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0120 HERRING RUN DRIVE
� P r' Y G d � o �� L B ' ���`J �'� ) ��i�-- ` TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION Map Parcel pP A lication #Z-b o ��O _ Health Division Date Issued 10 2-`It Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Boarc .1R Historic - OKH _ Preservation/ Hyannis Project Street Address 126 l rTi_T je vN Dr Ue Village Owner Ve_Gi Address Telephone Permit Request .E c AomeT'e ocI Pvjl &A i /oar, i y 2 lLf� /L(e4y Ce; f A( 2 bP�r oo�vl s, Y nscl/a�r i r►r o 0`0 r) Wa-11 s ee, r�v�c�_�V c;t eT erg✓ AVM b Ina /zC'-A dnT #A/-F�,r��x" Square feet: 1 st floor: existing '700 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 62,600.O0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family I&( Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 5dFull &(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: 2 - existing _new Total Room Count (not including baths): existing L4 new First Floor Room Count Heat Type and Fuel: U(Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing INew 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 ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name r C/►a.e/ A, Telephone Number �,�fU�,,�(�f J(v 39 Address PT_ L(N ro /n Ave. License # C S 0`77 0(� 60u4�dPs o—ma d2S32— Home Improvement Contractor# Email Worker's Compensation # RZ~ c--6 4-2 0�>u r ~ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ,��o�P(� � �/ DATE 9 I` FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCELNO. i ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION l�lll4 1 FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH �// FINAL FINAL BUILDING ® C SfZ.0 L DATE CLOSED OUT ASSOCIATION PLAN NO. A I ' c 4� V-7 pra �:I. ,• ". � �i., •! ., ic,pc1lFfi ��' �.�� /. ,1.[' A �4 I��+ V'�`��� `•„1f�1� N,aa b4�j Cl ' a of- Dar i - ►--.u.c� zo��rr y y ' Imo• .$ d..6 ,f 2 j .6 ,Ce o1;Consumer Affairs&Busme§s la • .OME IMPROVEMENT .CONTRACTOR egistretion {122015 - Ex TYPe 6n Z 9. irat pe Individual f MICHAEL A. b'ANdf RON, r r r _ ICHAEL .DANGELO�- �g `�-- 11 m LINCOLKAVE. r` BOL R_NE VA 02532 Undersecretary --.ice...--_—_.:a..:..-.:. "a::r•:... .. •'^ jK Unrestricted-Building' .ofany use group'which` ,. contau>t'less tan h 35,00.0 cubic feet;;(991m3j of enclosed space. c— Failure to possess a current edition of the Massa usetts 'tstate Building Code is cause for revocation of this license. For-DPS'Licensing inform ationvisit: www.Mats.Gov/DPS YS Safety t of P. rf e amen tand'ar+�s Setts D..p'utiatioPs.a�d S • 'y Masp. of au��d�n9'Reg isor' goat, choT''SuPen tr"a -077 506 N� 1 Avg 021 _ is7�gDS BAD BUZ. '.. .�� Expiration `04123120A6 F o ss 1 , 17ie Commomveafth o+f- assad iusetfs Depurknent o,f l'4dush ial A.ccidews t� Owe of 1m.wtigations. 600 Wasliiagion Street Boston, 02111 " n wivii?niamgovIdla Workers' Campensntian Insurance Affidavit Builder-sJCuntractorsJEIecfriciansJPlumbers Applicant Information, Please Print Legibly Name(BusinessllO mizationfFndidzlnalY l 64AR l l7'�IIA-r�© Address: rs LL1 Rr ro lAj Auc, �'ItF!` f3tPJ &U cg a Phone- 5 Are you an employer?Check the appropriate box: O ZSsZ. Type of project(required): I.❑ I am a employer with. 4 ❑I am a general contractor and I 6- ❑New const uction. employees(full an&or part-timed* have]sized.the sub-contractors 2.5 I am a sale pr9prietor orpartner- wed on the attached sleet I. Ed Remod-Img ship and have no employees • These sub-confractors have g- ❑Demolition wot'ldng forme in any capacity employees and have workers' El Building addition. [No vuorke-W comp.insurance comp_incumcf—t$ rewired-] 5- ❑ We are a corporation and its 16[3d Electrical repairs or additins 3.❑ I am a homeo-amer doing all work officers have ymxcised their 1 L[N Plumbing repairs or additions myself-[No workers'cuV- right of exemption per MGL ° 12.❑Roofrepairs insurance required-]i c.152, §1(4�and we have no employees_[No workers' 13-0 Other comp_insurance required_] r *Any applicznteut checks box 91 mast also fill out the sKdon below showing theirwoAere compensation poricyinf fete L l Homeowners who submit dais affid-A ii indicating they axe dGmg s1l wale and then hire outside contractors amst mbz t a new affxdwjt iadicatk6-sar13 rContractors-dut cbeck ibis boat mast attached as addibaml sheet showing the nacre of the sub-conirmtm snd state whether or not those entities have employees.Ifthesub-contzedaes have employee%theymastpmuidetheir workers'vomp.palicgnumher- I ant an enipLapr that isprmidbig irarkers'conrperlsai&-n hisvirallce-for my empkyees ffetow is tltepaiicy alld job sde informaliom Insurance Company 1fanie: /`� ✓N/� L S'f�lo7y c Policy our.self--ins.Leo_ III�3 I W C(o Expirdtion Date: r7`1-311�o Job Site Address_ % 0 Aeir -1 