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0012 JUSTICE DOUGLAS WAY
l v� ,Tip <<eo 14ts ° o y e s E e . s ,. Town of Barn __ ob and stableBuilding i __ t Post This Card So That it is Visible From;the Street:-Approved"Plans Must be.Retained on Jah�s Card Must be Kept ewres»raru e b39- � Posted Until Final Inspection Has Been Made. ' tWhere a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final,1nspection has-been made. Permit, Permit NO. B-19-424 Applicant Name: Richard Tupper Approvals Date Issued: 02/08/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 08/08/2019 Foundation: Location: 12 JUSTICE DOUGLAS WAY,CENTERVILLE' Map/Lot 191-190 Zoning District: RC Sheathing: Owner on Record: DRANETZ,ANITA D TR Contractor Name", Richard S Tupper Framing: 1 Address: 12 JUSTICE DOUGLAS WAY Contractor License: CS=069058 2 CENTERVILLE, MA 02632 rt"'° :Est. ProjectCost: $3,872.00 Chimney: Description: . Air sealing,weatherstripping door,add glon to door sweep, install Permit Fee: $85.00 Insulation: open R-37 cellulose in attic, install 2" rigid board to common wall, f . Fee Paid:.'! $85.00 install R-38 fiberglass in attic, install R19 FG batt to basement k final 4 sills,install soffit vents and ventilation chutes,seal and insulate attic Date: 2/8/2019 hatch. Plumbing/Gas Project Review Re : L—' Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after'issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures,shall be in compliance with the local zoning by-laws and codes. . Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for'public inspection for the entire duration of the work until the completion of the same. �' Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this,permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing h: 2.Sheathing Inspection — --� -- -- "" � Rou g 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low.Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department ' Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 0 N I'm 0 t£ rz.v�.1-�-L s rt r 09 2019 1032AM Tupper Construction Co, 15087785010 page 1 y 191�� jj>g3jTUPPER CONSTRUCTION CO. t_1-C 546A Higgins Crowell Rd,WEST YARMOUTH,MA 02673 PHONE: 508-778-o111 FAX: 508-778-5010 , EMAIL:admin@tupperco.com —4 5 t D T 4 Date: [—Jl. Ile) -0 PP Town of Barnstable Building Inspector ' 200 Main Street Hyannis, MA 02601 (508) 790-6230 fax Re: Insulation Perrr it at Permit # ' ( � 'L� c Issued On --� This affidavit is to certify that all work completed for the above permit application has bee i inspected by a certified Building Performance Institute (BPI) inspector. AI work performed meets or exceeds Federal and State requirements. Sincerely, Richard Tupper License # CS-6905 r - . 7 �n+e rq Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee s , sarnvsTAMr. MAW t639. Richard V.Scali,Director 16 oME ��' Building DiN s on Tom Perry,CBO,Building Commissioner JUL 27 2015 200 Main street,Hyannis,MA 02601 TOWN OF gARaUSTABLE rnstabl e.ma.us Office: 508-862-4038 www.town.ba Fax: 508-790-6230 EXPRESS PERMIT APPLIO T10N RESTDE?!TIA-1 ONLY Not Valid without Red X-Press Imprint Map/parcel Number 7 Property Address 1 Residential Value of Work$ '52M Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address tJ�,l. ,i(f el --C)0 ( L)aq aA-it e^v I 1 e YY--)q Contractor's Name)RUD )6 M6M Telephone Number / J '22p7 5OW Home improvement Contractor License'#(if applkt b`le) �OlV��� Emit Construction Supervisor's License#(if applicable) (Do f 3) V Workman's Compensation Insurance Check one: LU i am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name �L kc& t&akw�m (I'd ` -ns . Workman's Comp.Policy# �""P 1S r) b Copy of insurance Compliance Certificate must accompany eilch 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) Reside Replacement Windows/doors/sliders:U-Value ar—t (maximum.32)#of windows #of doors: _ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. Where required: Issuance of this permit does not exempt compliance with other town department regulations,,i.e.Historic,Conservation,etc. *Note: Property Owner must sign Property Owner Letter of-Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\Decollik\AppData\LocalMerosoft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doe Revriscd 040215 M y t 04� * BARNSPABIX + MASS. i639. Town of Barnstable A�� fp MA'S Richard V.Scali,Director Building Division Thomas Perry,CBD Building Commissioner 200 Ivtauc