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0076 LONG BEACH ROAD
f I t Town of Barnstable • s+",'"3.,. r 'van's "'t y .4�"� -.`. ` Building Post This Card So That it is Visible From.th'e Street "Approved Plans Must be Retained on Job and this Card Must be Kept <_ ♦ 1ARNSTABLE, s e,w ged.S4a t S ti • 1' 1� Posted Until Final inspectiYon Has Been Made.*, c7a y r � F Permit Fn,v ° ,Where a Certificate of Occupancy is Regwred,such Building shall Not be Occupied until a,Final Inspection has been made " .._ Y Permit NO. B-17-4440 Applicant Name: SCOTT E CROSBY BUILDER INC Approvals Date Issued: 01/04/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 07/04/2018 Foundation: Residential Map/Lot: 206-009 Zoning District: CBDLBSB Sheathing: Location: 76 LONG BEACH ROAD,CENTERVILLE Contractor Name.-,,SCOTT E CROSBY BUILDER INC Framing: 1 Owner on Record: HUNTER, DURANT A&SARA H Contractor License 151882 2 a r Address: 76 LONG BEACH ROAD "j Est Project Cost: $35,000.00 Chimney: CENTERVILLE, MA 02632 0 Permit Fee: -$228:50 Description:- REMODEL THE EXISITNG KITCHEN;SAME layou,no change 198sgff ` '' Insulation: Fee Paid.! $228.50 r d Date r. 1/4/2018 Final: a rr WE Project Review Req: *, a Plumbing/Gas 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 b .this permit shall conform to the approved a lication and theta roved construction documents for which this permit has been ranted. Rough Gas: Y P PP PP, PP P g All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. 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 Final Gas: 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 is permit. 4 Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection - 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 TOWN Of BARNSTABLE BUILDING PERMITAPPLICATION. r, t Map Parcel7 Application O Health Division Date Issued dZibv Conservation Division Application Fee BUILDING DEPT-� pp / Planning Dept. . ' Permit Fee V07,Q DEC 29 200 Date Definitive Plan Approved by Planning Board \LAI\ r11 N OF BARNST/�BLE E Historic - OKH Preservation/ Hyannis Project Street,Address C �Rya_& Village Owner Address N D �! +A �A J�1�J1'- ss`7b LD 6 b Telephone Permit Request 9L in Do L ` E: e:7 N 6 T< 1`mP e1 ,J , ,S A M� /-aurav� Nn A Oin&)GEE . 196 S� )`r Square feet: 1 st floor: existingL1 a i5roposed _0 2nd floor:'existing proposed _Total new Zoning District Flood Plain Groundwater Overlay Project Valuation , OW&onstruction Typelt� f�(`n� Lot Size . a)o AeRE,:_ Grandfathered: ❑Yes ❑'No If yes, attach supporting documentation. Dwelling Type: Single Family l� Two Family ❑ Multi-Family(# units) Age of Existing Structure �I Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes C9 No Basement Type: Full Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) 14- Basement Unfinished Area (sq.ft) �TI Number of Baths: Full: existing_ new —� Half: existing O new fb Number of Bedrooms: existing Onew Total Room Count (not including baths): existing 2 new ® First Floor Room Count Heat Type and Fuel: VGas ❑ Oil ❑ Electric ❑ Other Central Air: Yes dNo 9� 0 Existing ❑Existing Fireplaces: New wood/coal stove: Yes �(No P Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:4existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals JAuthorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 3 No If yes, site plan review# Current Use ejl N h h-=: -r 1 m, Li Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 9th L��� Telephone Number LSD �-'/9 9- 0 4 D Address RSA ol)fJ I'i S7t i)N� % License # C, - ©4 3 ,S,S b o� L�'v 6 l E. An A n S Home Improvement Contractor# S/ oZ Worker's Compensation #6S60 --U-A Y Id,r,7 PQ3 f3 l `1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO D SIGNATURE DATE 1�, z " ;7 s Y I - ' FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ' ADDRESS VILLAGE •OWNER j DATE OF INSPECTION: ' FOUNDATION FRAME h INSULATION FIREPLACE _ ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED OUT ; ASSOCIATION PLAN NO. Towu of Banistable Regulatory Services Building i3 loon Tom pexsty cso Building cumminkmer �402ySa L t3g*a»z�3�is�A t328 ', erartyt9tru:U�rnatabtea�a=�c Offilm 5I7d-8624438 Property Owner Must Complete and Sip This Section If Using A Buildet 1 11 k as o-omner of did sac`;rc°t lxerebf�uxix�t�z.� �, ',_„ '� ��s��-,�•._�___�_ t��ezuassayFs�h�l£; in a mmen teistivz to wodL authodzai by ims bua&ng mat tWmwiaa x Adat..otib} S,Q 12/28/2017 sipame of Owner ,P.dnt Name • t .T� ✓�r Tpy .� ,20 L1 '� � Cr•' 5 A.w P � . WiYgMo6+WrlYlmel. F I I II Sid c . v V- Y . -'tne�aoe• art ;. n r , i r r n i A/��® DATE(MM/DD/YYYY) i CERTIFICATE OF LIABILITY INSURANCE F11/16/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Germani Insurance Agency fPA o t, (508)428-9194 A/� No: (508)428-3068 908 Main Street E-MAIL ADDRESS: certs@germaniinsurance.com INSURERS AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURER A: SAFETY INS CO INSURED INSURER B: Hartford Scott E.Crosby Builder,Inc. . INSURER C: 1112 Main St.Unit 7 INSURER D: Osterville,MA 02655 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD SWVO UER POLICY NUMBER MM/DY EFF MM DDPOLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FXI OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ A BMA0022636 10/12/2017 10/12/2018 PERSONAL&ADV INJURY $ 1,000,000 GEN%AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 3953278 09/07/2017 09/07/2018 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS HIRED NON-OWNED PROPERTY $DAMAGE AUTOS ONLY AUTOS ONLY Par ac.Z X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ A EXCESS LIAB HCLAIMS-MADE CM00001805 10/12/2017 10/12/2018 AGGREGATE $ 2,000,000 DED RETENTION$ $ H WORKERS COMPENSATION X STATUTE EOR AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ! E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? N/ N/A 6S60UB4727P23817 06/23/2017 06/23/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 I F DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) - li Workers Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance).The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensation/investigations/. 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. Scott E.Crosby Builder,Inc. 1112 Main St.Unit 7 AUTHORIZED REPRESENTATIVE Osterville,MA 02655 Fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD &2ze zzzzz4�e.ccerclC/ �%j`ru ccc/cc elt Office of Consumer Affairs&Business Regulation License or registration valid for individual use only " ,6�HOME IMPROVEMENT CONTRACTOR before the expiration date. If found returai' to: jl�w� Registration: °'151882 Type: Office of Consumer Affairs and Business Regulation ` Expiration,,_;-7h13% 018 Private Corporation 10 Park Plaza-Suite 51'70 UILDER IN,C` Boston,NIA 02116 SCOTT E CROSBY G SCOTT CROSBY 1112 MAIN ST UNIT#7 OSTERVILLE,MA 02655 Undersecretary N t. Not valid without signature a i { Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-043556 Construction Supervisor SCOTT E CROSBY 62 CROSBY CIR OSTERVILLE MA 02655 � �� Expiration: Commissioner 12/13/2018 . r i Ae Cc► nr�ri vead�tle of Massra jiteft Department 4Ia�Acrid Office AVl" strgations 600 Washington wwk mamgor Workers' Compensatipn Inset a>noe Affidavits Bm�derslContracturslE�ectnciarisJPlumbe Aplpfic=t Inf®rmation:,.:. Please Pant b - Name(B AjL City/StatelZip: —Phone. .. . . # � 6 Ara�o an employer?Cbeckt appropriateboz. T ' ype of project(xa4uud} I I am a to with 4 ❑I am a general:contractor and I p ..... 6. ❑Nevi consnuctrOil employees(fOaod/ezpat-time).s bavefhuerlthe:sub-c�aitractars: 2.❑ I am a sole prog�tietor or ps er :. hated on the etti&ia sheet. 7 r. Rezno&hd9_ L� ship and haven- employees Tle snb-contractor hm��e 8: ❑Demohtron w- forme it c. cr employees and have viodce s. or ing any apa tY-. c I 9, ❑Building i".Ixon,: {No wonders comp ins rance ° = d 5 ❑ 1�1e a a aorpara�ton and its I8❑Ele ctnca!mP of addrttons 3 ❑ requireofficers have exercised tberr .:: l l Plunrbm aus or adthhons I am a homeowner doing all woric: ❑ g rep myself[No workers bomp right of exemption per MGL 12 Rflof usursmce r equinad t c '152,§1(4X anti we have ; ❑ . 