a,4 {Q(inY Uke, City/State/Zip: 1( !'V1Q, D 43 Z At tack a copy of the workers'caampensationpolicy declaration page(shoWing the polity number-and expiration date). Failure to secure coverage as required under Section 25A of MGL G_152 can lead to the imposition of criminal penalties of a fine up to$UOG 00 andlor orle-yeirimpisonment,as we11 as civil peaalties.in the form of a STOP WORK ORDERand a fine of up to$250_00 a day against the violator. Be advised that a copy of this statement raay,be forwarded to the Office cd Invest gatibns of the DIAL.for insurance coverage tieriffta#ion- Ido hereby cetfify rjukr"the/pains and pirnaWks o f p/erjcty that die informafiarl-pm i&dabmv is Grus arid correct S.iEnature_- t l� .0 (7 /t Dh,(pD.G(J Date: Phone 1�7 5a +t3�iai Ii$B a+!ITy. Do not Icrita ai�I t/irs area,tti be cvlttpieted by city+arten�n ofjrcfaL City or'To zu , PeradtUcense:9 Issuing Authority(drde one): L Board of Health 2.Bml&ag Departmeut 3.Qtp To m Clerk 4 Electrical hispector 5.Plumbing Inspector 6.Other Contact Person: Phone#: hiformation and Instructions � H f Massachusetts Gebe Laws chapter 152 mloares all empIoyers'to provide workers'compensation for their employees. t pursuantto his statnfe,an�&yee is deed as."_.e�'person iu Elie service of another under any cor�rdct of hire, express or implied,oral or writinu_" An ernproyer is defined as`pan individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in aloi at enterprise,and including the legal representatives of a deceased employer,or the receiver or trastee of an individnA partnership,association or otherlegal entity,employing employees. However the owner of a.dwelling house having not more than three apartments and who resides therein,or the occupant of tar e - dwelling house of another who employs persons to do maintenance,constaction or repay work.on such dwelling house or on the grounds or budding appu tin m-it themto shall not because of such employment be deemed t o be an employer." MCL chapter 152,§25C(6)also sties that"every state or local licensing agency Shall withhold tine issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for nap applicant:who has notproduced acceptable evidence of compliance with the insurance•coverage re:quirecL" Additionally,MCI.chapter 152, §25C(7)states"Neither the commonwealth nor any ofits political subdivisions shall enter into any contract for the performance ofpublic workunff acceptable evidence of compliance with tha filsuraT,ce.. requirements of this chapter have been presented to the contacting author*_" Applicants , Please fill of t the wor3=s'compensation affidavit completely,by ch=king the bones that apply to your situation and,if necessary,supply sub-contraetor(s)name(s), address(es)and phone nvmber(s) along with their c(--rfifrcafe(s)of ;nst�ce. Limited Liability Companies(I.LC)or Limited Liability Partnerships(LLP)with no employees other than the members or pal taers,are not requaed to carry workers'compensafion insurance- If an LLC or LLP does have employees,a.policy is required. Be advised that this affidayk may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage Also be sure to sign and date the of davit The affidavit should be retrrmed to the city or town that the application for the permit or license is being requested,not the D ep artnamt of Lojin.etrlal Accidents. Shouldyou have any questions regarding the law or ifyou are,rego:ired to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insUred companies should enter their self-insurance licaase number on the appropriate line. City or Town Officials f • 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 sine to fill in the pennitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple penni.t/Iicens5 applitatians in any given year,need only submit one affidavit indicating current p olicy m��rnation of necessary)and under"Job Site Address"the applica should write"aII locations in (Gtiy 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 fie permits or licenses- A new affidavit must be,filled out each year.Where a home owner or citizen is obtaining a license or permit not re7.ated to any business or commercial venture (ie, a dog license or permit to bum leaves eta.)said person is NOT regaircd to complete this affidavit The Office of Invesligafims would like to thank you in advance for your cooperation and should you have any questions, please do not hestate to give us a ca.M The Dep�rtmenfs address,telephone and fax number. CGMMMWe tE of AfassachuseZ- Deparimmt of Ii dial A Zents ice of�tv�ig�tia� $ostou.,M4 E I I F Tf,-1.4 617' -4 CMt 406 CX 1-&77 IASSAFF Fax 9 617-727-7M Revised 424-07 .ma� gfdia v, .: ` r � �,( , r,a •, W :e' iS r liilrl� �' �n ,i 3 illz - r ,,,�ail. a y �!, ., iZ s zhiiw a - 'S5 pgr tom. 4 RCIi81Y� Y'!L� t14WT' k s 5 Butll+d tg Uzv sloe , fldtd�Co»xt #sianer ` ' _ ' a ` 5 24a Ilan S y "t, ntgy 2ba1 r fit*wq ttt �le.