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E A a -v.�.s,x. eK,A. �# .� T .._ ,.., ., . ,., ( o- r .R.. t -;L t' .F';.:., . ,. 4 ,,"' n ei. 3r: M �'# #-..-.h'.. :: a.k� ,+ t, r .. . . ,,.,, ? - ,.yy(�� �q { ,SN :t.: ..:,a,,. :.0., „ ,. .. iu ibR ...:s ..3,. , .;+ t ,; ^' ,� :a:f. ,Pz�1' [x.:.17 UP An aF .: , xr.a:i..- v _. .. �:. .:. .3 ,:..t, y, ,., ray .,a.-t ,,,... r..,...w, x:. ,...:. .,, r i.Y. ,, ,, m ,t ,j"T.,', a. ,._..,, ,. ,�., ,. .,. :.�,. y.e. � 5 , . .,.,,s .,. - �,. ur:-..„ ,:: ,..ao-,.:.:. .. , - ^a. #a l.. 1. n.....Y ;. ........,,, ..,.. .i , ... .. .t a r'd't,� ,ys ,,b-:F ,vet. ,x :- a `.t. [ a �.�, - s .4 g'� k y �'` '� e4- `. ? ,�, S.Y, Y d*n 5 - Y ,s xn pn, 4 R l N '%5. :y, t 'SWk , � x a 1 .ate c ., ,: , , L 4. } - y ESS �I r Town of Barnstable *Permit#„� 2 5 2015 Expires 6 nIhsorjssue date �+ Regulatory Services Fee , BARNSTABU n ' i6;q. Richard V.Scali,Interim Director Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2110 Property Address $� Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /!J � Contractor's Name Telephone Number 6dP'P V-99W Home Improvement Contractor License#(if applicable) oQ?dZzf Email: Construction Supervisor's License#(if applicable) 02/i�0.2 r - ,, ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner W-I have Worker's.Compensation Insurance Insurance Company Name Workman's Comp.Policy# _5_& -2 51Y2Z 0IYA Copy of Insurance Compliance Certificate must accompany each permit.. Permit Re uest(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) fff Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#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.- i SIGNATURE: Q:\WPFILESTORMS\building permit forms\EXPRESS.doC Office of Consumer Mfs business Regula ap e - OME IMPROVEMENT CO _- License or reg�strat►on valid for mdiv�dul use only s egistrat�on NTRgCTOR before the expiration date. If found return to: . 120659 ' XPiration 2/99/�016 Type' Office of Consumer Affairs and Business Regulatign —_ DBA 10 Park Plaza:- LINNELL ENTERPRISE ,, I wp. : Suite 5170 B 2 .DAVID. i Boston,MA:O 116 LINNELL. rt } 59 FREE BOARD LANE µ, UTHPORT, MA 02675 Under a �! secretary Not valid without"' s19RSture y Massachtasetts -Department of Public Safety Board of Building Regulations and Standards Construction SupervI sor I &2 Family License: CSFA-Q71507 DAVID J LINNELL 59 FREEBOARD .N 6 YARMOUT170RT Expiration - J,,(,,,, �1 08M I2015 Commissioner The Cogs mommakh of Vassatchusefs Deprrh ent afliulusftwFlAccidents - ice afimlmhk�vfls 600 W4ff Y7WHfftM&reet Bostoza,,M,4 02111 wmv.masmgmii'di Workers' Compensation Insurance Affidavit:B>ceders/ContractorsMectricianslPlvmbers Applicant Information Ptease Print,Legibly Dame(Pus�FganizationlI &idnao= Address_ city/StatefZ : i . ©..7r�71C' Phone 4_ C-0V'Y''� -94-6'9' Are you an employer?Check.the appropriate bow: T of project a 4_ I ant s contractor and l J 3u (��d)- I am a employer with ❑ 1 6_ ❑New cu� la es full and/or -time * have hiredthe sub-eonhacfofs ye C P� 2_❑ I am a sole proprietor orpartner- listed on the attached sheet ?. Remodeling ship mid have no employees These rah-contractass have 8. ❑Demolition working for mein any capacity. employees and have workers' [No workers' camp.imumnce comp-insuraraa 9_ ❑Building addition 5. ❑ We area corporation and its i{l_ 1 Electrical repairs or additions required-] of hnm exercised their 11_ 3_❑ I am a homeowner doing all wadi ❑Plumbing repairs or additions myself[No workers'comp- right of exemption per MGL l�iZoofrepairs inmrancerequired_]1 e_152, §l(z,and.wehaveno employees [No workers' 13_❑Other . comp-insurance required.] *Pray appUuwC that checks b=1=st