I;ter rn ghe.$aods os die Setler";mod darl: do sa,:theRr i+Attiairl'liabte far: rfa 01 al>FabilgataarrsC4ig rtitdtr ate it+eitt7l+11 Ilab/e for perfoflitoC all oCiiigasior +�rrder,ditp<;e of cancel this tr, apdort�iitinail or dehv+ ,3 trgnerl �.; �onro�rac#,��5aiecei drtdbrty ntiail dRll+>er a signs t and dx#ed. tltr cancel9aiion,nouir3 ar snrtotber aind eoPY of this-t", eflatiort ittrkice or:airy: �rrrtt>aa�oo�ce,ceendat�ele�ramtolte w�IFrj+Andee�enof'l writberinatJre,vr�ntlx>ete toga lbfrllndarsencf iauflre li ewi�ng #I4AAlbian oadl,Lr y�28SS i, SdttlhbrnNew� nglattds�#T AtW&a RooaJ`43 oat fll4756li;. l � iJIT61iTli41MN M7CNll#W1`�OF� l .rjl'<NOT tATEItTIIAi�I MIDb116Hyf E i�a#a) ;� 1, D' °peYMI+i� i.THIB 01JT14t1. ME 1t'CAMCELi�I�STItl1Ns4cr li Mix OfdWA SUM 'so" _Zk Nx,ar• irrr+,�: MA'CBf►p iM4m`' g,rlerCaapYtlldw' Bulrtr,Zep}^Pkik.". Y The Commonwealth of Massach usetts Department of IndustrialAccidents Ile Office of Investigations ' I Congress Street, Suite 100 Boston, MA 02114 2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/orgmization/individuai): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone #:401-228-9800 Are you an employer? Check the appropriate box: Type of project(required): I.K I aha a employer with 20' 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. ❑"New construction employees (full and/or part-time)_ _ 2_❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition workingfor me in an capacity. employees and have workers' Y9. Building addition [No workers' comp. insurance comp_msurance+ g required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] T c_ 152, §1(4),and we have no employees. [No workers' 13. Other (,o �a G en comp. insurance required.] n *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. 1 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:ARGONAUT INS. CO_ Policy#or Self-ins.Lie. #:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: 2 7 6&a t Ma,t S l 't City/State/Zip: Pl i/ 1Ie—r A 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-f VGL 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 urance coverage verification. I do hereby cerdfA under the and penalties of perjury that the information provided above is true and correct Signature. l Date: /Z s Phone#: 4012289800 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#: r a SOUTNEW-01 SHETTYSHT '4�Rim CERTIFICATE OF LIABILITY INSURANCE °ATEYYY' 8/1912019/2015 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 NAME: Willis Certificate Center Willis of New Jersey,Inc. PHONE FAX C/o 26 Century Blvd WINE Ext:(877)945-7378 Afc No):(888)467-2378 P.O.Box 305191 ADDRIESS:certificates Ilis.com Nashville,TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of Southeast 39926 INSURED INSURER B:OneBeacon Insurance Company 21970 Southern New England Windows LLC INSURERC:Argonaut Insurance Company 19801 D/B/A Renewal by Andersen 26 Albion Road INSURER D Lincoln,RI02865 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 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 ADDLSUBRTYPE OF INSURANCE POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMID MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 i CLAIMS-MADE a OCCUR S 2029459 08/10/2015 08/10/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY 1 JET LOC PRODUCTS-COMP/OP AGG $ 3,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 A X ANY AUTO S 2029459 08/10/2015 08/10/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE Per acc $ AUTOS dent X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AHOED EXCESS LIAa CLAIMS-MADE S 2029459 08110/2015 08/10/2016 AGGREGATE $ 5,000,00 I I RETENTION$ $ WORKERS COMPENSATION STATUTE EMPLOYERS'LIABILITY YIN X STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N❑N NI A 0000068028 08/21/2015 08/21/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Workers Compensation WC928058352394 08/21/2015 08/21/2016 See Attached DESCRIPTION OF OPERATIONS/LOCATIONS/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. AUTHORIZED REPRESENTATIVE Evidence of Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD � a , Southern New England Windows d.b.a r Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License:CS4)95707 BRIAN D DEPIP 9,bN 7 LAB POND L'IIt 1 Charkm MA 01987 rt Expiration Commissioner 09108=16 ; i Office of Consumer Affairs end Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement.Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL;' Expiration: 9/1912016 DENNISON BRIAN — --------- 26 ALBION RD _----- -- LINCOLN,RI 02865 Update Address and rem a card.Mark reason for change. 9r4 t a aoucsnt p Address Renewal Employment p Lost Card �ho�cov�ww� gf� #E�OVE'ENT sesser Attain&Radaeu Regulation License or registration valid for individul an only M CONTRACTOR before the expiration date. fftsxad return to: Office of Consumer Affairs and Business Regulation n: 17324b Type. 10 Park Plaza-Suite S170 Expiration: 9M90116 Supplement•.;ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BYANDERSON ALBI ON BRIAN 26 ALBI 28 ON RD LINCOLN,RI 02865 Undersrsreury Not valid without signature Town of Barnstable *Permit# , .. O6f;�y-7 5 Expires 6 months from issue date X�PRE�S PERMIT Regulatory Services Fee AUG — 1 2007 Thomas F.Geiler,Director 0 �131 Building Division TOWN OF BARNSTABRm 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 Numbe rO 1'Y� Property Address s . I i:�ll< �`��/�1.._ '�•, f'.��t (�1 a1�C� 2 e'�� , �i ';� E Residential Value of Work CTZ),0) Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address r` U_ ,1 7f �4�i>ri'j).. JJ �i✓1:eC.%io !�✓%� ', r, ti.e ,, 1� � �.. �1 Gt tr) ��f; Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ -I am a sole proprietor Rr'I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) { b � of ❑ Re-side _ ';.r' 6�/ yReplacemer t Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: ; Q:Forms:expmtrg Revise061306 PERMIT PAYMENT R TONN OF ECEIPT BUI l BIN BARNSTAB HYAN0 jE ,SIN S REFI BENT OATS... O6 MA 026p, IME; /07/0? 14:06 PERMIT $ P4I0 AMT Tf - ANT NpfREp, �5.00 �NA�✓f P� 25.00 p p 25 00 •00 WW OR n 3 -ov r,'4�'x � h� �� ro 3' �{�-�' " �• aft �- _�"�>.« r,-�^�,_.�". �s,�yt .-: rIM, Aw— po 0000 a y- - V �:.. The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 31e (Business/Organization/Individual): .,, 4 /, a..h.t_;j Address -- `—n �a a /,�I a C) :? City/State/Zip: Phone.#: Are you an employer? Check the appropriate bog: Type of project(required):. I.❑ 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. El New construction . 2.0 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 me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance. $• i equired.] 5. We are a corporation and its 10.0 Electrical repairs or additions / officers have exercised their 3 I a_m a homeowner doing- 11 work 11.0 Plumbing repairs or additions -- --m self o workers' co right of exemption per MGL y [N` mp 12.❑Roof repairs t--- segi-� �r" ` c. 152, §1(4),and we have no j insurance # ed - employees. [No workers .13. i�Other__ comp. insurance required.] . J. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation. 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: 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 maybe forwarded to the Office of" Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains•and penalties ofperjury that the information provided above is true and correct. t o- - Date:-- j — Phone k Offtcial 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.BuiIding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: :J l 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 mere than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)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 complfance 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-cont actor(s)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 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,no#the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate-line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as.a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"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 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 Massaohusetts Department of Industrial Accidents Offim of Investlgah'Qns 600 Washingtaii Street Boston, MA 02111 Tel. 617-727-4904 ext 406 or 1-977-MASSAFE Fax 4 617-727-7749 Revised 11-22-06 www.mass.gov/dia V Town of Barnstable. y Regulatory Services 'eB MSS.. Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 "w.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner�Il�ust Complete and Sign his Section If Using A wilder I, ,as Owner of the subject property A hereby authorize. to act on my behalf, N14, in all matters relative to work authorizeld;bythis building permit application for: . I� (Address of Job) Signature of Owner Date J Print Name Q T O RM S:O W NERP ERM IS S ION Engineering Dept. (3rd floor) Map _/0 Parcel 70 4� Permit# House# Date Issued . Fee ��1br Ct8!NV P ) .tie►c�9. 