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0091 HOLLY POINT ROAD
J .� .,. 4: 4 $ - y � .�. i �. z. 1 .. y �. tN:' - " - .� � i .. >:.. �. _ _ - .. .. e n .,. o .� ., .. 1 .. � .. � a. L � - - .. ., ,. � .> _ - a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION C . Map `. Parcel Applicatior5 V Health Division Date Issued z AM Conservation Division Application F Permit Fee Planning!Dept Date Definitive'Plan Approved by Planning Board S�ZF�lo Historic ` OKH ± = Preservation/Hyannis Project Street Address // #UO4141 Village Owner / Address ' / Telephone ®Q0 Permit Requestt7 / /� DWD M/ Square feet: 1 st floor: existing proposed _w :2n floor: existing proposed (ZE Total new t Zoning District: Flood Plain Groundwater Overlay Project Valuation ��d�' Construction Type--� Lof Size 357 Grandfathered: ❑Yes' No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure f `� Historic House: ❑Yes VNo On Old King's Highway: ❑Yes )VNo Basement Type: X Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.); 3&6` Basement Unfinished Area (sq.ft) /#6 Number of Baths: Full: existing_ new Half: existing new _ Ndmber of Bedrooms: existing K ,4�jo� Total Room Count (not including baths): existing new First Floor Room Count, _&Ar__ Heat Type and Fuel: 'AGas ❑ Oil ❑ Electric ❑ Other F14 M Central Air: )(Yes 0 No Fireplaces: Existing New D Existing wood/coal stodge: ❑Yes �J No etached garage: ❑existing ❑ new size s❑ existing ❑ new size _ P 0 existing LIJI new; size_ "� ,� =j Ir ttached garage: ❑ existing ❑ new size _ e 0 existing ❑ new size _ Other: f�*7�P -; 0 Zw. ing Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes MNo If yes, site plan review# Current Use F-esickylbal, Proposed Use ����G* APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name l Telephone Number Address �,�li�/��` �G/�� License # 5/-7 Home Improvement Contractor# l z ZWO �2s 3 Worker's Compensation # ALL ,CONSTRUCTION DEBRIS RESULTING FROM THIS PROJ CT WILL BE TAKEN TO__C� SIGNATURE DATE1tn i FOR OFFICIAL USE ONLY . }APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION 3ll0 �1 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ., '9W10 AM- DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington 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):'?Cl\) Address: EC '130< o Z q nri �A1pTiAN DR1 V'F' City/State/Zip: f>&lbt K-fl MA 02_':.:3C, Phone#: Are you an employer?Check the,appropriate bog: Type of project(required): 1.K I am a employer with cQD 4. ❑ I am a general contractor and I 6. ❑New construction art-time full full and/or .* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- ( p ) listed on the attached sheet.x 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'comp.. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[_1 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 8 R P) IL 1��C7T CT/()N Policy#or Self-ins.Lic.#: Q013 IR Expiration Date: Job Site Address: li(i 1 7" City/State/Zip:t -O�1- (/I�(�' O-2l 3 2 Attach a copy of the workers'co nsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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 under th ains and penalties of perjury that the information provided above is true nd correct Si ature: Date: Phone#: 1/,-3 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#: ilassachusett%- Department of public Safety 1 Board of Building Regulations and Standards Construction Supervisor.License License: CS, 81782 a Restricted to: 00 JASON M HOLT-CULLITY 9 BUNKER CIRCLE SANDWICH, MA 02563 Expir3.tion: 7/21/2010 Commissioner Tr#: 236 P Restricted to: 00 00- Unrestricted 1G-1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS f nOfrice o �onsumer 4ail�/sa4nusinessiegu ati 10 Park Plaza - Suite.5170 Boston,-Massachusetts 02116 Home Improvement,.Contract 'r Registration Registration: 108642 Type: Supplement Card Expiration: 8/20/2 010 BENABBY INC/ DISASTER SPECIALIST JASON CULLITY - 9 Jan-Sebastian Way Sandwich, MA 02563 Update Address and return card.Mark reason for change. Address (7 Renewal Employment Lost Card DPS-CAI er 50M-04/04-G101216 T1,, & ...1 o�/Gl«oa 1, tta 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:.... 1.p8642 10 Park Plaza-Suite 5170 Expiration ;g/20/2010 Boston,MA 02116 TypeSupplement Card BENABBY INCZ DISASTER SPEC_IALIST JASON CULLITY. Box 480 — Sandwich,MA 02563 Undersecretary of valid witho signature V'-f-S7E-g_ (fop�f Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 12/30/2009 PRODUCER (508)775-0500 FAX: (508),790-7955 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Oceanside Insurance Group ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Oceanside Insurance Agency Inc ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 52 West Main Street Hyannis MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Arbella Protection Insurance Benabby, Inc. , DBA: Disaster Specialists INSURER B:American Zurich Insurance P. 0. Box 480 INSURERC:Rockhill Insurance INSURER D: Sandwich MA 02563 INSURER E: . COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OISUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION L R :XJECT CE POLICY NUMBER. D D LIMITS ITY EACH OCCURRENCE $" 1,000,000 DAMAGE TO RENTED AL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A X MADE ❑X OCCUR 8500038944 1/1/2010 1/1/2011 MED EXP(Any one person) $ 10,000 PERSONAL BADVINJURY $ 1,000,000 t Coverage GENERAL AGGREGATE $ 2,000,000 TE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 PRO LOC Bailment Coverage 250 000 AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 A X ALL OWNED AUTOS 47018400003 1/1/2010 1/1/2011 BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-0NED AUTOS (Per accident) $ VV f PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY '. AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ 3,000,000 OCCUR CLAIMS MADE } AGGREGATE $ 3 000 000 A DEDUCTIBLE 4600038945, 1/1/2010 1/1/2011 $ X RETENTION $ 10,000 $ B WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY E R ANY PROPRIETORIPARTNERIEXECUTIVE� E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) LETTER ID#3222138 1/1/2010 1/1/2011 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHER Contractors R CPLE002420-00 11/22/09 11:/22/2010 Each Occurence 1,000,000 C Pollution Liability Aggregate 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ' AUTHORIZED REPRESENTATIVE ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. 