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0098 LUMBERT MILL ROAD
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F1WHE Town ofBarnstable *Permit#b ^ " Regulatory Services Di ee 6 °rah °"" ate i sexNsrAsM, *' 9 MASS. $ Richard V..Scali,Director �A 0;9. . o�+ Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.towmbamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number q g 106 Property Address 1 L UMh er+ /411 J/ i\j CM T-fP I a % ✓414 o ,®Residential Value of Work$ 11013, 00 Minimum fee /of$35.00 for work under$6000.00 Owner's Name&Address / /Ct 0 h- J //4A,C • We /Xv. _ r 1� � o Contractor's Name �� C��.� � �C i6® 6 a 7 Telephone Number -77s- V-?RS Home Improvement Contractor License#(if applicable) Email: �(N �lef f ff tc6m�4 Construction Supervisor's License#(if applicable) CS 0 " 3 b 'g[Workman's Compensation Insurance Check one: ❑ I am a sole proprietor JUN Q 2. 2017 ❑ I am the Homeowner I have Worker's Compensation Insurance- TOW,N OF 8A R N ST ABLE Insurance Company Name [: / �t'/7t V l y D Workman's Comp.Policy �/# C a 3 I �(a IO I� r v 1 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.32)#of windows #of doors: *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q;\wPFn ES\FORMS\building permit formsTMRESS.doc 01/25/17 Y Town of Barnstable Regulatory Services ` INAM Richard V.Sca14 Director - s639. Building Division. , . Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder e ,as Owner of the subject property hereby authorize J Clef 74C to act on may bebal� in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools �s. are not to be filled or utilized before'fence is installed and all final- .inspections are performed and accepted. ignature-of Owner Signature of Applicant 'Y�/J�l E"!�' ���c/✓� S fie/ C.. rPJC�PII Print Name Print Name Date Q:FORMS:OWNERPEP MISSIONP00L5 Town of Barnstable Regulatory Services Q1F Richard V.Scali Director Building Division- sr►mvarwsu. * Paul Roma,Building Commissioner KAM 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: ,.JOB LOCATION: number street village "HOMEOWNER": - name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"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. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildm9 hermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,ruffles and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner • 1 Approval of Building Official 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 person(s)for hire to do such work,that such Homeowner shall-act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing.Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:IWPFII.ES\FORMS\bui1ding pennit formsTXPRESS.doe 06/20/16 4 The COMMMrWenkh ofmalyackupws w Department rrf'y &idAccidwrtg f} ce-of tit erns. 690 Wadiu eon met Bastona MA 1721H tpry-nmamgarla W,urIe' Compensation Im-arance Affidz' 'BuiexslC�antracWr--)MwU-«inn rphmmbers APPHcznt 1m[fa=z6nn Please Ilia E Iy +Tame - C�<S �C Are you an emplayer?Cbeekthe appropriate baarfect L�I aorta 1 nith 4 ❑I am s gemx9 ca:d sctar andI 6. 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INO wodM&comp-msarance camp-k=Mn p reclaimed_] 5.El We are a corpomtionand its 10-❑Elechicai repairs or adaGaas. officers h=eserr-ised thEir ' 3.El ama hrrmeau�doing all 11-0 Phumbiagrepairs or additia= MyNd'[Na woXIMM•comp- xigbt of era mpHm per M-GL ME]Iioafrepxis c.M§In and.wehweno employem[No wodne& tees comp.insmxmw nxuised.] �apxpg€r�r�+sra�et�s�az�lmastaLsasnor�the�hnabrlmv�esva��e¢,uadces"c�pe¢�Lnapercgia��saaa _ �eoaneawha saimt das ammd&mhiv--out idecnata "m t sahmit a new affida8t is og saCTI- ICa�rmcs�si cT�c3c is box I -st,ttachrd: sddid—A shea slioxdngtimn—of ft orb-�sxmd stafexhesher arnotthu se m7raksi s¢ employees.Tfftmb- slue empIv s,�ey�stpmside their •�P•P Tam an eugPlasr that is prauidii ti ckets'cotap tsr�ian grsriraaagccs jar m�eurPla3xex HeIoiv is iiiapo cy m d jab sda informr�aa. �A . Tssi r mCampany-Mkne: /6e/ FORLy 41,err Self-inL Ii ,�t. IN 71 J � � T®'/, Expin1fMnDate- l Job 1efiddtess �(� L U/�'1��y 1 f �� C ylStafet p_ jle Af#ach-a—copy of fie workers'campensationpohry&cTaratioa Eager(showing tbs policy ber and expiation dam). Faiil=e to secure covmmp as requirednnder Sew 25A of MCI.c 15-7 can lead to the imposition of criminal penalises of a fore up#a$L50D 0D andfar orie:yeazimpdsor meat as well as csv*tl penalises nor the farm of a STOP WORK ORI Mand a fine of up-to$25M a day 26-aimst#fie violator. Be scUised*91,d a copy of tbis,statement maybe fos�to the Offi�e of Investigations ofttie DJA for ins=aw coverage veriffaaham. . Ida herzby csrlify under diapmns andpsne&w o,jpffjury tfiattfis ire, omzaftupraP& d aPm e is hiss rnid correct Phone A: 7 Orwud we wff �a lust Evlife in areQ,tat be cvmpT tad by city rartolm dal': City or Taww ". 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U■�■ : /at w•4 1' �.a•It ...■ Y.