�aaus )` E f fltl�x 3a8-862-4038 fax Sp8 T9a 23a `, g , t tE p �fl Y' " 1t Y a k ��'LT ` A Biiiiiiii de�. { x h, 2 YET p,^ '� S y ,� , 't ,`�i ? i d ,,fir - _r ..l'.0 '�. lotn a ,ii _il lkwfi P Marie S "' \ :. YUfiI �S UWpiL O � j;c, tL3r � �r i i he, by sutho a 1.111. i. cbae�iT 'An ,, t o my be 4 ., s A y %u£ matters'relafitve t:z au#hexed by bu�perrsut 'Pbcationrrr g __ - :' i. h ' ;qqr ty x I e n 1 ,�7n�re,Ce t Yi�a A a p. r y, _ ; i 'Yn ,; �" . N �. .. .A :11 �;: s 91 Signature of`t�.!cF _- , I azc i . Marie X Svucct ,' 1' Natiner s, ,. A, Buz h4 - '� I. if�YP1]m1FpA01 t., }tl�v er S ► lyiag for "pl, se ctt1 fete the 1 o )!00 Lice a tempt vn I r os tote x i I4`4I w.S f✓� , C Y _ Mill .k iyll" , klTIABROMS '.� ' �h :'• �S 1.- v M - W S 11 I_ C lU I3 t1�l a, l kccrscssn11i4Vt ow&1 fi�mpdr'y 7ht !pau"atmtsh �ti, kl"Pli R PRF S dtJ� . 4 RCVS a�df213 dam .a w 2, s „� �� ,. �'i '+,�_,.� !,. fib' k`..�" ,y� M AM- .r4 .1 k u n M. .. ... ... '. .- :. < - s�Z3l�l Town'of Barnstable *Permit# -16 - 1210L Expires 6 months from issue date Regulatory Services Fee anxrtsreste, � M"M Richard V.Scali,Director �fD MA't s Building Division o ` Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 MAY 12 2016 W Ww.town.barnstable.ma.us Office: 508-862-4038 ®�N ® �� a�xN6r230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2 Z 7 O 4 7 Property Address lZ D cc✓'r 1 n Co /l V:�1 °' �-C-4<cJ V t Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address et V U GC 1 . Contractor's Name_ .. `1 Q eA rt G- ,T^G Telephone Number d Home Improvement Contractor License#(if applicable) Email: t3l:pery isei's License#(if applicable) A ` Workman's Compensation Insurance Check one: ❑ I am a sole proprietor have m the Homeowner Worker's Compensation Insurance Insurance Company Name N c r T o l k Workman's Comp.Policy# JC./ 13 O U 11 Ip1 Copy of Insurance Compliance Certificate must accompany"each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to E ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: Nrsmoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e..Historic;Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Rome Improvement Contractors License&Construction Supervisors License is re d. SIGNATURE: Q:\WPHLESTORMS\building permit forms\EXPRESS.doe Revised 040215 tr the+l^armamuerrlifi'o,�f 1lrfrrssuch useits Depd ftmt o flndustrial Acciderrts. .. O,j ke of I v siig�r rrrus 600 Washutgtrm Street Pvston4t ! 02111 wmv.masmgov/dia . Workers'Compensation Insnrauce Affidavit:BuHderslC iHft`2 t0rSM,a tricians/P bees Appiicant.Information Pease Print Lebty Dame(B,rsroess/Organizaa vidnal}: E.fZ.E:: E 1 In C, Crty�St�t�relZ�p_ uz-t acd 5 0►. M� 0 25 3Z � s a$ ,s q 'S.'1$8 Ar"e n an employer?Checkihe appr�priat+c boz. }:* 4►a ve . Tp Of f proect required).' d) 1 I ❑ cantactor andI amaeap1aye with 4• :Iamate�al []New consti flu the sub-c0ntr&Ctorsemp1ogees( ll atUor part-time 2:❑ I a a sole praprietar or partner- listeid on the attached sheet: 7- ❑ g sbip and have no employees These:sub-c have A 8. ❑Demolition woddng foimein:anYcapacity- ernployt�esaad have wa Cers'` ' .. c ..ir I ❑Buthitng addition No workers cnmp:`mstarance °IDP d 5, ❑ i are a cfla dporatresu and' 1{l❑F� retctricil repairs or additions l aft its have;exercised their 3.❑ I am a homeowner doing all vaorlr l I❑Pllimbiag repairs or additions myself[Nb:wor�e[s'cotmp:: right a iron ger MGI::: 12.❑Roofrepatrs of insivance regrd]t c 1523 1{`l�and we:hati*e no ployve°s-[No w ikers' 1:3❑Other cowp:ivaurance mquiied.] 'Aay applicant that checks'b=#F1 mast also fill oat tbesKtion below showing their wod.ere evmpeasation po infer=rian_ HOMWWw ers wbo submit this dEdsvir iadicaring they are dwag aB wmt sad am hire cusi&cannact©n most submit a new afdayst indicating sods. onitactors that check this beiat rest attaehed as addusnsnl sheei shooriog the name'i+f.the su&¢tartracoors and dtate whethar of not those®uties bsm emplcy+e ruse sabcanuactms have�Iayees,they must patf ade ter workers' ' If _ co®R.Policy number. I am art employer that is providing workers'compensation inmrance for my employees. Below is the policy and jab site in,totmadon. , 1 Lmnance Company Name: IV o r W k *. ll e 4,Q fV1 P sl cy#or Sd1f tns:Lc # W E t'3:o 0l l A trstxiaDate-:Z l:t-ll .. .. Job SiteAdtltess.t:2o rt-♦rnGi l�c�A �d": 1�4c^ �) tt. +Gity/State�+Ztp .. :�1 Arch a copy of the workers'compensation policy declaratipn page(showing the pokey number and ezpu tion date) Failure to stecure co,"ge at iie,*i under Sew 2,5A:of MGL c. IS2 can lea i:ito the M. aeition of criminal penalties of a fine up to$12500_00 andlor one-year in4xisovanenk as well as civil penalties m the form of a STOP:WORD ORDER and a fine of.up to$230.00 a.day aga ust the violatoe. Be advised,that a cagy of this start maybe&rwarded to The Office of Investigations of 112e DIN.for ice 6.overage:venficativa _:.. I tld hereby Ce.0 under s an nrtl#tes af'periJriy thetthe tnfottatian pravtd�d above is bus and corree t Si tore_ Date.: Phone#: $ '- 7 s g UU'leial use only :Do not write is this"en,a be coritpletdd by:taty artown official, y Pe City or Town rrmtlitc ease# Luuing Authority(circle one): L Board of Health 2.Bing Department 3:CitylTown Clerk 4.Uictrkal Inspector 5.Plumbing InVec#or.. 6.Other. Contact Persons `:: r Phane# . 