also fill out the section belaw sbnwing ibex wood me mmpensadon pol¢p iuffiamSm T Sameaarners vrho submit 1I.affidavit in&,xtkg d y are damg all wok and then hue outside contractors omit submit a new affidavit mefi<atiag.sarIL tCvmtmcmrs that check thi's box mast attached an artdi anal sheet shauiag the nmne of die suit-=xftw:tos and state uhether ornnt timse E ampkgves IMP snhtoutraam hose empkapes,they Est provide their warkess'comp.policy number. I am an empto5,w thatispiwWduig tt,orkers'eompensalion irrsuraric-e for my itnq;vyee-s Below is ttepolicy read job site; zrr;forreolira;a. latsurance CompauyName: Policy#ur.Self--ins_Lic (A/CC �� 3"4d`�zf� oZd/t/� FxgirationDate: � Job Site Address: City,'StaWZip: At#ach a copy of the workers'compensathm policy declaration page(showing the policy number and expim ion date). Failure to secarecoverage as requireduuder Section25A o€MGL c 152 can lead to the imposition ofcriminal penalties of a fine up to$1,500.00 and/or one year impr soffit,as well as civil penalties in.the form of a STOP WORK ORDER and a fine ofup tD P-50.00 a day against the violator- Be advised that a copy of this statement maybe forwarded to the Office of hnestigations of ff>e DIA for insurance coverage veriEcation- I do hereby certify carder thepains pe Was aRfPPIMY that the information provided above is bue and correct Si mature: Date: /�: r' Phone#: ©fficiai use only. Da Trot write in this area,to be completed by caty or town of j5ciat City or Town- PavdtUcense# Issuing Antharitg(circle one : Information anal Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the a.,.. dwelling house of another who enloys persons to do maintenance,construction or.repau•work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall•withhold the issuance or renewal of a license or permit to operate a business or to constrict buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage requir d." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone ninnber(s)along with their ceri..ficate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 ooverage. 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 Depart rient of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which vi U be used as a reference number. In addition,an applicant that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number: The Coon ealth of Massachusetts Department of lndustdal Aookdents Office of kvestigati=5 600 WashiVoa St=t Boston,MA 02111 '1 d#617 727-4M at 406 or 1477 MA SS AFE r oFmE r Town of Barnstable Regulatory Services �mxiv rE$ Thomas F.Geiler,Director 1639.Maia Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstafile.ma.us Office: 508-862-4038 'Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize i�UL,s / /�/i�/ // to act on my behalf, in all matters relative to work authorized by this building permit (Ad of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner ignature of Applicant Print Name Print Name Date THE Town of Barnstable Regulatory Services rS Thomas F.Geiler,Director E1 3 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis;MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION. number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeovmers"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage,an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such workperformed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the Iast page of this issue is a form currently used.by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decoU!k\AppDataV-ocal\Merosoft\VTmdowslTemporary Intemet Files\ContentOutlooklQRE6ZUBN02RESS.doc To: Page 2 o4 3 2C14-08-25 1,�:59:43(GMT) 15089380246 Frorn! Br12n P,eldy CERTIFICATE OF LIABILITY INSURANCE. DATF.