► ■ILO■r �•i11.1 mill wm i 111113i.V1/ ' c y■ sail . ■ • •._ . ■ ■ �1 i ��.IJIn■■• 1921 1 C• :r_1 - s • —• 1 c■.x • ■ • firs oATE(MM/ADmYY1 ACC CERTIFICATE OF LIABILITY INSURANCE 05131/2017 THIS CERnFlCATE I8 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(8), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. N SUBROGATION l8 WAIVED,subject rA 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 ando►seme a C.-e yy Scott Kerry PRODUCER - N E: - KERRY INSURANCE AGENCY PHCCONe 5De)25S8o0o Fac Nv: Er,,ass: scott kerrylnsuranae.aom P 0 Box 1945 INSURERS AFFORDING COVER-SE NAM O N.EASTHAM MA 02051 INSURERA: LIBERTY MUTUAL FIRE INS CO 23035 INSURED P INSURER B: S CRES INC INSURERC; .. INSUR4R0= 195 PINE STREET i INsuRER E: CENTERVILLE MA 02632 INSURER F: COVERAGES CERTIFICATE NUMBER: 159431 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. INBR LICY EFF FICY E LIMITS TYPE INSURANCE O PoLICYNUMBER M D Y COMMERCIAL QRNRRAL LIARILITY _ EACHOCCURRENCE 3 CLAIMSMADE OCCUR P MISES E8oc nance S MEDExP An oneDarson 3 NIA PERSONAL 6 AOV INJURY S GENERAL AGGREGATE S GEN%AGGREGATE UNIT APPLIES PER: _ - JERGOT ❑ PRODUCTS•COMPIOPAaG Y POUGY LOG S OTHER: 01,15 DS LE LIMIT g AUTOMOBILE LIABILITY Ea ac nt BODILY INJURY(Per Pelaon) S ANY AUTO BODILY INJURY(PS(ecotdard) S ALL OWNED SCHEDULED NIA ALMS NOM.OWNEO Pere.RTv g HIREDAUTOB AUTOS S EACH OCCURRENCE S UMBRELLA LIAB OCCUR EXCESSLIAS OIAiMS.MADE NIA AGGREGATE S f DED RETENTIDN$ v SEER TA ETH- WORXERS COMPENSATION X AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT 4 500,000 ANYPROPRIETORIPARTNERrEAECUTIVE NIA NIA. NIA WC231 S610224017 04/19�2017 04/19/2018 A oFF10EFUMEMBERERGLUDEo7 E,L.DISE OE.EAEMPLOYFG t 500.000 aro in NH - - Mend rY ) ( Ir s.5D0,000 If yyes,de®crDe und¢r _ E.L.DISEASE•POLICV LIM DESCRIPTION OF OPERAnONS below NIA DESCRIPTIDNOPOPERAnONSILacAT*N9/vI:MCLES tAcORDIOI,AaahtonYlRam.rkeaenaduk,nmyeaatlnoheeMman,epacalsreQVlroCI Workers'CompensMlon benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authari2atlon 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 certlflcate of insurance shows the policy in force an the date that this certificate wag 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,rnase.goollwd/workera comPensaWn/invesilgations/. CERTIFICATE HOLDER CANCELLATION •CAN D OF- FORE E ABOVE DESCRIBED POW CIEs BE CELIE THE E ANY OF THE ED IN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DElIVRR ACCORDANCE WITH THE POLICY PROVISIONS. Town bf Bamstable 200 Main St AUTHORIZED REP RESeNTATME Hyannis MA 02601 Daniel M.Crohey,CPCU,Vice President—Residual Market—yVCRIBMA 0198"14 ACORD CORPORATION. All righte reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD r. ' �JG—YIP Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5.170 Boston, Massachusetts 02116 Home ImprovementQ',actor Registration P Registration: 160627 Type: Individual z Expiration: 8/8/2018 Tr# 290900 STEPHEN W. CRESWELL STEPHEN CRESWELL o 195 PINE ST a �; CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change. SCA 1 e: 20M-05/11 ❑ Address Renewal Ej Employment Lost Card (9�ie Won�YaoaiacueaCC1b 11a&4aac1mmeC� Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration MN160627 Type: Office of Consumer Affairs and Business Regulation li '• 10 Park Plaza-Suite 5170 Expiration.F-=8&8t2018 Individual Boston,MA 02116 STEPHEN W.CRESWELL', STEPHEN CRESWELLI/�/ 195 PINE ST �.�.,�/ :._�._y:-�•.,,.�,.�._ CENTERVILLE,MA 026 J Undersecretary Not valid without signature r Massachusetts Department of Public Safety Board`of Building Regulations and Standards License: CS-076536- Construction Supervisor STEPHEN W CRESI�IELL.>� 196 PINE'STREET t, ' CENTERVILLE MA 0263'2 s Expiration: 0812712017 Commissioner to Mass. Corporations, external master page Page 1 of 2 at Corporations Division Business Entity Summary ID Number: 465557328 Request certificate New„search Summary for: S CRES INC The exact name of the Domestic Profit Corporation: S CRES INC Entity type: Domestic Profit Corporation Identification Number: 465557328 Date of Organization in Massachusetts: 05-05-2014 Last date certain: Current Fiscal Month/Day: 12/31 The location of the Principal Office: Address: 195 PINE STREET City or town, State, Zip code, CENTERVILLE, MA 02632 USA Country: The name and address of the Registered Agent: Name: PETER M. DAIGLE, ESQ. Address: 1550 FALMOUTH ROAD SUITE 10 City or town, State, Zip code, CENTERVILLE, MA 02632 USA Country: The Officers and Directors of the Corporation: Title Individual Name Address PRESIDENT STEPHEN W CRESWELL 195 PINE STREET CENTERVILLE, MA 02632 USA TREASURER STEPHEN W CRESWELL 195 PINE STREET CENTERVILLE, MA 02632 USA SECRETARY STEPHEN W CRESWELL 195 PINE STREET CENTERVILLE, MA 02632 USA DIRECTOR STEPHEN.W CRESWELL 195 PINE STREET CENTERVILLE, MA, 02632 USA Business entity stock is publicly traded: ❑ http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=465557328&S... 6/5/2017 r Aass. Corporations, external master page Page 2 of 2 The total number of shares and the par value, if any, of each class of stock which this business entity is authorized to issue: Total Authorized Total issued and Class of Stock Par value per share outstanding No. of shares Total par No.of shares value CNP $ 0.00 275,000 $ 0.00 1,000 ❑ ❑Confidential ❑Merger ❑ Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Administrative Dissolution ' Annual Report fill Application For Revival Articles of Amendment View filings Comments or notes associated with this business entity: New search f , http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=465557328&S... 6/5/2017 Town of Barnstable *Permit# A &a,3 73 0 Fapires 6 mouths from issue date Regulatory Service J Fee �� IARNSTABLE, * 9 �4�� �— MAW $ Richard V.Scali,Director �Own RFD(�IAr p Building Division A% 17 ?D16 Tom Perry,CBO,Building Comn !