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I , � � � -01113 -1 11, . �_!;� ��:�,,, I - I I I I I - -, , .; : "I �:,, . , "��,.'' ­ I _ � . :.�, - - , ­ �, , " � ., '. ,j: " I—- ­ �, �, " - - , ,2 , , �- - , ,, " � � , ,, �, , 1,1 I ,.�111' ," - , '" . , ,, , � ,- - I , , , , ,� _,�., , ., ;o��__:': ­�Y - -".:� �_��'.�,t,,,,�.,, ,,,--,�-,,%�, ,-�: �: ,z ,. , �:" ­ � �:`-- : ,,�,',,-,i� ,"',�," ��,���, :,-,��' , ',,,��'�;` -��_l ,I 11, -�:vl�;QQ;;: � , -,,� �,, �,��-_,�-,-,� � ,�,i, , ", ''.�;�, " �,',� � ,�� '', - �: '' ­ '.,,:, .-_ � . -�� i'i,i�,�,_- ",", ,�-,�l_-! ! t �, , " ��,,.,'-1,�:f:,,.,,,,,*,_�- . -,�,,� , ,.', : �` -.. :,� � ":����, , N ,�� ,� � _�,,�""'­,�,,,- ,�k;,,��,�:,:_-,�L_­_,:i'," ,--,,.,LL�� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 1,7 q Application°IVv/s Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee 30(, ` Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address �/7 J Q 1 g-°l'M RnAd Village Owner ' /'� AddressA-1 � I L Telephone Permit Request eel� � V SQA Square feet: 1 st floor: existing�_proposed O 2nd floor: existing proposed Total new Zoning District R Flood Plain /Lri> Groundwater Overlay Project Valuation Q ' Construction Type Lot Size 1 fo Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ;29� Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes XNo On Old King's Highway: ❑Yes )i(No Basement Type: jKFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) SAl? Number of Baths: Full: existing o"L new Half: existing C7 new Number of Bedrooms: 3 existing'-Gnew Total Room Count (not including baths): existing 6 new 0 First Floor Room Count Heat Type and Fuel: ❑ Gas *Oil ❑ Electric ❑ Other Central Air: ❑Yes 9No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 1&�No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:X existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ %: Commercial ❑Yes ❑ No If yes, site plan review# __JF Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name (P1 -77 I t[A iyim Telephone Number Address PL41PA 6 T• License # CS t, k LA&Adq W6,v4 Ad, M`7)il/ Home Improvement Contractor# 1 Z�J o2q Email lv� 1Jjdwiitwtrocium& Worker's Compensation #+�J� 3a5` ►�+�� "�`�° ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PPROJ CT WILL BE TAKEN TO q v� A ` e� SIGNATURE DATE ' 1 1 ' ;LO IS- FOR OFFICIAL USE ONLY APPLICATION# t , DATE ISSUED _ MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION t FRAME 5 INSULATION } FIREPLACE ELECTRICAL: ROUGH i FINAL PLUMBING: ROUGH FINAL 1. 4 GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 27te Commonwealth of-Massachuseffs DEepartnrezit offadusbzrrl Accidents - C;we Of finves4afians 600 Washington meet , Boston,MA02111 WtCwanasmgmAd is workers' Campens:atian Insu mnce Affidavit:Builders/ContractorsMectricianMumbers Ajaplicant Information Please Print Lep_ibly Na=(Bminessrargnization&&vidnaq: •� 1 Address: aQRA R 71 ICJ U IL f 2 Cityfstat&Zip_ .�S Phone 47 Are you an employer?Check the appropriate box.: Type of project(required): 4. ❑ I atu s feral contractor and I � pT J 1_gI am a employer with 6_ ❑New construc#iort employees(full and/or part-#ime)* have hired the sub-contractors 2_❑ I am a sole proprietor or partner- listed on the attached shimt y- XR,-_m debug ship and hate no employees These sub-contractors have g_ ❑Demolifioa w for me in an rapacity employees and have workers' oz�g y � �- 9_ ❑Building addition [No workiers' comp.in¢traanre comp-ii=aaw_I required-] 5. ❑ We are a corporaticn and its 10_.0 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 repairs instu-mce required_]T c.152,§1(4),and we hime no employees-[No workers' 13..