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Town of Barnstable 4k6WWm
" 200 Main Street, Hyannis MA 02601 508-8t 2-4038
Application for Building Permit
Application No: TB-16-2286 Date Recieved: 8/10/2016
Job Location: 255 GREEN DUNES DRIVE,CENTERVILLE
Permit For: Building-Addition/Alteration-Residential
Contractor's Name: CHRISTOPHER M DOUGHERTY State Lic. No: CS-083689
Address: Sandwich, MA 02563 Applicant Phone:' (508) 274-9261
(Home)Owner's Name: CHUTTANI,RAM& ANJALI Phone: (617)818-5783
(Home)Owner's Address: 40 DRAPER ROAD, DOVER,MA 02030
Work Description' Add an addition to and renovate existing home.Proposed additions will add a total of 964 sf to existing
home. Additions include: front porch(37 sf),front addition(115 sf),front bay window(8 sf), rear addition
(242 sf), rear dining porch(148 sf),& rear deck(414 sf). The existing dwelling is to be renovated
Total Value Of Work To Be Performed: $500,000.00
Structure Size: 0.00 0.00 10600.00
Width Depth Total Area
I hereby 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. I 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: Chris Dougherty 8/10/2016 (508)274-9261
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total,Project Cost : $500,000.00 Date Paid Amount Paid Check#or CC# Pay Type
Total Permit Fee: $2,600.00 anoi2ot6 l $2,boo.00 ! Paypal Paypai
. ........... .................... ..._.......
Total Permit Fee Paid: $2,600.00
Town of Barnstable *Permit# -Coo 6 511
Expires 6 months from issue date
Regulatory Services Fee 7
Thomas F.Geiler,Director
Building Division.
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601A �' '� ���PERMITwww.town-bamstable.ma.us '
Office: 508-862-4038 Fax:g2.1).71016M6
EXPRESS PEPMT APPLICATION - RESIDENTIAL OJCX
Not Valid without RedX-Press Imprint NN OF BARNSTABLE
;ap/parcel Number 245
-operty Address un S r
Residential Value of Work 15 00 Q Minimum fee of$25.00 for work under$6000.00
wner's Name&Address
Po CAne �2
mtractor's Name CAI V 1 z D �A���� Telephone Number 5DE-4
ome Improvement Contractor License#(if applicable),A 3 ,
mstraction Supervisor's License#(if applicable)
J&�orkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
surance Company Name 1rN\J
orkman's Comp.Policy# 06cog y A0
)py of Insurance Compliance Certificate must be on file.
zmit Request(check box)
>1--Re-roof stripping old shingles) All construction debris will be taken to ( �
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home JzVrovement Contractors License is required.
GNATURE:
Forms:expmtrg
vise071405
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigations
a 600 Washington Street
,�• Boston, MA 02111
W w.rnas&gov/dia
Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name business/organization/Individual)6 A-0 �`F 09 �_)C_
Address: [l` M c lY1
City/state/Zip:
Are you an employer? Check the-appropriate bog: Type of project(required):
1�I am a employer with `2_ 4. ❑ I am a general contractor and I s• ❑New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling
ship and have no employees These sub-contractors have 8•. ❑ Demolition
working for me in any capacity. workers' comp.insurance. . g, ❑ Building addition
[No workers' Cep.insurance S, ❑ We are a corporation and its
ir 10,❑ Electrical repairs or additions
required,] officers have exercised the
3.❑ I am a homeowner doing all work right of exemption per MGL 11•❑ Plumbing repairs or additions
myself.[No workers' comp: c. 152, §1(4),and we have no 12oof repairs
insurance required.] t , employees. [No workers' 13.0 Other
camp,insurance required.]
*Any applicant that checks box#1•snust also fill out the section below showing their workers'compensation policyinfonnation: .
t Homeowners wbo subarit this affidavit indicating they am doing all work andt'hen hire outside contactors must submit a new aMdavit indicating such
rCortractors tat check thitbox inns[attached as additional sheet showing the aarne ofthe subcontractors and their workers'comp,policy-id'a ation.