(MfXDD/YY fY) ��. 08/2512014 PRODUCER THIS CERTIFICATE IS ISSUEQ AS A MATTER OF INFORMATION Blackstone Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 3144 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester, MA 01613 INSURERS AFFORDING COVERAGE NAIC# INSURED INSU'3ER/. A.E.I.C. I Linnell Enterprises e: 59 Freeboard Lane c: Yarmouth, MA 02675 ,NSJR=R D NSJRc?E: COVERAGES THE POLICIES OF INSURANCE LISTED EEL'OW HAVE SEEN IS.`3'JEC Tp THE WISUREC•NAMED ALf VE Fur:THE FO_ICY PER,!-JD INCIC,aTEC.NOTLL'ITH3TA dc?tNG ANY REOUE.N IRENT,TERM OP.CONDIT70nTJFAN CONTR.ACI-OR OTH=R D3CLMENT V1r'?TH nEu=EDT T4`A'HICI TH:;: EaTiFiCf•t VA'r'5=ISSU=0 OR MAY j ?ERTAW.T^,E INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE44(S SUEJECT: :.LL TtIC r 0.45:E7.Ci 5i7(J4 F.hiD C0l47i IK"t\5 OF SUCH i POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED 61 PAID CLAIMS. I. R I'MSHG TYPE OF INSURANCE POLICY NUMBER ,DATE(Mhi:DQIYY) LIMITS GENERALLIABIUTY Y„i!OCCURRF,NCE ; COMMERCA.L GENERAL L LA5IUTY PRcr/,IS 5 IS O I S r rS�Ea'.r..,gnrce) CLAIMS MADE OCCUR I MEL:EXP Any en?Carson) S 1, PERSONAL&ADV INJURY £• GENERAL AGGREGATE 3 GENT AGGREGATE LIMIT APPLIES PER: I PI'±GD!1CTS COMP/CP AGG I POLICY PACUFCT LOC AUTOMOBILE LIABILITY COM3zNED 9111.;—E L:MiT S ANY AUTO (Fa txcid�r.:) ALL OWNED AUTOS I LOVILY INJURY g SOHEJU;EDAUTOS (Per HIREDAUTOS 500;LY NJURY $ H NON-OWNEDAUTOS (Per PROPERTY DAMAGE $ '%'cr ecz»ent; GARAGE LIABILITY ALTO ON?Y-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC .`. i AUTO ONLY AGG S EXCESS/UMBRELLAUABILITY FAC,1 OCCURRENt'E $ POCCUR CLAi?A,MACF. I AGGHEGA-E $ DEDUCTIBLE s RETENT!GN S r—� b YJOPoCERSDONPENSATIONAND ✓. EfAPLOYERB'LIABILITY f� •1,2015 1 I A ANYPRDPRIETGRIPARTIIERtEXECUTIVE WCCi500501.074L72ri i4A 8/1:2+J;� n E. E i:F.ACCDENT _ F OFrICERIMEMBER E.L.L'I3cF: EXCLUDED? I t,G0,70D Or dosctibs wrdar I r SPECI.A!.PRGVISIONS Laic. I 1 1'�• I r 5Q J,7DD E!.!i EASE POLICY_X S OTHER i L PhUVISMNS David Linneli is covered by the workers comoan>aban pclicy CERTIFICATE HOLDER CANCELLATION ,I ShOL'LD ANY OF THE ABOVZ DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE i£SUIIJG INSURER'WI-L ENDEAVOR TO MAil- V DAYS`WRITTEN Building Department NOTICE TO THE CEFITINCA E HDI.UER NAMED TO THE;.UT,BUT FAILURE TO DO So SHALL 367 Main St: Hyannis, MA 02601 IMPOSE NC OBLIGA7tCN OR L!A3lLFSl'0�:,NY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES., _ AUTHORIZED REPRESGNTFTNE ACORD 25(200110S) )ACORD CORPORATION 1968. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION aal�� .Map Parcel ©�S � Application # 5 I Health Division Date Issued Conservation Division Application Fee S� /d Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board q )Z,/J3 Historic - OKH Preservation/ Hyannis , Project Street Address �� ► C'� Village Ownerft 0 Ct Address./&_r t /n {'i.ae Telephone Permit Request t4MaM f C1 ZQ��y Square feet: 1 st floor: existing 0 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ��' �� 0� Construction Type Lot Size c3`S Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family a---' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 'Orrull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing� new Half: existing np- Number of Bedrooms: existing _new cn Total Room Count (not-including baths): existing SJ new First Floor Rp Counter � w Heat Type and Fuel: U- as ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/c al stovel Yet❑ No r- Detached garage: 'sting ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ ex ting ❑mow Tze_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# I Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name / , - e,e_J. Telephone Number,-5W 7 7?