13❑Other camp insurance required J *A�appfi�t that checks lets#1 amst also fill otu the sectiea below sl n**then warkexs'c�peg5attog policy igfarnffitgaa tam.. . whD jo"af5d"itiademnn : . . g they an:dcmg all w�ago then hue outside coaTtacmrs nmst submit anew sffadsit mduati�sack,. : 1Coatractnrs fat check Phis bmi must attached an additional sheet dwmog the nem'e of roe Wb�coaWctoh sod state whether ar not these eatrtees h� employees. If the snbtantractnts hags enkpiopees,Posy nnost p¢mdde their waikeTs'comp.policy mmtber. d our atz e r tlirit is trrortcers't�nioperisalisrr its anca or_rriy eote ._ etory is_the psTic}eicd mP P 'ab site nfot�rrihon Insurance Compffiy ATa®e. � Policy#,ar Self-ins Lxc.# lGt /� 4A oll P �Fxpuahonl?ate Job Site Addrew. Zl�t G; CityfStateJZrp_ Attach a copy of the workars'compensation poLcy declaration page(showing tha policy mrmber and.eapiTation date) Failure to secupe coverage as required undue St oa 25A.bf MGL:c.152 can lead to the iWosifoA o-f cdminal penakies of a fine lip to$1,50D 00 andlor an_ year rmgnsot ,as well a'civil penalties n die form of a STOP WORK ORDER and a fete ! Of up"to$250.00 a day agarustttie violatoz Se`aduisesl that m copy of this statement may be forwarded to'- a Office of Investigations of the.DIA for insurance coverage verification I do hereby ce rider thin and pt�nattras afPerfury thQt the information protRried a is ea>Jd correct Sl Bate. Phone 9: '0"rcaat n only. tw n©t av�ihta in this'00. t,to'be-IC pkesd 6' taty trr:tiihwr o,Qrc4rrL. ' Ctq or Town: Permitllieertse# -. Issuing Authority(circle one): 1.Board of Health 2.Buittiing Dwartment 3 Citgaown Clerk 4.Electrical Inspector 5.,Pinmbi>Ig Inspector 6.`other. Contact Person:- Phone#c _ r.: .d Town of Barnstable " 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-17-2850 Date Recieved: 8/21/2017 Job Location: 76 LONG BEACH ROAD,CENTERVILLE Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: SCOTT E CROSBY State Lic. No: CS-043566 Address: OSTERVILLE, MA 02655 Applicant Phone: (508)428-9090 (Home)Owner's Name: HUNTER,DURANT A&SARA H Phone: (781)799-7774 (Home)Owner's Address: 76 LONG BEACH ROAD, CENTERVILLE,MA 02632 Work.Description: Replace front door in existing opening ice. . eat Total Value Of Work To Be Performed: $1,500.00 m Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property.owner'and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Scott Crosby 8/21/2017 (508)428-9090 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $1,500.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $35.00 8/21/2017, $35.00 XXXX-)CM-XXXX- Credit Card ..........0644................................................................................. Total Permit.Fee Paid: $35.00 r , { TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �:.® I - _ Application # 2� Health Division Date Issued 3— 7 Conservation Division f' Application Fee .., Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board ' Historic - OKH Preservation/Hyannis L , �I Project Street_Address 84 Village l:' flky, V`d.k Owner J(1-y f I�K�/U�i Q �� Address `5CLOA'e Telephone Permit Request es-In-,?-L?g� Square feet: 1 st floor: existing JLRJproposed _�2nd floor: existing proposed —jD_Total new Zoning District Flood Plaines > Groundwater Overlay Project Valuation 0 00 Ot°Construction Type BUILDING DEPT. Lot Size, Grandfathered: ❑Yes &(No If yes, attach smrtps @mentation. Dwelling Type: Single Family: Two Family ❑ Multi-Family(# units) ' TQi1Jt�OF BAFiNSTABL Age of Existing Structure �� Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes G `No Basement Type: U Full G/Crawl LI Walkout ❑ Other Basement Finished Area(sq.ft.) (XQL'+ Basement Unfinished Area(sq.ft) i_, Number of Baths: Full: existing 1- new Q Half: existing C-) new 0 Number of Bedrooms: 3 existing C7new Total Room Count (not including baths): existing new First Floor Room Count 2 Heat Type and Fuel: 3/Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes Fk(No Fireplaces: Existing A New 0 Existing wood/coal stove: ❑Yes ®'No Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑'existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ®'No If-yes, site plan review # Current Use S- 141�.'!7G T !\ Proposed Use APPLICANT INFORMATION 4 (BUILDER OR HOMEOWNER) Name G to k 4 t r Telephone Number ` — — 4M`q qo Address l l 12,, Ats�fa r4- License # ` 6±3 S3 (_D QU ifflh f 4A cL Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO_ ,�� 6.Y Y16+ 0 SIGNATURE DATE Ila 1� FOR OFFICIAL USE ONLY n APPLICATION# DATE ISSUED r MAP/PARCEL N0. i ADDRESS VILLAGE ' OWNER ; DATE OF INSPECTION: FOUNDATION i FRAME w INSULATION FIREPLACE ' , ELECTRICAL: ROUGH FINAL f PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING vz j s DATE CLOSED OUT' ASSOCIATION PLAN NO. 4 L r ACC) CERTIFICATE OF LIABILITY INSURANCE °ATE`MM,D°"Y,"' 10/26/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT German)Insurance Agency PHONE T FAX 908 Main Street c 508 428 9194 A/c No: 508 428-3068 IL Osterville,MA 02655 AODAREss:certs ermaniinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:SAFETY INS CO INSURED INSURERB:SAFETY IND INS CO Scott E.Crosby Builder,Inc. SAFETY INS CO 1112 Main St.Unit 7 INsuRERc: Osterville,MA 02655 INSURER D:Hartford INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR - POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MM/DD/YYYY MMIDD/YYYY A COMMERCIAL GENERAL LIABILITY BMA0022636 10/12/2016 10/12/2017 X EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X❑OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 0 JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY 3953278 9/7/2016 9/7/2017 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident C UMBRELLALIAB HOCCUR CM00001805 10/12/2016 10/12/2017 EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED I I RETENTION$ $ D WORKERS COMPENSATION 6S60UB4727P23816 6/23/2016 6/23/2017 X ISTAT ER UTE EORH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance).The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Scott E.Crosby Builder,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1112 Main St.Unit 7 ACCORDANCE WITH THE POLICY PROVISIONS. Osterville,MA 02655 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD Office Of,CCoonsumer Affairs&Business Regulatione License or reQistrat'— e HOME IMPROVEMENT b Ion valid for individual use only c�. CONTRACTOR before the expiration date. If found return to: Eo I Registration: '151882 Type: Office of Consumer Affairs and Business Regulation O,;y` Expiration__";:=7[13%_018 Private Corporation 10 Park Plaza-Suite 5190 _- _- SCOTT E CROSBY BUILDER ING Boston,MA 02116 SCOTT CROSBY 1112 MAIN ST UNIT#7." OSTERVILLE,MA 02655 Undersecretary Not valid without signature i Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-043556 Construction Supervisor SCOTT E CROSBY 62 CROSBY CIR ' OSTERVILLE MA 02655 Expiration: Commissioner 12/13/2018 n The Commonwealth of Massachusetts Department of Industrial Accidents In (14 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): ( e-r, Address: City/State/Zip: �� -d1� � Phone #: Ar u an employer?Check th appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [rRemodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.$ 9: ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] i *Any applicant that checks box#I 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ Q_i/'�f(6 V Policy#or Self-ins.Lic: & Expiration Date: Job Site Address: City/State/Zip: , hA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify d r the pai an^dpenalties of perjury that the information provided above is true and correct. Si ature: -� Date: �pp Phone#: 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#: Town of Barnstable 161 �' Regulatory Services ` RFD MAt A - Thomas R.Geller,Director' Building Division Tom Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Fax, 508-790-6230 Property Owner Must Complete and Sign This Section p � If Using A Builder as Owner of the subject property hereby authorize So. 1 C'/ ! � to act on my behalf, in all matters relative to work authorized by this building permit application for: (Aftdress of Job) qjt Signature of Owner Date 03 lr r b +^U 1 Ur Print Name i Q:Forms:expmtrg Revise071405 �. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel A lication # --� pP Health Division � '- --�, Date Issued 3/3 0)l6 0 ' Conservation Division N wv-JApplication Fee 3 Liu Planning Dept. V '� 0 7 1��4jr� Permit Fee� � Date Definitive Plan Approved by Planning Board .8Y____ Historic - OKH _ Preservation/ Hyannis EMX=L S Project Street Address Village C2 j�q,.e dA Owner �v.cS � 5 �„` 43io Address 5 v� c ?A Oeb Telephoner :S'Oec�— Z b`1/6s Lo 053 V&6a!5 Permit Request Lc50 aS vki.9 4 Z 513 (ao--�5 Square feet:l st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuations Construction Type Lot Size .7(o G,c��L5 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .0— Two Family ❑ Multi-Family (# units) Age of Existing Structure Ise 4 65 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes A-bLo Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement.Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new 0 Half: existing & new Number of Bedrooms: 13 existing Onew . Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: tifas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes iMo Fireplaces: Existing _New Existing wood/coal stove: ❑Yes ®-No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes A-No If es, site plan review# Current Use I�-�SS� c� Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) r Name C , �• �o1r ri S 4- &-n, �n c- Telephone Number 5d S- 49fs-1 1 6 5 Address I3S QSher yi ( c - W. &2rnSk�=Lk . License # C'_ _5 © IS $-G I 061r v i(le , A A o a(o5G Home Improvement Contractor# 16.-t o I L Email Ca-�_h IA32Cb��W ejonOr r iS . Co yy\ Worker's Compensation # " "A, '� 3 C� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO? UR LLk_) SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE - OWNER DATE OF INSPECTION: `FOUNDATION FRAME ? ♦u i INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING y t DATE CLOSED OUT ASSOCIATION PLAN NO. t YIN) Town of Barnstable KAft Growth Management Department .`� Barnstable.Mistorcal Commission www.town;barnstable-ma.us/hiStOhcalcommission Jo Anne MillerBuntich,Director COMMISSION MEMBERS: Marylou Fair;Administrative Assistant Laurie Young,Chair George.Jessop,AIA Marilyn Fifield,Clerk Nancy Clark Nancy Shoemaker Len Gobeil ,:CL+W'it i Ted Wurzburg i'k.JF1 -H.r i Paul Arnold,Alternate - DECISION Summary: Demolition Delay Not Imposed Pursuant to Chapter 112 Historic' Properties, Section.112-3;F Applicant/Property Owner: Sarah& Durant Hunter Subject Property: 76 Long Beach Road,Centerville Assessor's MaplParcet: 206/009 Hearing Date: November.17, 2015: Pursuant to the Barnstable Historical Commission Chair's determination on.October 28, 2015;,a.duly advertised and noticed public bearing was held on November 17, 2015 to determine whether the,. significant buildings identified ras the single family dwelling on this property is preferably preserved and whether demolition delay would be imposed for the partial demolition of the single family,dwelling on the parcel addressed as 76 Long Beach Road; Centerville. After review and consideration of public testimony, application and record file,the Commission by a unanimous vote, found that in accordance with Chapter 1127F the partial demolition of the single family dwelling is not a preferably preserved significant building. The Commission further finds thatthe parts of, the significant building to be retained are preferably preserved and shall not be,demolished. The portions of.the single family dwelling to be demolished.are identified in photographs and plans included in the Intent to Demolish application received 10/23/2015 and'clocked with.the Town Clerk orr 10/23/2015. In accordance with Chapter 1.1.2-3 F, the Commission determined by a unanimous vote that the demolition of the single family dwelling would not be detrimental to the historical, cultural or.architectural heritage,or s resources of the Town. 1 Laurie Young, C t : Date 200 Main Street,Hyannis,MA 02601(o)508 862 4786:(f):508 862-0784 367 Main Street,Hyannis,MA 02601(o)50BL862-678(0 508-862-4762 t i 1 2015 OCT 23 Pr13:04 Town of Barnstable Bl;R STRELE TOWN CLEPK Growth Management Department Barnstable Historical Commission v,vw_sewn.barnsiatle.ma.usfiistoncalcommissien NOTICE OF INTENT TO DEMOLISH A SIGNIFICANT BUILDING Date of Application !/D 1 1.2111S Q Full Demotion 4!3-Partial Demolition Building Address: Number S et (('' �' jz,�2 Uz- Assessor's Map# Assessor's Parcel# Village ZIP Property Owner:5�,JrLft i\oiat � Name Phone# Property Owner Mailing Address(if different than building address) Property Owner a-mall a dress: Contractor/Agent: Cr,:2, ��' t ��f�S ©''� ,l 1�_C Contractor/Agent Mailing Address: Contractor/Agent Contact Name and Phone#: Ctrs �5k.LO�f* lsb j^7 18 NOS Na Phone# Contractor/Agent Contact e-mail art ess: Detail of Demolition Pr000sed: I Type of New Construction Proposed: Provide information below to assist the Commission in making the required determination regarding the status of the Building in accordance withicle'1, § 112 fp�/I, . , Year built: / ZZ Additions Year Built: Is the Building listed on the National Register of Historic Places or is the building located in a National Register District? No Yes 0 FS ,�riCL Prop y r ent Si urea May.2014 Town of Barnstable Geographic Information System October 23, 2015 206041 206042 �, 2#11 #1127 #1116 206091#1110 206051 #1187 �#34/#26 206045f #11 #1127 206048 #1116 #1110 206136 12 2� p6g2g #1112 #0 #1187 206040 T#25 0 #1125 "4#1096 206127 206092 #48 206047f�y #1094 206439 206030 206046 1 #1100 2061-2-81 '#56, #35 1 127 #137 206025 ���®�+� # 090 206038 #64 �Chri�'" #154 c e w �® 206037 ® add®fig 1 ��� 2 6 29 #1074 #70 .. .206033 206029 ,2 206106 466 206099 �� �61 206124 20613�206132 2#910 #55 #118 `#130 #140 #1103 #1078 #1072 #86" �®. 6133 2061051� #1068 - 206123 #65`� 206028 206100 # 068 #90 * #122 #1085 206103 #79 206012 206125 #24 #95 v 206011 2 6014 •206010 r#62• -206016 2060091 ® #7 2060088#76 ✓NG ICb� 206007 #78 206005 6000 #94 206013 #108 #98 �206004. � 206016 #997 205015 #112 #27 205413 206017 #140 205014 #126 206018 #47 #128 206020 106019 #57 #6 205010 205019� 206022 #75 #.1.50 . _ . _ 0 01 205016. -#85. . . _ . r20508 #103 1#06I 205020 205021 #129 205024 #137 #163 205025 #167 0 80 Feet DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:206 Parcel:009 boundary determination or regulatory interpretation. Enlargements beyond a scale of. Owner:HUNTER,DURANT A&SARAH H Total Assessed Value:$1099700 Selected P8rC61 1"=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.26 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:76 LONG BEACH ROAD '. such as building locations. Buffer '.rr`_ . 6r OAK16. VA I � 9 f 111 1� I1 a' LI s tea,•,, V �. n A R �E e .��••� � + 4i. S{I+.yl}J A- ,Yam' � ^�' I or CERTIFICATE'OF LIABILITY INSURAN E DATE(MM/DD/YYYY) TNIII160EITIFICATE 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 2LPRODUCER.AND THE CERTIFICATE IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME: DOWLING&ONEIL INS AGCY PHONE FAX 973 IYANNOUGH ROAD (A/C,No,Ext): (A/C,No): E-MAIL HYAN IS,MA 02601 ADDRESS: 76RNJ INSURER(S)AFFORDING COVERAGE NAIC N INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA E B NORRIS&SON INC INSURER B: INSURER C: INSURER D: 138 OSTERVILLEWEST BARNSTABLE ROAD INSURER E: OSTERVILLE,MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MIMDD\YYYY) (MMMD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE ❑OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PROJECT❑LOG PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE _ is DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND �STAT�UTORYTHER EMPLOYER'S LIABILITY Y/N UB-2EB937OA-15 05/03/2015 05/03/2016 X ANY PROPERITOR/PARTNER/ECECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L EACH ACCIDENT $ 500 000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS TIES REPLACES ANY PRIOR CERTIFICATL ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESHNT HYANNIS,MA 02601 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. . Client#:646400 2NORRISEB ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDONYYY) 06/08/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(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 lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil PHONE 508 775-1620 FAX 50 Insurance Agency E-MAIL o Ext: A/C No: 8778121 B 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC A INSURER A:Acadia Insurance INSURED INSURER B: E.B.Norris&Son.,Inc. INSURER C: 138 Osterville-West Barnstable Road Osterville,MA 02655 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. INSq TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICCY EX POLICYNUMBER MMIOD/YYY MMIDD/YY LIMITS A GENERAL LIABILITY 13INDER392782 5/03/2015 05/03/2016 EACH p�OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY PREMISES7 Ea o cu ence $250 D00 CLAIMS-MADE a OCCUR MED EXP(Any one erson) $5 000 PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2 OOO OOO POLICY jEO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accldent ANYAUTO BODILY INJURY(Per person) $ ALL OW AUTOS NED AUTOS SCHEDULED BODILY INJURY(Per accident) $ _ HIREDAUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Peraccident _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y f N E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? MIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ II yes,describe under DESCRIPTION OF OPERATIONS below E,L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate of insurance for workers compensation will be issued by the carrier. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 'M AUTHORIZED REPRESENTATIVE 01968-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S152050/M152049 LS1 "` , ��'amrraanweaz�'�'h af11�'tassrza:lxulse�ar DeParAidM of Iadwirlrl*41dend Ojft4d Of 4rPesdga da,to 600Wu hbtt rs►strod 1 Workers, componsadan InsuranceAMdavfi.- Axt 1��t#e�l�a�t,Laacfalr�/��q��1'�t~��r��ll�+g��b��s Mostat ' � (ill tua��t�r nLactiaer'ladivt�l l;1B Norris&,fort,Inc, 1 138 Oateaville W.] arnstable Road City/Stata/ ; 0stervillo,MA 02635 508. 28-1165 Are you 44 eamtploye>r?Check the appr'oprinto boat � nfp�ct��at(rsgtslr�t); 1„Z I am.a employer����y.���,y `� � S,lna a� Il aanix�ttac�t�1 �, ��e�act ��'taaClon ernptcayams� tll td/ar W5 F^71iit„,)Y have lted t o etti�rtztt�aayc� 2,Q X am a sole proprietor or partear. lx1ed'art the attwhad slaw, 7+ M RMO&HAO ahip ad h ve Aa=pswee 'l 4990 strWanhntctM blva 8, woridng fbs me in any ag*&7, ozapkpas sstd baayeworkw, E'Q'Fwork='QotV,ittar om Qtattmp,its oat 9, (�4aE1d add�ic�at rerq*cd:] 8Y 13 "fie arm a eorgamdon azd W 1 rllaodaal repala or addw 3.[] 1 am a homey ma-doits all work ofters love a tmisad tbok l l, j p b sa are+gaecata svr addatlaris raysaI4['a workw,oaMlw, ri�ktt aP mate ►bion peer tr1 l � 11oa rapsdrs idea ratrac.)�' QY 132,§1(4),srtd'( o�vo a,Q . 19=a bomfty"br iq&z u a Mplwe".No wozkow 13"M bt�nr,...n -' gr1 cortfatqt trera 2#4� Pulp.inac t agttf. w�by g�pl� i�t�hc+aatrc Gait�t kx�p nfaa Sta uut�ha s�d�tl��t1kYoV sEi��riimi�'wa 'caa,�,��yy tptcamsdgp. �'�ra�ue�route arsbaatk,tt�a�d�,Yt�In�iCt�a�adtqay a��atray�up wtY�(rdnd�►st hica 5�ucafd�°audaagtq�q prax����a},vasft Aaa'�►n�rkwtl�1ndtDatl�����, 00auftolt�m 2M a 04 box lau t%twow ago► dl10014 And show1ug d"mum oR the nws�caaa� d a vVttaWta ar a���a apddax tudrra mmployt*& thus sub-a=utcaa Give aztptoyoe� thry=,ax lrcavtcia tbc€r W��'aamw,patfny,acuaba�, A I !"ago urr plc t arr larm�drr� r ttrra a�mt�t ar rrelfaaa Imilrunco�ar m ►emp as .i glawu k Ad aradj/ - slid hsrr^ apctil�a bxst��Ato C p y Xpuw: Travelers Indemnity Company of America x UB-21,89370A-15 Bxpira art 11ai t 5/3/16 76 Long Beach Road, Centerville lob 64a Adclrmss„ Cikyl�tai�l�fpa MA 02632, , Attgak a upy of the worlaera°eDntpcasa909 Polley dealarat un page(sbawwtag the Policy anmb+atr%tad uptrAtloa Aare). � palltwe tO',$=:M a+ov 2a 0 eer M=dw Sodioza,2 A Of MQL 0.152 oft.lead to tho imposigoa of oritttl ltga7gaa of 0, o a1e to 1,500.00 and/or oaaYyear tatYprioQt eo as well1"efv7[VA41 tea in the Pawn airs M?WOMMMIR ad a fine Of UP tO$250- 0 a day a&airy tho vic+lator. Be advised that a copy of this statamoat maybe fbmWod ta to ofjca cf lhvexsdSadm of the D1A for htstt =e$ctivet�ge va t�ty. i f.d0,1R*t by tr^M- eta°er r p rrtt'p Q, for iNIOamata&r prmv1dtd abai o irvo and catrft r—L „ 3-4-16 ' 508Y42g�1165 Y WYt ....1 .9 enrowr'.w.'rlwnwr+.IMONkYYIYIIMIIIi({w�pp O id wig 0*, Do M tin�te Pro thk ran;'k�'r d�!rrrpleAud by�b Y or tet�.offielid 5 c1>`,'y or'Tow is �+'� m...ww,u..,wuu�ww�..wa�LLYa.wruY 19sublg AUthor1ty(circle once),, 1a t3oard oP ff"'th Z'IDut*19D00xrba0c0 S. ClWOWA(361'te 4.17wrical itharoator s,P'N'Mbi fugcdur d.otho ... _ ._. .....��._.. �+e�swttaa�.„ MOa Mtn "..QeY.M.�NMWN.NJAM.�.�.nFlL�uuMan°°�sMrlf1� ' 1 . Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration _ - Registration: 102414 - Type: Private Corporation Expiration: 6130/2016 Tr# 252322 ERNEST B. NORRIS & SON INC = Craig Ashworth " 138 Osterville W. Barnstable rd. =_ Osterville, MA 02655 ;_.. >" ..•: 'Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 5 2OM-05111 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only U_'PME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ;j62014 Type: Office of Consumer Affairs and Business Regulation gistration: 10 Park Plaza-Suite 5170 piration:_H-611W2014: Private Corporation Boston,MA 02116 ERNEST B.NORRISC :ON Craig Ashworth ==':_-=- --__ 138 Osterville W:Barnstqt�le;c _.- " Osterville,MA 02655 Undersecretary Not valid without signature • tlri Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-015851 Construction Supervisor CRAIG N ASHWORTH 138 OST W BAR NSTASLt- ?: OSTERVILLE MA 0219 '1 Expiration: Commissioner 09/28/2017 of +ET Town of Barnstable. Regulatory Services BAWMANUM WAM Thomas F.Geiler,Director --Building-Division - ..- .. 'T'om._?er>_-;�;_.B.uflding.Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, as Owner of the subject property herebyauthorize E.B Norris and Son,Inc. to act on my behalf in all matters relative to work authorized by this building permit application for. . 76 Long Beach Road, Centerville,MA (Address of Job) 3/1/16 Signature of Owner Date D Print Name I QTORMS:OWNERPERMISSION VN • L f { e�3 i I 44 ca t -t% 'C ff W J I V RAMWABSS.M Town of Barnstable ib �� F039. Growth Management Department Barnstable Historical Commission www.town.barnstable.ma.us/historicalcommission Jo Anne Miller Buntich,Director Marylou Fair,Administrative Assistant COMMISSION MEMBERS: Laurie Young,Chair BARN TABI_"TOWN CLERK Nancy Clark,Vice Chair 2015 OCT LB Pi'1 -45 Marilyn Fifield,Clerk George Jessop,AIA Nancy Shoemaker Ted Wurzburg Paul Arnold,Alternate October 28,2015 ' Re: Intent to Demolish Single Family Dwelling 76 Long Beach Road,Centerville Map 206, Parcel.009 Craig Ashworth k: i E. B. Norris&Son, Inc.., • "� . 138 OstervilleMest Barnstable Road Osterville, MA 02655 Ann Quirk,Town Clerk 367 Main Street,Hyannis, MA 02601 Thomas Perry, Building Commissioner 200 Main Street, Hyannis MA 02601 Pursuant to the attached decisions!please be advised that the Barnstable Historical Commission will hold a public hearing on this matter on November:17,2015 at 4:00pm,367 Main Street, Hyannis,2nd Floor, Selectmen's Conference Room. - s- This public hearing will be advertised, notices sent to abutters and a notice form.will be posted on the building or other visible site on the property The applicant is responsible for advertising'and mailing costs,associated with the pubic hearing. Please contact Marylou Fair at 508.362.4787'or marylou.fairQtown.barnstable.ma.us for processing information. Sincerely, �f Laurie K.Young,Cha"r: F 200 Main Street,Hyannis,MA 02601 (o)508-862-4786(f)508-862-4784 367 Main Street,Hyannis,MA 02601 (o)508-862-4678(f)508-862-4782 WWE Town of Barnstable ABL "T TOWN s BAfr•,NZ)I ` , CLERK ° BAMSTASM Y Growth Management Department MASS. 39. Barnstable Historical Commission 2015 OCT 28 Pt11:4a www.town.barnstable.ma.us/historicalcommission Jo Anne Miller Buntich,Director COMMISSION MEMBERS: Marylou Fair,Administrative Assistant Laurie Young,Chair George Jessop,AIA Marilyn Fifield,Clerk Nancy Clark,Vice Chair Nancy Shoemaker Ted Wurzburg Paul Arnold,Alternate Chapter 112 Historic Properties,Section 112-3 D. DETERMINATION of SIGNIFICANT BUILDING 76 Long Beach Road,Centerville Map 206, Parcel 009 Pursuant to Intent to Demolish Single Family Dwelling The Barnstable Historical Commission received a Notice of Intent to Demolish application for this address stamped by the Town Clerk on October 23, 2015. This property, located at 76 Long Beach Road, Centerville was built in 1920 and is associated with the broad architectural history of this area. In accordance with Chapters 112-2 and 112-3(D), Barnstable Historical Commission Chair has determined that this structure is a significant building. 