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HomeMy WebLinkAbout0110 HERRING RUN DRIVE ��!D �er�a n �� ��"• - � G 0 o � o aQ a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued Conservation Division Application F Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address id Village il!�IILAAiL Owner & �` Address 110 Telephone S''015r CG-] -11-IG Permit Request V o . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 60 Project Valuation X90 i Construction Type / ` Lot Size Grandfathered: U Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family C/ Two Family ❑ Multi-Family(f# units) ' Age of Existing Structure3lmn& Historic House: ❑Yes ®'No On Old King's Highway: ❑Yes 3 No Basement Type: ❑+ull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 420 Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: .3 existing _new Total Room Count (not including bathh): existing (o new First Floor Room Count Heat Type and Fuel: ❑ Gas C Oil ❑ Electric ❑ Other Central Air: ❑Yes ®'No Fireplaces: Existing New Existing wood/coal stove: ❑Yes d No Detached garage: ❑l�existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: C�I'existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Au orization ❑ Appeal # Recorded ❑ Commercial ❑Yes 3No I z �f yes, site plan review# rl Current Use Proposed Use o APPLICANT INFORMATION C° (BUILDER OR HOMEOWNER) r Name (.�� Telephone Number "7-7 993 960 Address License# Home Improvement Contractor# Email f l��� �. � , Worker's Compensation # XIS a"23y®`f�C . ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 1& f FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ®k 7 exel DATE CLOSED OUT ASSOCIATION PLAN NO. r r The Commonwealth of Massachusetts Department of Industrial Accidents a 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address: 6o U City/State/Zip: d,_t- Phone# "7-746 iq3-q6�_7 Are you an employer?Check the appropriate box: Type of Project(required): 1. I am a employer with I employees(full and/or part-time),* 7. E]New construction 2.F�I am a sole proprietor or partnership and have no employees working for me in $, emodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.F�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ®Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'.compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: �,73S70�'619 Expiration Date: { Job Site Address: 1 City/State/Zip: 0 Attach a copy of the workers' co ensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c..152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that-the information provided above is true and correct Si nature: Date: '7 Phoned -774) 9 ^ 7007 Official use only. Do not write in this area,to be.completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town'Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: b '�����^ {�r� �Q J�Z?�Z>��iLLzPGIiL•�IZ C?:age — = Office of Consumer Affairs and Business Re ulation: .10 Park Plaza - Suite 5170 Boston, `'Msachusetts 02116 Home Improvem ntractor Registration Type: Supplement Card t�nl �-�^- __ Y� Registration: 137943 LUX RENOVATIONS, LLC. I�- Expiration: 02/04/2019 60 Shawmut RdT1 ; Canton, MA 02021 W SCA 1 i 20M•05/11 Update Address and return card.'Mark reason for change. ❑ A `ro s L Renewal G E mpioymeni: u-?ot1 gird �e�omnaaiuuescl�o�C>�tiGac�zc�aetla ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only f UN Supplement Cardbefore the expiration date. if found return to: `�i-t Office of Consumer Affairs and Business Re ulation ##egl ,tration Expiration g v =� `. OPY04/2019 10 Park Plaza=Suite 5170 Boston,MA 02116 LUX RENOVATI( LLD D/B/A Owens GQrutl "'�ent Finishing g�S,y�stemms e EDWARD ALLEN, .ra -, 60 Shawmut Rd Canton,MA 02021 Undersecretary Not valid without signature Massachusetts Department of'Public Safety Board of Building Regulations and Standards License: CS-075131 Construction Supervisor EDWARD T ALLEN 30 STORMY HILL y`s DEDHAM MA 02026 -Expiration: %Commissioner 02/27/2019 ' r f AC40 CERTIFICATE OF LIABILITY INSURANCE DATEWMAID"'Y") ` ___ 11/16/2017 t 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((es) 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 endorsements. PRODUCER NT NAME: Jane Logan Gordon Atlantic Insurance PHONE (7$1)659-2262 FAX (781)659-4725 A/C No 306 Washington Street ADDRESS:Jane@gordonatlanticinsurance.com INSURER S AFFORDING COVERAGE NAIC# Norwell MA 02061 INSURER A.