@*, `' OF 200 Main Street,Hyannis,MA 02601 Il)p� "STABLE www.town.bamstable.ma.us A D L E Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number 6 Not Valid without Red X-Press linprint �lp$ -- ��Property Address 9 L Lf'? her f 1p7t ll k a • eeA (er t/t / Residential Value of Work$ 15-6 31 — Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address rq/l K b« t (mil, it 2d. C'P4f��v IP M to Contractor's Name '/l vt JAQ2/1 ( 4tspI7 Telephone Number(qo f,� Home Improvement Contractor License#(if applicable) S Email: Construction Supervisor's License#(if applicable) QCj 5 7 a 7 [IWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ L46 the Homeowner I have Worker's Compensation Insurance n Insurance Company Name C ja t` Workman's Comp.Policy# WZ 19 313120 f = Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value • 30 (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property caner must sign Property Owner Letter of Permission. A copy cKthe Home Improvement Contractors License&Construction Supervisors License is require � o SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet FilesTontent.0Utlook\21`101 DHR\EXPRESS.doc Revised 040215 Agreement Document and Pa mentTerms _ Iliaa l. d iettih�:ES�aiuiMA tM tma1 Napeu a Mrr Pa r��4tiF' i L Pill Rd RI P Ntll#� i ' p f 4 �p '". 1 °Ceow Ilex t 02632; .. 11i ate C,iocon re )SirectAdArm,'94 Wbtri M 1,11 MA 026 : Ptiifftir !O,cp fte-Number. 000911MIt NuriiL+ks �u Gal hea ay" tntlly 'to pt� l r, t�1e pivdu (hndlot sc vIi i.6 Qf,Sbu 6ft .N n W WIt d a i ti dl l f r it tJf tri clic ra+r iti$� a irt�S I:O &�p o�w&brdae r4ih the ad mii c li5 cei�ac�l I-ti t#ila ll c inan;t Order cci pc}`,10fm OiA Co6-4W0MS 6f Sklg,$plea t a,VIfi .ro t6AO r (mother n r, tt lui°d chiiApcc nt: mcnt,the ill aft ad:nra' t arad tvi�rarp+i l l.r�lei f�eatr $ ll a ,tW" ritiinc',).Si ;}OAl hn*'4ret w!job t%mount: $ 1e '1 11 Ind A 15 aswMcIItE Y00 kdra (Imt fJw ,Mmcc I)w,W itlim A-PtiAt l±linid mare�► I '�ei�rta.'I. lk} € . lx or cwh. I , lt t R ILIA Des., SUM E.ttii t&d-Start, COMPll 611: t �irrs PinrF 4 l li6d of P'ayritt:rit: ,. A Wh ` 6[gym bwcd'taW&doge€f the 4ipa Omi tilt(M.d WOO&MY CbP eli lea( Ili p1dt ohm i ltel�l. h ay "lam hiftaaltat6ratri rat that TAX In Berrtdtsb1c_ are pro ett�ar this tlnrrt l�' ly�fi c�tittiii� �gill�rt�r�isnicatc era� lei tLire deposit 55 t�tap'mint ad tbw at,a btcr dattu. Ma AndL�ticta at wvathew an the mos9 fie�nitriiaii balanco,due upon Ompletione r bnyev )a tend.tindwj6 & the. _ Litt c6Mtlti the c ijts ' tea hall citi tl pai tic rl t i ec a und- sari nil r.'. i lrti ®y�fttr t os s t 9 `.rant d�a wfacf r►wto or del-nerd ,this �t w�i�1 16 :r wit bmcheiigiwd,wrifttnicom cmt` b the g fi r )ind n r Dw" r� � +r t yca �l) � d t q�d h� t i it cM C .�� � add da l'c tlta rvrt!attar a r�tl tsf �nc6l tl, tI dA fir�t;.wri ri mid uaa ealik Informed of SwjcA*t to;ganc NWIC'.>v:TO MN I heir Alm - a Ounclut irblank., w6dilt=a i6,:k cm, !�j?'.�dic .ritra 'at th't iwt y4w n4m, OF 0911012016,ORTHETHIRD BUSINESS DAYAF MTHEDATM OF THIS N M; WHICHEVER DATE.ISIATEFLSM THEMACHM,NCITICE OF CANCELIAnION FORM FOR AN '' Cma�tt ' a; `•arc �� _� �- r - �1pliiat �rS&Laoi� . . _.. `_.SlRiiraGi�tct°• S3�ii�tti�" e A Nof -Pimbin Niffli Southern New England Windows d.b.a ' Renewal by Andersen of SNE I Massachusetts_Department of Public Safety Board of Building Regulations and Standards Constructioal SuperFbior i License: CS41195707 _f n. BRIAN D DRNNi�N 7 LAMBS POND 2R- Charlton MA 0107 Expiration Cornm ssioner 0910812016 I I Office of Consumer Affairs end Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: suppietnent Cab Emiration: 9/192016 SOUTHERN NEW ENGLAND WINDOWS LL DENNISON BRIAN 26 ALBION RD LINCOLN,RI 02865 Update Address and return card.Mark reason for change. .rl Address ;Renewal Employment ❑Lost Card scA,.a wswam ���ua.rraavcar.�G6 c��a ce of Couaemer Attain&Badness Regulation License or registration valid for individul use only E IMPROVEMENT CONTRACTOR before the ezpiratios date If found return to: Office of Consumer Affairs and Business Regulation aglstratlon: 173245 Type 10 Park Plara-Suite 5170 Expiration: 9119=16 Supplmnem:,ard Boston,MA 0I116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON _ (— pENNISON BRIAN r 26 ALBION RD _ LINCOLN,RI 02865 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents > I.Congress Street,Suite-100 a Boston,MA 01114-2017 wwwmassgov/dia Workers'Compensation Insurance A.ffidavit:.Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organizationtlndividual): (.l, f V) �o WA Addless: �plD� - City/State/Zip: 011>- S� Phone#: Are you an employer?Check the appropriate boa: Type of project(required): 1.;9 1 am a employer.with #20tenployees(full and/or part-time). 1. New construction 2, i am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3:Q I am a homeowner doing all work myself..[No-,vrkers'comp:insurance required.]t. 9. El Demolition 10 E]Building addition 4 f❑I am a homeowner and will be hiring contractors to conduct allwork on my property. I will ensure that all.contractors either have workers_'compensation insurance or are sole 11.❑Electrical repairs Or additlorts proprietors with no employees. 12.0 Plumbing repairs or additions 5f-1 1 am a'general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROt)f repairs These sub-contractors have employees and have workers'comp.insurance. t 6.❑We are,a corporation and its officers have exercised their right of exemption per MGL c. 14. Other t,J I'AC(0 152,§1(4),and we have no employees.[No%vrkers'comp.insurance required.] 're, v 14 tt^ e/L � S *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 1 t H omeowners 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 thepolicy and job site information. �esff;RA.)Insurance Company Name: C 0r� Policy 9 or.Self-ins.Lic.#: Expiration ate: /Z 6:7 r �1 Job Site:Address: U/n be M l (I I? City/State/Zip: CAlI' efi/r lI,e. Mtn+ e Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure.coverage as required underNIGL c..152,§25A is.a criminal yiolation•punishable by a ene up to$.1,500.00 t 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 00A t. day against.the violator.A copy of this statement may be.forwarded to the Office of Investigations of the.DIA for insurance coverage verification. ' I do herebycei ' ruder the rs arrd enalties o er•a that the in orruatiort provided above is trtie:and correct. P P fP l +T f. Signature: Date: ( 7— c� 1. 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#: r; SOUTNEW=01 UOLLINGER ACORO" DATE(MMIDONYYY) CERTIFICATE OF LIABILITY INSURANCE, `.. 6/29/2016 , THIS CERTIFICATE IS ISSUED AS,A MATTE R 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 WT CONSTITUTE A:CONTRACT BETWEEN:THE'IS' G INSURER(S),AUTHORIZED'. 1. REPRESENTATIVE;.OR PRODUCER,:AND THE',CERTIFICATE.HOLDER:` IMPORTANT If the certificate holder is an-ADDITIONAL INSURED;;the poll)y(!as)must be endorsed.of SUBROGATION IS WAIVED,subject to the tsrtns and conditions of"aho policy,certain poticle may require an endorsement A statement on th{s certificate does not confer rights to tfie. 3 - certifl6i6:h6lder in Ileu of such•endomement(s) PRODUCER. CON ACT NAME. COBiz Insurance,Inc.-CO PHONE. FAX 821 17.th'-St AIC.No Ext:(303)988-0446 Arc No .(303)988-0804' " Denver,CO 80202 E-MAIL - ADDREss.CoBlzlnsuranc obizinsurance;com INSURE S AFFORDING COVERAGE : NAIC#. INSURERA.Continental Western Insurance Company 1.0804` INSURED _ INSURER B: .. Southern Now England W(ndows.LLC' INSURERC .:.". DISIA Renewal by And0men .26 Albion.Road, INSURER D Lincoln,R1:02865 - INSURER E COVERAGES1 CERTIFICATE NUMBER ,. REVISION NUMBER: THIS IS TO CERTIFY"THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN.ISSUED TO'THE INSURED NAMED`ABOVE'FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY:REQUIREMENT, TERM OR.CONDITION OF'A NY CONTRACT OR OT HER�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; EXGLUSIONS`AND'CONDITIONS OF SUCH POLICIES.LIMITS SHOW---N;HAVE BEEN REDUCED BY PAID_6LAIM$_`` ILSR TYPE OF INSURANCE:. INSD'.NND POLICY NUMBER'. MMIDD EFF - MN D LIMITS': A- X COMMERCIAL GENERAL LIABILITY. EACH OCCURRENCE" $ 1,000,000 CLAIMS-MADE OCCUR CPA3136080 07/01/2016 07101/2017 -PREMISES*Ea occurrence $ 100;00 . "•r 10i�0.. .. ' MED EXP(Any one person) $' PERSONAL&ADV INJURY $ 1,000�000 GENL AGGREGATE_LIMIT.APPLIES PER: GENERAtAGGREGATE $ . 2,000000 X POLICY a JEC7 FLOC PRODUCTS-COMP/OP AGG .$ 2,000,000. OTHER:... EMPLOYEE"BENEFi $ : 2,000;000 AUTOMOBILE LIABILITY': COMBINEGSINGLE LIMIT Ea acdAe 19000000: M ' $ A X nNY nu7o CPA31Wed 07/01/2016',07/.O1/2017 BODILV INJURY(Per person) $� ALL:OWNED . SCHEDULED: AUTOS AUTOS.. INJURY(Per dent) NON-OWNED PROPERTY DAMAGE HIRED AUTOS. .... .AUTOS. Per accident w - $ x UMBRELLA LUU3 X OCCUR EACH OCCURRENCE A. CLAIMS-MADE . CPA3136080'. 07/0.1/2016: 071011201.7 AGGREGATE EXCESS LIAB DED 'X RETENTION$.: 0 99regate5,000;00.. WORKERS COMPENSATION H AND EMPLOYERS UABIUTY STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y�NIA A .' CA3136O81 O7/O112016 07/07/201 T E L EACH ACCIDENT $ LOOOrOOO OFFICER/MEMBER EXCLUDED? - (Mandatm-yIn NH) E.L.DISEASE,.EA EMPLOYE" $ 1,000;000 UI yt4s,desaiin under DESCRIPTION OF OPERATIONS below E.L.DISEASE:-POLICY LIMIT $ 1,000;000: DESCRIPTION OF OPERATIONS I LOCATIONS:I VEHICLES(ACORD 101 Addttlonal F6ar1411ctiedule,may-be attaetied if mo e:epace i required) CERTIFICATE.HOLDER CANCELLATION - SHOULD ANY OF THE:A13OVE DESCRIBED POLICIES BE CANCELLED;BEFORE.