200 Main Street,Hyannis,MA 02601 (0)508-862-4786(f)508-862-4784 367 Main Street,Hyannis,MA 02601 (o)508.862-4678(f)508-862-4782 I �^ 2015 OCT 23 pr13:04 Town of Barnstable B"RMSTRBLE TOWN CLERK Growth Management Department Barnstable Historical Commission ,N,,m.town.barnsiablem a.is,histoncalcnmmission NOTICE OF INTENT TO DEMOLISH A SIGNIFICANT BUILDING Date of Application / /S Full Demotion 4!3-Partial Demolition Building Address: ��L`r a-ct.� aa _" Number S et C'A .Z�`l - 02 Assessor's Map# 2��`� Assessor's Parcel# Village ZIP Property Owner:5-r¢L"t_I},-r_o-w � �,v��7 �!J� � Z�`- � C/� E 0,5zTtS Name Phone# Property Owner Mailing Address(if different than building address) Property Owner e-mall�a/�dress: Contractor/Agent: Cna �5���"� � �-`"� Contractor/Agent Mailing Address: ,[ Contractor/Agent Contact Name and Phone#: Ctrs �SkLL- NanfeJ Phone# Contractor/Agent Contact e-mail a d ess: Detail of Demolition Pr000sed: C. J Type of New Construction Proposed: _Z Provide information below to assist the Commission in making the required.deterrmination'regarding the status of the Building in accordanc e with Article 1, §•112 Year built: Additions Year Built: Is the Building listed on the National Register of Historic Places or is the building located in a National Register District? No Yes Prop y r ent Si - May.2014 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a� , - �l ff Map 0( Parcel C '�� =-J. �',", STA8L Application # I ,`�� 1 Health'Division Date Issued Conservation Division _ Application Fee` PlanningDept. 1. . p ` Permit Fee srzy YR-vac +.T3a=s'.6iJlfl� Date Definitive Plan Approved by Planning Board ' ' rtj Historic - OKH _ Preservation / Hyannis Project Street Address Village Ce Owner 5c Address Telephone ,Gb� -� C D g 9'��S Permit Request � cal o�-1�4�Ufo ►LA_ 1(11411Vti (0,1: G s u ut 4 ow��e t� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District. Flood Plain Groundwater Overlay Project Valuation �D� �- Construction Type Lot Size a 2 Grandfathered: UYes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure S rs Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing Onew Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes Flo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached ❑ existing garage: g ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No.� If yes, site plan review # Current Use 1�25 Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name E 6 . Ao-rr�s � �o-,r1 , �nc. Telephone Number- Address t.�$ Dsle ry i I It, - L h 4n ,k K/ License # 0�0 Is l D Sle,ry*f l , . AA ba Home Improvement Contractor# I D ao 14 Email l QS h WurUQ)cbn D r r, l S - cm Worker's Compensation # Uj' 9'E N� 71)A- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO IDa-)Cc) Ot SIGNATUR DATE FOR OFFICIAL USE ONLY APPLICATION# - 5 DATE ISSUED MAP/PARCEL NO. t ADDRESS VILLAGE a OWNER 3 DATE OF INSPECTION: FOUNDATION D4341)15 ' FRAME + INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING - a DATE CLOSED OUT ASSOCIATION PLAN NO. Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 .UIV Horne Improvement Contractor Registration Registration'. 102014 Type: Private Corporation Expiration: 6/30/2016 Tr# 252322 ERNEST B. NORRIS & SON INC Craig Ashworth 138 Osterville W. Barnstable rd. Osterville, MA 02655 'Update Address and return card.Mark reason for change. Address Renewal Employment �] Lost Card SCA 1 :5 20M-05/11 - �he Tparn�ma�urreat o��/ aaach"°eCt' License or registration valid for individul use only Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: W,jistration: ;t$2014 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 iration: =6f3[?7201:13 Private Corporation Boston,MA 02116 ERNEST B. NORRISii BON l � Craig Ashworth ` 138 Osterville W. Barnstable Osterville,MA 02655 - Undersecretary Not valid without signature • ry: N Hatch, Jenn From: ConveniencePayClientSupport@hp.com Sent: Monday, October 12, 2015,10:05 AM To: Hatch,Jenn Subject: Department of Public Safety Authorized Payment Confirmation This is an electronically generated acknowledgement of your payment to Department of Public Safety Payment. Please print this message or save it,on your computer for future reference. Here is your payment information; License Number: CS-015851 R Payment Date/Time: 10/12/2015 9:51:29 AM (ET) Payment Amount: $100.00 Convenience Fee Amount: $2.49 Method of Payment: Visa Card Number: ****3286 Confirmation Number:. 802115 t' - SearchResults Page 1 of 1 The Official Website of the Executive Office of Public Safe and Security, EOPSS Safety Y� ) Mass.Gov Home State Agencies Search Results I ' • Select the licensee name below for more information.'(If your search produced more than one page,•you may select page numbers at the bottom of this screen.) • Select the Search for a Person or Search for a Facility button to perform a new search. • Select the Preview File button to view a sample of the fields included in a file you can download: • Select the Download File button to download a text file of your search results at no charge. • Select Public Information Re guest Form for a form to order a data file. Search for a Person Search for a Facility Preview File Download He Name License Number License Type License StatusAddress SHWORTH CRAIG N CS-015851 lConstruction Supervisor Active JOSTERVILLE MA 02655 1 ©2011 Commonwealth of Massachusetts Site Policies Contact Us •http://elicense.chs.state.ma.usNerification/SearchResults.aspx 10/21/2015 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T IFICATE 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 PRODUCER AND THE CERTIFICATE IMPORTANT:if the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate doer;not confer rights to the certificate holder In lieu of such endorsement s . PRODUCER CONTACT r NAME: DOWLING&ONEIL INS AGCY PHONE FAX 973 IYANNOUGH ROAD (A/C,No,Ext): (A/C,No): E-MAIL HYANNIS,MA 02601 ADDRESS: 76RNJ INSURER(S)AFFORDING COVERAGE NAIC p INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA E B NORRIS&SON INC INSURER B: INSURER C: INSURER D: 138 OSTERVILLEWEST BARNSTABLE ROAD INSURER E: OSTERVILLE,MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMIDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE , $ COMMERCIAL GENERAL LIA131LITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR, REMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: POLICY E]PROJECT E LOG � GENERAL AGGREGATE �$ • PRODUCTS-COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE I$ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-2ER937OA-15 05/03/2015 W03/2016 X LIMITS ANY PROPERITORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED. N/A E.L.EACH ACCIDENT $ 500,0 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 ff yes,describe under DDESCRIPTION OF OPERATIONS below E.L;DISEASE-POLICY LIMIT $ 500,000 *^ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT ` VE HYANNIS,MA 02601 ; ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. .�elrrrz�ttsd�t�0,�'1�selustrl�arj�ltscxde'rrts �,�`��of XrrveSl��atla,i� - b'd� �r�s�rfn�'ars 5tr�et Bostary MA 02111 WOrkOrs' CoMPOnsA,don Insurance dav&: Blt>lflder�ICp�.tr��'tar�lEi�t ��lttlslPltt�F�e;� N l� e /Or iaatic�lndivirl Y�; IaiB Norris 8r 5on, Inc, Mdresa; 138 Ostervllle W. Barnstable Road City/State/Zi : Qsterville,MA 02655 � 508-428.1165 Axv you aA employer?Check the appropriate boxp 'Type afpYa�ect(re�s�lrecl); 1,� T �.a employer with� � � I aarz a aeaeara!acrutxxcstor alnd Z 6. �NOar��'t�aatloa ol�npicay as Cull andlor p ma).