❑Other comp-insmance required-I *Amy applicant that ched:s boot 91 mast also fill out the section below showing Their wottcets'compensation policy infttr T Homeowners who submit this afhdwit m&cxt ng they ate doing all wont and then hire outside contractors mmst submit a nets affidavit inrrrsfin mdL 1CUnttact3rs that check this Goat must attached an additional sheet showing the name of The sub-oohs and state whet3ier ocnot tbnse emfities have employees if the sub-{ont mctars have employees,they must ptavide their workers'comp.policy number. I am an employer that is ptvr►dding workers'compe7u Lion irzsttrance for rtzy amplayees Below is the policy artd joh site informado:n_ Insurance Company Name: Police#or Self-ins_Li, l: CJ�- �l l S - 1 ��' o E�rpiration bate. 2,0 A �� Ls � , ° JoU Site Address: City/StafelZig:��•��- �}-J(`L , Attach a copy of the�orkers'compensation policy] declaration page(sho Ndng the policy number and e3*ation date). Failure to secure coverage as requiredunder Section 25A of MGL c- 152 can lead to the imposition of rrirninal putties of a fine up to$1,500-00 and/or one-year imluisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of to$250.00 a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office of hwestigations of the DIA for insu once coverage verification_ I do hczt eby certirut pains and penatlies of perdu ,[itntfhe irtorxzalian prm*idRd abotq�e is hue and correct Signature- / 1� Date_ Phone# Sb ` -Tr�Q ' (3•55 (3jfuz:aI use onty. Da not write in this area,to bs completed by city or town officiaL Cite or Town:. PermitUcense# Lmuing Authority(circle one): 1.Board of Health 2.Budding Department 3.Cit ytfown Clerk 4.Electrical Inspector S.Plumbing.Inspector 6.Other contact Person: Phone#: 6 • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 IocaI 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'subdivi=ions 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-contractor(s)name(s), address(es)and phone number(s)along with their ceriificatc-(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no tmployees 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 indusu ial 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. Sell insured companies s:o.ould 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 permitllicense applications in any given year,need only submit one aftida.vit indicating current policy information(if necessary)and under"Job Site Address-"the applicant should write"all locations il-r (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 mast 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would lice 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 Commanwaan of Massachus-Ats Depaz4mant of Indust dal Accidents Office of kvestigatiwls 600 Washingtan Street Boston,MA 02111 TeI.4 617-727-4M W 406 or 1-9 I ASWE Revised 4-24-07 Fax#617-727-7749 www.masss-gavldia f AC RO O® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYYi 10/28/2 14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.OTHIS 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 DOWLING &O'NEIL INSURANCE AGENCY INC COON A T 973 IYANNOUGH RD PHONE PO BOX 1990 FAx HYANNIS, MA 02601 E-MAIL aC No: ADDRESS: INSURER(SI AFFORDING COVERAGE NAIC p INSURED INSURER A: LM Insurance Corporation 33600 J J DELANEY INC INSURERS: 20 RASCALLY RABBIT ROAD UNIT 2 INSURER C: MARSTON MILLS MA 02648 INSURERD: INSURER E COVERAGES INSURER F CERTIFICATE NUMBER: 22119353 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 ADDL SU R LTR TYPE OF INSURANCE POLICY NUMBER MM/DDY/YYYY MM/DD� LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DA q GE PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC GENERAL AGGREGATE $ OTHER: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY $ COMBINEDSI Ea N LE LIMIT $ acc dent ANY AUTO BODILY INJURY ALL OWNED Per SCHEDULED ( person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NONOWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ A WORKERANDEMPS YERS'LSATIONILIT WC5-31S-318101-014 - 11/2/2014 11/2/2015 PER OTH- $ AND EMPLOYERS'LIABILITY Y/N ✓ STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? FN N/A E.L.EACH ACCIDENT $ 500000(Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ 500000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HYANNIS MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 22119353 CLIENT CODE: 1315596 Lucy Garfield 10/28/2014 7:58:12 AM (EtYr) Page 1 of 1 'Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-0O9961 JOHN J OELANE 211 PLUM ST West Barnstable MA �c Expiration Commissioner O411412016 �e�pomumalaeaea,�l�a�C �oac/zccsella Office of Consumer Affairs&.+Baseness'-k' "'I" ME IMPROVEMENT CO,,NTRACT:R egstraUon ,�25529 Type xpratknn,: 1f�5/20.16 Individual. JOHN>J DEUINEY )!H � JOHW DELANEY /? 