I am an emplayer 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.#: l Ann Vp1 Expiration Date: 0-7
Job Site Address: � ) ()'-S City/S ip': Z(o_77L. _
Attach a copy of the workers' compensation policy declaration 6ge(showing the policy number and expiration date).
Failure to secure-coverage,as required undet Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Sae up to$1,500,.00 and/or one-year imprisonment as well as civil penalties in the form oi'a STOP WORK ORDER and a fine
of up to S 50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLk for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjure that the information provided above is true and correct.
Si afore' Date: ',
Phone#:
Off dial use only. Do not*rite in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of 3lealth 2.Building Department 3.City/Town Cie
rk d.Electrical inspector 5.Piurrhina Inspector
6. Other
Contact Person: Phone#:
ra
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,.&al 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 dw�clling 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 budding appurtenant thereto shall not because of such employment be deemed V 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."
AdditbnaIIy,MGL chapter 152, §25C(7)states"Neither the commomvealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requ:irements 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. Lunited 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 maybe submitted to the Dep artment of Industrial
Accidents far confirmation of insurance coverage. Also be sure to sign.aad 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'
compensationpolicy,please call the Department at the number listedbelow. .Self-insured eomparEics•iffiauld=rtertheir
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 perniMicense 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
fft
town)."A copy of the affidavit that has been ocially 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
le a dog heense or permit to burn rives etc.))sand person is NOT required to complete this of(i.e idavit
The Office of hnvest gations 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 nnnnber:
The Commonwealth of Massachusetts
Depaztiment of Industrial Accidents
Office of Inves#igations
600 Washington Street
Boston, MA 02111
Tel..# 617-727-4900 ext 406 or 1-877-MASSAFE '
Revised 5-26-05 Fax#' W-727-7749
vrarw.mass.gov/ilia
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t�3s222`�wEST tu,IN'aTRr.ET. HOLDER. THIS CERTIFICATE DOES=NOT'AMEND EXTEND''OR
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7 �S lwN 1031 MA•IN`'STREET
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T THE POLICIES INSURANCE LISTED BELOW HAVE BEEN ISSUED TO-THE INSURED NAMED*ABOVE FUR THE POLICY:PERIOD
tr INOICATEO�>NO7WITHSTANDING'ANY REOUIRENle .:TERM OR=CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITN RESPECT TO WHICH THE
+ CERTIFICATE MAY°BEe1SSUED OR"MAY)PERTAIN,'TH E'INSURANCE`AFFORDEQ,BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE;TERMS
¢y 'r'EXCLUSIONS ANDCONOITION3OP3UCHPOUCI[S:LBv11TSoHOWNMAY=HAVEBEENREDUCEIYBYPAIDCLAIMS: '
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TYPE OF INSURANCE - .f POLICY EFFECTIVE POLICY EXPIRATION'
.t•<{.a POLICY NUMBER LIMITS
s OATC(tAi:d10D�YY) OATE.(MU\OU\YYI.
GENERAL LIABILITY .
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(Pa Accident)
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+ yri THE PROPRIETOR! ! v INC EACH ACCIDENT g �
'OARTNERSlEXECUTIVE DISEASE-POLICY LIMIT'OFFICERS AAE:`' EXCL 3
Mr OISEASE-EACH EMPLOYEE g
of ram•, < ,DES L
THIL REPLj�CES ANY PRIOR CERIIFICATE I,,yUED TO THC CERTIFICATE HOLDER ACFECT+ING VIORKERG COMP COVERAGE.
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3FIOULO'ANY OF;THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFOR%IKE? ! �
I � � Paul_J,Cazeault&3ons r,
t ra `sr r EXPIRATION DATE THEREOF, THE'ISSUING.' COMPANY WILL ENpEAYOR tT0 MAUL+ ,c
2n Ti a
3.