'All rights reserved. 'INS025(200901) The ACORD name and logo are registered marks of ACORD l 03/20/2910 14;41 9413583924 STAPLES PAGE 02102 o� ToWn of Barnstable Regulatory Services AM& xhuinne X Gefler,Drrector a Building Divfis!on Tout Ferry,ftUding Commissioner 200 Main Stmat,Hye nWa,MA 02601 1'V1YW.tri{ti'n.bArg6�e1718.Rta.U.a . OtE= 508-862-4038 Fax: 508 790-62: Properly Owner Must Complete and Sign This Section I�Usu�A Bu�Xder _ as Owner of rbc subject property hereby ail, o.aze to act on my behalf, in all matters relative to work authorized by this-building peznair application for, 91 d P Address of job) o -/V Sifima—VM of Owner Date P9Ve.S J Pt7n Name - Tf PropeKtyInc is applying for penrut please complete the . Homeowners License Exemption Form on the reverse side. c�:rortMs;�wuER:pr;:raMrssloN Basement %•3. 25,7, i . Basement ROTH-RECON 5/4/2010 Page: 9 -Main Level - 26'3' 4' peg, - Bak Hall 20 4' '.._.._._...3 10' -I'll*- 3'10' t 5'7' m Down [losec fll dose[(I1 5c 11112 Bath 4.3• - - - 12'Ti 107: R Main Level ROTH-RECON 5/4/2010 Page: 10 Disaster Specialists P.O. Box 480 Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecialists.com Client: Phyllis Roth Home: (941)730-0202 Property: 91 Holly Point Centerville,MA Operator Info: Operator: JCULLITY Estimator: Jason Cullity Business: (508) 888-1113 Business: 9 Jan Sebastian Drive Sandwich,MA 02563 Type of Estimate: Reconstruction j, Date Entered: 3/19/2010 Date Assigned: Price List: CAPECODUD Restoration/Service/Remodel" Estimate: ROTH-RECON This estimate includes only the items specifically listed. f Disaster Specialists P.O.Box 480 Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecialists.com ROTH-RECON Main Level l'b Den Ceiling Height: TV _ T 560.11 SF Walls 270.53 SF Ceiling _; 830.65 SF Walls&Ceiling 270.53 SF Floor. 30.06 SY Flooring •72.67 LF Floor Perimeter 75.67 LF Ceil.Perimeter Subroom 1: Closet Ceiling Height: 7'8" 75.83 SF Walls 9.56 SF Ceiling T ra N ClOiet1 `85.39 SF Walls&.Ceiling 9.56 SF Floor 1.06 SY Flooring 9.50 LF Floor Perimeter. 12.50 LF Ceil.Perimeter Missing Wall: 1 - 310" X 6'8" Opens into Den Goes to Floor DESCRIPTION CALC QNTY Paint the ceiling-.Guaranteed coverage(similar colors) C 286.09 SF Crown molding PC 88.17 LF Paint crown molding PC 88.17 LF Batt insulation- 3 1/2" R13 1/2W 317.97 SF R&R Outlet or switch 12 12.00 EA 1/2"drywall-hung only(no tape or finish) 1/2W 317.97 SF Paneling(3/8 nantucket style bead board) W 635.94 SF Paint the paneling -Guaranteed coverage(similar colors) W 635.94 SF Window trim set(casing,stool&stop if needed) 2 2.00 EA Seal&paint wood window trim(per side) 2 2.00 EA Window trim set(casing,stool&stop if needed)-Extra Large 1 1:00 EA Window Seal&paint wood window trim (per side)-Extra Large 1 1.00 EA Window ROTH-RECON 5/4/2010 Page: 2 Disaster Specialists P.O.Box 480. �'•,'w'~ r Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspeciali sts.com CONTINUED-Den DESCRIPTION CALL QNTY Window blind-horizontal or vertical 4 4.00 EA Window blind-horizontal or vertical-Large 1 1.00 EA Cased opening(casing one both side-Closet opening 1 1.00 EA Paint cased opening(both sides incl.jamb)-Closet opening both 1 1.00 EA sides R&R Interior door-panel-pre-hung unit 1 1.00 EA R&R Door lockset-interior 1 1.00 EA Paint door and trim(per side)(interior). 2 2.00 EA Finish carpentry-(Custom cabinet built-in)-Re-build bottom of 1 1.00 EA bookshelf Paint cabinetry-full height-inside and out 6 6.00 LF Batt insulation-9 1/2 -R30 F 280.09 SF Sheathing-plywood- 1/2" CDX-(3 Layers)- F*3 840.27 SF Tile floor covering(3.per square foot material allowance) F 280.09 SF Baseboard-Colonial PF-20 62.17 LF Paint baseboard . PF 82.17 LF NOTES: ROTH-RECON 5/4/2010 Page:3 Disaster Specialists °�'--El P.O. Box 480 Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecialists.com Laundry Ceiling Height: 7'8" 1'7"F2'6"V 10' T s° 2. 1 ea`k"a'I 13 0.3 3.SF Walls 30.67 SF Ceiling " 161.00 SF Walls&Ceiling 30.67 SF Floor La�naw.'v'' - - 3.41 SY Flooring .17.00 LF Floor Perimeter 5 s 17.00 LF Ceil.Perimeter 5.7 Hall 'Staid' 1 26ath Missing Wall: 1 - 514" X 718" Opens into Back Hall Goes to Floor/Ceiling DESCRIPTION CALL QNTY Batt insulation- 3 1/2"-R13 5'9*4 23.00 SF 1/2"drywall-hung,taped, floated,ready for paint 1/2W 65.17 SF Paint the walls-Guaranteed coverage(similar colors) W 130.33 SF R&R Interior door-panel-pre-hung unit 1 1.00 EA R&R Door lockset-interior 1 1.00 EA Paint door and trim(per side)(interior) 1 1.00 EA Batt insulation-9 1/2" -R30 F 30.67 SF Sheathing-plywood- 1/2" CDX-(3 Layers)- F*3 92.00 SF Tile floor covering(3.per square foot material allowance) F 30.67 SF Baseboard-Colonial PF 17.00 LF Paint baseboard PF 17.00 LF Sand&Poly new stair/plumbing chase 2 2.00 MH Finish carpentry-(Custom stairs to hide plumbing chase) 1 1.00 EA Replace dryer outlet 1 1.00 EA Washing machine-Remove&reset 1 1.00 EA Dryer-Remove&reset 1 1.00 EA NOTES: ROTH-RECON . 5/4/2010 Page:4 Ste;ss �o1 Disaster Specialists P.O. Box 480 .� Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecia]ists.com Back Halt Ceiling Height: 8' 8" M I 230.67 ,SF Walls 47.22 SF Ceiling 277.89 SF Walls&Ceiling 47.22 SF Floor 5.25 SY Flooring . 