271 PLUM ST S J ' W BARNSTABLE,MA=O2668 id errs ecretary j a Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing i iformation visit: www.Mass.Gov/DPs Incense or registration valid for�ndiv�dul;use only { before the expiration date If foupd'return to Qf�ice of'Consumer AfT 6 and B:us�nessFRegulation 1�Park'1PlazaE-S.u�te 51:70 - Boston;lVlA 021i6. ' r, 'Not valid without s►gnature �IHE ray Town of Barnstable Regulatory Services vRMtNSTABM$ Richard V.Scali,Director �ArfDrdlA�A,� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder y I' Ip&k ' , as Owner of the subject property hereby authorize Zk1J to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) "Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. 'IlCeVI, Si nature f er 4UA 'Applicant Pant Name Print Name Da Q:FORMS:O WNERPERMISS IONPOOLS Town of Barnstable Regulatory Services ��pFZHE Tp�� Richard V.Scali,Director Building Division anxxszas Tom Perry,Building Commissioner v$ �6¢ ��� 200 Main Street, Hyannis,MA 02601 'TEb µAS www.town.barnstable.ma.us Office,: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone m CURRENT MAU-ING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_ DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &`Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a Iicensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 FALLON RESIDENCE' : - 47 HEADWATERS RD ,„ w- 1 CEMVI ERLLE MA 0.7<�02 . .. ,. 71 . VERIFY FF EXISTING .. . '. .. DOOR IS IN SUITABLE , CONDITl7H To REMAIN REMOVE EX44TING' • • POORE-AM WINDOW$ D PREP WALL AS; �--REMOVE. N REOUIRED FOR . .CARPET.—� WHERE'NOTED. --REMOVE ,�--REMove -- CARPET CARPET .. .. REMOVE. EXITING_ ' CABINETS ., - T7 EMOVE .I J DELANEY. INC: ' .REMOVE EXISTING REMOVE EXITING' CARPET-1`. 2D RASCALLY RABBIT RD DOORS AND.WPIDOW$ CABINETS,'APPLWMCES _, MARSTONS MILLS,MA DZ640 AND PREP WALLAS FOLTVRES.STORE sae....60ss 'REQ AF FOR NEW FOR SALVAGE a WHERE NOTED. .. oRoJBir Nuinsw:' . . ec�ie.Ae No,Eo ' . . . . GEBRWRY2Iy ' 28 - TITLE:... .. , • - EXISTING 1ST FLOOR PLAN X11 EXISTING FIRST FLOOR PLAN WITH DEMO NOTES FAIN OF BARNSTABLE I I -3 PIS I. 04 D 1 VI510N TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #I �� Health Division Date Issued _l Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address -1 _7 T �� Village' Owner 'Le—" r�rc. aa r� Address Telephone 5- (0 `-1 .Permit Request �o��l � `� ��.����'-c. �`� '�eu:r -�-� Square feet: 1 st floor: existing proposed 2nd floor: existing - proposed Total new Zoning District Flood Plain Groundwater Overlay _ Project ValuationO r^�a0o p '� E Construction Type Lot Size / Grandfathered: ❑Yes ❑ No If yes, attach supporting docuro;entation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) , Age of Existing Structure �o arl Historic House: ❑Yes ❑ No On Old King'sflighwa�j�❑Y ❑ No Basement Type: M Full ❑ Crawl ❑Walkout ❑ Other x` 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 IdN6 Fireplaces: Existing New Existing wood/coal stove: ❑Yes dNo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing . ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name fete Telephone Number Address / 3 S Ze 41.; License# c/_5 O C1 y69 l Home Improvement Contractor# /5 7 7� 5 Email /am &J Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ! FOR OFFICIAL USE ONLY F APPLICATION# r DATE ISSUED- MAP/PARCEL NO. ADDRESS VILLAGE F OWNER r DATE OF INSPECTION: FOUNDATION 5,. FRAME INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL 4 GAS: ROUGH FINAL FINAL BUILDING L) ZJ l E DATE CLOSED OUT t ASSOCIATION PLAN NO. J 7 , Hze Cominownwakh of 4assachusetfs Deparftnen`t Of I7tl msftZaI Acc7[�EtItS Oi7CE Of finvestigations 600 Washulgtoa,S reet Boston,M4 02111 wmv.inass goi-ldla Workei"s' CumpensafionInsaranceAffidavit:Builders/Con"ctorsfF erfriciansfflumbers Applicant Infarmation Please Print Legibly Name Address: l `3 S 641 S - City/5tateMp: s k-AY- Ph...47 Are you an employer? Check the appropriate box: T , of. o"ect (r nire _ 4- lama contractor and I 3'l� 1� J �� �- I_ ] I am a employer with l 6- ❑New traction employees(hilt and/or part-#ime)* havehiredthe sub-contractors ?_ listed on the attached sheet 7- ❑Remodeling El I am a sole proprietor or and have no employees These:sub-contractors have g_ ❑Demolition working for-me in any capacity employees and have workers 9- ❑Building addition [No work' comp_in¢urance camp-tnsnrance_l 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 I_.