6 Al 1 5 � Off , To -AMA egg' NW&AN �i j ow- of=Barnstarie t b' s z R@iilattry Services' 3 } . \: 1 fiom p9Y>B Wtrg ., IM ner 2�Mara;SceeI�yanna�,>*M�Agpt��2�6i0! c� MAI lox I � - �'�lVW.t0iYII�}38t°lIS�8�3!@.ttt8 pia..-• E X - J � t e M i ; M { Of SOS H62-�O3H FBX�SOH90-6230 z g Complete and Sxg '1"his Section Ifs A Balder f } Sao 4 Matnow F � Q, TjE f ;a3 C3svnez-0 the sub je c�propert� 4 hexeby�aOloraz �� c ward act ors aiy beialfp y ARM B. xa all rac ers relaave tss'.wor C autho d by this bwliiurg pc rue app ca" A AWN. ter: "Mold so— MAN "!�HB[Iirt$Run Orne,CeitBtvitig,N#fl # � C�tSS UOOtto b} z } tyou KIM Poal fends and�s aye tie xesponsabla o£tie a : cash.Por�ls, R\ x � . P ' arc not tip be fslled o xtecl before fence is jnstaec gad all fsnal_. y iris"pecaoals pexf� ei and accc�recl Signature Uwa Saactre cif AppLcaat r , t - Ias1e 7 Saivuccs Edaafrtacobacc -577 W, win # 'Print Nar 3e f (' -y K ' c i :pr.x1t. laEue" r �`� y t 4 2t\a y t r t � z r iu ti. k1 A ONE- `sue glum W -Lv N r rst r x sY a ,F S i c y•t i t f � G Fu1 Q� a - + LL! 14 Qw w 1st . FLoc 2 I '� a o g LLJ ILIL LU EL' u , I` F- ® Zui uj ct Or I! Q � !B3 � \ w w �.� a�L� - ® m � I a� c 1 LL' b J �/ ` m $ 7 � ` ✓ I •,' l�•??Gllnf� �-(� - ` .1.�. I. i� i,(y/�- �• ��(IJ ul� :J N kS N i=b tl f5 iEM E N T -- I f c v '•. vie a °P3iRP'aR' sd,.,c} 4 ''7 '+'`�``,�z��%`��•*� •F MAMA ASA�HLLIST '_ � " s SCR�I5,� THtE F,O�LLOWI�NG L�t'�� ,S�E AS ,� ���'Ei�I�D'^ MASTE�R +E'LE��C �► �.� �� � • ���WAFt���'`R�El1�CflBA��C I �`� � •r �� ��,` Raw [ ARD'S�gBAY 53�2� 44t .. l( `�. .'�'1 _ '. s.•e'�'—.'_."Te 7F ax vn�wnr,., .��t a j 4 Town of Barnstable *Permit# - - iQ-71 Expires 6 months from issue date �T Regulatory Services Fees snxxerasz.�. : _ - uasa Richard V.Scali,Director 1639. a�� ' Building Division Tom Perry,CBO,Building Commissioner ----- -..�-- 200-Mam-Street;Hyannis;MA-02601...--- www.to_wn.barnstable.ma.us AY 12U16_ Office: 508-862-4038 , t4l; 08790` 230 EXPRESS PERMIT APPLICATION - RESIDENTIAI.IPN �I fits E ^� Not Valid without Red X-Press Imprint Map/parcel Number l 3 aC Property Address z2 sidential Value of Work$ �'o�o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address SC'/ Contractor's Name ,,e •� �A92v� Telephone Number ;5-<7 rr Home Improvement Contractor License#(if applicable) /0210 41' Email: Construction Supervisor's License#(if applicable) D 7 1�0 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance k Insurance Company Name Workman's Comp.Policy# ltJG' �0d J O 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) s® Re-side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: .0 _ ❑ 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 Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations ` 600 Washington Street Boston,MA 02111 www.massgov/dia _ _Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Please Print Name(Business/Organization/Individual): ,iQ t/s�� �.!�7i'N�✓/ Address: City/State/Zip: - / dol C Phone 'p- Are you an employer?Check the appropriate box: Type of project(required): am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑Building addition [No workers' comp. insurance comp.insurance 1 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 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and.state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. fj-d .9 Y",001,S-A Expiration Date: Job Site Address: ��� �"�a' �N � City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi der the pai d p I piallies of perjury that the information provided above is true and correct Signature: Date: `1� ✓�� �Phone#: + J 41, C �6 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#: 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'Aates that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states,"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants PIease 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 an LLC or LLP does have employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington,Street Boston,MA 02111 Tel,#f 17-727-4900 ext 406 or 1-877-MAS8A FE Revised 4-24-07 Fax#617-727-7749. www.mass.gov/dia To: Page 3 of 4 2015-08-04 19:31:56�GPAT) 15087527172 From: Brian P.e!dy CERTIFICATE OF LIABILITY INSURANCE f�I(-0�a DATE(NM/DDN YY r} 08103/2015 rRopue>r, THIS CERTIFIClATE.IS ISSUED A$A MATTER OF INFORMATION Blackstone Insurance ONLY AND CONFERS NO RIGPTS UPON THE CERTIFICATE +� HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. BOX 31 f ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester, PAA 01613 - INSURERS:AFFORDING COVERAGE NAIC IYSUR4D �^i T )NSUP.