� have hired Nha�'mb shalt 2•C7 X an a sole proprietor or prmer, liete =the&Wwhed sheet 7. M R modelaag ship ad bavo as%;zalayeas 'These a b-cothatan have 8. (�l0ana0116013 vwbrkfng fcr'Ma in any oipatity, a»playeaff and have-Warkw, ENO Wcack='coup.i taurazsae aOxup,irtalmoe,t adA&n 1 mquired.:i 3. ❑ We eve a carparaft=d W 10.0 Elaatxical reps Or' a8d$tttma 3.❑ I am a haraeowmer doing all work Q cera havo ex=150d t'holr lalrurcbiag rerpwra or addidaus myself.[No vvorkam' comp. rirt of asxcupun par NML repairs Roof imsumoa regWrail t a. 132,11(4),awl we ha'vo� . 12.0 Roof 3 a•0 1 am a 1 owwwdar aa&,z as aemr loyeea.[No wo eral' - genetul ocm.tm too(raft to*4) *A;%y appJ1=f&t ti wkt b*x#1 twa alas Su atd the aw" W�aia w 3E�aw a slami�woxkmm'�oa>� ►u�y ia� am t Fp erm vft mhWt,dd%zMdav1t hq aftg thMY are dolug all,weak find dm him c;utRldc annon4taM'clmrk.atbjlt 4,10W MMdagl{t 1ndl tW1 MfL Ccut c t t8ue;ate l it hax m ed asust atua addRtfosai axz�sh0wjzg dw==of do a{►b-aonrr wm add a��vhdshee ter�r�tun osl�la fawn omployeaL tfthe sub-aaanaat 1=4 zmployr"S,*q=W pM**th&WD*C a'enm#•P034Y.11WAba. �"aarrr era a at aP�a#h,prnv{o";warlren"camrpmr<s�rt err In ursr�sce fbr empfaye Below Is daa patter arid—lob s?fe l"�prtye�sd�ra� Inmmuce,COMP247 NMa; Travelers Indemnity Com any.of America N114..4 or Self lb%,Lie,#: >UB-2E89370A-15 5/•3/16 m Bxpi��art l�ebcs _ ! sob l Adclraes. V L L0, Cikyltatolip: MA026565- Ash as aupp of the wta -�alr declargtl®a leaps(Showing the policy number axad r�xpiratl�on date'). ' i pailttt aectaz ccv ga a re�ciccd under eatio 2 A of UGL o. 132 can-lead to the imposition of anal pmaOW'go of a fne up to S I's0 -00 Md/orone*year'imprieatsrrx= a,I w011.33 CIA[peuakdes to tha fbrn df"a STO?WORX01DER izd a rme of up to$250.00 a day agar the violator. Be advised dmt a copy of this statement may be£orwsrdod to tho QZca of � fav'estip'l;lova of thrr DIA for instsmnco cavem&*'ve#c4to . i I o'er h arrrt r c rmtd rrsa,er&e pa Md p, o f p the firformablex prav1*d aba , i o z: 508-428-1165 O ld use of ►. Do not Nwid Poe I'M area„dd be coMpletrd'by ofty nr to*t o fie&L Cltly or Taut: Po►' Rltll:,ice�srm Issuing Authority{circle on@); 1"Boomd of lXealth �1.8����13a�a eer& �. CX+kytX'a Clwwla I.�l�aattrrlas�X I�slp+actnr 8,Fit�tt�bi lnataetmsa 4.c ��,y/�{yy��yyy��,,jf•,Penchi . - VIIVIUP�IAGRi IY VLAVABi IS'{�1YNAiW . .. �..•�+.i�^hNMM W Me W�wMi.+u W Mies WSYyY+•NYr W , IIMp{'s�ie•sayoMa•Inp E Town of Barnstable. Regulatory Services Thomas.F.Geller,Director Mass. , Building Division M . ....._ .... .. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 — ,;___ Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder A . l-lt/n teY ,as Owner of the subject property . hereby authorize E.B Norris and Son,Inc. to act onmybehalf, in all matters relative to work authorized bythis building.permit.application for . 76 Long Beach Road,Centerville,MA (Address of Job) 10-13-15, Signature of Owner Date D v rA rI Y -A Print Name Q:FORMWWNERFERMISSION I � � Town of'Barnstable *Permit# p� Expires 6 months from issue date Regulatory Services Fee . b n M'9' Richard V.Scali,Interim Director I . ta IT Building Division Tom Perry,CBO,Building Commissioner Air{ 2 4 2014 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 �' -8TA230 TOF A EXPRESS PERMIT APPLICATION - RESIDER 1,04 AL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2�w ®Q°� Property Address Qand ,.v T�jResidential Value of Work$ I���oi Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address S�rL^VATl yr J1 elt . 153 R 18A 0_y q Contractor's Name 1 �,,� Cow+,n.��� Telephone Number 5W qw WOO Home Improvement Contractor License#(if applicable) Email: jAh,nk, Construction Supervisor's License#(if applicable) CS—0_]Q Q g Workman's Compensation Insurance Check one: ❑ 1 am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name VA11yA�� � _I �� , eo, Workman's Comp.Policy# j 75703)P437-1�T Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side Replacement Windows/doors/sliders.U-Value (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. . r *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic;Conservation,etc. ***Note: Property Owner must signProperty Owner Letter of Permission. opy of the ome Improvement Contractors License&Construction Supervisors License is' required. SIGNATURE: TAKEVIN MBuilding Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 Massachusetts -,Department of Public Safety Board of Building Regulations and Standards Construction Sul)&N iso► License: CS-070086t Is {t DAMON L KENDAIL 48 KOMPASS DR e FALMOUTH Mir 0253 % , � ` ,1 0�� Expiration commissioner 11/2112014 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-083484 RONALD W W ELCI[i 85 BRIGANTINE-VR I HATCHVMLE MA O x >:.xpiration 92, 07/11/2014 commissioner `_,� tVl�ivrnrliucoit� - 1)rnoctntlnt nl'hulltir bat'rte . Office of Consumer.Affairs and Business Regulation t 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement; Contractor.Registration Registration: 128405 Type: Partnership Expiration: 4/5/2015 Tr# 240091 KENDALL & WELCH'CONSTRUCTION: DAMON KENDALL P.O. E30X 490 OSTERVILLE, MA 02655 - Update Address and return card.Mark reason for change. Address (] Renewril (� Tmployment [J Lost Card SCA 1 0 20W05/11 e Tpoalowlrzcuea`M,11P/&6acluoeCt Office of Consumer Affairs&Business Regulation License or registration valid for individul l�tse only , OME IMi�ROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 128405 Type: Office of Consumer Affairs and Business]tegulation 10 Park Plaza-Suite 5170 Uxpiration:_:.4/5/20;1:5= PartnershipBoston,MA 02116 _ KENDALL&WELCH 6NSTRU(;fiION DAMON KENDALL MPASS DR. e� t , -54 KO ___ FALMOUTH,MA 02536 'Undersecretary Not valid without signature 77ie C'onutionwealth of Massachusetts Domain of Industrial Accidents Of ice of Investigations ' 660 Washington Stmet Boston,MA 02111 nvvty.tnamgov/dia Workers' Compensation Insurance affidavit: guflders/Contractors/E•Iectdcians/Plumbers Applicant InfolMatiGR Please Print Lezibly Name(Business/Organ on viduai) e,16( Address: -32 �, A,.,-,, Avg City/Sta&Z p: 1954f2y1 Ik, 1'►'0 A 62 425- Phone- ow— oo Are you an employer?Check the appropdat boa: Type of project(required): L IN I am a employer with� � I am a general contractor and I 6: ❑New construction employees(full and/or part-time).* have hirer)the sub-contractor 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and live no employees These sub-contractors have 8. ❑Demolition w for me in capacity. employees and have workers' working any apa ty. [No workers' comp.insurance comp.insurance: 9. ❑Building addition requited.] 5.. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised fir 11.❑Plumbing repairs or additions myself [No workers'comp: right of exemption per MGL 12.❑Roof repairs insurance required.]3 c. 152, §1(4),and we have no employees.[No wormers' 13®1Other wL l � comp.insurance required.] • a titan that checks tax#1 amst also fill mar the section below a ' �Y PP slgoaring.ahe workers campemsatiompol6cy i�or�t@on. i , Iiomueowaers who subnret ehisaffidavit imdecating They are doing all wok and then Lire outside toatracrors mast submit a an,sffidesit indicamag.such tContmctors that chad&this box must attached am add taoaal sheet showing the name of the sub-conuxtors and state whether or not those enifies have employees. If the sub-contactors hwe employees,they nmst provide them workers'comp.polky number. I een an eenplo.vr that is proW&W workers'conW msadon insurance for my ernq;loyees. Bedow is the policy and job site ieefbnuation / Insurance,Company Aflame: Policy#or Self-ins.Lic.#: Expirat on Dater Job Site Address: 7 b L DNa tsc JC 17�D C� cityJState,zip: Co.' Attach.a copy of the workers'compensation policy declaration page(showing the policy member and expiration date). Failure to secure coverage.as required under Section.25A of MGL.c. 152 canInd to the imposition of criminal penalties of a . fine up to$1,500.00 and/or one-year imprisonment;as well as ciNil 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 fao ' e:coverage verification. I do herek� erh.