-Liberty Mutual A enc' 6201012 INSURED INSURERB:Commerce Ins. CO. 34754 Lux Renovations,LLC,DBA Owens Corning of New England INSURERC:Peerless Insurance Co. 24198 60 Shawmut Road INSURERD:Libert Mutual'-A enc 6201012 INSURER E Canton MA 02021 INSURER F: COVERAGES CERTIFICATE NUMBER:Master JL 10/26/17 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. ' LLTR TR TYPE OF INSURANCE I N-qn SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY CBP8512851 09/05/2017 09/05/2018 EACH OCCURRENCE $ 1,000,000 A CLAIMS MADE FICI OCCUR DAMAGE TO PREM ED SES Ea occu cote $ 100,000 " MED EXP(Any one person) $ 5,000 I PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X I POLICY i PRO- _J JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY EaaBBIINE�DtSIG LIMIT $ 1,000,000 B ANY AUTO j BODILY INJURY(Per person) $ BI & PD CSL ALL OWNED B SCHEDULED AUTOS AUTOS L I c I 1 4/4/2017 4/4/2018 BODILY INJURY(Per accident) $ BI & PD CSL I ^j NON-OWNED j PROPERTY DAMAGE HIRED AUTOS AUTOS I Per accident) $ BI & PD CSL $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 C g , EXCESS UAB R CLAIMS-MADE CtJ8511953 9/5/2017 9/5/2018 AGGREGATE $ 1,000,000 DED ! X 1 RETENTION$ 10,000 $ WORKERS COMPENSATION PE R AND EMPLOYERS'LIABILITY x STATUTE ER !ANY PROPRIETOR/PARTNER/EXECUTIVE V�N,I XWS57350449 5/24/2017 5/24/2018 E.L.EACH ACCIDENT $ 1,000,000 D y in NH)OFFICER/MEMBER EXCLUDED? Y N/A' '(Mandator E.L.DISEASE-EA EMPLOYEE $ 1,000,000 I If yes describe under I ( - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000 i I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Cert Holder is added as included as Additional Insured for General Liability Coverage per Blanket Al form 22-133 (01/08) and 22-45 (12/02) Primary & Non-Contributory (22-133 1/08) and Excess General Liability coverage is "follow form" where required by written contract. WC excludes Dan Bawabe & Paul Deguglielmo, both LLC Members ' r CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE INSURED'S COPY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jane Logan/LOGAN ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 poiiiot) ® Owens Corning Basement Finishing Systems ® g � ms �of New England Wilbur,Robert&Paula Contractor / Agent Authorization From P14 17 Davis St,; Taunton,MA 02780 401-644-3184 508-567-7776 �s , authorize Owens Corning Basement Fir shin g Systems of Boston to sign the building permit application on my behalf,to perform the work at: Home Owners Signature: Date: Project Manager Signature: Date: 60 Shawmut Road 0 Canton, MA 02021 9 Phone: 781-821-0060 Fax: 781-821-8552 0 w-w.ocboston_Com No 0 1.11 r.m i Town of Barnstable' *Permit# O Expires 6 rim f is a to Regulatory Services Fee s * BABNSrABLL, Richard V.Scali,Director CFO MA't�` Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTS ONLY Z"L O Not Valid without Red X-Press Imprint Map/parcel Number Property Address 11 o ff r r', 4�r residential Value of Work$9 S Minimum fee of$35.00 for work under$6000.00 �Owner's Name&Address P Q u J a WI t t> j r 00 110 Herr;A c jq)0 1/r �pa4"l 1/► l�e MA 3 2— Contractor's Name is `!)dt7,,,J 2?/1 / /I rspl( Telephone Number No 1 2- Home Improvement Contractor License#(if applicable) / '3 Email: Construction Supervisor's License#(if applicable) 7 c7 7 coWorkman's Compensation Insurance Check one: U ❑ I am a sole proprietor 062017 m the Homeowner [OWN I have Worker's Compensation Insurance [ OWN Ot tIAKIYSTqBLE Insurance Company Name R r, En tj ra,1 z Workman's Comp.Policy# W��� � S 8 :2 9 r 2 0 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side [Replacement Windows/doors/sliders.U-Value 3 0 (Maximum.32)#of windows Z #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit.does not exempt compliance with other town department regulations,i_e.Historic,Conservation,etc. ***Note: Property caner must sign Property Owner Letter of Permission. A copy cKthe Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: C:\Users\Decollik\AppData\Loca!