` THE EXPIRATION ;DATE` THEREOF,.,.NOTICE:,WILL:BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS:: AmmoRizED REPRESENTATIVE ©',1988-201.4 ACORD CORPORATION Ali rights reserved.' ACORD 25:(2014/04) The ACORN name and logo are registeoo.. arks'6f ACORD" r o �pF SHE Tp� *Permit# Town of Barnstable � I✓Zc NAP p Expires 6 n the from issue date Regulatory Services Fee + BARNSTABLE, « �a �e_A 163S. ,�$ ��®/ Thomas F. Geiler, Director v lfD MAC A �J� 2A ?oOCI i 7 BuildingDivision N OF 84RN Tom Perry,CBO, Building Commissioner 'ST,�BC� 200 Main'Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY // Not Valid without Red X-Press Imprint Map/parcel Number �0 L y Prose Address �Q zUP16 1 y ---- Residential Value of Wort. 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address _ Contractor's Name ���/ll 'C S C�(o�/ Telephone Number �'"C7�' C` ®0 I tome Improvement Contractor License#(if applicable) Construction Supervisor's License #(if applicable) ��C� 7�t✓ ❑Workman's Compensation Insurance Check one: ❑ 1 am sole proprietor ❑ I ff the Homeowner have Worker's Compensation Insurance Insurance Company Name P"ew RtJV- bo Workman's Comp. Policy# l� Copy of Insurance Compliance Certificate must be on file. 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) ❑/Replacement e Windows/doors/sliders. U-Value 3 _5, (maximum'.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. "Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: --T --- — II.I.S\F0[ZMS\building permit forms\EXPRESS.doc Revised 100608 LYc.ar CJttnmer Name: Renewal by Andersen of Renewal by Andersen 'o Address:4 `p: hl6tell]'H f I,4L 21� Customer ID#: of RI&Cape Cod Cod L ■�y�t�,.lnleWa Sales Agreement may,State.Tap: order Number: w37 Ph lR RI rive yr w`de n' Phone-Home: �'Jp 5(� -. 895 wouDww lBPLAcamamr mAndaanCompomY Phono-Work: Par:-)—of Date: �� IICCnSG#RI 12259-MA It 9535-Cr Email: 0562725 UNffS iedwlul Mswre GRILLES _ oirodoira gg , xaoar $ �_ _ a g }fps $ t § & $ d k c s VRi V SPRICES 91 R all or L.t_ K, 1- 7F COi GQG 17D a E a L a 7 n A n r n n n D n �,A SubTatal own PropoaaLARoram.LovcaiadowsmadoommbePru.idoara<dr.totdaawoa[.nmdi¢d.e Ttc ( per&�qF ocntpa A�mlu6oecc) � P�IileMOAe�Ujlod piopod via aacudo..0 for W Lind m.mpma..by bad.Cuamoa and Roce-d by-A-A—a Min ger.. sub lbw WAL Oedt 71' 'n pmaNed ba— ! -� !Sl.�� ►Y} f�1PP��a P o c�} Serb Total ye■.o .� Andneea Slm a<patseor+dra s;ai,a,2 ` /� ❑ CmM Cara l�atamer Yim Coe herby C. aumo®ad m[ae.umb dtwtadoae Cad duos u9uiead eD aoaoplea chic iY '�„ �f crt a...� U Cj( Nfse Credits M 6gl�sas b Z _Q .peemrnr sae.vh:ds uudnsgced ag®to pay dx.oroimaeeamdle diu agi.emea[aad.eoommgg to tbeu�slserror. See Bctnerse Sdde for Tame and Candidons of Sale-You.the buyer,may Cancel. L'u-,L 6f- Z O C-,fLC J l f jr Foie Taal ;LAFC ❑ fh'ar"Irg this transsc&m at airy eit>be so midnight of the third business day after the date of this transaction P�lcsee see attachai of canecUattian for an (�t v Ji Pd/t.C,,4 430 4 j``�` Salcsra c enk:enwa+r of this right. y � 1 -i-ont Mlcr:Jianmw C}edp«Fspmca �„rOy,�Ath.&W �%''1.J! (myary mul b I— u riabct VAxk F*Mdt Cost h pO1C pr°swt Ot°m` W appm Special Order Noes Totil AnmrrtalAgrerrrreirt 'LW' O.D—ribs ftm T A—pmt 6 lawn. �lD— ar naa saaear.l by Aral—n-%-manes DCPasit RrWred l4C Z �o1y1�01f 0 Mr q minlna> serca.ibt Aad— aeawds mkmudan Raesidedmsi�.Rmdeembidmnepikg sahmom OW an CarPlrlettah fn ra¢�eFptnay dcnM B! dw4rsowmied at ml unity.dm�e.Nwie.raa7 rnk<rl�¢ N be needrdkrnlndudN ffidap�indaa soirl'tla nepaawiiarof trdimrnec In9W nnq��eessnn�ettt mlesa oxaM�ftrnewumn the Oliaarl.f unles nt d�vpefw k.Pr Haan upon Y•a aPpavl Pelee urcladCs]a6ot rnaariala.inaalladva. fl ipedlfraeenoedab— rI.Ird. ahnwlc.w0d. Nsltrendddrpbaammeioeoi debdr idltr rcnxwWandxe wilt<ka.y.arrer wndoaa and remoral,and dispoml ofpmducrs replaced. m rtklfbas `�m'U CLatorrer ) Cauamr�y� // nee lndall.rm ane WbIEe•Renewal br Andersen Vkiow-installation Pink-llonawmer M !! InkialC fjJ kmarF C3 N 9awN�'Hobo.'W drt a.o�r NAeY..r.bi re.dvua.dM4no,('i.pam.a Care nrv.n 4.pomn.N rylu.:wd�lDe amde RM1?eal.� ` The Commonwealth of Massachusetts - - - - Department of Industrial Accidents _ Office of Investigations 600 Washington Street _- Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):- C Address: 3 '7 R--,t! Ea.s .pryy-e_ City/State/Zip: �N�NS 6 G, �� o a�f Phone Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 0 4- ❑ I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. Venio�elmg nstruction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. shipand have no employees These sub-contractors have 8. ❑ 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 ME] Electrical repairs or additions- 3.❑ I am a homeowner doing all work officers have exercised.their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per.MGL 12.❑ Roof repairs insurance required.]' c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 thepolicy and job site information. /� / e Insurance Company Name: 0_6CI ) _ ! 