= 01 � Address 7 h7/ C License # Sy NO ylS Home Improvement Contractor#hma h18%L� i • a,/,/? ,,2�z ft/�U,Ce*orker's Compensation # ALL CONSTR CTIO EBRIS SULTING FROM THIS PROJECT WILL BE TAKEN TO�T�� Q�Cal SIGNATURE DATE Llal_1�3_ FOR OFFICIAL USE ONLY APPLICATION# k ` DATE-ISSUED Y MAP/PARCEL NO.. A �Ly a Y ADDRESS VILLAGE OWNER DATE OF INSPECTION: - FRAME - - - - - 0. t; . INSULATION;;=_t:�;;...���!_� _,_.v:.�• FIREPLACE ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL. GAS: ROUGH FINAL FINAL BUILDING- - "t DAT.E CLOSED OUT ASSOCIATION PLAN NO. �w . t l . ~ 0 mass save Tl/Vfyr�}y [4pt�fMMC, CM PERMIT AUTHORIZATION FORM I, Mina Vaughan ,owner of the property located at: (Owner's Name,printed) 165 Knotty Pine Ln Centerville (Property Street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. X ` ( Owner's signature �! 06/17/13 Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Rev. 12132011 The Commonwealth of Massachusetts .Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass govldiu Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I,eeibly Name(Business;'OrganizationilndividLial): Tupper Coast ruction Co. , LLC Address: 79B Mid Tech Drive City/State/Zip: West Yarmouth, MA, 02673' Phone# 508-778-0111 Are you an employer?C'heck.the appropriate box: TV pe of project(required): 1.❑X I am a employer with 4. ❑ I am a general contractor and I b✓ ❑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. t 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 area corporation and its officers have exercised thei 10-❑Electrical repairs or additions required.] - 3.❑ 1 am a homeowner doing all work right of`exemption per MGr L 1 LE]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' I3 [1ether comp, insurance required.] *Any applicant that checks box#I_must also fill out the section below showing their workers'compensation policy information. t Eiomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ,Contractors that check this box must attached an additional sheer showing the name of the sub-contractors and their workers'comp.policy information. .lam an employer that is providing workers'compensation insurance for my employees. Below is the,policy and job site information. Insurance Company Name: AE Z C Policy#orSelf-ins.Lic.#: WCC 500559301.2012 Expiration Date: 10/03/2.013 i &,91 Job Site Address: 5 1 l n Cityr/State'Zip: V f Attach a copy of the workers'corn cation.policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of N46L 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 dry hereby r7V e pains and penalties of perjury that the information provided above is true-and correct. Si nature: bate: Phone#: 508-778-0111 Official use only. Do not write in this area,to be completed by city or town Oficial. City or Town: Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing inspector b.Other Contact Person:. Phone'#: Q } UKL, DATE(NIMIODIY" CERTIFICATE OF LIABILITY INSURANCE 12/19/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed: If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in ileu of such endorsement(s). PRODUCER CONTACT NAME; Lora Lowe Southeastern Insurance Agency, Inc. -( °NoE (508)997-6061 FACN,; (508)990-2731 439 State Rd. E-MAIL ADDRESS: P.O. Box 79398 PRODUCER CUSTOMS I s: N. Dartmouth, MA 02747 � - INSURER(S)AFFORDING COVERAGE NAIC B INSURED INSURER A: Arbella Protect on Insurance Tupper Construction Co LLC -� pp INSURERS AEIC. . - MURERC: CNA Surety _.............:...._......._.....__._................ 