\Microsoft\Windows\Temporary Internet Files\Content.0utlook\2?I0I DHR\EXPRESS.doc Revised 040215 J 1� s R . ,1. A7A tittnse#173141 - i Aersen newal CT Waente#0634555 r en wal. RENE,WrAL BY ANDERSEN tend rlrtn#,237 MIMOOA ■ertAOeOttlT u,n„m,mc q o, 26 Albion Road. • Lincoln,RI 02865 redemi Tax ID#46-0566630 Phone 866.563.2235•Fes 401.633.6602 Southern New England Windows,LLC d/b/a Renewal by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT �(L�1�n`r 1, Le,�,L'g �,.I L m - 2l 8uyer(s)Name: Oafce�afF�reemene � Buyers)sweet Address•Gry State.am Zlp Code I P.O_Baal: /�D L 2/i" J`Z G A U "r ` - 2n /r�� 1'' i�f ,e ti7Ea)yf� /�/ / G 2 E-Mail Address:i.��V���17/A VD�7 ,COy ..,Telephone Number:_Y01 47-3% worlcTelePhwne Number: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d!be reverse of Renewal by Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described on the front and the . this agreement and 9p,LhS a tac d_specification heet s (collectively,this"A reemenr". 0 Historic ❑ Condo O HOAT To Job Am't ):o�unc4� Estimated Smiting DateL: ( Method of payment O Check O Cash Financed o l DeposDepositReceive ?!% Credit Cards are accepted for deposit only—maximum 1/3 of the ------ project cost(Please see Credit Card Payment Farm.)BY signing this Balance at Start of Job(33%): Estimated Completion Dace: Agreement,you acknowledge that the Balance at Start of Job and the Balance on Substantial Balance on Substantial Completion of Job cannot be made by credit Completion of Job(33%):E .Mk-a card and must be made by personal check bank check,or cash. Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal Understandings changing any of the terms of this Agreement.Buyer(s) acknowledges that Buyer(s) (1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated COPY Of this Agreement,including the two attached Notices of Cancellation,on the date first written above and(2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only)Notice to Buyer.(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it.(3)You may at any time pay off the full unpaid balance due under this Agreement,and in so doing you may be entitled to receive a partial rebate of the finance and insurance charges.(4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(5)You may cancel this Agreement if it has not been signed at the main office or a branch office of the seller,provided you notify the seller at his or her main office or branch office shown in the Agreement by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement,excluding Sunday and any holiday on which regular mail deliveries are not made.See the accompanying notice of cancellation form for an explanation of buyer's rights. Buyers)received the consumer education materials provided bK�Ioand Contractors Registration Board. (Biryer's Initials) Renew Andersen of Southern New England BuyeBySignature of Product Manager zure Si attic Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. k— — — — — — — — — — — — — — —r- — — — — — — — — — — — — — — -9.C— — — — — — — — — — — — — — —� 1vOTICE OE gANCELLATIONNQ-1ICE OF CANCELLATION Date of Transaction `( You may cancel Date of Transaction .You may cancel this transaction,without any penalty or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any 1 three business days from the above date.If you cancel,any property traded in,any payments made by you under the I property traded in,any payments made by you under the Contract or Sale,and any negotiable instrument executed I Contract or Sale,and any negotiable instrument executed by you will be returned within ten business days following I by you will be returned within ten business days following receipt by the Seller of your cancellation notice,and any I receipt by the Seller of your cancellation notice,and any security interest arising out of the transaction will be I security interest arising out of the transaction will be canceled.If you