❑Plumbing repairs or additions right of exemption per MGL m'i'�`1f [No workers'tromp_ _ I2_❑Roof repairs insurance required-]b - c_152,§1(4),and we have no employees-[No workem" 13'_❑Other comp_insurance required._]; *Any appbctnt that checks box-1 taus#also fill out the section beJVw showing Their wotiiem'cv=pensatiou policy infarsnatiM_ T Homeowners vrho submit this affidavit indicating they are doing all wcA art-d then hire outside contractors ffi submit anew affidavit imlirming such lCoutcactors that cliPck this box must attacked an additional sheet showing the name of the sorts-ems and state whether or not those¢Yiries have employees.. Ifthe subtontiactars hale employees,they must provide their workers'comp.policy number_ Iam an employer thatisprm iding tt,orke-rs'comperuation irLrttrarzce for rit employees. Retaty is tare po&c}and,}ob site informatiOrL Insurance Company Name: /�' I f G�c��,•. - ` p y Policy##or Self-ins-Uc-4- Expiration]late: Job Sifa Address: r t'c ci Ue c,, -e-r City;"5tateiZip: At#ach 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$1,504.Oa 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 far in=mce coverage a eriEcation- I do hereby certify cinder-the pe nrs and penaIties ofpe ury brat the infornzation prm ided abave is true and correct Signature: / cs/ Date: /J-— —l'. Phone#: QRj vial use only. Da not write in this area,to be completed by city or town officiaL City or Town:. PermitUcense# Is.-ming Authority(circle one): 1.Board of Health- 2.Building Department 3.Cityl)`own Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 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 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 ar,y applicant who has not produced acceptable evidence of compliance with the insurance.coverage required.- Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to yaur situation and,ii necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their cerii-ficate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(L LP)with no employees other than the members or partners, are not required to carry workers' compensation insurance_ Ulan 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. AIso be sure to sign and date the affidavit 'I1?e affidavit should. be returned to the city or town that the application for the permit or license is being requested, not the Depai anent 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. Sell in-Surcd companies should enter daeir 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 Ell 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 permitllicense applications in any given year,need only submit one affid-avit indicaaag 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 tilled 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: 'Fhc Commonwealth of Massachusetts Department of Indust dal Aocidents Gfrke ofkvc�Ptlons 6.00 Washington St= Briton=IAA G2111 Tel.i4 61 7-727-4900 ext 406 or 1-9771,LkSSA E Revised 4-24-07 Fax#617-727-7 74-9 www.mass-govldia nigntla.x cs t , DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE T E '- IFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: PAUL PETERS AGENCY INC PHONE FAX 680 FALMOUTH ROAD (A/C,No,Ext): (A/C,No): E-MAIL MASHPEE,MA 02649 ADDRESS: 28LBR INSURER(S)AFFORDING COVERAGE NAIC aX INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY MACKEY,THOMAS P DBA TOM MACKEY FRAMING INSURER B: i t INSURER C: i INSURER D: 135 CEDAR STREET INSURER E: i WEST BARNSTABLE,MA 02668 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DMYYYY) (MM1DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE DAMAGE TO RENTED $ OCCUR. PREMISES(Ea occurrence) ED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY F]PROJECT F]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ - A. WORKER'S COMPENSATION AND X =STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-4774P983-14 07/27/2014 07/27/2015 ANY PROPERITOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ I00,000 (Mandatory in NH) E.L..DISEASE-EA EMPLOYEE $- 100,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR MACKEY,THOMAS P. CERTIFICATE HOLDER CANCELLATION TOWN OF BRANSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED T� BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV D -BLDG DEPT. IN ACCORDANCE WITH THE POLICY PROV 200 MAIN ST. AUTHORIZED REPRESENTATIVE HYANNIS,MA 02601 A.CORD 25(20I0/05) The ACORD name and logo are registered marks of ACORD R988-2010 ACORD CORP RA WWI reserved, � E rti Town of Barnstable ' Regulatory Services * awxxsrwsi.E. « - Mwss. $ Richard V.Scali,Director �A 039. T� �a Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-700-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 1J/LIL-Sa P--� , as Owner of the subject J property hereby-authorize �c to act on my behalf, in all matters relative to work authorized by this building pe t application for: (Address of Job) ""'Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature of Owner Signature of Applicant Print Name Print Name Date 1 S J ` 1 F Q:FORMS:O VJNERPERMIS S IONPOOLS Town of Barnstable Regulatory Services ��°F r►te r°iy� Richard V.Scali,Director Building Division * saursTaslE x Tom Perry,Building Commissioner i+uss. s6gp. ��� 200 Main Street, Hyannis,MA 02601 '°rEDy www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: _ number street village "HOMEOWNER": _ name home phone# work phone CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts LssIMLryisor, DEFINrrION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. 2Z-,-- --% gn re of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that; "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &ReguIations for Licensing Construction Supervisors,Section 2.1S) This lack of awareness often results in serious problems,•particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a Iicensed Supervisor_ The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fuIIy aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a,`.ormlcertification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 � a�oac�ciaeC .Office of Consumer Affairs&Business Regulation _ — O I License.or registration valid for individul use only ME IMPROVEMENT CONTRACTORg egistration + before the expiration date. If found return to: 157765 Type:xpiration Office of Consumer Affairs and Business Regulation ' r 11/5/2015, DBA 10 Park Plaza-Suite 5 TOM MACKEY FRAMING y `i Boston,MA 02116 170 THOMAS MACKEY 135 CEDAR STREET W. BARNSTABLE, MA 02668 - - Undersecretary, Not valid without signs Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-094616 THOMAS P MACOEY W BAI2N135 3 ST TABL� 02668 ✓ Expiration 08/31/2016 Commissioner �, r-- �� � � � _ .. f �� r � � � � �,�, - � -:: " • �.,,, -ter, x� .� � � `� � _ _ ,. ti TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION rV�-,C�lMap Parcel Appcatio U6 Health Division Date Issued Conservation Division Application Fee C7 Planning Dept: _ _' Permit Feew Date Definitive Plan Approved by Planning Board ' Historic OKH _ Preservation / Hyannis V . . y Project Street Address Nea Gf.4,/ s Village C, f h dc.,�✓r l�� /4 A Owner ,6rx*.s2h Address Telephone 5�0 1 ! __E��Permit Request �nsw���G baSt wt i,✓I� r��� w t+y J f 4'Ac aW .�i I-Z. 4 17745 r ,'a/ 4 bt A s'S A 0 k / Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatiorf 'G V 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 0 n,) Total Room Count (not including baths): existing new First Floor Room Count �� o s Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ pOther � ...� Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:0 Yes❑ No P� -. Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑dew �Qze_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ' Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name .e S h ,c Telephone Number L/0/ 79 1 3?SO X. /0 Address �y/- i�wt W /�t� License # �� cl 3� �raH,�7 n;-If IV Home Improvement Contractor# 2W649q ld-0279' Worker's Compensation # We Z ALL CONSTRUCTION DEBRIS RESULTING FROM THIS (PROJECT WILL BE TAKEN TO �3 0 fin.r C e F- X P. Ke J k it SAPti E SIGNATURE DATE 4 FOR OFFICIAL USE ONLY APPLICATION# -DATE ISSUED I MAP/P,.ARCEL NO. ADDRESS VILLAGE , OWNER , � r t< DATE OF INSPECTION: ` FOUNDATION FRAME r n f INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ; PLUMBING: ROUGH `:: FINAL GAS: ROUGH FINAL FINAL BUILDING R DATE CLOSED-OUT ` ASSOCIATION PLAN NO. 10/20/2009 13:28 16174962636 CLINICAL&PRO BONO PAGE 02/02 I RISE ENGINEERING .