27 Roberta Drive INSURER D: West Yarmouth, MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 12/13-2 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A13OVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR _ INSR 4NJD POLICY NUMBER ; MMtDD MiDD�E��_--��T LIMITS GENERAL LIABILITY 9500008743111/.01/2012 1/101/2013 EAr-H u r:ENCe s 1,000,00 DAMAGE X ;COMIMERC':A' GENERAL LIAf3IL11Y I i TO RENTED _._.... 1 P<EM�S;Eeo-,cur enL(,: $ 100,00 II .. ...... .. ._,("n:A MS-FtV+DE ;�CICCUR i i 'AEC E.LP(Any one Person) $ 5,000 A I. I PERS01W aAuV INJUPY $ 1,000,000 -. . .NE�?AL AGGREGATE., . $ 2,000,000 GEN L AGGREGATE LIM T APPUES PER: PROCA.ICTS-COV-P,OF Ac G $ 2,000,000 PR . j POLICY :IEC,T I� LOC 1 $ _ _ _.. AUTOMOBILE LIABILITY . . - ..;. . . :.. 5666240000 12/01/2012 12101120131 C0 DINED SINOLE UMIT ..$ - I l IEawNoe-t) 11000,000' ANYAUTO _. ..______.:____._._,.____....... I BOD'LY b J1JRY(Per person! $ ALL OWNEDAL;?w i - i3UUiLY?trJURY-;Pe'SCtidenF) $ A X SCHEDULED AUTOS PROPERTY OAMhC-E X 'H RED fu1rOS 1(Per s=Iden'.) !$ INC X NCtyOWNED K;:'-S $ I 1$ UMBRELLA LIAR H=W4EEA Ii OCCURRENC-F ($ - _........EXCESSLIAB I AGGREGATE, $ .........-_ _ i DEDUCTIBLE REIENTrON WORKERS COMPENSATION WCCSOOSS9301200 10/03/2012 10103/2013 X `TA'} X n AND EMPLOYERS LIABILITY YIN TUKY UM T5R ANV PRoPRIETor�P�R Err E I;, c RICHARD TUPPER I E Fnr HACCIDIE14T $ S00,00 B O=FICERiIAEMBEPECCLUDEU� �;tVtti; --: {Mandatory In NH) INCLUDED FOR WC COVERAGE E ,EX ,.EASE-EA EMPLOY el$ 500,000 Mes,descnb�Under' ........ .__.:.__- - . SCR P1ION OF 00ERATKA5 b0c" 1 E DISEASE-POLICY LIMIT $ 500,000 Bond or theft of money & or 71068913 02128/2012 02/28/2013 Limit of $10,000 property. DESCRIPTIO OF OPERATIONS i LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) ill.ju�io@csgrp.com CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 'DATE: THEREOF, NOTICE WILL BE DELIVERED IN r ACCORDANCE WITH THE POLICY PROVISIONS. Conservation Services Group AUTHORIZED REPRESENTATIVE Attn: Bill 3ulio _ 50 Washington Street Westborough, MA 01581 Lora Lowe O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD N. �� wtrvc.-t su - rrrr o Public Safety • 107 Homm PW,SsAe 110 r3. t Buil4ing.Reg6lationsand Staodaros M,IVY 12020 " {.�3talErttrrttYit�tt Lr�3vc��' (877)274,1279 www.bO.WM License:.CS4690a8tio, " RI CHARA'S"C UPR WEST VA UPW t fil BPI ICW.5040040 CRATIFUD ROVES Expiration �1Commissioner 12131 i1$ y ON ftce rf�tstwtt^Aftax'&:21 xis�t�lsw�ua a�tg Pe ts g et p ldx�� � _ flow ImPRt)Ve"wfi C014MC1't3R R1f aC� j � " t8istrst3on. .1 Type: C(3UE �� 1. Expiofl fbttnrkua! f s y 3, R Ri T#JPP -= i� ' Rfch3 'U'Ppe'r t' ' psC {7ti81 UC1t3tt 29 Rfll?Crka-C3rive W,YARMOi.dThi.MA MIT:. (itft?E�t1lt#f� F a 09/15/2011 20:31 5087785010 TUPPERCO PAGE 01/01 0/z)l7 ITUPPER .CONSTRUCTION CO., , 79B MID—TECH DRIVE,WEST YARMOUTH,MA 02673 PHONE'.-508-778-0111 FAX: 508-77&S010 WWW.NPPERCO.COM Date: Town of Barnstable Thomas Perry CBO 200 Main Street Hyannis, Ma 02601 (508) 790-6230 fax CZ z Co Re: Insulation Permits z Dear Mr. Pent' This affidavit is to certify that all work completed for permit application # pzagAm' Issued on has been inspected by a certified Building Performance Institute (BPI) inspector. All work performed meets or exceeds Federal and State requirements. cere y, d Tupper L' nse 4 CS-69058 � ., Town of`Barnstable *Permit# Expu Regulatory Services Fee 6 u anatasTABLE, : ����'�. MAM Thomas F.Geiler,Director /19 639• 14 2413 Building Division U � 1 Tom Perry,CBO, Building Commissioner Wt " �QP PARNO 200 Main Street,Hyannis,MA 02601 r 6�(�11? Liv Aft_ www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY t Not Valid without Red X-Press Imprint Map/parcel Number J 1 Property Address ( ! 