SUvM yarinis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using X Builder UI-a"J-Z , as Owner of the subject property hereby authorize AkA Kagozym to act on my behalf, in all matters relative to work authorized by this building peirnit application for: I Tus hc' e�- T hu Otiq 0 w4v'V N4 (Address of Job) l 5f Signature of Owner ate Print Name ju rrope�ty owner is applying for permit,please complete the iiouneow[►ers License Exemption Form on the reverse side. C.XtJsmEftoi iklAppDataV ncallMicm.sof31WmdowcV'emporarylntmwlFileslContmt.ing mkl2PIOlDHK1M, TRFSS.dpe Revised 040215 Massachusetts-Department of Public.Safety 'Board of Building Regulations and Standards Cut"tritction Supervisor License;CS470131 ALLEN P IC4f W$ 311 N Fl3ADI"Snv—uf ~= HOLBROOK to" „' ",O) 7� VV Expiratc'n - a. commissioner I �_:. .. �j,n�.77r7SIJJ,u1lYiL/�C�nlLaIJUC�u.inCfJ;� .... �. Officebf Consumer Affairs&Business RegttlfttOp OME IMPROVEMENT CONTRACTOR gistration 125121 7Yie,, Expiration 10/15/2015. Individual_ ALLEN.KAPSON d (c ALLEN KgPSON r . �+ 311 NORTH Fi2ANKLIN ST ,HOLBROOK,MA'02343 t,ndP ex eta ''; y lI - I _ r s - ALCOR DATE(MMIDONYYY) . �./ CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER:THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE.A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATI:HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain poticles may require arisndorsement A staternent on this Certifiea does-Rlat tonfer rights to the certificate holder in lieu of such ondorsemsnt(s). PRODUCER - -CONTACT Nora Cadman .. Dowling Insurance Agency, Inc PHONE (781)fl48-7652 FAX (AIL.No:(781)380-8783 44 Adams Street AppgEss�.ncadman@dowlingins.com P.O. i307[ 85{)962 INSURE S AFFORDING COVERAGE- - NAIC• Braintree MA 02185-0962 INSURERA.-UUtica Mutual Insurance Co. 5326 INSURED - .. .-... .-. Kapson Home Improvement - , INSURER.0:. - 311 North Franklin St - INSURERD.; INSURER E - - Holbrook MA 02343 INSURER F: COVERAGES CERTIFICATE NUMBER-Yong Wang REVISION NUMBE,!: 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.tMTH.fi SFECT TO t':gitCW THISCERTIFICATE 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. i;INS. TYPE OF INSURANCE - POL Y F :P000YEXP - 91)UCYYi1)MHER, __.� M MMIDDIYYYY UNITS GENERAL LIABILITY -. .. EACH OCCURRENCE §., COMMERCIAL GENERAL LIABILITY DAM 0 RENTED - CLAIMS-MADE ®OCCUR MED EXP.(Arty one per S .PERSONAL&ADV INK Y y GENERAL AGGREGATt GEN'L.AGGREGATE UNIT APPLIES.PER: PRODUCTS•COMP/ORAGG § POLICY.f_j PRO- Lam.. S .. AUTOMOBILE LIABILITY BIND I LELIM,i - Eaeaiaeln -. . . ANY AUTO 80DILYINJURY(Peep,. ,n) '§.. ALL OWNED SCHEDULED - AUTOS ALTOS - BODILY INJURY(Per.a: —1) - - HIRED AUTOS NON-OWNED AUTOS • PROPERTY DAMAGE - Per § UMBRELLA UAB OCCUR EACH.00CURRENCE E - E)tCEBS L1A$ ... - CLAIMS-MADE - AGGREGATE § ED R ENTI N S _ § WORKERS COMPENSATION .. AND EMPLOYERS'LIABILITY YIN X - ANY PROPRIETOR/PARTNERIE(ECUTIVE E.L.EACH ACCIDENT S .$OQ OOO OFFICEWMEMSER EXCLUDED? NIA (MandatoryJnMR) 48178.3, 1/22/„2934 1/22✓•.2015;•E:L.OISPASE-,•EA.EMi. rE § Ba0 j100 If yes.6SWbe Iu1E6r DESCRIPTION OF OPERATIONS belaw E.L..DISEASE-POLICY "!IT S. $OD DUD DESCRIPTION Of OPERATIONS I LOLA11ONS tVINIC119 IANaeh ACORD-1K AGCItlonal Repyrb 8che0uh,B more space is required) ....... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES'.: CANCELLED BEFORE THE-EXPIRATION DATE THEREOF, NOTICE V,,'";. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTNORDSEDREPRESENTATIVE - - ai Paul Dowling/NORA � <- ACORD 26(2010/05) 01988-20 3 ACORD CORPORA!!: All rights reserved.. INS025 r7nlno 1 m Tho a(,npn nAma anti Innn are mgnrcfurarl markc nr t.r*non L— dsaiAcia 'are. va tlgations 600 Workwe C.' sli t . "cant IM"lin"IfiduPlease Print IA _ N city/stitte/zip. Pt710 Are you an employer?.Check the approprmte bos ��of pr61 i'°4m-'�'- L Ial+yes d ] Iama;g and T I LI s a - - i w Forme in employees ndbavewodoere flS. .. 9. Q Bnodmg.add fi ` :[Alo rgi3oets' .m ce ca :. srau .I 5_ U YNe me a conwmaon and Its. v.