> Federal to#05•0406629 RI Contractor Reglstration No 8186 A divicinn of Thtelseh Engineering MA Contractor Registration No 120979 CT Contractor FlogIstmilon No 620120 '1341 F.hnwood Avcrtne,Cruvonn,RT 02910(4nT)7R4- 7t'nf j CONTRACT , 3�rio PAX(ant)9sa.a9ri 0ICT 2 0 ,- . yp v9 Page's 9 A4`W E THIS;CONTRACT IE ENTERED INTO BETWEEN RISE E.lgrhh3NFVIt'ONC* HP,aP.gM"ftP!I,QINMERINO WNECUSTOMERKOHWORiC/ti CUSTOMER PHONE DATE, Cllnnl It Lc e Brtn ton (508)771-1 532 10/20/2009 102381 SERVICE.^,TnEET a1LLINO'STREET 47 FTculwatcrs Road T'.O.Box 511 SERVICE CITY,STATE,Zit' - SILLINO CITY,STATE,ZIP Ccptcrvillc,MA 02632 Centerville,NIA.02632 r 'OB DESCrR PT'O 1 MSii 13,ngi need Ili will provide hlhilr ilnrl nullCrlalR rG.901 nrenv Of your 1101nc against wnctcful,CxCCss air leakage„Thls work will he prrfnr'InCd III C(mCorl with tile.use oI'.gpcclnl tools and diagnostic tests t0 nssdre Ihm your home will he ICft with a 11CIRITful Icvcl Of air exchmlgc and indoor nir gnnlity.Materinl9 to hc'usccl l0 sul your home can nclude oaulkR,foamH,weatherstripping and Other products. I'rimnrY nreas for scaling ihcludc air lealcnrr,Io attics,hammcntR and ntbcr unheated nrcm(windows are not l;enel:illy aflfIrgmed,) This work will he pCiTormed at the rntenr$or,per man per hour,which inciudo,thnlerinls nod testing. I Oman hour. WO.00 RiSi?l?ngincerhi£will prnvirlc lahnr and mnteriads to inxulntc the back of Iltc Hnsamont hulkhend door with i"rigid fberglaRR board nod Real the door cclgc with weatherstripping to restrict air Icalmeo, ` 100,00 RISK F,npincr.Hnr will provide labor and nnntcrints to install 156 squire Poet of R,19 faced fihergimn inwhltion to the perimeter of the hascmcni ceiling nl.the house.Rill. $171.60 RiSF.Enrinnerinr will provide inhor nerd mnterinla to instill Chss I Cc1h110SC inRNlation to the shectrock walls,of tliv.-O is xoirwetl which are common to heated spnce,through a surfacr.drill and ping,method. The holey are plugged with slyrofontn plugs,and spacldcd to a rough finish. Any xnudinit and pninting required are Ilhe cuslomer's responsibH11y, $235.00 RISE Plipincerinr will apply all npplicahic;eligible iRecnlivas In this cr ntracl; You will be billed only the Net amount, Currently,rOr eligihin mensures,the C'npc Light Compact ol7ei-.,75' Incentive,not to exceed$2,000 per crdandcr ycm•, WP:A011S11 HBReRY TO FURNISH SERVICES_-COMPLETE iN ACCORDANCIZ WITH ABOVE SPECIPICATIONS.FOR 71111 SUM OF R Two Hundred Ninety-One&651100 Dollars x $291.65 UPON NNAL tN31,1:00N AND APPAOVAI,RY RI.F MCINEERNG.CUSTOMER ADAEG.'i TO WIT AMOUNT DUB W FULL INTEREST OF 1Ta WILL DE CNAROCD MONTHLY ON ANY UNPAID nALANCC APTM nn DAYS.nEF-REVER9E FOR IMPORTANT INFORMATION ON GUARANTEES:RIOHT8 OF RECMION,30r111M,ILNA,AND CONTrIACTOR REOISTRATION. - - VO NOT SIGN THIS CONTRACT IF 1H=RE ARE ANY BLANK SPACBS t AUTHOn@F.D?IONATURE-hiRE 60INEERINO a Cus*,6WAtCEPTIWCr ` NOTP.;THL:PONTRACT MAY BE WITHOnAwN By us IF NOT ,J so „,• [XECUtFD VATHtN DATE OF ACCEPTANCC• b/��I• N".-, - t - ACCEPrANCEOFCONTRACr,THEABDVEPRt=,3P=IrICATICN!AND.CONDITICNSARP, - OATISTAOTORY TO UD AND AM HEREBY ACCDPTED,YOU ARE AVTHOR1bEo TO DO THE WORK hAYS, 14 NPMPIED.PAYMENT VALL BE MADE AS OUTLINED ABOVE i -. -. ........_ --- - - e Ej ------------- i i� w, { i 7 `i r. : — .' r `$ = = : - - -- .-- - - N tee:, LT vFFmrlro.TR:G K. Vs.-':k L AI88`'tEALIN K. 0 -FLE)OP f ^l r i . i f ENERGY CONSERVAT-ION APPLICATION FORM FOR ENERGY EFFICICIEINCY FOR ONE-AND TWO-FAMILY DETACHED RESIDENTIAIL;CONS'I RUCTION (780 CMR 61.00) Applicant Name: Site Address: rt el e k, er print Town: Applicant Phone: l Applicant Signature: Date of Application:, 2 (, NEW CONSTRUCTION: choose ONE of the following two options),-, `°- 780 CMR TABLE 6107.1 - PRESCRIPTIVE ENVELOPE COMPONENT CR1TER11AFOR NEW ONE-AND TWO-FAMILY BUILDINGS MAXIMUM MINIMUM Ceiling or, Slab QOption 1: Basement p Fenestration exposed Wall Floor Perimeter U;factor floors = R-Value R-Value Wall ,R-Value AFUE HSPF SEER R- R-Value Value and Depth National Appliance Energy .35 R-3 8 R-10 R-19 R'10 R-10, Conservation Act(NAECA)of 4 ft. 1987 as amended,minimums or eater as applicable Note: This form is not required if you choose either of the two versions of REScheck as'listed below. El Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed 1780 CMR 6107.3.2) REScheck-Web which can be accessed at http://wvrw.energycodes.gov/rescheck/ ADDITIONS 0R ALTERATIONS TO EXISTING BUI.LDINGS.OVER 5 YEARS OLD*. *Buildings under 5 years old must use option#1 or#2 in New Construction section above. Complete the following formula to determine the %o of glazing: (a)--Gr-ass Wall & Ceiling Area equals Formula: (100 x b a) p ` 100 x — _ • .