1 v P � sidential Value of Work$ —� inimum ee of$35.00 for work under$6000.00 Owner's Name&Address J Contractor's Name Telephone Number Z � Home Improvement Contractor License#(if applicable) Email: X � Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 01 have Worker's Compensation I surance Insurance Company Name Workman's Comp. Policy# �� l Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingly Il construction debris will be taken to Qom» ❑Re-roof(hurricane nailed) g. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum .35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Se a Electric &Fire Permits required. *Whey required:.I ce of th' permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. * *No Properly er must sign Property Owner Letter of Permission. A copy of a Home Improvement Contractors License&Construction Supervisors License is r ire SIGNAT Q;\WPFILES\FORMS\building permit forms\E RESS.doc Revised 061313 TU PPE R CONSTRUCTION CO.LLc 79B Mid-Tech Drive West Yarmouth, MA 02673 Phone 508-778-0111 Fax 508-778-5010 Registration#121845 License#060058 Date: CD D l 13 Attn: Building Department I hereby authorize Tupper Construction Co., LLC to pull the permits necessary to complete the project described on the attached permit application form. Thank you, Owners' Signatures Print Owners' Names: nhina- L - Vgj�:SkaA Street Address: ��� �� AkA, &A eetill,✓tyI�, ��3d�- t3tAi#JRA1Ci f'� Ad T t t�i , 1 1 s u tt -3 r1f s rt.of Pu.bfic Safely 107 maft NY 12M � -o-: tWn 4M{t rs»sir �j (0 274-1274 gi n .CS s8 to;.ct � 690 }7;9l�p II`I,>-�iy E7�,�CH DR. y sdwO T - - s -c , ' ° � `.�, . . ACER "I Es A. itt�as �.,.;. rt sioa r{flfE RtYtN5€SIDE fflfl l fi kA1l A#3D 12/3112414 E1fl�2RT N W 17 rs a �f �PC�sapl ttf 'Sa1�Wa f #t?�!6 IMPROW ENT CONTRACTOR Am xcietinls fA.. Individual- Bf `M TUP.P y�{�ER�y �f > d 6�, at y@ 3 RIL7'fATl� " trt3 dap�e r RICHARD t t7FPF3 " 'pTU pE: CC3t1StUCtl�3(i "rod Rooerta 06vo 11 g afety t afe n � W.YARN9f}UTH,MA 02613 ttadassscrrtary� 24i2 sec. 3�. 4:37PM No. 85.24 F. i12 AG6-my, DATE IMMA701YYYYl CERTIFICATE OF LIABILITY INSURANCE 12/19l2ou _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT.AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY'THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A.CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. P SUBROGATION IS WAIVED,subject to the forms and conditions of the policy,certain policies may require an endorsement.:A statement on this certificate does:not;confer rights to the certificate holder in lieu of such endorsenient(s). CONTACT PRODUCER _ NAME: -Lora Lowe Southeastern Insurance Agency, Inc: Arc o E41: (.5o8:)997-6061 �No .(508)990-2731 439 State Rd:. E:MAI: _ ADDRESS:. ....... . P.O. Box 79399 PRODUCER CUSTOMER IQ N. Dartmouth, mA a2747 INSURERIS)AF FORCING COVERAGE NAIC9 INSURED _ INSURERA.... . Arbella Protection Insurance... Tupper Construction Co LLC pp INS uRERs; AEIC INSURERC. CNA Surety _................__.......___:._..........._._._....._..__.__....._..._.... 27 Roberta Drive INSURER I): West Yarmouth, MA 02611 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 12J13-2 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE.POLIMY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN;THE.INSURANCE AFFORDED BY THE POLICIES:DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, W TYPE OF INSURANCE LTR INSR.:t�Vtl POLICY NUMBER tvlMitltl M��.I' A D LIMIT'S GENERAL LIABILITY 850000874311110112012 11/0112013.,EACH WWENCE S 1,000,000 DAMCETREX -COMMERCIAAL GENEMkL LIABI1,.II Y ( ::Pf2EM& ff{E-cT ur er+^sj„ $ 100,00 ;�OCCUR { .