[Rli' Linne)i Enterprises INL'UCtLR-. 59 Freeboard Lane ItJSURER C Yarrnouth, MA 02675 ItasuRe — INSUHE.R E. COVERAGES THE POLICIES OF ihi$IJPANCF LIST GD BEIAt0.r:-{AVE KEN IS:;U`0 TO THE MSURED NAMED ABOVE;=OR'THE POLICY PERIOD IN0 GATED.N?TwfTI-ZTAt-mImc, ANY REQUIREMENT,TERiJ OR'CONDIT[(3N OF ANY COI TRACT OR OTHER DOCUMENT Wii`i RESPECT"O-' IiICH THi:_CERTIFICATE MAY BE.ISSUEi1OR T<<f FERTAIN•THE iNSUri.ANCE AFFORDED 9Y T14E PJIJCiEs DES(:RI3FC H_REm IS SU9Jz:CT T<i;--%u,�c?=RtAS. ;inLUSIDII =14C C <DiTl014o OF SUCH POI.ICiES.AGGREGATE LIMITS SHOWN MAY'HAVE 5E°EIJ REDUCED BY PAID C1Jh1S. Mbr( 'FECTiVE'r LT -- LTR MISRO TYPE OFINSURANCE POLICY NUbiecR 'I TA Rtidl0 WI C jk�NlDC(Yi) UA31TS GENERAL L"UTY LA Oi:(-rJRREN::;E. S. COMMERCIAL.GENERAL LIABILITY DwnSn,:a•T{ FN I�V PF:EM,'�,>r.-'•S E8 eccvrerte�l1 S _� CLAIMSMADe GI 6CCUR 1 AtED f•.X?tAny a;e l:orton7 $ PERSONAL&ADV INJURY 5 •I GENERAL AGGREGAT' 5 GEN'L AGGREGATZ LIMIT APFLIES PER. - I I PRODUCTS•COMP,10P AOG 5 - POLICY MUECT LOC AUTOMOBILE UABILTe COMBINED 8140t.�LIMIT g A!IY'P.l:'r0 (Esa•.::iJertl A L.OWKED AUTOS EODF.."INJURY $ SGi1=CV.LEU AJT.OS (?5 �eY_cn: rvuD AIJT'OS BODILY iN,IURY S klDN-OWNEDALTC5 :rers�Klenti i PROPERWDA41:,GE g GAUGE LU40LITY AU?0 ONLY-EA ACCIDENT S ANYAUr,3 0_1 PF.F 7IIAh2 EA AGC N •AUTO ONLY: AGG g EXCESSIUMBRELLAL1ASIUTY EACHOCCURRLNC.E S OCCUR Q Wa,45 MADE AGGREGATE ;; I ( a DEDUCTIELE RETENTION S VYCRILERB COMPENSATION EtAPI-IYERB'LIAMUTY T'C.n':L13A1T5 ! [ ER j W A ANY PROPRIcrORJPARTNE4lEXECUTn.Z WCC50050074472015A 8i1i2015 I 8i1/2018 FL..E_k!_;,A ccMENI' fs :ce.ODo OFFiGE RW=_MBE:i EXCLUDED? If•os•daserlhu�nder Ex.il:w:a�e• Et.P:(:yE:. 5 'ItO,DOC 6 AL PROMWIS be.1niv j F_L DISEASE-POLICY LIMIT 5 `_•iO,Ot?0 OTHE? I i Davlo Linne.4 is coveted by the workem c"pensation•policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OmSCTUSED PQLICIEB BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER VALL ENDaVOR TO MAIL 15 DAYS YmTi6N - .NOTICE TO YHE CShTiFICATE HOLDiR NAMED-0:'HE LeF:,'BUT FAILURE TO DO SO S4ALL IMPOSE NO OBLIGATION O3 LIABILITY OF ANY KIND UPOH THE INSURER,ITS AGENTS OR REPRESENWIVES. AUTHORmer REPRESENTATIVE ACORD 25(2001108) ACORD CORPORATION i988 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ."HOME IMPROVEMENT CONTRACTOR. before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation i,:.. Type: O g Registration: 9 Yp 10 Park Plaza-Suite 5170 Expiration: 2/19/2018 DBA Boston,MA 02116 LINNELL ENTERPRISES N� 59 FREE BOARD LANE. y Y.ARMOUTHPORT, MA 02675 Undersecretary Not valid without signature a i i �I Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSFA-071507 , 3upe-: DAVID J LINNELL,JR 59 FREEBOARD LANE YARMOUTH PORT MA p267S C1Expiration: `ommissioner •i __ 08/11/201.7 GENERAL CARPENTRY ROOFING FULLY INSURED P-GMN zfiwefi HOME IMPROVEMENT/REMOOEI-M DAVE UNNEU.,JR. Mart 508-362-1294 Yam6u#WrL MA 02675 Property Owner Must Complete.and Sign This Section 1 ,as Owner of the subject property hereby authorize to act on my behalf in all matters relative to work authorized by this building permit application for. (Addi6s of Job) Signa , 6f wner date Print Name Q:FORM&OWNERPERMISSION Commonwealth of Massachusetts' , Sheet Metal.Permit Date: . Z Permit# [ ' o Estimated Job Cost: $ ROBLFee:��� � rt $ Plans Submitted:YES NO u! JAN'25 ZO1filans Reviewed: YES , NO Business License TOWN,OF B A STABLEse# 1 Business Information: Property Owner/Job Location Information: Name: l �r h. Nam . (; r./ e a ?Gi 11l v�Gi r Street: 2- R,0�--2g .'Street. tY Ci /Town: City/Town: i4� / f . Telephoner J 6 7 '� �1 Telephone: 490 b Photo I.D.required/Copy of Photo I.D. attached: YES NO Pw Staff Initial J-1estricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories,or less Residential: 1-2 family V Multi-family " _ 3Condo/Townhouses Other Commercial: Office' - Retail Industrial Educational ° } Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq..ft. . . Number of Stories: Sheet metal work to be completed:. :New Work: Renovation: ,p HVAC Metal Watershed Roofing _ Kitchen Exhaust System Metal Chimney'/.Vents Air Balancing t Provide detailed description of work to be done: lie men t r ANS-URANCE=130VERA E.! I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below. A