26.00 LF Floor Perimeter fb 31.33 LF Ceil.Perimeter CD Missing Wall: 1 - 514" X 818" Opens into Laundry Goes to Floor/Ceiling DESCRIPTION CALC QNTY Batt insulation- 3 1/2" -RI 45 45.00 SF 1/2"drywall -hung,taped,floated,ready for paint 45 45.00 SF Paint the walls-Guaranteed coverage(similar colors) W 230.67 SF Door trim(casing only)(per side)-Bathroom hall side only .1 1.00 EA Paint door and trim(per side)(interior) 2 2.00 EA Sheathing-plywood- 1/2" CDX-(3 Layers)- F*3 141.67 SF Remove Additional labor to remove tile from concrete slab F 47.22 SF Tile floor covering(3.per square foot material allowance) F 47.22 SF Baseboard-Colonial PF-6 20.00 LF Paint baseboard PF-6 20.00 LF Finish carpentry-(Custom stairs to hide plumbing chase) 1 1.00 EA Sand&Poly new stair/plumbing chase 2 2.00 MH NOTES: ROTH-RECON 5/4/2010 Page: 5 Disaster Specialists P.O.Box 480 Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecialists.com Laundry Hall , - Ceiling Height: 7'8" 80.50 SF Walls 12.14 SF Ceiling 92.64.SF Walls&Ceiling 12.14 SF Floor 135 SY Flooring 10.50 LF Floor Perimeter N 10.50 LF Ceil.Perimeter Missing Wall: 1 - 3'10" X TV Opens into Exterior Goes to Floor/Ceiling Subroom 1: Closet Ceiling Height: 7'8" "H 2'3" I 75.39 SF Walls 5.75 SF Ceiling - i 11 81.14 SF Walls&Ceiling 5.75 SF Floor " 0.64 SY Flooring 9.83 LF Floor Perimeter 1 27"-i 9.83 LF Ceil.Perimeter DESCRIPTION CALC QNTY Paint door and trim(per side)(interior) 3 3.00 EA Paint cased opening(hall side only) 1 1.00 EA Touch up stain and polyurethane threshold 1. 1.00 MH Paint the walls-Guaranteed coverage(similar colors) WO 80.50 SF NOTES: ROTH-RECON 5/4/2010 Page: 6 Disaster Specialists P.O.Box 480 Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecialists.com $,9„. Stairl Ceiling Height: 8' 5 137.33 SF Walls 16.75 SF Ceiling �- HSII Stairl 2Ba 154.08 SF Walls&Ceiling 16.75 SF Floor fV 1 1.86 SY Flooring 17.17 LF Floor Perimeter 17.17 LF Ceil.Perimeter DESCRIPTION CALC QNTY 1/2 drywall-hung,taped,floated read for paint, 64 64.00 SF T�' g, p Y p Paint the walls-Guaranteed.coverage(similar colors) W 137.33 SF Door trim(casing only)(per side)- Stair side of door 1 1.00 EA. Paint door and trim(per side)(interior) 1 1.00 EA NOTES: GENERAL DESCRIPTION CALC QNTY Building permit fee 1 1.00 EA 14 yard dumpster 1 1.00 EA During and After construction cleaning(2 men 8 hours) 16 16.00 MH includes placing contents back. Plumbing Per attached sub-bid(Whiteley Plumbing)' 1 1.00 EA NOTES: ROTH-RECON 5/4/2010 Page: 7 I Disaster Specialists @�7 P.O.Box 480 Sandwich,MA 02563 508-888-1113 508-888-2951 (fax) info@disasterspecialists.com Grand Total Areas: 2,682.83 SF Walls 1,805.31 SF Ceiling 4,488.14. SF Walls and Ceiling 1,805.31 SF Floor 200.59 SY Flooring, 337.33 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall- 348.67 LF Ceil.Perimeter 1,805.31 Floor Area 1,906.28 Total Area 2,682.83 Interior Wall Area 2,060.00 Exterior Wall Area 263.00 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length . 0.00 Total Hip Length i A ROTH-RECON 5/4/2010 Page: 8 ' OF BAR\IAB RF.(.t 11.10Rt SF RN It 1� 131 II DIN(. DT\Isio N STOP W-ORK P-FI{tiTTf1 CIS j;E:ATVU;t1RPltf:��1��;& WSPECITI)11I)fIiEF()11QR f` 1.)M"I'HI>RI.'(LUL�GCnA6%1,� ORUIN CVA:HAVEBEENF TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION _ Map Parcel Application Health Division `Date Issued Conservation Division Application Fee Planning Dept; -.Permit Fee Date Definitive`Plan Approved by Planning Board Y Historic ° OKH =Preservation/ Hyannis1�oe Project Street Address Village -kilvIl ra tl Un IV. Owner �//'L /As ) Address / Telephone Permit Request nc 1 0 l k j l (/ , r Square feet: 1st floor . existing LiWrroposed `2nd floor: existing proposed N Total new Q Zoning District, ,¢ Flood Plain Groundwater Overlay Project Valuation"? Construction Type t� Lot Size J� Grandfathered: ❑Yes ❑ No If yes, attach supporting documertion. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) x a r Age of Existing Structure ` "' g g �� Historic House: ❑Yes "fit No On Old King's H':ighway: 4Xes No Basement Type: Full ❑ Crawl ❑Walkout ❑ Other -Ea Yp 1� _ Basement Finished Area(sq.ft.) /V(�/�f�� 9 Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new ® Half: existing 0 new VC3 Number of Bedrooms: existing 0 new p. Total Room Count (not including Jbaths): existing _ new jn .!' �( First Floor Room Count J c Heat Type and Fuel: � Gas ro ❑ Oil • ❑ Electric ❑Other 6-) Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes a No Detached garage: ❑ new size_Pool: ❑ new size _ Bar . ' g ❑ new size_ Attached garage:_ ❑ new size _Shed ❑ new size _ Otl {la ;J Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ;&No If yes, site plan review # Current Use RtS(ciex qc" Proposed Use �ufC,t!C r t7'I GIB \T APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name (, / Telephone Number r1o,At Address License # r°7r 112l�f C Home Improvement Contractor# /0 a ' ' , _:�Norker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Cal`( ,1116 . Y) 6SIGNATURE '� /, �� I e�C DATE i1?6�it G� • FOR OFFICIAL USE ONLY q APPLICATION# z� DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER I k DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington 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):'?,C-N AEEy,Tj"�f�fk Address: FCC '�X A45, QZ G City/State/Zip: ('YA OZ�:'� Phone Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with cQO 4. ❑ I am a general contractor and I 6. ❑New 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. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ERPALIA pEQ-TC7CT/0N Policy#or Self-ins.Lic.#: Expiration Date: / /�? Job Site Address: 91 L r'. ° '�'T i /� City/State/Zip: (a$�� Y�11 :i �,0 2�C 3 Attach a copy of the workers'co pensation 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 under t ains and penalties of perjury that the information provided above710 rue and correct certi Si ature: Date: �� Phone# '7 s 2'0%3 ll/,-3 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#: ,aco CERTIFICATE OF LIABILITY INSURANCE °A °°""") 12/30/30/2009 PRODUCER (508)775-0500 FAX: (508)790-7955 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Oceanside Insurance Group ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Oceanside Insurance Agency Inc ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 52 West Main Street Hyannis MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Arbella Protection Insurance Benabby, Inc. , DBA: Disaster Specialists INSURER B:American Zurich Insurance P. O. Box 480 INSURERC:Rockhill Insurance INSURER D: SandWiC MA 02563 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE.ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OISUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION LTRN INSURANCE- POLICY NUMBER — DATE(MMIDDNYY)n DATE IMM/DDfYYYYI LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A X CLAIMS MADE �X OCCUR 8500038944 1/1/2010 1/l/2011 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 X Bailment Coverage GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 LOC PRO Bailment Coverage 7X POLICY 250 000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 A X ALL OWNED AUTOS 47018400003 1/1/2010 1/1/2011 BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ 3,000,000 OCCUR Fx—]CLAIMS MADE AGGREGATE $ 3,000,000 $ A DEDUCTIBLE 41600038945 1/1/2010 1/1/2011 $ X RETENTION $ 10,000 $ B_ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY I ER ANY PROPRIETOR/PARTNERIEXECUTIVE I E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Lj (Mandatory In NH) LETTER ID#3222138 1/1/2010 1/1/2011 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 U yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHERContractorS R CPLE002420-00 11/22/09 11/22/2010 Each occurence 1,000,000 C Pollution Liability Aggregate 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL,10 DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD Massachusetts- Department of Public Board of Building Regulations and Standards Construction Supervisor License License: CS 81782 Restricted to: 00 JASON M HOLT-CULLITY 9 BUNKER CIRCLE SANDWICH, MA 02563 Expiration: 1/2112010 (' nuui..incr Tr#: 236 Restricted to: 00 00- Unrestricted 1G-1 2 Family Homes Failure to possess a current edition of the... Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS I i n umer Affai s an usiness e u anon 0 ce o o s g 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement,.Contractor Registration Registration: 108642 7'-- — 3 i Type: Supplement Card Expiration: 8/20/2010 BENABBY INC/ DISASTER SPECIALIST,_ _, JASON CULLITY 9 Jan-Sebastian Way — h Sandwich, MA 02563 Update Address and return card.Mark reason for change. - Address 0 Renewal ❑ Employment ❑ Lost Card OPS-CAI 0 50M-04/04G101216 ✓/ie -C�am�nzaruuea� o�✓�aaoaclucaella 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: ;.108642 10 Park Plaza-Suite 5170 Expiratron -g/20l2010 Boston,MA 02116 Type Supplement Card BENABBY INCkIDISASTER°:SFECIALIST JASON CULLITY Box 480 g —. Sandwich,MA 02563 Undersecretary of valid witho signature ���sr> cod y 03/20/2010 14:41 9413583924 STAPLES PAGE 02/02 ToWn of Barnstable Regulatory Serykes nw�e Tho&A9 F,C.eiler,Drrector Building Division p�A Tom Ferry,Building Commissioner 200 Main street,Hymda,MA 02601 vvvvw.town,bnrostable.ma.ua Of ca: 509-862-4038 Fax: 508 790-62.; ProperL7 Owner Must Complete and Sign This Section xf�C75ln g A'Builder as Owner of the subject property here an o.dze �' _ _ to act on mybclialf, in all rrratters relative to work authorxz..ed by this-bi ilding permit application for, 91 pel�d P P Addriess of J'ob) ,�, Z::2210 Sikna of Owner Date P#V Prin Name If Pro e Owxaer is applying for pernrut please complete the Homeowners Licerise Exemption Fon-n on the reverse side. (rFORMS;oWid$R1'F'R.MiSS10N - i 03YI312010 10:45 9413583924 STAPLES PAGE 01/01 .r: We make rdesalftrs disappear. Disaster Specialists Professional Restoration Assignment and Authorization to Pay The undersigned herein called claimant,has authorized and ordered from Disaster Specialists, the materials and/or services as agreed upon.This agreement shall not be considered a release and/or proof of loss. Claimant hereby assigns to Disaster Specialists any unpaid proceeds due or to become due, under claimant's policy with the insurance company to pay direct to Disaster Specialists or to include Disaster Specialists'name on check or draft. In the event that Disaster Specialists'claim herein is not covered by,or paid by,insurance company,claimant agrees to pay Disaster Specialists within sixty(60)days after work has been completed. Claimant understands that Disaster Specialists is working forthem and not the insurance company or the adjuster. Payments remaining due and payable after claimant has received payment from the insurance company shall bear interest at a rate of one and one-half(1-1/2%)percent per month. In the event of breach by claimant of any of the conditions of this agreement,Disaster Specialist,shall be entitled to recover,as additional damages,attorney's fees.costs and other collection expenses reasonably attributable to said breach.If payment is not received within 60 days,collection action will commence without further notice to claimant � 13-/0 Date Claiman s Signature Disaster Specialists-PO.Box 480•Sandwich,Massachusetts 02563 508-888-1113.800-675-3622-FAX:508-888-2951 -info@disasterspecialists.com Main Level H m . 41 40110dOC � 20.4° 3'7` 10'— 1'11'—'/ —3'10° 5'7" cw.e�tit kt Dawn Llorset_lil Ud S[Ntl - 1L28nth , 4'3` �—2'7' - rrJ Maim Leve! ROTH-EMG 3/19/2010 Pagel Main Level 3t 3° 9e to m H 1011640E 20'4• T 7' llvet.ell Down . ry - Clniet.LU Ufa St001 1I20ath . - i 2'7' S C� Main Love; ROTH-EMG 3/19/2010 Page: 1 1 , Main Level 31'3' —� 25'3° 4' Buk Hall 6 1810lmL � 1'4' cue[(1) m Dawn [IvlseLfil Wd Steltl 1129ath. 4'3' .. 