% of glazing ' (b) Glazing area equals SF b a' .:; If glazing is.<40%.use the chart'below. If glazing is> 40.0/6' pr6ceO to "SUNROOM" section 780 CMR TABLE 6101.3 T PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING � r LOW-RISE RESIDElNTIAL,BUILDINGS MAXIMUM MINIMUM Fenestration Ceiling and Wall Floor Basement Wall Slab Perimeter Exposed floors R-Value factor R-Value R-value -�R-Value -R-Value and Depth R-19 R-10 R_10� 4 feet 39. R-3 7'a R-13,; a R-30 ceiling insulation maybe used in place of R-37 if the insulation achieves the fu11.R-value over the entire ceiling area(i.e.not compressed over exterior.walls, and including any access openings). .SUNROOM-An addition or alteration to'an existing building/dwelling unit where the total ❑ glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note;,, Owner to fill,out Consumer Information Form (found in Appendix,J20.P) The Commonwealth of Massachusetts Department of Industrial Accidents . .: Office of Investigations = r ' c 600 Washington Street f Boston MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: l$>uild(ers/Contractors/]Electricians/Plumbers Applicant Information ]Please Print Legibly Name (Business/Organization/Individual): f 10 3 e�enkg- Address: j of City/State/Zip: rlt 45Jrk Phone #: ����� ZX - . 7 � AVyan employer?.Check the appropriate box: 'Type of.project(required): a.employer with ` 4. ;❑ I am a general contractor and I have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner listed on'the attached sheet. 7..;❑ Remodeling, . ship.and have no employees These sub-contractors have 8. ❑ Demolition working for me in an capacity. employees and have workers' _ g Y P Y• 9.;❑ Building addition [No workers' comp. insurance comp, insurance.$ required.] cod its 10.0 Electrical repairs or additions . . _ ,. ❑5. We ate a corporation an _ 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plu nbing 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' 13.0Other comp. insurance required.] *Any applicant that.,#I 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 acid job site information. 0- P Insurance Company Name: A aa. Policy#or Self-ins:Lic.#: �� k " �' :a x Expiration Date: , Job Site Address, "l Gil I`� City/State/Zip: ��rt�r th/le- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).D� � Failure to secure coverage as required under Section 25A of MGL c. 152 c'an 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 co rage ver'fication. I do hereby certify d11h so perjury that the information provided above is true and correct. Signature Date: Phone#• 1 -79 9 ""'` 3-70 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License#r Issuing Authority(circle one): 1.Board of:He.alth 2.Building Department. 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: AMORb CERTIFICATE OF LMILITY INSURANCE ' .-, OP ID 27 DATE(MMIDD/YYYY) THIEL-1 08/07/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Preston Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1350 Division Rd Suite 303 _ HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 810 x ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Greenwich RI 02818-0810 Phone: 401-886-8000 Fax:401-885-1700• INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Hartford Underwriters Ins. Co - INSURER B: Hartford Casualty Insurance Co. Thielsch Engineering, Inc INSURER C:" Liberty Mutual Insurance Group 195 Frances Avenue INSURERD: North American Capacity Cranston RI 02910 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 NSR TYPE OF INSURANCE POLICY NUMBER' ^DATE MMIDD/YY DATE POLICY EFFECTIVE POLICY MMIDD/YY ON `LIMITS - GENERAL LIABILITY - EACH OCCURRENCE $1,000,000 A �. COMMERCIAL GENERAL LIABILITY. 