❑ s qr adu�`i►ii ua 1 II l3k tamer',t-�'.: co teq ] *AY P �:$ checbbok#l=aaUofiUmtdeg season bet aT g l(8 .vixite s' g®ticy Hoare s a =b=t this za � }site oaf mae a as mast i is eg 2i. fin3cFe�fiias _ .. � .. -- - - i Tam an employer that as pr workm:tao sc+tins insaPance for yeas BeTow is fhepa[icy aaa=.jvb ate:. i4JoMdion. o 1� job ha r p Attach a copy of the.worken!compensatcos po" decbration gage-(shoes the policy number and`eiq*adon date Fmloire.m secdre coverage as�ut Semm 2SA 6fMGL c l52 can lead.t6 tlio' position©f'ixi�ai pel altm of a ilne up o s 1,500:00 anwor cxia-year as wren as cm penalties m the form Of a STOP:WORK ORDER and a fine of W to$250:0l3 s day against. viol dr B a a aw'. this matt be dw Offf of I dv he�eiiy cerh y antler.the pains and penabhes. r, parymy thtit s urformativn prvvide�rd�above is. on cvnvft Thone O}�icial rrse arty Do not wrke in.this.area,#►bg cotnpYete�:b�eaty or town a�iretat City err Tom: i"ermitlLicense h Issuing Autb©rity(circle.oue) I.Board of Health 2.Binding Deparhaent:3.Cityffown Clete 4"Electrkal Inspettor S.:Il m r�.lispeeftr. Contact l'ecson lone#. 6 Aug. 04'2015 09:55 AM Allen Kapson Home Improve 781 767 5723 PAGE. 1/ 1 .41 sacnuse ,-Department of lyumic Sal e! Board of Building Ro$�+tssliocrs and Staraerara's Unrestricted-Buildings of any use group which ii [1�a•'i5rsf contain less than 35,000 cubic feet(991m3)of Z,Aki6YPW)11(S enclosed space. tx'..3. W' GFAADW .;•,. w ,.t 311 N FRANf !W? - HOl3l�tOOK]� � . Failure to possess a current edition of the Massachusetts Expiration State auilding Code is cause for revocation of this license. C sss�t�ec 112h VA117 Wr M Ucar►uina infonmWan vlsit; www.Moss.6ov/oPs . . ..-,?'v4r Fr s:orinnyr�Nrr��a?1.^<�aticn:�rrtr.F�;• '� i'-� �„�' Utticeof c'oesamerAtioio�di 1ckt •, Wig,,, ME IMPROVEMENT CONTRACTOR, C_ "3 ' eglatration: 125121 piration: ' 1 011 5/20 1 5 Individual, ALLEN KAPSON ALLEN J(AP.SON m 3..J.1 Kd0TH FRANKLIN ST. -V0 •j3R0QK;MA 02343 irndal3elrc�a41 - :•: �a� �� �� C� � Y► I IQ, . ►� , corn � �P6'38 RTo� �n of Barnstable *Permit# Z�I �7) MAY 2 2 2015 Regulatory Services > Fee 6mo>rth.°r uaxsrn M » `J�✓ A N ®F BA R N118iP 8���Scali,Interim Director Nth Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 _ www.town.bamstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Mao/parcel Number 0 Property Address Pesidential Value of Work$�3 t �c3� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 41 n 6 1 Z Z,Tug c 6,"tg� Contractor's Name S O cAfire u€•. v A/t l J IPJ S NN/ O Telephone Number 16 R 900 Home Improvement Contractor License#(if applicable) /732`-sC Email: Construction Supervisor's License#(if applicable) D 1 '76 7 XWorlanan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ 1 am the Homeowner ` I have Worker's Compensation Insurance n Insurance Company NameA%_ � //,) Workman's Comp.Policy# WC Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side f F-Replacement Windows/doors/sliders..U-Value r 3 y (maximum.35)#of windo #of doors: ' Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement.Contractors License&Construction Supervisors License is required. t • SIGNATURE: T:\KEVIN—D\Building Changes\EXPRESS PERIv1I1 MRESS.doc Revised 061313 I Renewal - ' - -� M Ucemse#36079 �An�dersen. RENEWAL BY ANDERSEN ` MA Licenn#173?45 { Cr License#0634555, er:nuus: aerucENENT xi„►na „coe,,,oy 26 Albion Road -.Lincoln,RI 02865 Lead Finn#1 E37 Pho ne 866.5 o e_ 63.2235 Fax 401.633.6602 I Federal Tax 1D#46-056"30 i Southern New England Windows,LLC d/b/a , tRenewal by Andersen of•Southern New England' CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name —� Dau of�e Buyer(s)Sum Address,City Sure,and Tap Code !PO Bo": C V r✓C_ it 0.4 Z t E-Mall Address , me Telephone Numbers"� 771 /4 i Y WorkTelephone Numberif Buyer(s)hereby jointly and severall y agrees to purchase the products and/or services of Southern New England Windows,LLC d/6/a Renewal ` by Andersen of Southern New England C'Contractor");in,accordance with the.terms and conditions described on the front and the reverse } i eof this agreement and on the attached specification sheet(s)(collectively,this'Agreement"). _ Q Historic O Condo ❑ HOA? i Total obAmount 1 ,�3� Esumared.Sardn Dace: Method of Payment l ) .