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HomeMy WebLinkAbout0026 HENRY F LORING ROAD A k Cape Save Inc. TOWN' OF RNST IL 7-D Huntington Avenue South Yarmouth, NIA 9A,",? ; Tel: 508-398-0398 Fax: 508-398-0399 DITS101 1/16/13 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St.Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 26 Henry F Loring Road,Centerville has been inspected by a certified Building Performance Institute(BPI) Inspector. Ceiling: R-22 cellulose Box sill: R-19 fiberglass All work performed meets or exceeds Federal and State Requirements. Sincerely, William-McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map d Parcel Application # Health Division Date Issued L LA% l Conservation Division Application Fee Planning Dept. Permit Fee 3 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 4. 6 rKo a� Village Censer �(;116 Owner � C a a.SS �,do o P 0 Address Telephone 02 _4 5.0 - 0 g q k Permit Request C �-a� �+,�tglPs�i 1�S�,�a�ion 4t 4hc a-}�' L lucre se a' is yedla+1104 +o COAr, Uli� s04;i VCAA1 , rt0 -fig- &Se1hed Io ox s;11 N sf,k 4t tic -&n e r,A 6elute AA Bp i Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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 44500 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)m --P Number of Baths: Full: existing new Half: existing M newer Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count ?° Heat Type and Fuel: IX Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes p No Fireplaces: Existing New Existing wood/coal stove: ` Yes*© No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes Id No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDERR OR HOMEOWNER) Name Telephone Number O$" qg 03 q U Address -1 License # 7 Ysa(no 4 Home Improvement Contractor# Worker's Compensation # 1&3 31 80n 4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO )(ICKMI&A SIGNATURE DATEI730 / 1�, } "t FOR OFFICIAL USE ONLY APPLICATION# ] DATE ISSUED r - MAP/PARCEL NO. 3 ADDRESS VILLAGE OWNER DATE OF INSPECTION: � r ` FOUNDATION FRAME p y ` INSULATION S l .. FIREPLACE ' ELECTRICAL: ROUGH FINAL I ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i , y The Comillonivealth of 1llassachusetts Departnlellt of Industrial Accidents „ Office of Itivestigations = - 600 Washington Street Boston,MA 02111 1vww n1aSS.yOv1dla ; bers Workers' Compensation Insurance Affidavit: Builders/ContractorslEleclease Print Legibly P ARpUant.Information . Name(Business/Or;anizatiOn/individual): Address: City/State/Zip:s od►*fin Y9sLS ou. , t OARPhone : 5 0 " 3 9 8 - 0312 ro riate box: Type of project(required): Fyou rti to er. Che k the app pp y .with :�• � I atn a general contractor and I.- 6 a New constructione (f er have hired the sub-contractorse > delisees(full and/or part-tun )• listed on the attached sheet. 7. ❑Remo g ole roprietor or partner- have DemolitionP rs sub-contractors S. — These "�❑ . em to ees ship and have no p Y. employees and have v;orkers working for me in:any capacity. _ 9. Building addition comp.insurance= ' 10 Electrical repairs or additions [No workers'comp.insurance We are a corporation and its - required.] - officers have exercised their II. plumbing repairs or additions 3.❑ 1 am a homeowner doing all work - right of exemption per MGL 12:�Roof repairs myself.[No workers �-,omp. y'4 c.1 52,§1(4),and we have no insurance required.]t "' employees. a workers' 13.0 Other _'n comp.insurance required.] *Any applicant that checks box RI must also fill out the section below showina their workers'compensation policy information. z Homeowners who submit this affidavit indicating they are doing all work and then hire outside wntractors 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: _T eo�no I o n S wr an aC G n " Policy n or Self-ins.Lic.r: ` W C 3 3[ 8 � Expiration Date: y -' r ` 3- l 1 Job Site Address: r Lain City/State/Zip: Attach a copy of the workers'comp nsation 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator..Be advised.that a copy of this statement.may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.. I do hereby cei-tifi,-under the paiiis and penalties of perjury that the iiiforinatioii pr`oi�ided abo7' is�tfandcorrecL Signature: Date:: t' 3 Phone 4 J�S 3 9� Official use only. Do not iurite in.this area,to be completed by cit),or to,tir official t City or Totivn: Permit/License t a' Issuing Authority(circle one): 1. Board of Health ?. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbin-Inspector ' '6. Other f ` -Contact Person: Phone DATE(MMIDDIYYYY) c ®' CERTIFICATE OF LIABILITY INSURANCE 11/9/Zo12 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 WANED,subject to the terms and conditions of the policy,certain policies ay require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Shannon Sperrazza Risk Strategies Company PHONE (781)986-4400 FAC No:(781)963-4420 E-MAIL ssperrazza@risk-strategies.com 15 Pacelia Park Drive , DR p Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURER B:Safet Insurance CO an 3618 Cape Save, Inc INSURER C-.Technology Insurance company 7 D Huntington Ave INSURER D:. , INSURER E: South Yarmouth MA 0264.4 INSURERF: COVERAGES ' CERTIFICATE NUMBER-CL1211954576 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. ADDL UBR POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER. MIDD MM/D0 LTR 1,000,000 GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED 5 100,000 X COMMERCIAL GENERAL LIABILITY 3 PREMISES Ea occurrence 199448001 0/16/2012 0/16/2013 MED EXP(Any one person) S 10,000 A CLAIMS-MADE • 1,000,000 a' PERSONAL B ADV INJURY $ GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ' S }{ POLICY PRO- LOC COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY Ea RMdlent BODILY INJURY(Per person) $ *PROPRIETORIPARTNERfEXECUTI\/E AUTO 1/6/2012 1/6/2013 BODILY INJURY(Per accident) $ OWNED SCHEDULED 6208200 OS AUTOS PROPERTY DAMAGE S NON-OWNED Per accident ED AUTOS X AUTOS S 100,000 Underinsured motorist BI s lit EACH OCCURRENCE S 1,000,000 RELLA LIAB OCCUR 1,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE S ,s ' a 0/16/2012 0/16/2013 ' $ 199448001 RETENTIONS X WC STATU- OTH- S COMPENSATION ffieers excludedPLOYERS'LIABILITY YIN ! rom coverage E.L.EACH ACCIDENT $ 500 000 PRIETOR/PARTNER/EXECUTIVE I� NIA /9/2012' /9/2013IMEMBER EXCLUDED? - C3318007 EL.DISEASE-EA EMPLOYE $ 5OO OOO ( ory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below . DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Issued as evidence of insurance. Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a/ National Grid, Action Inc. , Colonial Gas Company and NStar Electric are listed as additional insureds as respects General Liability as required by written contract. CANCELLATION CERTIFICATE HOLDER _ ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cape- Light Compact X 427 SCH AUTHORIZED REPRESENTATIVE Box AUTOO PO / , 3195 Main Street Barnstable, MA 02630 Michael Christian/SMS �-6 ` F + a' ©1988-2010 ACORD CORPORATION: All rights.-reserved ACORD 25(2010/05) —A Innn IhICrf M07. n10r1510'I�' ern•nn)cforerl m�r4c of Al:fll�rt i•' R„ �ia•,achusctt - Gepal-iment of Public SaretN Board Of Building, Re�,ulation; and Siandards , rOt1S ilCtion Super'iIsOr Specialty LiCeISe r , License: CS SL 102775. Restricted to: IC J WILLIAM MC CLUSKY' ,. 37 NAU SET ROAD _ WEST YARMOUTH. MA 02673' Expiration: 6/28/2013 Tc=: 102776 Office of Consumer Affairs and usiriess'Regulation ` 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 ° Home Improvement Contractor Registration ; } „ ion: 171380 _ - Registration: Corporation ` T e: o • • •. YP rporaon Expiration: 3/14/2014 Tr# 222184 CAPE SAVE'INC. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE = SOUTH YARM�OUTH, MA 02664 t Update Address and return card.Mark reason for change. Address,., —j Renewal [, Employment ; i, Lost Card PS CAt Ca 60M•04/04•G101216 ackaez ,License or registration valid for mdrvidul use only ✓fea�rvnzazzurea z c� ''•, Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR ' ' Office of Consumer Affairs and Business Regulation'A ; Registration: 171380 Type: 10 Park Plaza-Suite 5170 � •.• Expiration: 3/14/2014 Corporation Boston,MA 02116 CAPE SAVE INC. WILLIAM MCCLUSICEY a 7-D HUNTINGTON AVENUE"' SOUTH YARMOUTH Mk .64 Undersecretary` Not valid wit o signs Building Permit Authorization I, Capasso: as owner hereby give my permission to Cape ,Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office: 508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 26 Henry F.Loring Road' Centerville MA 02632 Signed ° Date r i Town of Barnstable *Permit#aD L I �f Expires 6 months from issue date ®ttL �� 5�P Regulatory Services Fee Thomas F.Geiler,Director F�P Building Division r o r7/1406 Tom Perry,CBO, Building CommissionerfQ_ 't 200 Main Street,Hyannis,MA 02601 U - www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number / 7o-2 1 7 Property Address 1-064 IJ✓G [4esidential Value of Worr 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address /C/Tvr if t��1g"S-sd Contractor's Name R6 6�-r-_FyM &L Telephone Number dCV'yo o Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orkman's Compensation Insurance , Check one: ❑ I am a sole proprietor Laal'the Homeowner ' I have Worker's Compensation Insurance Insu rance Company Name Workman's Comp.Policy# w c ooc&L J col Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ 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. . e Improvement Contractors L' se is required. SIGNATURE: Qlomis:expmtrg Revise071405 �TYNDALL ROOFING S ��-�. ,`^i�cS t tJ y Ys Lcs, proposal. (508) 420-4456 Oz&1/1P Page No. of Pages PROPOSAL SUBMITTED TO PHONE DATE . Y JOB NAME ,Q AA 6 STREET 14 fi.SS C) CITY,STJ,.TE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS . JOB PHONE We hereby submit specifications and estimates for: d S Furnish and install new•Class"A" Roofing as Follows: A. Strip existing roofing and remove debris. �� B. Check all boarding and nail as necessary: C. Check all flashing. D. Install aluminum drip edge. V �r E. Includes ice and water shield to be adhered to roof 18" along entire lower edge of roof to prevent ice leaks also around chimneys, skylights, roof stacks,and roo 1leys. F. Apply shingle under layment- (felt paper). G. Includes new flashing around all roof stacks. H. Apply customers choice of shingle. ,�cTLC,!� t4ohSC4PF_ ,30AX Cti w Cr BlAe cdoo_ I. Apply continuous ridge ventilation. x Any unforeseen rot that may be uncovered during construction, the owner will be informed and made aware of. the extra cost. y. �— dollars---- $7a00•00 Payfnent to be made as f2 ws: ) All check t e made payable s o b p y to TYNDALL ROOFING All work to be completed in. a sub- stantial workmanlike manner according to specifications submitted, per standard Authorised Practices. Any alteration or deviation from above specifications involving extra Signatur costs will be executed only upon written orders,and will become an extra charge over.and above the estimate.All agreements contingent upon strikes,accidents or Note:This proposal may be delays beyond our control. Owner to carry fire, tornado and other necessary in- surance,Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. ACCEPTANCE'OF PROPOSAL T;he above prices, specifications and condi- tions are ysah0factory and are hereby accepted.You are authorized to do the work as specified Pa ymeq.t will be made as outline above. Signature ate_ S. � t ll - c ':Date o}AtEeptance: Signature . a5fy; r '=k iVORKERS Ol�ll_yPENSATIO�N�AND�E11�,.PLO UERS'st}�B[L1TY���SURANCE�P�OL�CY�; __ ���.�.� r.:w^,>- .ca..s. �:s ,mr,.1 �..: �.2. «�• ssk3x'_: � «z....z..oe. _ a..,v�.t. s_..xn.. .,...»sn Atlantic Charter Insurance Company VDAC Cl Co. No.:29211 Policy Number: WCV00643001 INSURED: Prior Policy Number: WCV00643000 Robert Tyndall Producer: 30 Jillians Way Fredericks Insurance Agency, Marston Mills, MA 02648 Federal ID Number:174560293 Inc. Risk ID Number: 1046 Main Street Osterville, MA 02655 Business Type: Individual SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS Other Named Insured:See WCE106 Other Work Plac 07 POLICY PERIOD: The Policy Period Is From: 4/6/200 o. 4/6/2007 12:01 A.M. Standard Time at The Insured Mailing Address COVERAGES: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA , B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A All states except Monopolistic State Fund States D. This policy includes these endorsements and schedules: See WCE105 COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates& Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Total Rate Per Estimated Code Classifications No Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 .' Minimum Premium: Deposit Premium: 'p_ $500 $516 ' •� e Interim Adjustment: Annually Estimated Premium (Minimum Premium) $500 Servicing Office: Surcharge(s) 16 i 25 New Chardon Street - ` Boston, MA'02114-4721 I Total Premium a4 Surcharge(s) $516 sue Date 03/29/2006 Countersigned By:_ _ _ DaWAR2-2006 iht 1987 National Council on Compensation Insurance ' Form:100m p� ✓�e emvnw�uuect i o�✓ aaaac�auaet b 4 Board of Building Regulations and Standards Lieen HOME IMPROVEMENT CONTRACTOR befor _'3 r Board Re 116064 One Ekptrafidf 511512008 Bosto } Type Ltd"L.iability Corporati TYNDAL