liability insurance policy, ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑_ Agent ❑ Signature of Owner or Owner's Agent s , ereby certify that all of the details and information I have submitted(or entered)regarding this application are true and By checking this boxE rj h accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments - ' Final Inspection Date Comments 4 � Type o �icense: By y aster - •� Title r ❑Master-Restricted City/Town . ❑Journeyperson Signatures of ensee Permit# C� ❑Joumeyperson-Restricted Vnseber: Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval Town of Barnstable Regnlil tory Services A Thomas F.Geffer,Wednr Building Dwi m-0II Tom Perry,Building donlmissi�ner 200 Main Sheet,.Hymimis,MA 0260, wfvw.town.barnsfable.ma.ns Office; 508-862-4038 Fax: 508-.79.0-6230 Property .Owner Must Complete and Sign This Section If Usk A.Builder as Ownerof the mbjectptppett7 hereby authorize_ OAe `� %c°U (° R/ � �1�� to art on tap behal� in 2R rots relative to work authoEzed by this bmlding pemait 12-0 (Address of Job) **Pool fences and alatms are the responsibili f the ty,o e applicant. Pools are not-to be filled•before fence is*installed and pools are not to be utilized until all ftn2l inspections are performed and accepted, time of Owner Aoft Print Name Print Name _Z_ Date Q•.Fox�:owrsorn'oo�s The Commonwealth of Massachuset& Nnnt korm Department of Industrial Accidents . Office of Investigations I Congress Street Suite 100 - Boston, MA 02114-2017 www mass gov/dia ° Workers' Compensation Insurance Affidavit: Builders/Contractors/)Electricians/Plumbers A ' licant Information Please Print Le VName(Business/Organization/Individual) �: nCP C Address: 27 X t 2 City/State/Zip: 0-k,*t g fi Plk C Z S / .Phone i. .Are ramaemploYerwith employer?Check the appropriate box: - T31)e of project(required): 1. (p ` . ❑ I am a general contractor and I6..❑Ne construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on.the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g_ ❑Demolition working for me in any ca acit%': employees and.have workers' p 9. ❑Building addition . [No workers'comp.insurance comp. insurance.+ required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions ❑ officers have exercised their I L Plumbing repairs or additions .3. I am a homeowner doing all work ❑ myself o workers'comp. right of exemption per MGL [N P 12.❑Roof repairs insurance required.]t c:152, 1(4),and we have no employees. [No workers' 13.0 Other- 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 a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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 employe'that isproviding workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name: S.-.7 l CA r-q< Policy#or Self-ins.Lic.#: v4-yc� 7 -( D Expiration Date: Job Site Address: "l P 9 P City/State/Zip: CP�`Ld v t Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a : fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties-in the form of a STOP-WORK ORDER and a fine of up to$250.00 a day ag ' t the'violator. Be advised that a copy of this'statement may be forwarded to the Office of Investigations of the DIAytofinsurance coverage verification. I do hercbv certi , le pains and enalties o er ury that the information provided above is true and correct. :, . , ' Signature: - - _._ _ Date: Z_ - - -� - - -- Phone#: t0 Official use onh. Do trot rite 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 i.Plumbing Inspector 6.Other Contact Person: Phone#: 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 local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials ya Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant ,,that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4906 ext 406 or 1-877-MASSAFE Fax# 617-727-7749, Revised 7-2010 www.mass.gov/dia ACO LI CERTIFICATE OF LIABILITY INSURANCE F9/14/2015'' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 CONT MEPTCheryl hollis C.L. HOLLIS INSURANCE PHONE (508)295-9500 FAXNo- (soe)295-9a9e 140 Marion RdE-MAIL AppgEss:choz7l3.ee@insurehollin.com INSURERS)AFFORDING COVERAGE NAIC 0 Wareham MA 02571 INSURERA:Safety Indimnit INSURED INSURERB:Safety Indemnity JAMES DIEDE DRT BEATING & AIR CONDITIONING DBA INSURERC-TVia CitY Fire Inauraace Co PO BOX 666 ► INSURERD: INSURER E: BUZZARDS BAY MA 02532 INSURERF: COVERAGES CERTIFICATE NUMBER:CL156202364 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 A D SU R POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 11000,000 CLAIMS-MADE a A A $ 300,000 BMA0024109 9/12/2015 9/12/2016 MED EXP(Any one ) E 10,000 PERSONALBADVINJURY $ 11000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 S POLICY JECT LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: EPLI $ 10,000 AUTOMOBILE LIABILITY COMBINFD I E 1,000,000 accident) 13 % ANY AUTO BODILY INJURY(Per person) t ALL OWNED % SCHEDULED 6233263 5/4/2015 5/4/2016 BODILY INJURY(Par aoddent) 9 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS $ E UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ED RETENTION $ WORKERS COMPENSATION $ P E H' AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN NIA E.L.EACH ACCIDENT $ 500 000 C . FFICERIMEMBEREXCLUDED? a 08WECTX6573 9/13/2015 9/13/2016 E.L.DISEASE-EA EMPLOYEE 6 500,000 andatory In NH) If yS,desafbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE A13OVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. — AUTHORIZED REPRESENTATIVE Cheryl Hollis/CHERYL ? ��- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025ownn Ili .cOmMONWgLkLTH OF MASSlftCHUSETTS. . 4 SHEETSETAL ,WORK£ S G. { ISSUES THE F0, LOWING'�LICEldSE AS A MASTER N'H ST, AGT'!'E -,r HEAT I NG & A/C IAMIES I � 1= E rzUZI '00 BflX t ' « f�RT NEAT I NG � A/C BUZZARDS A 02532 o66b 3`99982 , BOOZSL!0^aN StOZ'CZ-CO a0 S• � -- 7� ; �;'r 't- . tlW''wv'143 N1x' _ 9Z4Z, — i M. pvkWfS3Wdi uc + o 3NONiv W'4jC35•j9L y3�$a HAll, 3 r • !s�y 13.T�.� t�38WI1NVPq ��„ ���,,�`rt � .. vsn - 3SN3�Il, err' -1 i r Loc l `�. />. n X w �u a IN y r c ��� 4 AMA k iwo f j a % / � � � / �/✓ / .r „�r�' � zc�,,, y �, � w d b �keg a� ar .a. f 3 trte tom, Tow' n` 0f Barnstable;' �~ � *Permif'# E,rpir moat r ssue date P � t Regilatory_S'ervices Fe MASS.1 SS PERN BARN Thomas F Geiler,Director ' �G f2a.ha gTFDMAt ' Buildin �_1VIS10nR < , v g 1 U�� 010Tom Perry;`.CBO, Building.Commrssionerr 00 Main Street;'Hyannis,IV1A;02601 "OWN OF BARNS AB =; a a 'Y 4www town;barnstable.ma.u_s Y. -6230Office: 508-862-4038 Fax 508-790 EXPRESS PERMIT APPLICATION - 'RESIDENTIAL ONLY:' " Not Valid without Red X-Press Imprint �r Map/parcel Number Property Address t 11 kZ sidential Value of Work �' Minimum fee of$25.00 for woek.uriderr$6000 00' Ax e, Owner's Name&Address �a l U 1� G Sf r RIOContractor's Name .� „Telephone Number 7 1�� -=x Home Improvement Contractor License#'(if a p cable) t �j7 Construction Supervisors License#(if,applicable) �© ❑Workman's Compensation Insurance v C�eck one: X; I am a'sole proprietor` , ❑ I am the.Hotneowner I have Worker's Compensation insurance-. Insurance Compariy Name «t` .t ' Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany.each permit ` • �''= Permit Request(check box) r' r.� �' �? r , .y ;• e-roof(stripping old'shingles) All7c'onstruction debris will'be taken to r ❑Re=roof(not stripping..,Going over +gxi'stirig layers of oofl�, Al PP P Re slde a Jgg � 't nf, h #,of doors 5 ;' Replacement Windows/doors/sltdersaU Value r .ya (maximum`.44)# ofwmdows 77, 3 .. ,. -. ;w *Where required Issuance of this permit does not exempt compliance.with other.town'departmept regulations',i.e.Historic;Conservation;"etc "h * ote " perty Owner mu rgn Property Owner Letter of Permtsstoti copyiof th o e Improvement Contract6rs Ltcehse &Construction Supe,rvtsti s License is egwred 4. � �" `�' � �' / � 4 " � .. ,fir � ,;'sr �� ,' F .1• 7 t � � �..�z - * SIGNATURE r; Q'\WPFILES\FORMS\b 1ding permit forms\E PRESS.doc §§ K 4 t ; w # r "A' ' 01 pp David Sawyer Construction 318 Meiggs Backus Rd., Sandwich; Ma 02563 508.539.1992 Proposal Submitted To Work Address Marie J Salvucci 120 Herring Run Dr 249 Winchester St w ' Centerville;MA Newton Highlands,MA 02461 617-9694484-H 617-431-1256-C r Work to be Performed: *Strip old roof shingles and replace with new 30 year"AR" Architect CertainTeed Shingles , Color: cobblestone Grey " *Nail Boards as needed *Clean Gutters as needed k * Install White Aluminum Drip Edge Ice &Water Barrier on all edges of roof,chimney and valley Underlayment Paper System Pipe Flange Ridge Vent Hurricane nail roof *Clean & Remove all debris from work place after job and take to landfill. *Please note when putting on the ridge vent sawdust from the roof may drop.into the attic......please covers anything you do not want sawdust to fall on. w Total Investment&Labor: $ 4,200 four thousand two hundred dollars ' Payment due in full at time of job completion. All materials guaranteed to be as specific, and work to be performed as stated. above. Work to be completed in a.workmanlike manner. Any alteration or deviation from the work specifications involving extra costs will be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond: our control. Please remove and or secure any fragile household items. Not responsible for broken or damage to household items. Five Year Labor Warranty/Plus,Manufactures Shingle Warranty. �... We may-withdraw this p o osal if not ac ep ed within 30 days. Respectfully Submitted ceptance of Prop .. The above prices;`,specifications and conditions are satisfactory.and are hereby accepted. You are authorized to.do the work as specified. Paym is due in full at . 