= 8 yment D Check E3 Cash D Financed i Deposit Received(33%):_L�L - Credit Cards are accepted for deposit only—maximum 113 of.the ` Balance at Start of job(33%): - Estimated Completion Dace: project cost(Pkose see Credit Card Pbyment Form.)By signing this 1 Agreement,.you acknowledge that the Balance at Start of Job and the , ! Balance on Substantial �/G` ((__K Balance on Substantial Completion of Job.cannot be made by ci edit + Completion of Job(33%): card and must be made by personal check.bank check or cash- Buyer(s) agrees and understands that this Agreement constitutes the.entire understanding between the parties, and_that l there are no verbal understandings changing any of the',te'rms of this Agreement. Buyer(s) acknowledges that Buyers) + (1) has read this.Agreement,understands the.terms of this Agreement, and.has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,,on the date first written above and(2)was orally informed.of Buyer's right to cancel this Agreement.DO NOT SIGN.THIS CONTRACT IF THERE ARE ANy BLANK SPACES: (Rhode Island Sales Only)Notice to B er. 1 Do not si this ny ( ) gn Agreement if any of the spaces intended for the agreed terms I to the extent of then available information are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it. (3)You may at any time pay off-the full unpaid balance due under this Agreement;and in so doing you may be entitled-to receive a partial rebate of the finance and insurance charges, (4)The seller has no right to unla ender, i or commit an breach of the peace to �y ��pent 4 y P repossess goods purchased Hader.this Agreement.(5).Yon may.caacel this Agreement I if it has not been signed at the amain office or a branch office of the seller,provided you notify,the seller at his or her,main office or branch office shown,in the Agreeaaent by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement,eacclading Sunday and any holiday on which regular mail deliveries are not made.Seethe accompanying notice of cancellation.form for an explanation of buyer's rights. ` Buyer(s)received the consumer education materials provided by the Rhode,Island Contractors.Registration Board. (Buyrr'r Inilindr) Renewal,by Andersen of Sou ern New England Buyers)• Buyer(s) By:/ i y Signature Of P uct.Manager Signaturr y Signature khho 477 i Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL TMS TRANSACTION AT ANY TIME PRIOR,TO MWNIGHT OF THE THIRD l BUSINESS DAY AFTER THE DATE OF fTDS TRANSACTION.SEE THE ATTACHED:NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS:RIGHT. �— - - —..- - - - - - _ — NOTICE OF CANCELLATION X NOTICE OF CANCELLATION—, Date of Transaction - S You,may cancel I Date of:Transaction .You may cancel j this transaction, without any penalty or obligation,,within this transaction, without any penalty or obligation; within three business days from the above date.If you cancel;any 1 .three business days from the above date.if you cancel,any property traded in,any payments made by you under the' l property Laded in,any,payments made by you-under-.the Contract or-Sale,and any negotiable instrument executed 'I- Contract or Sale,and,any negotiable instrument executed by you will,be returned within ten business'days`following I by You-will be returned within,ten business days following + receipt by the Seller of your cancellation notice,-and any 1, receipt;by the Seller,of your cancellation notice, and. any security interest arising out of the transaction will bey security.interest arising-.out of..the transaction will be canceled.if you cancel,you must make available to the Seller :1 i canceled;If you cancei,you must make available-to the Seller at your residence,in substantially as good condition as when 4—at your residence.in suhctant; 11V 2e Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License,CS4M707 BRL4N D DENNMON 7 LkKM POND C1R L Charlton MA 01507 Expiration Commissioner 09108=16 Office of Consumer Atfairs and Business Regulation 10 Park Plaza_Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Rogistralion: 173245 Type: LLC Expiration: 9I19R016 Up 2S73S3 SOUTHERN NEW ENGLAND WINDOWS LL MATTHEW ESLER __�_..__ --- 26 ALBION RD --- -.. -- LINCOLN,RI 02665 .'�Update Address and return card.Mart reason for ehnnge- XA1 a D Address F :Renewel [I Employment ❑f.06t Card C-%ae+iGemwonar:�h{e�G{{ie::ar�i In Cossv:ner Affain d'.Dasioeps Rsenladm License or registration valid for Indialdal use only ME IMPROVEMENT40NTRAC70R before the expiration data If found return to: on: 172245 Type: Office of Consumer Affairs and BuslntssRegulation xplration:_GIIW2016 LLC 10 Part Plum-Suite 5170 Boston.MA 02116 .. SOUTHERN NEW ENCLAND-WINDOWS LLC. RENEWALBVPNCERSON - - MATTHEW ESLER - 26 ALMON RD LINCO-N,RI 02855 Uadmecrcmq Not r litwithout signature t The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvaWrations 600 Washington Street Boston,MA 02111 www mass govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/orgmizatiman&vidual : ,,nn � n I ). '��'Y�6tt✓r-�v /U•2�J �v��Ct�h�C �/i�✓r�-r�.