cancel,you must make available to the Seller canceled.If you cancel,you must make available at your residence,in substantially as good condition as when 1 at your residence,in substantially Seller a received,any goods delivered to you under this Contract or I received,any goods delivered to as good condition to thas e when e you under this Contractor Sale;or you may,if you wish,comply with the instructions of I Sale;or you may,it you wish,comply die Seller regarding the return shipmentiof the goods at the the Seller regarding the return shmant of the gclods with the lat the Seller's expense and risk if you do make the gods availabli'l Seller's expense and risk.If you do make the Dods available to the Seller and the Seller does not pick them up within I to the Seller and the Seller does not pick- irii— within' twenty days of the date of cancellation,you may retain or twenty days of the date of cancellation,you may retain or dispose of the goods without any further obligation.If you I dispose of the goods without any further obligation.If you fail to make the goods available to the Seller,or if you agree I fail to make the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,then you I to return the goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the I remain liable for performance of all obligations under the Contract To cancel this transaction,mail or deliver a signed Contract.To cancel this transaction,mail or deliver a signed dated copy of this cancellation notice or any other I and dated copy of this cancellation notice or any other Out lien notice,or send a telegram to Renewal byAndersen of I written notice,or send a telegram to by Andersen of T ,n New England at 26 Albion Road inc n, 1028tS5, j Southern New England at 26 Albion Road,Lincoln,Andersen f OT LATER THAN MIDNIGHT OF . I NOT LATER THAN MIDNIGHT OF ate) I (Date) EREBY CANCEL THIS TRANSACTION. 1 I HEREBY CANCELTHIS TRANSACTION.. '' reran FrMt Name pea Buyer's Signature PHnt Nana Dan i L - _ Massachusetts.Clepartment of Public ,,atari 14- 3oard of Building Regulations and Stand�� s _icense: CS-095707 BRIAN D DENNISON 7 LAMBS POND CIRCLE CHARLTON MA 01507•: ,.ten =xpira?;cn: Commissioner 09iO8i2018 e,.z)T JocSu�re_ -_a rs and BtSJinZao :.�Qa a a 1 i lark P11=;2a -Atli i i ry -' >✓L?Sitr�ll,i<ii:iSS:li:tlLiCCS i1'> -.� d _ . Home Ln-prove rient 'C7^ti1Ct-o Registration --- Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 SOUTHERN NDNI ENGLAND VVINIDOW8.LL ---- -- BRIAN DENNISON 25 ALBION RD ---— — LINCOLN, RI928-15 _ --------------- . L'_odace.?ddr-ss and rewrn aicd.:4lad:—vu`or dmo c. t Los-,Lard -- tfce or la,usa�uer�Rairs x auA.,s a.4awioo Aegstratioo valid inr individual ise orttr Be are:&e , expiration date-if found return:o: IMPROVEMENT- .. --_ _- 01tic:r Laos7tnic:.aTai.-.and 3nsinus,'tea iaCnn Registration:,78245 T'�e 10 Par[:Plait-Suite Si?Q c.piration:.:9i:1§/2Di3 Supplement Card Boston.NLATI15 SOUTHERN NE'N-tNGLAND WINDOWS I_C. .� RENEWAL 3Y ANDERSON - BRIAN,DENNISON. LINCOLN.RI 02865. '-undersecretary yo[v amrc� - s i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,AM 0211 4-2 01 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electriciansi?lumbers. TO BE FILED WITH THE PERMITTING AUTHORITY: Applicant Information Please Print Leyriblv 'Vai17z i"Business/Organization/Individual): E e .a �t.LJs _address: 2& ALISIC2 ) CityiState/Zip: N Phone 4:*1 - 2 Zg Are you an emptover?Check the appropriate box: Type of project(required): 1.KI am a employer with ZO femployees(full and/or part-time).* 11 New Construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp.insurance requirea.l 3.F�I am a homeowner doing all work myself.[No workers'comp. insurance required.-,; 9. ❑Demolition 4.f—]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ]0 []Building addition ensure that all contractors either have workers'compensation Insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions (e ❑I am a general contractor and I have hired the sub-contractors listed on he attached sheet. 3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurancev / 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. I 14.