02UUNTD5678 04/01/09 04/01/10 PREMISES Eaoccurence) $ 300,000 CLAIMS MADE ®OCCUR - - MED EXP(Any one person) $,10,000 PERSONAL&ADV INJURY $1,,000,000 GENERAL AGGREGATE ' - $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: , _ - PRODUCTS-COMP/OP AGG, s2,000,000 POLICY X- JE� iOC - _ Em Ben.` 1,OOO,_000 AUTOMOBILE LIABILITY B X ANY AUTO 02UENTD4850' 04/01/09 04/01/10 COMBINED SINGLE LIMIT $ 1r 000�000 (Ea accident) ALL OWNED AUTOS T ,y y BODILY INJURY $ . SCHEDULED AUTOS - `• (Per person) HIREDAUTOS ax " * BODILY INJURY $ NON-OWNED AUTOS (Per accident) ` PROPERTY DAMAGE $ _ (Per accident) - GARAGE LIABILITY - - AUTO ONLY-EA ACCIDENT $. ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY. EACH OCCURRENCE' $ 10,000,000 B X HU OCCUR CLAIMSMADE 02XUF6573 04/01/09 04/01/10 AGGREGATE $10,000,000 $ RDEDUCTIBLE 4 $ w I X RETENTION $10,00O v $ WORKERS COMPENSATION AND - X TWC LIMITS ER EMPLOYERS'LIABILITY C WC2-Z11-259874-019 04/01/09 04/01/10 E.L.EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE a.. - OFFICER/MEMBER EXCLUD ED? - _ �E.L.DISEASE-EA EMPLOYEE $500,000`.;._ f yes,describe under * d E.L.DISEASE-POLICY LIMIT $ 500 000 SPECIAL PROVISIONS below, , OTHER D Professional Liab ,DVL000025902 04/13/09 04/01/10 Prof Liab 2,000,000 , A Leased/Rented Eqp 02UUNTD5678 04/01/09• 04/01/10 Equipment 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS_ADDED BY.ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days for non payment of premium. Certificate Holder is included as an additional insured as required by a written contract with-respect to the General Liability coverage x"> CERTIFICATE HOLDER CANCELLATION r1.WNBARN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION t Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL *,30' DAYS WRITTEN Building Division r,_ NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Tom Petry ; IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THEINSURER,.ITS AGENTS OR 200 Main Street . HyanniS,MA 0260.1 -. - - REPRESENTATIVES. - - AUTHORIZED EPRES ACORD 25`(2001108) :-M ©ACORD CORPORATION 1988 �:Po THIEL-1 PAGE 2 � INSURED`SNAME Thielsch Engineering, .Inc OP ID 27 DATE 08/07/09 Also for Y. RISE Engineering, a division of Thielsch Engineering, Inc. ' Gaskell Associates, a division of Thielsch Engineering, Inc. BAL Laboratory, a division of Thielsch Engineering, Inc. ESS Laboratory, a .division of Thielsch Engineering, Inc. ALCO Engineering, a division of Thielsch Engineering, Inc. Water Management Services, a division of Thielsch Engineering, Inc. ` s Division of Thielsch Engineering,Inc. 1341 Elmwood Avenue :NGINEERING Cranston,Rhode Island 02910 �fze 1°ayz7xo��usecz/,� o�✓�/`aaaac�zuaetla Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 120979_ Board of Building Regulations and Standards ' A. 'One Ashburton Place Rm 1301 s . Ezptraan3-3125/2010 Tr# 263460 Boston,Ma. 02108 T:ype: Pravate Corporation THIELSCH ENGINEERING STEPHEN HINES F _= 1341 ELMWOOD AVE.,._;=- �•. ...m. CRANSTON, RI 02910 _ ;.`,Administrator `.Not validwithout signature- `4. 100463 WS,IC STEPHEN HINFSP. ` ^� 222 NARRAG ETT AVENUE JAMESTOWN, r,.-02835 7 6/23/2012 = 100463 r a 102935 00 STEPHE'N>HINES' 222 NARRAGANSE T T AVENUE JAMESTOWN, RI:02835 6/23/2013 102935. ✓ Page 1 of 1 )fficial Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home PR,(b k Safety Department of PuNic Safety Licensee Cootrup8 nts License Type Construction Supervisor License# 100459 Restriction WS,IC Name Erik Nerstheimer City, State,Zip North Scituate, RI, 02857 r Expiration Date 3/28/2012 Status Current No complaints found for this'Licensee. Back To Search Board of Building Regulations and Standards _ f License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR ;. before the expiration date. If found return to: Registr.`ation.. 120979 Board of Building Regulations and Standards ° Exprration 3/26/2010. One Ashburton Place Rm 1301. Type Supplement Card ostd�f,Ala.021.08 f -HIELSCH ENGINEERING E :RIK NERSTHEIMER_? 341 ELMWOOD AVE ,RANSTON,RI 02910; ------ Admin.isti;ttor ( Not valid without signa ore 6 _ - http://db.state-md.us/dps/licdetails.asp?txtSearchLN=CSL 100459 t 9/24/2009 I 100463 ;2s ice. c•;.c: WS,IC •9 ht STEPHEN HINFS 222 NARRAG.% ETT AVENUE x JAMESTOWN, t..02835 . 6/23/2012 100463 102935 sa 00_ STEPHEN HINES � 222 NARRAGANSETT AVENUE JAMESTOWN, RI 02835 6/23/2013