2'7'--I i 10'7' —� C�J Main Level ROTH-EMG 3/19/2010 Pagel Main Level V3" H to t` H m 3'7'— —10'— 1'1I'—/ 710'— Cl..t cu m Dawn 4 3" —i 10'7"— • h7 Tr Main Level ROTH-EKG 3/19/2010 Pagel Main Level t "' - y Ea [Io•et t» to ,Down Sr Main Level ROTH-EMG 3/19/2010 Pagel Town of Barnstable *Perrn1t#,20Z,> 9j 7 Expires 6 months from issue date Regulatory Services Fee C2 — �// Thomas F.Geiler,Director t(C— L Building Division U Tom Perry,CBO, Building Commissioner RMI 200 Main Street,Hyannis,MA 02601 -PRESS www.town.barnstable.ma.us 22 Office: 508-862-4038 ax: 5h 790-62230 EXPRESS PERMIT APPLICATION - IRESIDENTIALWA4OF BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Numberi� Property Address 91 011S 0I-& " dR, esidential Value of Work I�t7/ Minimum fee of$25.00 for work under$6000.00 + ° Owner's Name&Address P a �f1e t ti Urawer n�PL 91vw Contractor's Name��1 - Z1 � �L�C Telephone Number gO 1 C?3s Home Improvement Contractor License#(if applicable) �. � Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑/Ih m the Homeowner ave Worker's Compensation Insurance 1 Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. P Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [/Replacement Windows. U-Value_ °J (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. H e In]pTovejhent Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 -nuuut;aH THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY No CONFERS MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE ATTN:BRENDA BOOKER (404)995-2594 POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVr;RACE MAYA MCCLURE(404)995-3206 OR AFFORDED EY THE POLICIES DESCRIBED HEREIN. TA,MI ROUSE(404)995-3430 FAX(404)760-5663 _ 3475 PIEDMONT ROAD,SUITE 1200. COMPANIES AFFORDING COVERAGE _ ' ATLANTA,GA 30305 CCAIPANY }0'492-IPUSA-GWA-03/04 A STEADFt,ST INSURANCE COWIPriNY HSUR£0 ; I CCMFA;lY THD AT-HOME ?VICES INC. 8 ZURICH A':'IER!CA'N ii°"URANCE C(_%,!PA,*lY DBA THE:HOME :,c?OTAT-}iCME SERVICES,ING, _ HOME DE PCT L15 INC. CCMP'�• - 2455 PAC_:S FE R`.'ROAD MN C NE'•I`• 2'ANIFSI-IIP�R•C COMPANY BUILDING -13 r— ATLANTA.GA 203.1.1 __ :��— .-_..._-0 •---AM(:?IGA;iHO(vi •:�SSI;R,gNCJ CC)P:„ANY---_.---._ 2OVER::GES This cer i ::ate supersedes.and replacea any pre* iouSly issued Ceriifica(e`er the pclicy`period pr ::d below.: 3,TF115 :5 TO CERTFV THA- 'CLIClES OF INSURANCE DEflC?tBED HEREIN»AVE BEEN ISS%;ED TO THE INSURED NAMED HEREIN FOR THE-P(A.,' •/ PERICO INOICATZ:, NC%'NRHSTANO,NG ANY RECUIREMENT•TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE-CERTIFfCAT= BAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO.ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATF LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION .TR DATE(MMIODIYY) DATE(MWDD/Yl') UMITS q GENERAL uAeuiTY IPR 3757 608-01 03/01/06 03/01/07 X COMMERCIAL GENERAL Luellen 'LIMITS OF POLICY ARE EXCESS- GENERAL AGGREGATE $ 4,000"MPRooucrs•coMProP AGG $ 4,000,Ot CLAIMS MADE Q OCCUR *OF SIR:$1,000,000 PER OCC° PERSONAL&ADV INJURY $ 4,000,0( OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,0C E DAMAGE A one Rra) $ 11000.0( MED EXP(A one person) $ EXCLUDE 3 AUTOMOBILE LIABILITY BAP 2938863-03 AOS 03/01/06 0 3/0 1 7 X ANY AUTO COMBINED SINGLE LIMIT $ 1,000,0E ' ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Par Damon) HIRED AUTOS BODILY INJURY AX NON-OWNED AUTOS (P�sraedclant) $ ELF-INSURED AUTO PHYSICAL DAMAGE PROPERTY DAMAGE $ GARAGE UARIUTY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH AC (DENT $ �� EXCESS LIABILITY AGGREGATE $ EACH OCCURRENCE $ �— UMBRELLAFORM AGGREGATE OTHER THAN UMBRELLA FORM S WORKERS COk1P SATID AND 6610998(AZ,ID,MD,VA) w 15MFLOYERS'LUIBIUTY 03/01/06 03/01/07 X TORYLIMITS 6610995(AIDS) 03/01/06 03/01/07 EL EACH ACCIDENT $ 1,000,00 THE PROPRIETOR X INcL 6611326(OR) 03/01/06 03/01/07 PARTNERS/EXECUTIVE 6610999 BdY,VY! ELOMEASE-PoLiCYLIMIT $ 1,000,00, OFFICERS ARE: EXCL ( ) 03/01/06 03/01/07 EL DISEASE-EACH EMPLOYEE $ 1,000,001 G H WORKERS �. _ COMPENSATION CONTINUED 6610997(FL) 03l01/06 A 03101I07 6610996(CA) 103101/06 03/01/07 IESCRIPTION OF OPERATIONSILOCATIONSIVEHICLCSISPECIAL ITEMS ERTtFICATEHOLtJEt$ N` j DELI � I[l )a{P71(J �lr-i TrAtNCELLATI(IPt+...,....�, SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELBED BEFORE THE EXPIRATION DATE THEREIN THE INSURER AFFOROWG COVERAGE WILL ENDEAVOR TO MAIL�-10 DAYS WRR'TEN NOTICE TO TH FOR INSURANCE PURPOSES ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE Me OBUOATIOH 0 UABLI Y OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR TH: ISSUER OF THIS CERTIFICATE. MARSH USA INC. av Walter Gilgtrap VALID AS OF:;02l2T/O6 .,. ., L c,:`r",. .,.. <..; .�. �., mil•:Dfi �'......Z ,..- .c�.3 i.bf.."`� � s.I.tea��fix ti,�y...r t t .5 5 \ - - 1 CM NFIC Male! y.� ~I .. ...... t�Oud ENERGY PERFORMANCE RATINGS U-Factor(U.SJhP) Solar Heat Gain Coefficient ADDITIONAL PERFORMANCE RATINGS Visible Transmittance �i . 4f WIN �fat�ufeehnerstlpul�eslhatthese ratln0econrarmtoappWie NMCpmeedumf0detenniningMate prodrretperbmlance.NMC raftp are determined forafixed setot emlmnmentel cand'ittonei and a epecNlepraductslze.Consuttmanutacturereltteraturefer other pmdudperfomumce tnformat en. wwwrdre•org :!r•it ryueiifi�3:5 for, Energy S.ar. C ntr.xl. South ContreL, ..� s>>u.her r. O I!f . . �: 51 Si: �i•i X h�� '+.—....-,•y-.-.......—'S.l:J1J 11I1.L � 4'_1:lL 1:l•+ ' o� ./��jidm/j)j(yN.L(lEG� O�a./�LRGa(lGIUOf.I.(O S Board of Building Regulations alyd Siand rds 1{ HOME IMPROVEMENT CON'fP,ACTCIc. � 2 CC) Registration: ,1268y� 1 Expirati �'nt Typ.. rd i THE Home Depot At-Home Servic RI•CHARD FALLCNE 3200 CC©B GALLcRIP,PKWY 20 i��•�;—,r`�r�r rw•� ALTANTA,GA 30339 Administrator The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician/Plumbers Applicant Information ]Please Print Legibly Name (Business/organizationadividual): Address: City/State/Zip: • f4+6y,'r,. eGk .W900 Phone#: i9D &5� 51 4&P_ Are yy�t an employer? Check the-appropriate bog: Type of project(required): Ell I am a employer with 4• ❑ I am a general contractor and I 6. ❑New 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. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have & ❑ Demolition working for mein any capacity. workers' comp,insurance. g, ❑ Building addition [No workers' comp.insurance 5; ❑ We are a corporation and its required.] officers have exercised their 10.