���. Address:_ c�k AIAi i4-} CitylState/Zip: /A1c•a XJ - 0,-786,5 phone#: y0 Are you an employer?Check the appropriate box: Type of project(required): 1.[�I am a employer with fir/ 4. ❑ I am a general contractor and I employees(full and/or part-time)-* 6. New construction have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling s and have no employees - These sub-contractors have �P �P Y 8. [3 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance cemP• . $ 9. ❑Building addition 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 •"LV Y comp.inn umce required.] *Any applicamf that checks box#1 must also fill out the section below showing tick workers'compensation policy am. t Hamzeo,1,M who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such onhs lCctors that check this box must attached an additional sheet showing the name of the sub-comiractors and state whether or not those entities have employees. If the sub-conhsctors have employees,they must provide their wodmrs'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the pokey and job site information. Insurance Company Name: O - Policy#or Self-ins.Lie.M W , 9:,� 7 �j r S�R 3 `? V Expration Date: a �S Job Site Address: City/State/Zip• ' Attach a copy of the workers'compensation policy eclaration 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby "depains and penalties of perjury that the information provided abo a u' and correct Signature: Date: Z/ Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6;Other 08�25/281a 6a7�g& CEffnFICATE OF LABILITY INSURANCE TMS CERMCUE 6 IMED AS A NATTER OF WORPS/ITION OMY AND CONFERS NO RIrM UPON THE COnWrATE HOLOM 7W CERTIFICATE DOES NOT.AFRRUATf6MY OR MUMMY AMM,EItTTND OR ALTER THE COII MW AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTR=BETWEEN THE ISSUING fN p),AU MM I I'OiBF $ ffewowewa-&- ADVITMNAL INSURK }: andoed. SU IS QIod-tD e48}6tofdet he Qen otsutli���, ' willie of sm zoxnw, rue- c/o ao Cma2as7 Blvd ?$ E.O. 8=30S 92 _ -879- 4- 348 -BBas 78 .'7r=bville, 7Y3 372305191 aea COVEVW WARD HOMMA, z2vm= w c==mv o£m-. .35926 uRfa V—lt*92.d vindaaa rac ems ,am... _. sS01T a/a/a a®ensa by Bn@arson 26 AIM oa Road uisuRstc:Axgc=vt mmaursaw Cmmanv 29801 r i cola, ffi 02865 08DrREa D_ ' - - DISURERE: 0mnmtP COVERAGES CERTIFICATE ERBEPhysa916o REV�04t AIUB9BE1@: 'i NG IS TO Cam."TMT THE MIMS yr iFNSitRO USTED DaIDW HAVE BFM ISSUED TO THE QdSlf M NAUM A90VE FOR WE Pwrly Pam ?e`I1'rC�TI�}. KOT'v1r71td,S1'ASVa7(dG AA}3'r�uuiy,a�. E t�,�y�'�-tiit#Pd�3=,��a,�Idiitrt�ar? �'OIi ' f'dl�i.' II'3:3-'�}IC#i Zf� CEHiIF1CATE-MAY BE 3'QR MAY ParTAK TK 94SURMCF AFFORDED BY 7W f0'.:IC-ES DESQWM+om-m TIE Tr:."--,. 1 D=MS2 S AND CMMOPIS OF S(ICH POLICIES:L41 M SKWM MAY MM—E BMN BY PAN)CIAM. 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Diecam policy rat- 81,000,000 n Ddsaaso ma. ploy.- 01,006,000 DEsca T=0FoPERAnoatslI.a6a==fV9M=(nc=l0l.Adit"auwftSdgftK=ybn�memdam�►ap�nrsns ed} CMFICATIE HOLM CMCELLATTON sI'tout�atl��at�a�oveo �u,ee�s�€ Lam®E�ae� { THE mp4R wm DAYS "MGM. trDiTGE W" BB oEiww" 0 t, A<�RD�CEYBff;pf01[GYp�Yffi�RiS. I sontbaaa IM race Au ON=�R��nTivE as albi=9oedSvcie fdnwin. ffi 02US-0000 ®998&201,6 ACORD CORPORATION. All rights rsW4" -ACC RD Ea(249409) The ACORD name end logo are mguterd marks of ACM sa I2:i629623 RAMIgntCh ti. 79627 Al' i �e o t i n ( S t Xssessor?s map and lot number ....... ........ /04-0,17WSETIM C .SYSTEM ST BE Sewage Permit number ............I(....... �FS'Tr�l_L"�� ? ,N r r{PL 1 8 r e st> 11 .STATE �PyoFTHEro�o TOWN OF BARNS�T TA` - ` q° TO,YN BAHBSTLELE. i "6 9 BUILDING INSPECTOR �0 MPY A' APPLICATION FOR PERMIT TO ............ ................... ..................................................................................... TYPEOF CONSTRUCTION ........... ' '�r ?4' .................................................................................. .......191....?.:` TO THE INSPECTOR OF BUILDINGS: The undersigned h reby applies for a permit a rding to the follz'4 ing information: Location ....... .. ........ ". ........... .. .. ........................................ �. ... . ProposedUse ....... . ......................... ......... ................................................................... ................................................ ZoningDistrict ........................................................................Fire District ...... .... .................................................................. Name of Owner :.....