'l V T vGl Policy#or Self-ins.Lic. #: S ,b Expiration Date: Job Site Address: t L.Of �1�B� /I l a 1 P City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided abW is true and correct. Si ature: Dater Phone#: Official use only. Do not write in this area,to be completedbV citg 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#_ I Reatnded troy RF;1AtS �� ##iislnt#i,e ttitea to lDn#!iItns act S49aaQRerd� ;lA Masonry nioiy'. RFeot Cover#na C ra rutsor Sa##fir �s� VVS -W nduws and Siding Salmi Fuel um"i; F' 3 DM 06imo4itlon.Only 10 �)aiiure,.f0 sows a eurrst od#tteltbtthv Massachusetts State.Butldit a�tlda Ifr� i4 cease for revachtian.Or:thts llo@lt K Reter ta:• WWW Mase..GOvmp -Board of Building Regale ons:and Standards ® oshburton Place - Room 13O l ostori Massachuseits:02' la�nld Iprvvemertt Contractor ReAistrt�o y R�Aistr�ti�n; �.9t���13 Type, piivot®carpofflon A�1� Expirati®�; 7raral MOON ABSOCING . JAMES MOON s s � 1137 PARK EAST DR,, X WOONSOCKET, ICI 02806 Update•Addre and return cer(L Mork m abii.fof damp.; ars cn+ cs s�t�MrssfotaC+za4 Address 13+ttle�vni' (:( �ulpii�yt �t �F .���e +arNHwc� r4.� susc1�e,�aoe�ii ` ilf�l�iidlnp ietlOas end I�tonrlsrds l::tceose or rc�istratlOa;valid fOcfudivtdul:li�tx r>til� 1401 IMPROVOMIN°coNYAMYOR before-the exgit anon date If f0"'A&r urN Etft �oa�d 0.f 13xlifiln�i�o�!�lletil#ilsdiiA�#s#I!t#i'1i4 Aae' sliburton Piece Sul tQt.: a„ r tig T iIB�S Boston, A?03i0ii ` per p�'etO Cr�rpora�on '.. JJR{{IbCMCppIV.t°tR7�A��lV��� MMOMY,RI 010 Adlhlelet"r`etor Not valid Itl►nllt,�l llat!!re _ v .� �. Ls3.�tt1G`Jibts t i.PG.� r•.tt,}rx.a v+ r-%,.:t, °'si3La%n4t7zecaa n,`#tttlik I}nN'a a*e3 Fit:Flccnfec}RLts'dFtcce,trK. Yap.f : To:bit? MT-& �.,.�. .. rt ►w � tCATE OF L1�ABl� Tl( 1�i. t,13# kCUFDAS �%TTER OF;}M � � � CATE rRCi>✓'VCCR ONLY AND CONFERS NO RIGHTS UPON'1'HE.140,P. TEND HOLDER.THIS CERTMCATP-DOES NOT tk149Ee�C�,�X S BE LO Hunter Insurance, Inc- ALTERTHECt�VERAGEAFFORDEDByTHEPottC!£5E3£L,Dv�! _._ R9 Old Rivar Etioad, P.O. Box 1 2-f anville R1 02838-0001 FlA4C "X }Pd5!)f{EFtS AF1=C?R}3}NG COVERAGE �._ __......... L'hCaA�: 4f3i�?�i9-950s� E'a�::4Ctl 69 ��®,� } moon A5zocic7tO$ xi1C. ZaA, Butter Helmet �FatK�E>e�j �.aeon,mtsrt lrect�rvu« ca « DSA Rene wa.l j?'Liersen of RZ D Guttex He met RoafiUg _ �_._.1137 park East DtivO E: CCsvERRGES r,tx T}tE t PE:�tct7 is #t .EIS. tS;�;? dwt' ; +7£ r'c:#„t {':::'r{ ea?.t*`+•n-"s .r,li.s�a::L'3 wLCS' +t 3 t#;1:=t7t.•£z= .:P+T.FEgitt OR r`d. �.G'!3?ICXd C E`AL4Y 4; 4 tYF�a,GT�#I $F C "d a: fX6 Willi Cf'i'l)1?74ikCh47Nt w.r 't'`tst;A�'.nfAY'i c.+t.?J )ICY )4"+XFC'd#�`i><;2 Cii_ 4t1M W.s'C.PY tr�.iti,R-L'i i�3�t..L.�#'lti.Yk:FM�,�:�-:lE3�Y3it•'�i PSa"1�'C7Pd1.iKy-&i ice"s'r9J("fs" .,.�__..____._._____._-.,....___.._. t`!-.#at.95 'myrz'DM i`, "..`."."...._,._._..._.._._....L ._ tf s£f 13 f jM Y 6rtlUC NtJ?l7 k►3 i DATE{iEAAtLtt}ftifY i tt t +'1C1 I`x P�pf�'a»51?2i+f'FGC. ...-.-•-.._..«......,.__...._... ..a..----•t^-_^+._"., a`7�'�1Cx.$44C- � 0 GE,.WERAL t.StA3#1.CY f { St0 U{}00 1 p(rr r kc rat€t ...i��t,irr YfI'S?f:619 09116108 f 09I1.8/OS ` t srEa s,a: t} Y iJ 3 Gam°{P8•i••.:Y1N ai6f3a�!)} j .. d .�.-_..,. t q)v _..-... �...;:�:Z.atY (. I i PZWSO AL 3?LW i�S.Yc#'2'/ is S 1000000 .,-,,..,.w .-..m.....- _ ,.,_...., f o L f F -..._...«u...�....,---.-•+ ; r���'s4'6��#Tbv.scei-.16fa:.A AUTO OF ILE LFA ti3„.(3Y C*C }j't'Y GV 4W't 6� ° Y 4 - ., t?F4lCtC3 'v# # aAAZG�Lt0. 'N3IY ; �i as ( r Naf'f&;,(FE.F � �Af.,t•'}C1 n"A.Y: ��� T�_........... j( eXCCs,%j"4RVtL.Alusu+'r, t091161013 � 09/16/09 ssGRO_WE 4 $10000 ." _ 1 STY Lii,�...........5 j WORKERS co sa ctt�.4�t M Arasa q' _ >�ca rs 500000 #eg t.o ts,uAztLm 28 L�6 1Q 6 10/0�10 ((rr+ rf t ttTrys } E:R,tt;s= ti i3 EA EA LOVEF O S 500QtI0_ (Off sC:'ht i56EP r050000 .�....._. f'dr3 -ad+Gfx+Gat tR`xkd .. f ,_,,,.,�,.1.......--..._-•-"".---�•E.,...o.......,,..__ #cJ'46"KAf.i�'ts'Er dtY t.3bX=x`:#tb^.r`F,..«.-....,_..,.s...,.,__ _�.�-•,... .......,,.......,.--......•,^_'.•_.-•.'.-•• 3 ( t.f t�ftiP"i'tC)iJ .3F UPtift&TtGSti�tt:C'c�.;�"{Is'3k8 d b'1'�F1�f+;C�r:E F k�kCi.l.tS�##�?!�A'34?E•t3£lj SfA1t't3T F v�-CI?;I. CANCELLATION «_....- -- C R.RTIT sscc=t to Arty ar�AaosE oesemeeo POUCIEs cartc.�LLi o s.EFr.)gli"�<e EXPRA"' w RUILD1N vA J fit ## 1 CI *AY-3 WMM OAA-fe Ttfega-tIC TttE IS`MGe C�°ab7KER VkT-L i f _. �ia.I a:i:r�i ticT Cont. Rtxr�. 8a�•rd rat7r�e .t.�-c~,�G�R7�•`tt�R7E IibLf3f£A2 taK3>�I3 srz xt�L 'I.a�FAtt..tApw Tcz DO.;�s±wa. t e. t. o f d cirni st i tz i.cxn vnt*r:s xzc�0 ak'*A'tvrr t�L4c Xjy OF atar i(t av z,aParra HE tj.'