ROBERT TYNDACL` ir... 30 JILLIANS WAYIz =< -- MARSTONS MILLS, MA 02648 Deputy Administrator r° w The Commonwealth ofMassachusetts f a Department oflndustrialAccidents Office of Investigations 600 Washington Street Bosto,-;M4 02111 www.massgov/dia- Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le WbIy Name usia pnizatiavrndividual?; c Koyirw G- for ir��� Address: 30 i LLf � Lrll9 y city/State/Zip: 1LC�D �r�1,�S/nAY �l _- Phone Are yo employer?.Check the-appropriate boa: Type of project'(regaired): I. I am a emplo er ith / 4. ❑ I am a general contractor and I d. ❑New construction employees( or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor,or partner- listed on the attached sheet t 7. Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' gorap.insurance S. ❑We are a corporation and its required.] officers have exercised their 10,❑ Electncal repass or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Mmbing repairs or additions myself.[No workers' comp. e. 152,§1(4),and we have no 12.[3 Roof repays insurance required.]t . employees.[No workers' corms,insurance required.] *Any applicant that checks box#1 must also fit]out the section'below showing than•workers'compensation polioyinfo=ffdon: ` t Homeowners who submit this affidavit indicating they are doing all work and then bin outside contractors must submit anew affidavit iodicating such Contractors tat check Ibis box must attached an additional aheat showing Iha name of the sub-contractors and then wo&are comp.policy information. ram an employer that is providing workers'compensation insurance for.my employees. Below is thepolljo andJob site information. :r Insurance Comp any Name;_ �}'7"t; Lrr1 el ClA�T�/2 Policy;or Self".Lk0 �(.1 ('_ [/O G(o q.-60 ��e D Job Site Address: 0,.(a H&vu F, 6oiln`6- Abe City/state/Zip:�y�GC Attach a copy of the workers' compensation paliey declaration page(showing the policy number and aspiration 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$1,540.00 and/or one-year impriso�ent,as well as civil penalties in the-form of a STOP WORD 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 himrance coverage verification. I do hereby certify yx4r the pains andpenalties of e)jury that the information provided above is true and correct Si tore; Dater Phone#; �o tl�_ ! yS 6 G irk,u�� o o e tar area,try c d 'c.t or mm o 1 � id City or Town: 1?erm1VL1cense# Issuing Authority (circle one); 11.Board of R.e&,.h 3.Building Depat-tment 3.Cityrl'owa Clerk 4.Electrical Inspector 5,plumbing Inspector 6. ether COUyaCt Person: Phone#: Information and Instructions Massaghusetts General Laws chapter 152 requires all employers to provide workers' cornpensationfor-tbeir 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 dr 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 . Io employees, receiver or trustee of an mdividual,partnership, association or other legal entity,employing However thr, . 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 bur7ding appurtenant thereto shall not because of such employment be deemed tote 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 p ernd 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 et of olio work unto acceptable evidence of co liance with the insurance enter into any contract for the performan pn eP m r ul uiremerds of this chapter have been presented to the contracting an thonty. Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If as LLC or LLP does have employees,a policy is required. Ae 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. Thvaffidavit should be returned to the city or-town that the application for the permit or license is being regaested;not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workcas' compensation policy,please call the Department at the number listed.below. Self-insured compann=aliould saner i heir self-insurance license number on-the appropriate lime. Cite or Town Officials . Please be sure that the affidavit is complete and printed legibly: The Department has provided a space at the bottom. of fig affidavit far you to fill outin the event the Office of Investigations has.to contact you regarding the applicant. Please be sure to fillin the permir/lieense number which will be used as a re mce amber. 