`... .........:.: ..... ......................Address Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ...................................................................Address .................................................................................... Number of Room .......7.......................................................Foundation ........ " ............................................. Exierior ...... ...... ................ ..................................................Roofing .................... .... .................. ............................ 14 Floors .......... ................. ........................................................Interior .................. ... ...... .... Heating ..s... �...!/ .....................................Plumbing ................ ....a..... �......` Fireplace ...P�� ...... ... .... ..... ...............................Approximate Cost ......:....ZA.f..................................... . ..... Definitive Plan Approved by Planning Board -----------_-------------------19________. Area ....�.(� . ........SS........... Diagram of Lot and Building with Dimensions Fee ��.............................. ............... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................................................................................. r Small, flan E. rr No ....16962 Permit for .........one... t`o........... �.� single family dwelling ............................................................................... Location\ Justice Douglas Wa .. ..................g y ......................Centerville Owner .........Alan..E. Small .............................................. Type of Construction ...............frA,.4§................. ........................................................................... Plot ............................ Lot ................................ Permit Granted ....... arch .20................19 7'4' Date of Inspection ..........:.........................19 - Date Completed ... P� ...,7 ............19 PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ _ -- -- -- - — ........................ .................................................. ............................................................................... Approved ............................................................................... ........................................................... a Assessor's map and lot -number./< *THE Zw"a""4ge I OerimitZnumber. ......�; STABL Ousenumber .......................................................................... N63 AM 19- TOWN ' OF' B ARN S TABLE . BUILDING INSPECTOR APPLICATION FOR' PERMIT TO i 0� X TYPEOF CONSTRUCTION ................%.I.M ........................................................ .......................................... ..................... ................. .........:19.... TO THE INSPECTOR' OF BUILDINGS: The undersigned hereby applies for a per it according to the following information 7 Location ......A. —...cUS . ..1.. . ...... ........ .................................................................... ........................................................ ,Proposed Use .......wa....................... Zoning District .... .................. ........................Fire District .......................... ........................................... Name of Owner ddress .... 41 Name of Builder' ...... ........... . ....Address ... .... Nameof Architect ...=...........................................................Address .................................................................................... 13 eT, M?���.................................. Number of Rooms ..................................................................Foundation ................ ............ Exterior ...AV47 X .......Roofing ....... ............................................................. Floors .....gx!/q_/... ........................................Interior, .................................................................................. HeatingPlumbing ..77................................................................................. ................................ ........................................... Fireplace .................................................................................Approximate Cost .......... .............................................. Definitive Plan Approved by Planning Board - ------------19--- Area .............. Diagram of Lot and Building with Dimensions Fee ..... ........