%; ER.ar s caErrr a�_ O#'ac Capitol Hill Providence R1 02908 m_ ___ RC't3R9GtRPURATItt t AC ORD M{2001.108) nhMt1N114f}�,., MP i g � n z w• Y & ri \\ EE o n I oFT r Town of Bar IISable *Permit# ���a6m, Expires rrront s from issue date Regulatory Services Fee Mk"S kBLE. Thomas F. Geiler,Director v MASS �* 1639. Building Division �712-a/07 prFl)hW't a Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 wwW.town.barnstab le.ma.us Office: 508-862-4038 " " Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ` Not {valid without Red X-Press Imprint Map/parcel Number l CP C GYM Property Address `'( L,;+'`1z-y 6 esidential Value of Work C Minimum fee bf$25.00 for work under$6000.00 Owner's Name& Address — r � �..1, ,t�_j Telephone Number (- Contractor's Name ,L'li-tt� �`� � P Home Improvement Contractor License# (if applicable) ❑Workman's Compensation Insurance -P S PERMIT Check one: ❑ I am a sole proprietor El tam the Homeowner JUL 21 2008 �I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name �`r� /k��� i APLCVFb`2-_-S ' Workman's Comp. Policy# /�� �;C� .G icA ()o"7 Copy of insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken tot� 't ❑ Re-roof(not stripping. "Going over existing layers of roof) e-side . - t 1 ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) I *Where required: Issuance of this pei-mit does not exempt compliance with othertown department regulations,i.e. istoric onservati&H,etc. I Property Owner must sign Property Owner Letter of Permission. required A copy of the Home Improvement Contractors License is c O SIGNATURE: rr! Q:\WPFILES\F0 ding permit forms EXPRESS.doC R evi.cP(17(11(lR The Com.tnonwealth of Massachusetts Department of.industrial Accidents Office of fnvestigations a 600 Washington Street Bostort, AM 02111 < www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AppUcant Information Please Print �Le 'bl aII1t; usincssl Jlnd honividual): VtLC9 � `J City/Statdzip: C*NzIM0Vk Are you an employer? Check the appropriate bwc 'type of project(required): 1.❑ I am a employer with 1 4. I am a general contractor and I 6 New construction 4 employees (sill an art.time have hired the sbb-contractors 2 El I am a sole proprietor or pUtCfr- listed on the attached sheet 7. ❑Remodeling r ship and have no employees These sub-contractors have g. Demolition to ees and have workers Y walking for me in any capacity. �' 9. El Building addition [NO workers' comp.insrTranrC Comp.insu a.ncc.t S. F] We are a.,corporation.and its 10.[]Electrical repairs or additions rhirired.] officers have exercised their l LEI Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself [No workers' comp. right b£exemption per MCrL 12 ❑RDof r airs P. 152, §1(4), and we have no incrnance r ►frt"'Tr1 1 ti� -I t. employees. [No workers' 13.0 Other�r � comp.mSurarICC required.] `Any applicant that clhccl5 box#1 rmmst also Rout the section below showing tbcff waricr_rs'corv�on policy infotmatinn t Homucrt who subait this of davit indicating they an:doing aD work and then hire outside cmtraetors must submit anew affidavitindicating such cow xCrmtractnrs that chxk this box must attached an additional sheet showing the name of the sub-cmtract my and state whether or not those entities have errrployecs. If the sub-conhaeton have anploycrs,they must providh their worlctnz'wmp.policy number.: I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Iasrv-ance Company Name_ C� �i" -� � �� MS Policy#or Self-ins..Lic.#: Expiration Date: !!. Luj,-'V -'C j•l City/Statdzip: V r!.}ad? �t . rob Site Address: ZJ n Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpi3' ate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fv of up to$250.00 a day against the violator. Be advised that a copy of this stAcmnrit May be-forwarded to the Office of Investi lions of the DIA far insurance cov e verification I do ker certify un the pains-and penalties of perjury tfcai the information provided above is tine and correct Si Date:, Phone#: O Reis!use only. Do not write in this area, to be cortrpltted by city or town official City or Town: Perniit/License# Isstriag Authority(circle one): . L Roird of Health 2.Building Department 3.CityMwu Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Otlier (�nnfart Farcnn• Phone#: l y°FTHEr, Town of Barnstable t2egulatolry Services vsUrr MASS. Thomas F. Geiler,Director T�o �a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 1 Property Owner Must Complete and Sign This Section r 1 If Using .A Builder h 7 , as Owner of the subject property hereby authorize e J �� �J�.'J�J to act on my behalf, in all.matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date . x Print Name ' If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. (. A .. Town of Barnstable �oFst+e ray Regulatory Servic s s t BARNSTABLE Thomas F.Geiler,Direr or b 9 A Building Divisi n PTED MAC Tom Perry,Building Co ssioner . 