&,render thepains.an penalties of perjury that the inforrantion pros ded pbOVAS bare and correct Si Date: n� Phone#: c� Official use only. Do net write in this area,to be completed by city or looms official, City or Town.: PermitUcense if Issuing Authority(circle,one):: 1..Board of Health 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ik ghtfax N2-1 3/17/2014 8: 17: 57 AM PAGE 2/002 Fax Server CERTIFICATE OF LIA13ILITY INSURANCE DATE(MM/DD/YYYY) QERITIF IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATVE PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME: MURRAY&MACDONALD INS PHONE FAX 550 MACARTHUR BLVD (A/C,No,Ext): (A/C,No): I E-MAIL BOURNE,MA 02532 ADDRESS: 75NHN INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY KENDALL&WELCH CONSTRUCTION INC INSURER B: INSURER C: INSURER D: PO BOX 490 INSURER E: —� OSTERVILLE,MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: _ THIS S TO C15ATIFY 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE: AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MM\DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $PREMISES(Ea occurrence) ED EXP(Any one person) $ GEN'L AGGREGATE LIMITAPPLIES PER: PERSONAL&ADV INJURY $ ENERALAGGREGATE $ POLICY PROJECT[ LOC'. PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X I WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-5033P435-14 02/06/2014 02/06(2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE p OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT Is 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 1$ $00,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.. AUTHORIZED REPRESENTATIVE HYANNIS,MA 02601 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPO iT" llts reserved., �ti seartsrnB> . 059. Town of Barnstable Regulatory Services Richard V.Scali,Interim Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,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 A Builder I, SAJt#*rt 90VTeK as Owner of the subject property hereby authorize A[ -a"1( A eft{ �Ys�w`1 t� to act on my behalf, in all matters relative to work authorized by this building permit application for: e7,� ® d ddress of Job) . Gt%t14 . Signature of Owner Date r Q h Uk?l CY` Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. TAKEVIN Muilding Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 p THE T ToBarnstable wn of py ti Permtt# Erpires 6 mont!s from issue date G Regulatory Services Fee II BAMSrasLE, t y MAss. i639.. `�� Thomas F. Geiler,Director Jra Building.Division �K Tom Perry, CBO, Building Commissioner- 200 Main Street, Hyannis, MA 02601 www,town.barns tab le.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY No/Ya1id without Red X-Press imprint- Map/parcel Number �� / `�o C7 . Property Address 'Residential Value of Worl Minimum fee of S35.00 for work under$6000.00 . Owner's Name &Address . I�tlf tak i . S't�t t4UA C_ r Contractor's Name ��� f-S lf— Telephone Number. Home Improvement Contractor License#(if applicable)' Construction Supervisor's License#(if applicable) t 6- 1 LlIT / ❑Workman's Compensation Insurance Check one: APR I am a sole-proprietor lam the Homeowner ���N ®F �����STL���� El have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. 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/doors)sliders. U-Value CtPSO ✓r #of_doors (maximum .44) of windows Where required: Issuance of this permit d snot exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. . ***Note: Property must sign Property Owner Letter of Permission. ' A copy t ome Improvement Contractors License& Construction Supervisors License is requir SIGNATURE: QAWPFILEST0RMS\building pe i ormslEXPRESS.doc Revised 070110 The Commonwealth of Massachusetts Department of Industrial Accidents, . Office,of Investigations - 600 Washington Street . " Boston,MA 02111 01a/ r AM Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant InformationA Please Print Lelzibly 0 Name (Business/ ization/lndividual): Pc /� U Address p � City/State/Zip: �Ll Phone #: Are you an employer?Check the appropriate box: Type of project(required)`. ].❑ I am a employer with 4. ❑ I ain a general contractor and 1 - 6: ❑New coristructiori employees(full and/or part-time),* have hired the,sub-contractors 2. 1 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 required.] officers have exercised theira. 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right'of exemption per M.GL 11.0 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' /• comp. insurance required.] 13.❑ Other lr� -S *Any applicant that checks box#t 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: Policy#or Self-ins. Lic.#: Expiration•Date: Job Site Address: City/State/Zip:_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.-152 can lead to the imposition of criminal penalties"of a' fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. .advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insuranc erage verification. I do hereby certify under s nd penalties of perjury that the information provided above h'true and correct Sip-nature: Date: Phone 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.CityrTowti Clerk 4. Electrical Inspector,5. Plumbing Inspector ; 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ee ' de i ed as"...eve person in the service of another under an contract of hire Pursuant to this statute, an employ is fn "...every p y , 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 riot more'than three apartrnents 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 uch'employment b deemed to be an employer." J , MGL chapter,152; §25C(6)'also states,that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or.to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy'is-required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 Tel..# 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia T s ro ti Town of Barnstable ' Regulatory Services i f , i MAsr �, Thomas F. Geiler,Director 16Building Division C Tom Perry, Building Commissioner 200 Main Street Hyannis,MA 02601 www.town.barnstabie.ma.us Office: 508-862-4038 Fax: 508-790-6230 - g Properly Owner Must Complete and Sign This Section If Using A Builder I, ,�� v✓� , as Owner of tfie subject•properCy herebyauthorize '/f .1,n e to act on my behalf, in all mattes relative to work authorized by this building permit application for. (Address of Job) ,3 Signature of. Da Print-Name If Property Owner is applying for permit please complete. the Homeowners License Exemption Form-on .the reverse side. Town of Barnstable �ofVE r � H� Regulatory Services D . SrAB Thomas F. Geiler,Director BAMLF— h sr. �+ A. Building Division r,fD Tom Perry,Building Commissioner 200 Mairi.Street,_Hyannis,MA.02601 www.town-barnstable.ma.us Offi6e: 508-862-403 8 Fax: 508-790-6230 HOWOWNER LICFNSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER". name home phone# work phone At CURRENT MAILING ADDRESS: eityRowo state up code The current exemption for"homeowners"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. DUINTrION OF Bum LONVINTR 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 constrgcts more than one home in a two-year period shall not be considered a bomeowner. Such "homeowner"shall submit to the Building Of5cial on a form acceptable to the Budding Official, that he/she shall be responsible for all such work performed 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.be/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 Burlding,O1icial Note: Three-family dwellings containing 35,000 cubic feet or larger 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 peson(s)for biro to do such work that such Homeowner shall act as supervisor." Many homeowners who use this cxerrrption are unaware that they are assurning the responsibilities of a supervisor(see Appendix Q, Rulcs&Regulations for Licensing Construction Supervisors,Scction 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 is Supervisor is ultimately responsible. . To ensure that the homeowner is fully awwu ofhis/hcrrespormbilitics,many communities require,as part of the permit application, that the homeowner certify that hrlshe understands the responsibilities of a Supervisor. On the last page of this issue is a.form currently used by several towns. You may care t amend and adopt such a f6nTVicertification for use in your community, s� ✓fie ✓lf r \ Board of Building Rcgulalio sand Stand ads,,. R License or registration valid for indiviJul use ouly HOME IMPROVEMENT CONTRACTOR before the erc!.riration(Inte. If found reiarh to: ` Board of Building Regulations and Stan lards Registration, 155997 1 Expiration One Ashburton Plac m 1301 0/2,`;2011 Tr# 28356 'Type Pr M.ate Corporation Boston,Ma.02l i Yx� i D I I"•.EALTY GROUP INC FATE ISENSTADT •'' 55 l EKE"AVE. .