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Tow off Barnstable regarding the above 'T construction. Nam ............... .................. ........ et' ......................... ....... ........... ..................... DRANETZ, CHARLES No 24335. Permit for ....B.u.i l.d Addition .. .. .... .. .......... .... Single Family Dwelling ............................................................................... L 1�2 ' Justic Douglas Way Location ............................ ........... ...................... . ...... ..........Centerville..................................... ....... .... .. .... ..... Charles Dranetz Owner .................................................................. ....... ..... Type of Construction. .....F r a,.me......................... X ............................................. ................................. Plots........................:t. Lot ................................ A 'Augus t 3 1,,. 82 Permit Grated_ A6.9 ........................Date 6f)4:pec�ion ..... ....... ................ t Date Completed 'or ...............11993 oe i 02 o7 IOU 10. r. Assessor's map and lot.number ... E • 'Sewage Permit number ............................................. ........... Cj eF - 17 a-t- Xe IIAMSTABL House number ............ .................................. ........................ K"& t639- 0 M TOWN OF BARNSTABLE BUILDING INSPECTOR eW6 C�7 110a X 7-- 1��iv 040t, APPLICATIONFOR PERMIT TO ............................................................................................................................. TYPE OF CONSTRUCTION .................... ........ .................................................................................................... 19..... ............................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information---- L4,1 Location ......./C... .... ...... .J .... ..... ........., ..... ... ............. . ....... ..................................................... Proposed Use ......(—IVIA16' 1AJ e6j ............................................ ........................................................................... ......................... I i I '(�4�j Zoning District :7............./.......................... ....................Fire District ........................... .... ......................... -e Name of Owner ........ . ............ ............ Ze, ..................... ,Address ... ...? ................... ...... ........................ Name of Builder" ..................... ...Address ... ..... .........../W14-1........... Nameof Architect ...=...........................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation ................ .................................. Exierior ....dlv .......Roofing ......./e ................................................. ..........i!n........ ..... .. 7A Floors ..... ...........................................................................Interior .................................................................................. Heating ................................................................................Plumbing ..:7............................................................................. Fireplace .................................................................................Approximate Cost .........i...................................................... Definitive Plan Approved by Planning Board --------------——----------- Area .............. ..................... Diagram of Lot and Building with Dimensions Fee .....aL............................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to confo rm to all the Rules and Regulations of the Taw of Barnstable regarding the above construction. Name..... DRANETZ, CHARLES A=191-190 /i�0No . 335.. Permit forBuil oSingle Family Dwe.... ................................. .......Location ,.,12 Justice_ Doay................Centerville ..................................................... ..........Owner .......... Type of Construction ....Frame ................... Plot ............................ Lot ................................ Permit Granted ...August 31, 1°9 82 Date of Inspection .......... 19 ........................ Date Completed ......................................19 �p C/a a,�x�y 92Oc7.