�Jther k)i/1 d o ✓ 152,g 1(4},and we have no employees.[No workers'comp.insurance required-) re����--,.-e,,--S *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my emplovees. Below is the policy and job site information. Insurance Company Name: F11-P n)2 s. 6 MptAVII _ Policy#or Self-ins.Lic.#: �,(�C 3f>8 ! z q — 2-0 Expiration Date: ! ! O Job Site Address: l O _14-rt,l S r U City/State/Zip: i!f?/d../1 r> Attach a copy of the workers' compensa ion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 at r.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under th ains andpenalties ofperjury that the information provided above is true and correct. Si ature: Date: — Phone#: CIO ZZ.e— Official use only. Do not write in this area, to be completed by city or town officiaL Citv or Town: Permit'License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityi Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: f — - ESLERCO-01 SANDERSO '4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE 06107120 1 7Y) 06/07/2017 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 have ADDITIONAL INSURED provisions or 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). CT PRODUCER NAME CoBiz Insurance,Inc.-CO PHONE FAx 988-0804 1401 Lawrence St,Ste.1200 (Alc,No>Erd:(303)988-0446 (wc,No):(303) Denver,CO 80202 ADD IESS:COMail@cobizinsurance.com INSURERS AFFORDING COVERAGE NAIC 9 INSURER A:Acadia Insurance Company 31325 INSURED INSURER B:Firemens Insurance Company of WA D.C. 21784 Southern New England Windows,LLC.dba Renewal by INSURER c:Liberty Surplus Insurance 10725 Andersen of Southern New England 26 Albion Road,Suite 1 INSURERD: Lincoln,RI 02865 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP. LIMITSLTRINSD WVD D MM/DD A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 AMARENTED CLAIMS-MADE ❑X OCCUR CPA3158728 01/01/2017 01/01/2018 pREMG ETOEa occurrence S 300,000 HIED EXP(Any oneperson) S 5,000 • PERSONAL BADVINJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY❑jEE7 F1 LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER. EBL AGGREGATE S 22000;000 A AUTOMOBILE LIABILITY Ea 2mdeeDnSINGLE LIMIT S � 11000,000 X ANY AUTO CPA3158728 01/0112017 01/01/2018 BODILY INJURY Perperson) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident) S HIRED NON-0WNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident S S A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 5 1,000,000 EXCESS LIAB CLAIMS-MADE CPA3158728 01/01/2017 01/01/2018 AGGREGATE S DED X I RETENTIONS 0 Aggregate S 1,000,000 B WORKERS COMPENSATION X PER OTH- AND FJIA PLO YERS'LIABILITY y/N WCA3158729-20 01/0112017 01/01/2018 - STAT E ER 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EA ACCIDENT S ga,gR/MEMBER EXCLUDED? N/A 1,000,000 (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE S If yes,tlescribe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S B Worker's Compensatio WCA3158730-20 01/01/2017 01/01/2018 1,000,000 01/01/2017 01/01/2018 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 17-18 Workers Compesnation Includes-All states except ND,OH,WA,WV,WY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE F R Informalig2nalP ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .. 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ON THE GROUND AS INDICATE® " m CIVIL LAND . *_ t' ' EN0INEER SURVEYOR DR:BYX �Ca� CONFORMS TO THE ZONINti LAWS r r � y� ' OF BARNSTA03 E , AS ' CH. sY p a y rNO��„MAIN .STD ! }A ,, 712. MAIN ST � �?�! ' a r _.. SQiy �l�tA�9UTH,:MASS.`` HYANNIS, MASS. SHEET OF DATE ' REa. LAND �URVMR ICI a2 _77 Assessor's map and lot number, Sewage PeAit number ................. ............ ......... *TNE �Qy° TOWN OF BARNSTABLE BAWSTABLE, MASt 1639- 41.11LDING - INSPECTOR APPLICATION FOR PERMIT TO ..........................X-..)........../,c................................... TYPEOF CONSTRUCTION .. ........................................................................................... .................................................I 9./?�. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .... ......... .......................................................................... g Proposed Use ....1-.A., ...../(:.5R................................................................ .................................................................. Zoning' District ............ ............................................Fir e District ..... o ..................................................... Name of Owner .....�en z:s........................ ......Address ... ........ Name of Builder ?V<2A!R,.4.5.... <.::.Address .... . ...... ..... Nameof 'Architect ..................................................................Address .................................................................................... Number of Rooms ..IS........260.. 1. .......................................Foundation .... ......................... Exterior 11:14,0 ...SW11'1.41(Roofing ....... .... ...11KA.7..................................................... .. . ..... .. .. Floors ........W...V... ...... ...... 10..............Interior ....�no_X4!r.?�V:10�..................................................... Heating ......................................416..... .....Plumbing ..............pXe2e14.4g ........ ...... ............................................ ...... Fireplace ........................................L..........................................Approximate Cost ....... .................. Definitive Plan Approved by Planning Board ------------------------------ Area _... 1A....................... Diagram of Lot and Building with Dimensions Fee .......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 1/0 / 1 ca I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................................................................................... Roberti Tom A 229-46 No ZQ97.6...... Permit for ...1.11r,-..story. ..dwel. ng tory. ./..dweli ng ........................ I ..... ................................ ........ Location ....1.1.0...He.r.ri.ng. Run D A . . .... . . . .... . ........... ...... .............. Centerville ............................................................................... Owner ............................Tam.-Robarts.............. Type of Construction ....... . ........................ ................*................................................................ Plot ............................ Permit-Granted .......a a n ua ry.......17......19 79 Date of Inspection ............................19 Date Completed ....................19 PERMIT AEFUSED .................................... ...............�. nt�............... .......... 19 .............................../.. 6Y .......... . .......... ...... ............................. ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... .................. ............................................................ TOWN-OF, BARNST"LB 6i { Permit No. -------2097 _ Building Inspector swsr.0 Cash - —- —- 4 6 OCCUPANCY PERMIT Bond ---X (ownerli No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by'the/Building Inspector." Issued to Taro Roberts Address Iaig Beach Rd,, Centerville 110 Reri irlg Run Drive, Centerville Wiring Inspector Lis Inspection date ' , Plumbing Dmector Jr. Inspection date Gas Inspector F' Inspection date Engineering Departmentg f p� Inspection date THIS PERMIT WILL NOT BE VALIDI/AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ................... . Building Inspector X r Ile, CA R- Assessor's map and 'lot numb`e4 ... .. �5 .... r _ r SEPTIC SYSTEM INSTALLED IN C MUST BE Sewage Permit number - (l� : :... t ' WI7 OMPLIANCE •' g Y' .......... N ARTICLE II STATE SA ; NITARY *THE toy r + CODE_ 11 l\I T N �Q TOWN OF; BATA .: ' i BAEBSTADLE, i 1 9�0063 MAX Ar BU I L D'I H G � I HAS P:E C T O R ` e� ) APPLICATION FOR PERMIT TO .C�c? ! '!4u�.T..'..�� �!f ......Q4V.c-.6 .......:......:.. TYPE OF CONSTRUCTION .....Gl?D.D10., ./a, ,.: ....................... ......:............................................... Fi ..............%.. ..........................19. 