❑ Blectrical repairs oa additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs oT additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ R of repairs n insurance required.] t . employees.[No workers' 13.[Other_ Y7d/Du� 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 summit a new affidavit indicating such :Contractors that check this box must attached an additional sheet showing the name of the sub-eontradtors and their workers'comp,policy information. I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and,yob site Information. Inslu•ance Company Name: t�lP„7 t7�uM �,re Policy#or Self-ins.Lic. #: (�4e i DQ J` Expiration Date: Job Site Address: f[fj IV b,V,+ City/State/Zip: if lo"�u 1-L Attach a copy of the workers' compensation policy declaration page(showing the policy number and exp.ia•ation 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$1,50Q.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a flue 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. 1 d®hereby certify un the pain an penalties of perjury that the information provided above is true and correct Signature: 4 Date: Lliv!0 Phone#: Official use only. Do not write in this area,to be completed by city or town offaciaL City or Town: Permit/License# , Issuing Authority (circle one): 1.Board of He&h 3.Building Departmerut 3.City/Town Cleric 4.Electrical Inspector 5.P'lumbinc,la3spe&tor 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,.offal 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 bean 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 permft 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 ofpublic 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 numbers)along with their certificates) 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 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 eater 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 permit4icense 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. Anew affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (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 Ue 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. t 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 WWW.mzss.gov/vita aFISE r Town of Barnstable Regulatory Services $a .MASS a Thomas F.Geiler,Director y mass. � 639. a Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstabl e.m a.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner bust Complete and Sign This Section If Using ABuilder I, 964ri e- ,as Owner of the subject property hereby authorize 1 Gyl�.�('GY f ID►7�'- to act on my behalf, in all matters relative to work authorized by this building pemut application for, f H011V P1-)1-0±26Q (Address of Job) Signature of Owner Date , Print Name Q TORM&OWNERPERMISSION THE TOWN OF BARNSTABLE BUILDING INSPECTOR TYPE OF CONST 'RUCTION ....../°A^.(lP.......................................................................................... ..................... .. --.J�--.,.......l�./��� TO THE INSPECTOR OF BUILDINGS: The undersigned 6ore6v applies for o permit according to the following information: Location --�� /--' ~/ _ �!��-- ^� � . � ���~.��.&/.L/ /--. —.. /__�>c�. . — / | Use ��� �� � , - r,opo�op —'�v:��^^.��^�/^..^.��.,... —'���^^.=�,�.---------.-------.---.---'--------. Zoning District -----------.----.-------'Rnu District ..vr.' ' Name ofOwner �� 4� ---'A66,ex ....."ty_ ~ / . ��—/.. ........................... Nome of Builder 4/J.`1RAd6reus ................. .' . .......................... Nome of Architect ----------------------.A6dres -----------------'----------.. Number of Rooms .........../.....................................................Foundation /'�>....... « —��_ .� Emehor —�A/��'����77.. --------Aoofi»g — � - ~ /�� --------------.--.— ' Floors ....xi.��.,y..... E 4�-----------------.]nterior ---J--' ............................................................. Heo�iHeating � ng --'``,�/���.���-----------------'F1umbng --.-«.x' � Fireplace --. 'to --------------'Approximate Co� '�—.�� ^�'{�h[�.r..�~�__.. �__. Definitive F1on Approved by Planning Board lQ----, Area --./����,�----'.-- �^» //�^� Diagram of � and Building with Dimensions Fee ----.(�!��—'-----' SUBJECT TO APPROVAL OF BOARD OF HEALTHoerk ' New 1100 ' ' | OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS F CT-- , ' | 6o,e6y agree to conform to all the Rules and Regulations of the Town of.Barnstable construction. ' Nome ' Construction Supervisor's License ...... | / ^ LEVY, MR. & MRG, ' A=352-135 No ... Permit for .�UQIMJI)N----. ........*agle...EamiIy...DuoaIl' ............. Location ......9l—BoIlv...p p in+. ........ ' - ..................... ............................. Ovvne, ........88�:...k.A�P.t...Levy.------ ' Type of Construction —�ra�e------,------. . ' --------------------------. Plot ............................ Lot ----------' - ' Permit G,onuy] —.MY... .......................lV 85 Dote of Inspection ------------lP ' Date Completed ------------'lP ` . v*� ' . . ^ ' . . _ ' . . . . . . - ' N 0� Assessor's. map and lot number`. .'. . SEPTIC SYSTEM MUST BE _IAI� Q..°`THE INSTALLED IN COMP Tory S�,Alaye'Permit number .......:............ ZS........... /ITI'I TITLEd� .. ENVIRONAVI'ENTALCO`��' t .2. BAHH4T4DLE, Housenumber ....... ............:..............................+................ e 1639 rt �fp YPY a\ TOWN ' OF BARNSTABLE R.UILDIHG INSPECTOR APPLICATION FOR PERMIT TO .. �N.. .t./. �C.T-....!�d.�X. .c��.....J�IC/2 reN1...%.c?.h ................... TYPEOF CONSTRUCTION ...... OO.���................................................................................................................ ...... .....................19.& TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ,�/ / �+ / Location ......��.r..�........1./.Bl<. ..... /./ .T... . ...../.4.e�11Tt.l ..V..t../L. ....`...../. :......®. .2�.���� ... .4' ?.�eN '�o Proposed Use ...... .... ....... .... .....(�.....l�.....(,2e.s..).