1 p _ f 1: job com let�on. Date Signature Q' l • David'Sawyer Construction t318 Meiggs Backus Rd 'Sandwich, Ma 02563 508.539.1992 Proposal Submitted To '; Work Address Marie J Salvucci 120 Herring Run Dr. 249 Winchester St Centerville,MA' Newton Highlands,MA 02461 617-9694484-H 617-43171256-C Work to be'Performed:' ' *Strip old roof shingles and replace with new 30 year"AR"Architect CertainTeed.Shingles Color: cobblestone Grey ` *Nail Boards as needed *Clean Gutters as needed * Install - White Aluminum Drip Edge Ice & Water Barrier on all edges of roof, chimney and valley F` Underlayment Paper System Pipe.Flange Ridge Vent Hurricane nail roof *Clean & Remove all debris from.work place after job and take to landfill. *Please note when putting on the•ridge vent sawdust from the roof may drop into the . attic......please covers anything you do not want sawdust to fall on., Total Investment& Labor: S 4,200 four thousand two hundred dollars Payment due in full at time of job completion,. , ` All materials guaranteed to be as specific, and work to be performed as stated above. Work to be completed in a workmanlike manner. Any alteration or deviation from the work specifications involving extra costs will be, _ executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Please remove and or secure any fragile household.items. Not responsible for broken or damage to household items. Five'Year'Labor Warranty/Plus Manufactures Shingle Warranty. We may withdraw this proposal if not acce ted within 30.days. Respectfully Submitted cceptance of Proposal The above prices, specifications and conditions are satisfactory and are hereby - accepted. You are authorized to do the work-as specified.'?Payment is due in full at ,' ,• rr job completion. s Date Signature �= Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 134313 Type: Individual Expiration: 10/24/2011 Tr# 289550 DAVID SAWYER CONSTRUCTION DAVID SAWYER -- ---- 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. Address a Renewal C} Employment F-I Lost Card S-CA1 Ca 5OM-04/04-G101216 ✓fee i°a�rh�za�u�ea�/ a�✓�aaaac�iuvPlta — Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: -- Office of Consumer Affairs and Business Regulation Registration: 134313 . " 10 Park Plaza-Suite 5170 Expiration: 10/24/2011 Tr# 289550 Boston,MA 0211 Type: Individual DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. — SANDWICH,MA 02563 Undersecretary Not vah ho t sig ture G' ' la�sachu;utts- Depannlcnt of Public Safete. Board of Building Re!-,ulatiuns and Standards Construction Supervisor Specialty License License: CS SL 98859 -� Restric ted to: RF DAVID SAWYER 318 MEIGGS BACKUS ROAD SANDWICH, MA 02563 ` Expiration: 1/27/2011 (', nmu.a,ni•r Try: 98859 .k J• The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 YVashington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: -QiU�'1� �til City/State/Zip: Phone #: 3 Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.El I am a employer with ❑ 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors tam a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling `stir and have no employees These sub-contractors have g, ❑ Demolition p e workers' h employees anav working for me in any capacity. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing.repairs or additions :_.myself, [No=worke.rs' comp,.. right of exemption per MGL _.-...12. - oof,repairs . insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other 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 a new affidavit indicating such. lContractors 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 joh site information. Insurance Company Name: — Policy#or Self-ins.Lic.#: ! Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a daA against the violator. Be advised that a.copy of this statement may be forwarded to the Office of Investigations of th IA for insura r verage verification. I do hereby 4certinder the pa' s anll penalties o erjttry that the information provided above is trite and correct. signature: Dater Phone#: , Official use only. Do not write in this area, to he 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#: 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 local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,.MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of 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-contractors)name(s),address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers compensation insurance.`If an'LLC or LLP does have` employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may'be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass,gov/dia