5r1 ` 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE £
Roofing!{;1C. LEFT,•BUT:FAILURE>TO,'MAIL`SUCH NOTICE SHALL'1MPOSE°NOSODUGATION
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1031:Mal T.Street LIADIUTY OF ANY fUN0.UPuN piEC(yypANy,1TSAC.Fi1TSGgRBp f
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Osterv111c,,.MA 02655 K '
AUTHORIZED REPRESENTATIVE' '
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Client#: 19989 2CAZEAU LTPA
ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(M I DID'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dowling$O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
222 West Main St PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Hyannis,MA 02- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Western World
Paul J.Cazeault 8<Sons Roofing,Inc.
1031 Main Street INSURER B:
Osterville,MA 02655 INSURERC:
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.
LTR INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
DATE MM/DD/YY DATE MMMD LIMITS
A GENERAL LIABILITY NPP1012091 04130/06 04/30/07 EACH OCCURRENCE $1 QQQQQQ
X COMMERCIAL GENERAL LIABILITY DAMAGE ME a $50 000
CLAIMS MADE F-X]OCCUR MED ESe(Any one person) $2 5QQ
X BI/PD Ded:1.000 PERSONAL&ADV INJURY $1 QQQQQQ
GENERAL AGGREGATE $2 000 000 ,.
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $1 000 000
POLICY1-1 jECT M LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT $
(Ea accident)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $
WORKERS COMPENSATION AND WC MITj I OTH-
EMPLOYERS'LIABILITY rR
ANY PROPRIETORJPARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICFRJMEMBER EXCLUDED?
If yes,describe under E.L.DISEASE-EA EMPLOYEE $ m
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate of insurance will be issued directly by the insurance carrier.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Informational purposes only DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL If, DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED RESENTATNE
Ae-
ACORD 25(2001/0r;)1 Of 2 #42866
LS1 0 ACORD CORPORATION 1988
a
j
Board of Building Regulati ns and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration.
Reqistration: 103714
Type: Private Corporation
Expiration: 7/9/2008
PAUL J. CAZEAULT & SONS, INC.
Paul Cazeault
1031 MAIN ST -
OSTERVILLE, MA 02658
Update Address and return card. Mark reason for change.
Address Renewal I Employment Lost Card
PS-CA1 Co 5OM-05/06-PC8490 '
Board or Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: ,103714 Board of Building Regulations and Standards
Expiration: '7/9/2008 One Ashburton Place Rru 7301
Boston,Ma.02108
;. Type: Private.Corporation
PAUL J.CAZEAULT.;&',SONS,;INC.
;; :. t
Paul Cazeault
1031 MAIN ST
OSTERVILLE, MA 02658"' '" Deputy Administrator Not valid without signature
Board of Building egulations
One Ashburton Prace, Rm 1301
Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 10/20/1959
Number: CS 026325 Expires: 10/20/2007 Restricted To: 00
't II
PAULJ CAZEAULT
1031 MAIN ST
OSTERVILLE, MA 02655
" Tr.no: 7696.0
Keep top for receipt and change of address notification.
PS-CA1 Cr 5OM-04/05-PC8698
_ -- -
/te Voo�vnu»»tc�eall� a�✓vu ¢�/Lute
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
i Number;;CS. 026325
Expires;f10/20/2007 Tr.no: 7696.0
Restricted:=00.
PAULJ CAZEAULT ,.
1031 MAIN ST C
- OSTERVILLE, MA 02655 `"
,,+ Commissioner
Property Owner Must Complete & Sign This Form
If Using a Roofer / Builder.
(Please return this form with your signed contract,.thank you)
(print),, as Owner of the
subject property hereby authorizes Paul J. Cazeault & Sons Roofing
Inc. To act on my behalf, in all matters.relative to work authorized by
this building permit application for:
(Address of Job) 5 J �C-fe Do- nry 5 Poq-�
Signature of Owner OAT LA
Date �/13/0 Tel#