................................................................................................. Zoning District ........................................................................Fire District ...C C. A T PIZ .dho......Q,FZ Rz�lf..Cl/ Name of Owner /././.��. !/l 5.... ..V. ..................Address ....../. ... ��1/ ... ti.. 4 .r........................... Name of Builder j...... .. ........�/li.......... � Nameof Architect ...........................................................:......Address .................................................................................... Number of Rooms ..........f....................................................Foundation 0?..... ...�.... Exterior ....will:Te..Co.t7 ..........................Roofing ... S. i1.l.f.. ..................................................... Floors ....1.x.Y....../...t.JR................v....................................Interior ....... ........................................ ................. Heating ........ ......................................................Plumbing .......N.P./.U.. ..................................................... Fireplace ......../ .D.-N...e.........................................:............Approximate. Cost .........�/.��o.�..�:©............ .. ....... Definitive Plan Approved by Planning Board ________________________________19________ . Area .......l.�.�..................... ..Diagram of Lot and Building with Dimensions Fee /............... .............. SUBJECT TO APPROVAL OF BOARD OF HEALTH ?9iu'k De �- -� /Vew Aix td j0. 14°v s a 3 a�r ANkfo� rGhPlv sj, ,k4 , AuivD2 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS S72 F C7— I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. P(a. .1 Name 2jj .. . .. . .... ..... Construction Supervisor's License ®.. ..�.. ....... \/ ADDITION No2FAB.6/z....-Permit for ....................................Eii : �aoIv Dvvell ' ng ' ---.--.. d' `----.--~-------_---. - . . . - ^ ' `^.^..on 9-1—Bo—l-.l..v—P—intRoad---^ — ------- ...................... ............................................ . {�vvnar —A-K:—.�-8���:—���!��—.-----. Type of Construction ....7X4W......................... ^ - ---------.- ---------------.. Plot ............................. �� ----------.. Permit Granted May 9[ � lV DS ------' ---.�—'� , . � Date of Inspection ---------�:--.]P ' �/�' Date Completed .����------'»~ _-lg�= ' - ' - . � . ' ^ ^ ^ , ~ . | Assessor's map and lot number 1.�?. � '�',2Z 7 THE Sewage' Permit number SEPTIC, �SYS M (/ INSTALLED IN TanLE, i House number W1TM TITLE 6 rya 1............................................................ + 1639. ENVIRONMENTAL CODE TOWN OF BARNSTAOMLATIONS BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..G' ieA � 7 .s' ...CO 015 .222...F.�4/j?/..�Yr�° TYPEOF CONSTRUCTION ..................................................................................................................................... AY....f;K� ...........,9. 9 TO THE INSPECTOR OF BUILDINGS: i The undersigned hereby applies for a permit according to the following information: Location9,l !l� y �,v�-.�o......C !(1 ��1Pvl /...�r7'r................................................ .... .. ...... ................................ ProposedUse ..... -q/.1lrL.Y.e< ........................................................................................................................... Zoning District ..,�:`�,�(�..Z ....................Fire District .. /vT f � ...�.1,.fT�r . .................................... .... ..... Name of Owner AAA-1/.P .....e'Y.e l4................Address Name of Builder C....rlJ..... ...................Address rBQIY ................................ fJIV.f -....azeco ....... Name of Architect -t .....r!r,�.l.F.�..�/71.�. .................Address ...St4e5� .............................................�.......�.............. Number of Rooms .....0 ........r-Z—)..........................Foundation .... ............... . ......... Exterior .. /q!e......S.11111)63 X..65 .1�1A.IP Roofing A011,40. . ... Floors ... .......................................................Interior .................................................................................... Heating /l�QT... rlt��TE. ........c* ... 45..................Plumbing "WC.....Oe%lo: 72Z..,X V.110.7.A.�TeEPe.ft�f�41r Fireplace ...AVOWX..............................................................Approximate Cost ..,a�j Q.Q............ ............ . ... . . .. ..rr dd .::.. Definitive Plan Approved by Planning Board ------------19 Area 44.(.f. � G - ----- ----. ....... Diagram of Lot and Building with Dimensions 0 Fee ..............I............................ SUBJECT TO APPROVAL OF BOARD OF HEALTH ddp �D4 140 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable re ding the above construction. Nae . .... . ............. Alper, Darlane A=252-125 No ...... Permit for ..Remodel.JGarage... ..................................................................... Location ....91....Holly..Point-Rd.................... ............CeMte=iiie.......................................... Owner ...Darlane.-Alper................................. Type of Construction .......................................... ............................................................................... Plot ............................ Lot ................................ Permit Granted .......May..22...................19 79 Date of Inspection ....................................19 Date Completed .......... ...............19 PERMIT REFUSED fn ........ ...................................... 19 ............................................... ............................................... M 7. ............................................... M Appr ...... ...................... 19 0 1`0 ***...*'******** ............................................................................... ............................................................................... Assessors ma and lot number � �=.......f^-�:•.....yr��� �2' F�E T ._ p .....-...... Quo o�y Sewage'Permit number .....