-MEC ExP(Anyone Person) $ .,oa A ER ONAL 3 ADVIONJLr,Y $ 1,000,00 ERAL AG GATE $ 2,ooa,aoo GENL AGGREGA E LIMIT APPLIES:PER: PRODUCTS-COPMP:OP AGG $ 2,000,000 POLIO Y PRO- LOC II $ AUTOMOBILE LIABILITY ... , .._ 56662400002 12/0112012 12101120131 OMBINEDSINGL:E�WIT $ a acne , 000,000 I ANY AUTO BODlY NJURYIPerperson) $ ' ._de :_.,......�..........._..._._.......,_ Ali OVdNEGAUTOS ! ;�3UULi f'JL�'f iFe^acc� ni}, $ 1J'`OS; a A X SCHEDULED A RgP RTY CAVAGE {__..-( --- X HIREDMiT05 (( eracGdeaa INC X :NC i O'NNE fU :'OS j 71 UMBRELLAIIAa OCCUR EICHOCCUP.RE CE ($ w T�- EXCESS CIAB CLAIMS--E .......... 4IAAE j AGGRF AT>= b DEDUCTIBLE rrETENiON $ s I$ WORKERS COMPENSATION tkCC5aa559301200 10iO3/2012 1010312013 X onrntTs: AND EMPLOYERS LIABILITY YI N ANY PROPRIETORIPARTINIERP_.?ECI Tly[ RICHARD TUPPER is F, FAC i ACCIDEW $ 500,00 B ;OFFICER/MEMEIER EXCLUDED? NIA_ INCLUDED FOR WC COVERAGE E E,Ds�ASE E EMPLGY c $ 500,000 (Mandatory in NH) t yes descrioe Unce- D S R.PTION Or OPERAT,O S oelcfw E- DISEASE-P01ICY LIMIT $ Sao,00 ---Bond for theft o. money & qr 71068913022128/2.012 0212812013 Limit:of $10,000 C property. DE CRIPTON OF OPERATIONS!LOCATIONS I VEHICLES{Attach ACORD 101,Addaionai Reinarka 5cherltide,H more space is raijulrbd) il.julio@csgrp.cotn CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE'CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Conservation Services Group _ Attn 'Bill 3uli.o AUTHORIZED REPRESENTATIVE 50 Washington Street We tborough, MA 01581 Lora Lowe Q 1988-2009..ACORD CORPORATION.All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD e The Commonwealth of Massachusetts Department of Industrial Accidents Off ce o -Investigations 600 Washington Street Boston, ,UA 02111 www mass.Kriv/dia Workers' Compensation:Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers Applicant Information Please Print Legibly Name(Business/Organization/indivi Euat): Tupper Con8truction Co. , LLC Address.- 79B Mid Tech. Drive City/State/Zip: West Yarmouth, MA :02673 Phone# 50-8-77.8 .01.11 Are you an employer?Check th ppropriate boy: Type of project(required): 1.0 1 am a employer with 4. ❑ I am a general contractor and 1: . 6. ❑New construction employees(full and/or pa - lime):* have hired the sub-contractors 2:.❑ 1 am a sole proprietor or partner- Iisted on the attached sheet:+ 7. ❑Remodeling ship and .have no employees These.sub-contractors have $: ❑ Demolition working, for me in an capacity. workers' comp. insurance, g y ,Budding addition [No workers'comp. insurance S. ❑ We area corporation and its required:] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all.work right of exemption per MCiL. 1..1..❑.Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12,E Roof repairs insurance required.].t employees.[No workers' comp, insurance required:] l l'❑Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidayit indicating they are doing.all work.and then hire outside contractors must subinit a new affidavit-indicating such. +Contractors that check this box must attached an additional shu tshowing the name of the sub-contractors and:their workers comp.policy infotnmtion. lam an employer thails providing workers'compensation insurance for my employees. Below is the:policy and jab site information. Insurance Company Name: AE IC Policy#or Self-ins..Lic.-ft:. WC�C15 0 0 5 5 9 3 012:012. Expiration Date: 10/0 3/2 013 Job Site Address: 165 Knotty Pine Lane City/State/Zip: Centerville, MA Attach-a copy of the workers'compensation:policy declaration page.(showing the policy.num I bet and expiration date}. Failure to secure:coverage as required>ltinder Section MA of MOL c. 152 can lead to the imposition of criminal penalties.of a fine up to$1,5.00,00 and/or one-year imprisonment,as well as civil penalties in the farm 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. 