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"Jola Site Address"the applicant should write"all locations in__T__-(city or town)."A copy,of the aflidavlt that has been officially stamped or marked by the city or town may be provided to the applicant es proof that•a valid affidavit is on file for future permits or licenses. Anew affidavit mustbe filled out each year.Where a tome owner or citizen is obtaining a license or permit nptrelated 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 hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a can The Department's address,telephone and fax miner: The Commonwealth of Massachusetts Depa went of Industrial Accidents 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 e-nt 406 os 1-877-MA.SSAFE Fa_{#617-727-7749 Revised 5-26-05 v immais5.gov/dia II-7 13 Ml -A. t ot lot 2.2.. pPA,�05�'v 5E4U62Als� ,��N'A tfitct�,�atE� �, 1000 ,'-AL SAIL TAQV4. (p HAXTE R 1000 64(� LEACH PIT el W I TIA i ao °fv UC?• si�fN x 2v r LOCATIO" 1 CAL u: �?d SAT d- /I /--r7 �j I CMRTIF*�( THAT TI�r� �iR�AT10tJ Sua,,uU Pt_At.P R I+ERcyGE %4W G MW CO APLVS W I TN TtAG 5 l D'E_l.i NE-- AWD SETl3AC4 FC-4UiiZEMaWTS OF THE PL• I DATE Q. ! IQC_ T%415 DLAW 1S WOT BASe✓o 064 AN vsTEIZv►Ll� c, M(ASS. It-419ML)AAE1.1 i e"4ou/4.17 APPLI CAtc�T' hbT eE U5c4 To De:reZMilb-4= LOT' LlWeS A. Assessor's map and lot number -�Y i li ;V PUANCE WITH, ,1;;TCLIe €9 S�"�el E � SANITARY O€ AN1) TOWN " Sewage Permit number ............ ......f.. ., RECUI..:ATION8., �QygF.TNETp�o TOWN . OF BARNSTABLE 9flBSTAIILE. • w / *' r ;"tMAees � . t, N ` WING INSPECTOR pp 163q'-\00 z 7 :APPLICATION FOR PERMIT TO• ............ ........................... ................. TYPE OF CONSTRUCTION ' ........... ......... .'.............. ...... .... ► .... .. ry.7......19 2 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... ..../.. ./ ..J,/............. ... .. ........ ........ .......................................... ................................... ProposedUse ........ .............................................................................................. Zoning District ......... ..... ....:.......... ..................................:..Fire District ....... .:.:. ..............: ..... Nameof Owner ... . ............................................................Address ........... ........ .. .......... ...................................... Nameof Builder .....................................................................Address ......................................................................... Nameof Architect ...................................................................Address ................ .................................................................. Numberof Room ..................................................................Foundation ..... . .. . .................. ........................................... Exierior .... .... ... ..... ........:..............................................Roofing •.... .. . .. ...................................................... Floors .....................................Interior ................................................. .. . .. . . .. .. . .... ........................ r Heating ... /.................................................Plumbing .... .........:... Fireplace .......... ...... . . . / !. : .. .. .. ..................................Approximate Cost ..:...... Gl../., ."...."....................... oved Definitive Plan Appr by Planning Board ___-----------------------------19________. Area .... ................... Diagram of Lot and Buildir g with Dimensions. Fee y-7 . SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of'the Town of Barnstable reg rding the above construction. ( Name ..... . .................................' ... Small, Alan E. 19160 one story, No4'2i............... Perml�for ..................................... sPgle family dwelling Hinry Loring Road Location ............................:..................................... Centerville ................:...A ... ...............:........................ ........... lan E. Small Owner. ............................................. frame Type.of Construction .......................................... . ................................................................................ P ..................... Plot ............................ Lot ...........#117 April 29 -77 Permit Granted April.......... . . .....19 Date of Inspection .... ... ........19 Date Completed . . ..............J9 PERMIT REFUSED ........................ 