� e.. ...........0 ABLE. House number .....w«"7 i .d' , NAM a .................................................................... '°0 �9 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ............................................................................................................................ TYPEOF CONSTRUCTION ..................................................................................................................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: %ocation .. .... 7�'.tll. .............4r��'�t.�f���'�/.',�!� •,./`/'7�� �.....:... ProposedUse � "l.Y. '®c?,rr1.........................:..........................................................................................:...... Zoning District ... :........................................................Fire District ........................ ............. Name of Owner ...............Address 9/ ,! �J %:.. s� ::...CF1(J7�c'�c?l//e l•;�?�1�, Name of Builder C..,�.��d.... , %5��r />%la ...................Address :r.................................................. i( Name of Architect re.e..... 'F/S %.�%llf/.................Address .... ................................................................... ` Number of Rooms (-)A/,L= ........ ..........................Foundation.............. ................................................... ................... Exterior !`";1 ......:��,f��i(1 Z -E..(,�7.)Roofing Aj;'t ....... ..... Floors ... ......................................................Interior .................................................................................... Heating ...1510 ,/./,ll ,G" .......IeK... .. ..........Plumbing .: 1!��.?F• GTl� i .i'.��'AN.��OT; / T t?/rf 4T Fireplace ... ? `^..... .......................................................Approximate Cost,.010 2.......................... Definitive Plan Approved by Planning Board -----------__________________19 Area ......................................... Diagram of Lot and Building with Dimensions Fee .....................:....................... ' - SUBJECT TO APPROVAL OF BOARD OF HEALTH .ter ti I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name......... Alper, Darlane A=252-125 No .... Permit for Remodel..G�ge---.- ............................................................................... Location ..91-Hally-Poiat-Rd........................ ............................................... Owner ..........Darlane-Alper........................... Type of Construction ................................ ............................................................................... Plot ............................ Lot� ... ......... Permit Granted ................May.....2-2........1979 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ....................... ......... 19 .. .................................. .......... ........................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... .............................................................................. yo�THEro�y TOWN OF BARNSTABLE S . i H6SBSTULE, i ° "6 q 0 MAXa BUILDING INSPECTOR �F APPLICATION FOR PERMIT TYPE OF CONSTRUCTION ......11/ ..... ..... ....... C......................................:........................................ o�r.. .19..70 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..104af '6............... 1� L11� t��/.�1!T.... .I.......... .�t�T..�.r4�y� 'f0 . ...................... ProposedUse ......... V440W—.404110.4,.................................................................................................................................. Zoning District ............:...........................................................Fire District Name of Owner ..../7,r�J, ....RdV, ....00440V........Address ..../..11q..A0..AGI!4 JX- Name of Builder .../ .....l v..... .. ................Address ....J�t�.'.!�d�!..,�.�........... f.......... Name of Architect.6.14r .... 4 '/S�T�.�r................Address .......jr,&.."4104....OA.........0-M2 !�/y Number of Rooms ................v..............................................Foundation ........GO.W..CAlf ................................... Exterior .......r.ISI/ �iL4�........................Roofing ........00P..A!VO4A'V........J4&eW..W.Ar. Floors ....................0.4...A�-.....................................................Interior .............7.! .44.4.w........................................... Heating ..........A.P.4-cf0....IjAr....4aJ17.45.4...............Plumbing .............. *Q- I#..WVX....................................... Fireplace ................0W.tr...................................................Approximate Cost ...........�.�JQfy.fJ................... ................. Difinitive Plan Approved by Planning Board ______ -------------- Diagram _ . of Lot and Building with Dimensions / ®� g X r Ld CL w 76 �� W; ® 0 r o M ¢ O n� � IJ, �' p V �^ . N ® 0 O R I �O O ? D < � w 9�aqR LU CL 0 a^ w tom. �z6 < Kc LU hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . / .. ` a/ " a 'qv' Mar Realty Corp. D �r t_1971 No-..13�r18.... Permit for ...... One story........ ... single family...........dwelling ................................... Location Point Road ........................ Centerville ............................................................................... Owner .........Mar..Real. ty..Corp. ... .... ...... .. ................................ Type of Construction frame .......................................... ................................................................................ Plot ........... Lot ...... 6.................. Permit Granted .....N ember„ 0..... .....19 70 Date of Inspection .........19 71 z. Date Completed ......................................19 7� PERMIT REFUSED ................................................................ 19 r ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ...............................................................................