1 do hereby certify under the pain t! ties of perjury that the inforrnadon provided ahove is true and correct: Si nature: Bate. 6/12/2 013 Phone#: 508-778-0111 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): I.Board offlealth.. 2. Build ing.Departnletit 3._C.ity/Town:Clerk 4.Electrical.inspector 5.Plumbing.inspector 6.Other Contact Person: Phone#.: yofTHETo�� TOWN OF BAR.NSTABLE • r Z SAUSTADLE, 6 i " 9 o BUILDING INSPECTOR � uaY a• APPLICATION FOR PERMIT TO .. ..... . . ... .. . ..... ...... TYPE OF CONSTRUCTION !: -..0 Z......... .. ......... .. .... .. ... ... ... .., .. 1 /�!. !s�(M... . 19....�/ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a ermit according to th/�e following information: Location .. ..�T.... .. ......! ......... ..... ... ... ...... ......k�a5' __.. ........ .............................................. � � . ProposedUse �r... ... ...... .... .. ........................................................... ZoningDistrict ... � ..... ....................................................Fire District .............................................................................. Name of Owner ..V4�... . .. M� ...:. ....!R ..� .......Address ��....... !.r.... Name of Builder 1J .Address Nameof Architect ..................................................................Address .................................................................................... r Numberof Room......................................................Foundation .......1.D.,...... ........................................................ Exterior ...... ..... . .... - .......................................Roofing ....... ........... . ....A* ..................... ........................... Floors .Interior �---............................................................... ...... ........ . ......................................... Heating ...Plumbin 2 g .................................................................................. Fireplace ..................................................................................Approximate Cost .....p�a'1..v.�.U.................................... Difinitive Plan Approved by Planning Board ________________________________19 Diagram of Lot and Building with Dimensions �' r U- U) LU � to M ® U 0 ® U? ~ z L7 � C- C / U) x 0- 0 0 W WWN ¢ ¢ fir '-- I ZZ ® LJ d' C7� c� �- z �' u7Q O >- ::)! FL-�C>C) —,x cj� < D c 3�� O Z o~ < 1-7 � to 5 hereby agree to conform to all the ules and Regulations of the Town of Barnstable regarding the above construction. Name ....V`!. .. .............�....,�� .......... Dacen ,u-����m � "z " E. ~ �.����� ' 9K � �` " 14050 one story � No ................. Permit for ------.-�----. ' � � single family dwelling -----.---------.----.------. . Knotty Pine Lane � Location ---..............-------------- Centerville —'~--^'--------'------------- | WfIliozu E. Dacmy, Jr" Owner ...--------.------.----.—.. � _ frame Type of Construction .......................................... �-----.-----.---------------. ��� } Plot ---------. Lot ---. -----. ' ' 4 _ / .~ Jn]v' 13 71 Permit Granted ---.......--------lV Date ofInspection ------------l9 �� ~��� �� Dote Completed --..L--.�—�~—.�.� .....lg ' PERMIT REFUSED .____.___---_--------- lA _______________-----------' --------------------------- ^` ------------------'-------- ' K � --------''--~''--'~~--^^'^'~---^'' � _`__-----------... l� Approved ' -------------~'—~'----^---^^''' � --------'-----------^~—^'—~^^ U ' � K. >