�G-x�...�_ __�I IaYr..1;fIc Onm- MA 02647 Administrator o valid without signature Massachusetts - D�pa►trncnt of P Board Of Buildin« ublic Safet, Construction"SR(Mutations and Stand, pervisor irds License: CS License 98149 � • TATE ISENSTAD7 PO BOX 796 + HYANNISPORT MA 02647 ('unm�issiuner Expiration: 3/24/2013 Tr#: 10982 I i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map o� � Parcel 9 ASS Permit# Health Division Date Iss d Conservation Division Fee �� d Tax Collector �h y/�/�� Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis 0 'Project Street Address L S i Village (' CIA/1- -v Owner 'XA rn.es kh i zGkA-L� 6 Address `� 0(�Wk `U-ty . 0 R, Telephone Permit Request �G —✓�d7J C;2,0 1 PPr M�S Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation 1`10;0 61 Zoning District Flood Plain Groundwater Overlay Construction Type �Z,coQ )e!;%, : Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family > Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full N(ravel ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: N(Gas ❑Oil ❑ Electric .❑Other y Central Air: ❑Yes &No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed: ❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name P=12 kem- 6L',P��� Telephone Number zl Z o— b 8S0 Address do*-e*�e-!)�Lam✓ License# ��Y Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT,WILL BE TAKEN TOw� SIGNATURE DATE FOR OFFICIAL USE ONLY . MIT NO. t. r DATE ISSUED MAP/PARCEL NO. Q4 ADDRESS VILLAGE y. OWNER Y ' DATE OF INSPECTION FOUNDATION FRAME � )' -t �.. • r INSULATION FIREPLACE .. ELECTRICAL: ROUGH FINAL 4 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ` The Commonwealth of Massachusetts - -- � Department of Industrial Accidents 600 Washington Street Boston,Mass. 02111 ! Workers' Cam ensation Insurance Affidavit �/��%�/j/�%" name city C,,Z- lam �E Oz6 3 z— phone � no G I am a homeowner performing all work myself. -s�I am a sole pro rietor and have no one working in any capacity ///%//// /% %%%%%%%%��%%//%%/%/%%%%%///%%%/%/////%%%%%%/%��%/%%///////i�//// %/////////%/%%/%//%/%%/%%%/%�%%%%�/%%�%%%%�//r/..%,,.: I am an emplover providing workers' compensation for,my employees working on this job. cornonnv name: address: .:. ... .. .. ... . one.# city: —_ msurancc en _ oiicv# I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the follo«zng workers' compensation polices: -- comnanvname: address: �._.: � _ :. .:•. hone•ix city: _. :.:•. :.:" ::.:. .......:.. :...:......:.:.:.:.. msornnce co. pricy# / .::::.:..... .. .: .......:.::::::::v::::::::::..:::.::....:::::i::i::�:::::.";.:: :::.::is::ii'iii:'.iii: i:;:;:�:i: •>:i`.::�-i:ii:;:iiii:�.r:i::vi?:i::::::: :�.::f.�`:•:Iiii iii:��:�i:.}ii::•::::.::.. comnnnv name: address: cit4 :::...:.:. insurance co. / ��// > , Failure to secure coverage as required under Section 25A of MGL 152�eawleid to the imposition of criminal penalties ga a fine up to understand that or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Me of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification. 1 do hereby cerrify der the p and penalties of perjury that the information provided above is true and correct Date Signature Print name Plane# 4 otaci:l use only do not write in this area to be completed by city or town officialpermit/license# ❑Building Department cite or town: ❑Licensing Board [3selectmen's Office ' ❑ check if Immediate response is required ❑Health Department phone 0; (]Other contact person: 1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for heir d from the"law",an employee is defined as every person in the service of another under any contnac employees..As quote 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 trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apart and who resides thmwn, 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 c building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renes of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h: not produced acceptable evidence of compliance with the insurance coverage-_required: Additionally,neither-the shall enter into any contract for the performance of public work until commonwealth nor any of its political subdivisions acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contaac=-- authority. Applicants completely,by checking the.box that applies to your sitaation and ', r Pleas fill in the workers' compensation affidavit -- s supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be Accidents . of insurance coverage._ Also be sure to-sign and submitted to the Department of Industrial - lication for the,permit or li a is- date the affidavit. The affidavit should be returned to the city or town that he.app.. `, have aay,questi the"law"or if yc being requested,not the Department of Industrial Acciden$. Should Yon °�_ . are required to obtain a workers' compensation Policy,please,call.the Department at the number listed below" City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of t has to contact you regarding the applicant. Please affidavit for to fill out in the event the Office of -- affida You be sure to fill in the pen�t/license number which will be used as a reference number. The affidavits may be returned io eats the Department by miff or FAX unless other inningem have been made. The Office of Investigations would low to thank you in advance for you cooperation and should you have any questions. please ease do not hesitate to give us a call. The Department's address,telephone and fax number.. The Commonwealth Of Massachusetts Department of Industrial Accidents 0MC0 ofInvestl0atlons 600 Washington Street _ Boston;Ma. 02111 - far#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 EVE rq� The Town of Barnstable 9 K Department of Health Safety. and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-862-4038 Building Commissioner Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPUCATION MGL c. 142A requires that the"reconstruction,a>terions,renovadon'mPai4.modernhation,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to sttuctues which are adjacent to such residence or building be done by registered cm=Ctors,With certain exceptions,along with other requirements. Estimated Cost ewe- Type of Work:� p � � Address of Work: Owner's Name: T,4 t,,�o < j/I1 Date of Application: 9�z4x< I hereby certify that: Registration is not required for the following resson(s): Work excluded by law oJob Under S1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: DEALING WITH UNREGISTERED G THEIR OWN PERMIT OR APPLICA13LE HOME _ OWNERS PULLING WORK DO NOT HAVE CONTRACTORS FOR ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. ACCESS TO THE SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contactor Name Registration No. OR Date Owner's Name } , h -Tr r I ffill . • M t t , ' REVIEWED t NOV 17205 Town of.Barnstable - Historical Commis sion . � ( - - ---...- - ----- ____•b. t a. RECEJL m u'D i. 1 n 1 —Errr Puru,. V rY� i _ r _ D f 1` vI —= w F D, •v o r h . �! 0, r 17, t4 V Al C Z O r � o - y M a, P R J D ti o n sp to . D � a f i " S •a 4 � Qj . clo E r � 1 t u E f I ,E i a l /I, I i , 1 ' y 1 � 1i� ti t I •• + a 2 E 9 a , } f ti . i , i P i • zi IN 1, IN. a e ! !' ijij I s . �t''1 �\ In .. ................. i ! ' ` _ � J 371 . !" 6 i 1 1 , : +� `V ASCO 3 - tip I�� `` � t �:: � � •. 4 4l, ' 'r! i I M F dam.•.' � - Qi , z — 1 -" trN . r ILI I � � .. - - - - .I � .. 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