5. TO THE INSPECTOR OF BUILDINGS:' The undersigned hereby applies for a permit according to the following information: • Location ......c`'!f�`s% f......................................................................... Proposed Use ... t�1/t!�T�.£ ...................:...................:............... Zoning .District ..................Fire. District ..... .,:... Name of Owner .1.0,04.... ............................Address Name of Builder ..Z�<..-Address Nameof Architect ......................................................:...........Address ...........................................,......,................................. Number of Rooms f 1..............................: �fJ _�..... C4.....k)?�;I....... . ..�...�:�..!��.f.'?' ........Foundation .... .. ..�� �� Exterior ...:�/!v4400fin g ..... . .................. ..................................................... Floors ..... W00/�•10.............Interior ....sQ ,/4q �.. 4ff .................................................... Heating ...A/o ...Gc7A�' C�.....r ..Y...ee�� .....................Plumbing ..... fJG..G !nIr?G ............................................... ' Fireplace ..... �hll ...... 1C7 .L�. .'""....................A,Pproximate Cost d�06... ....7 `��.....,....... Definitive Plan Approved'by Planning Board -------------------_---_- � ------19--------. Area,.�`�. ........................ Diagram of Lot and Building with Dimensions Fee .................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH ;t /•006 G�-✓i•f- TOW4 PA ro t I' 3 v � v . S rb > Ab I hereby agree to conform to all the Rules and Regulations of th;To of Barnstable regarding the above construction. Name .. ... .. .............................................. 0 y Roberts, Tom A229. 41 -No .......... 2097.6 � .... Permit fort ...�.s..S:�.OT',Y.:.�.w�1..�.7n9 .1. ........... ............................... Location 110 Herring Run Dr. - , :.........................Centervi l.l.e.......y:.................. Owner ......................Toa.RRberts.................... r r I Type'of Construction .....frame.......................... ........ ...................................................` •................... Plot ............. ...... Lot ................... ......... n Permit Granted 4Rory......17 .�9 79 ' W f Date of'Inspection ... V7�lt Date CompletedY 9 COP, -4 j _ PERMIT REFUSED .. ......................................`y.............. .... 19 i.... .. ... ..... .. 1 ...... ....................................... ` ..... _ ..........•yam........ .................................. ;. .............. .. .................... ........:.................._........... .............. . . Approved ........................ 19 ...........................................................................: ................. ........................................................: 'S --` f ' p TOWN OF BARNSTABLE 20976 Permit No. ________---- - s��,ac Building Inspector Cash ,e,o �0MAI OCCUPANCY PERMIT Bond X (owner) _ "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Tom Roberts Address Long Beach Rd. , Centerville 110 Herring Run Drive, Centerville Wiring Inspector Inspection date Plumbing r Inspection date /Gas Inspector Inspection date 1/Engineering Departme Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ...........Qjiel-. Bul �� FROM TOWN OF BARNSTABLE BUILDING DEPARTMENT Mr. Francis Lahteine 367 MAIN STREET Town Clerk HYANNIS, MA 02601 Phone: 775-1120 � . SUBJECT: FOLD HERE DATE August 4 1980 MESSAGE Work has been completed under Building Permit #20976 (Tom Roberts) . Please release Bond. SIGN D DATE co REPLY SIGNED N87-RMI _ RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY PRINTED IN U.S.A. i TO 1 ) l TOWN OF BARNSTABLE BUILDING DEPARTMENT n it Francis Lahteine 367 MAIN STREW?' Town Clerk F HYANNIS, MA 02601 Phone. 775-1120 SUBJECT: FOLD HERE _ DATE - August 9 1980 MESSAGE F' L Work -has been completed, under Building Permit _#20976 (Tom Roberts) ~,. Please"release Bond. �.I SIGNED DATE - REPLY a SIGNED i i N87.RM1 RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY PRINTED IN U.S-.A.