19 : URNVABLE. 6D 19. TOWN OF BARNSTABLE Building Permit Application Project Street Address. q 1 G avK man—S)4 Village I L,l Owner M 0 G E),J t_s' k" Address Telephone 21 5- -9 3 3 Permit Request L4 L`VS ® (IS ML S 6J(AJ G LL S 43^1 (came . First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ ®� o Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑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 No. 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Tt-yv fly W L' V k l'Z Telephone Number 6 t 1 293 U9 3 Address � CLA R J-HoAf {2Q . License# (6 Z (ago Lc Ls NA MM 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 RESULT NG FROM THIS PROJECT.WILL BE TAKEN �'/ ( �s21 C/�� {2� 'tj s j \," ((1�f G' SIGNATURE DATE v $ 4 BUILDING PER N D FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLYAIT ., PERMIT N#O. DATE:',ISSUEW I MAP/:PARCEL`NO' 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. l- The Commonwealth of Afassach usetts Dt.•parbtrenl ojlndustrialAccidents ';K Officeo!111FOS INfoils ' J 6O(I H'ashin�tan Street L\. :' Boston,A1ass. (I2111 Workers' Compensation insurance Affidavit - ►�ps�tcant information• Please PRINT;lebtbltr� name: L'y"�`YLI�I loc•ttion• C L are co4 ow 2 D , I a homeowner performing all work myself. 50- am a sole proprietor and have no one working in any capacity a..� - 1_:.":`.d�-.�.._ '.�.-,I""�`r-'s-�'�.�.a.� .,bar'.T�'-°R'V.',�'"'""tm'�'.drl�i�r-, .,...✓.� .. -.::."•.*!'� '_�r�;"'.'!"T'eT=,....,.,.•.= 0 1 am an employer providing workers' compensation for my employees working on this job. company name: address: r may• phone#• insurance co polio'# I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: -- city: phone#• mcurince co Po icy# -*-,"5'"' ., . .... ..a-7',,1Jti-=`r,•s...�W ae�, -. i•�-.+. �••.-rr�yp^�+:�t�-J,`irl'•7AZ!"7�'�'n -•nr ^" _ •�... „_,` 3A" "•S"fit` company name: iddresc• city Rhone#• insurance co policy .Attach addi_tionaI'shcet if tiecessar �._ f• ?_,,): y •= :`;•�:�_ •`ce.r_;� „r„ ri..iiu.asa.;ts:�x: Fuilore to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1SO0.00 and/or one years'imprisonment as well as civi penalties in the f m of a STOP NYORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement m/fonved the trice investigations of the DIA for coverage verification. Idoherebycertl• ndnd pe tics perjury that the information provided above is true and corre L . Signature Date /0 i� Print name �t= t{VZ L-7 - V t Phone# c ( 7 " 19 / q s.. {official use only do not write in this area to be completed by city or town official +' city or town: permit/license# r'illuilding Department Licensing Board • E3 check if immediate response is required 13Scleetmen's Office C3I1calth Department contact person• . phone#• nOther (revised 3M5 Pl'A) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers* compensation for their employees. As quoted tom the "law", an e»rploree is defined as every person in the service of another under, any contract of hire, express or implied, oral or written. An enrpl(!rer 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 rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant,who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. ..�.i �i'' , Y 4 �..J t .A .�? o f ..lAa .... y'r ter. ... .......�. .—. .t Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 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. : s City or Towns Please be sure that the affidavit is complete and printed legibly. Tile Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. 7�7- . n. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 °F THE t° . � The Town of Barnstable ELAMSTMM 9� MAM1e�' Department of Health Safety and Environmental Services ArEp�.�A Building Division, 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: Est.Cost Address of Work: Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for at ermit as the agent of the owner � /2XZ I r) Date Contractor Name egistration No. OR Date Owner's Name - .. �- .. ( ', ,. r ' s 1 t .✓}'. 1. DEPARTNENT OF PUBLIC SAFETY CONSTRUCTION.SUPERVISOR LICENSE ' Na�hei Expires: Res�iete _ 10 '=�` �EFFREK D YEAVER y CYRIL AVENUE v YGEMBROKE, NAB -02359 I CoMMISSIoNdh ?` HOME IMPROVEMENT CONTRACTOR Registration 117618 Type - INDIVIDUAL Expiration 10/26/96 JEFFREY D WEAVER �_JEFfREY D. WEAVER ` ADMINISTRATORCYRIL AVE PEMBROKE MA 02359 s" I•