19 ............................................................................... .. ................................................................ P .. .................. ............................................................ ................................................................ .............. Approved ................................................ 19 ............................................................................... ............................................................................... r -... _! ?. d t..i• i•�: � .s.... w. _._K tea. t _ 4 � `✓n�i n:+,?�'}',. .� a%jx`f^x"'.:-...C.�•w��r��Y. ��`s.�+_,h+�e'��=(C. 2w'k.i.r....+-...—�.x....r•N•.� -7 7 Assessor's map and lot number ..... ....�. d.. ... ...... f -i Sewage Permit number ........... ..!.. .................................... T"Er°�o M TOWN OF BARNSTABLE i 33 STAkE, M BUILDING INSPECTOR aY a• `v . APPLICATION FOR PERMIT :TO ........ TYPEOF CONSTRUCTION ............... .:.............................................................................................. i ......".` .. ......19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 1 Location ..... ...... .......l��z !�fla .................................................................................. J , ProposedUse -Izzz/ ...... '.....:........................................................................................:............................... ZoningDistrict ...............................E` ....................................Fire District .......,,; ``.........................`........ ........................ �,— ,�a Name of Owner .. & ".... ..............................................` t '—` Address .......... ................:,..............,............. �. . Nameof Builder ....................................................................Address .................................................................................... Name of Architect ..................................................................Address ...........................................;...................... .. ................. Number of Rooms ..................................................................Foundation . ............ ;.. �/!.............................................. f Exterior ..... .` " ✓ .:.... *.. ...............................................Roofing ... , ,•4 ... Floors k .Interior W,./ Heating ............�...:....:........:...............................................Plumbing ..................... .....: . �. .......... ....................... Fireplace � � Approximate Cost ............... .......... .. ...................... Definitive Plan Approved by Planning Board --------------------_-----------19________ . Area ... .P................... Diagram of Lot and Building with Dimensions Fee ........ .?. � SUBJECT TO APPROVAL OF BOARD OF HEALTH t If I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . ... .!... ................... Small Alan E. A=172 l76 ' m� l l96R � r . . now m ' No ................. .Permit for ------- —.. � T—�''' o1omle f"i lliog —^---^--'—'-----------~----^'' Henry Loring Road Location ................................................................ ^ � � Centerville � -----^--------------------- ' Alan E. Small Owner .............. � frame � Type of Construction .......................................... ' ----.------.--------....------. � Plot ............................ Lot ..........#ll7.............. � � � ^ April 29 77 Permit Gnon1a6 ----�----� ---.lA � ' Date of Inspection ------------lg ' Dote Completed ------------..lq . . � PE . . R8&IT REFUSED . ' 19 � ................................................ ................... ` / 11.1—._.---..~---- ---.,.~----.— ' ---- 'M[--------'---'—'--'' � —.---.---..--..----.....---.---- . . . , � Approved ................................................ lA . ^ - -------'--^-----'-----'--^--- . ' � ----------------------^—^^—' ^ � ��� J 24 -J-•� � � r i lat 22. WkA t k f> , �r k �r'iSTi'aQ`$pq' C6IZTIFIED }�LcbT LOCAT1OW -7-7 i C 6 R T l t=Y T"A T Ft-A Q AzeireizewceL Wr--e C OW CO APLYS WIT" T14G St DE.Lt+-�� jj AWr-> SETVAC14 VE-QUtt'ZeME:WTs bF TNC PL.-av-- f� �G ',Z.$.• -Tow w�0�i=�-���3 aes-rsr_ - DAT REGIS"tea LAW'p SUZVEYOtZS TNIS VLAW IS ►JOT BASED tam AN 05TEtZVku o �1,CASS. It.lsrQzl.trlE�.l; StJ2VE`� THE dFt=S�fS S�-Ia .JUD APM S..GA"J—r t"bT e-t= USCc> To De:TE2Mi*4 LoC t_ItiE� ALAS �k4A ,-