200 Main Street, Hyannis MA 02601 vcww.town.barnsia le.ma.us Office: 508-862--4038 Fax: 508-790-6230 HOMEOWNER LICEN EXEMPTION Please PH t DATE: JOB'LOCATION: number street village "HOMEOWNER": name home p one# work phone# CURRENT MAILING ADDRESS: city/town state rip code The current exemption for"homeowners"was e ended to nclude owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for ' e who oes not possess a license,provided that the owner acts as supervisor. DEFIN' 0 .HOMEOWNER o Person(s) who owns a parcel of land on which he/she re i es or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or detached s ctures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year od shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a f nn cceptable to the Building Official, that he/she shall be responsible x r all such work performed under the build' Rpe t. (Section 109.1.1) The undersigned"homeowner"assumes responsibility fo complia cc with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she and stands the To of Barnstable Building Department minimum inspection procedures and requirements and th it he/she will co ly with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 c is feet or larger will be require comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Coda 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'J-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.,. Many homeowners who use this exemption aie unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed personas it would Hrith a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that hdshe 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 form/certification for use in your community. AMRA CERTIFICATE OF LIAS-1-UTY INSURANCE DATE 05/14/2008) PRODUCER (781)344-3200 FAX (781)344-1425. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Malcolm & Parsons Ins. Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 Freeman St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 527 Stoughton, MA 02072 INSURERS AFFORDING COVERAGE NAIC# INSURED John Dunn INSURERA: Associated Employers Insurance INSURER B: P.O. BOX 924 .,/ INSURER C: Centerville, MA 02632-0924 INSURER0: • - - INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION - LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE ElOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY S GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC JECT AUTOMOBILE LIABILITY u COMBINED SINGLE LIMIT $ ANY AUTO - (Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ " ANY AUTO OTHER THAN EA ACC $ I E ' AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $' OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE �, S RETENTION $ $ WORKERS COMPENSATION AND - WCC5004658012007 09/29/2007 . 09/29/2008 X WC STRY ATUS ER EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry Contractor John Dunn is covered by the Workers Compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TqE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Insured's Copy OF ANY KINP UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Evidence of Insurance AUTHORIZED REPRESENTATIVE �. ..4 Irvinq Parsons ACORD 25(2001/08) ©ACORD CORPORATION 1988 1 Board �di'zn'°'aurep / � a of Building.Regulations and.Standarrac� d� HOME IMPR VEMENT CONTRACTOR Registration; 101.149 f� E)Pihation Q �/'5 2010 ' -T e : r: Tr# 267680 { Ypt Individual JOHN P..DUNN 1 '{ John Dunn 80 MARIE ANN.TE 1j t CENTERVILLE, MA 0 632 g^l I' ..` Administrator: r Town 'of Barnstable *Permit# arf Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Feea 3' Thomas F.Geiler,Director OCT 10 2006 Building Division / TOWN OF SARNSTARL�'om Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 V" www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Af Property Address ,72 C fi" � �f' zlala, Residential Value of Work ® Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address � ia/�� �10�� q G � Contractor's Name ��� � � Telephone Number1-J0_,9—??d--Z�®-' Home Improvement Contractor License#(if applicable) lyf' Construction Supervisor's License#(if applicable) 'E�orkman's Compensation Insurance CheF,k one: am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to Xi ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pr perty Own st s' Property Owner Letter of Permission. me Imp a en tractors License is required. SIGNATURE: - Q:Forms:expmtrg Revise071405 The Commonwealth of Massachusetts Department of 1`ridustrial AccidentsQA ' - :rc:n Office of Investijadons 600 Washington Street Boston,MA 02111' " www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaius/Plumbers kpplicant Information Please Print Legibly Name(Budaess/oigaa zation/In&vidua1): kdress: E�LA one - Ph #: � �z��2�7 ,'ty/State/Zip: ��,O Wit, - xe you an employer?C,heck the appropriate box:. _Typ e of project(required): . • 4. ❑ I am a general contractor and I ❑ I am a�loyer with have hitcd the sub-contractors -6..❑New construction yees(brand/or part-time).* .7. Remode am a sole proprietor or pminer- shipimdhavenoerriployees These sub-contractors have 8. Ej Demolition workers' co insurance. working for me.in any capacity. mP• 9. ❑ Hu$ding addition workers' co insurance 5. ❑ We are a corporation and its Il`10 �� 10.❑Electrical repairs or.additions required.] officers have exercisedh their •❑ I am a homeowner doing all work . Pgat of exemption per MGL IY.❑ Plnnibing repairs or additions e. 152,§1(4),and we have nQ 12 O'l4aofrepairs mysel�£•[No workers comp: . . insurance required.]t employees.[No workers' 13:❑ Other camp.insurance required.] - my appliceat tbat'checks box#1 must also Swat the,section below showing their workers'compensation policy information: *. _ 3emeownas who submitthis affidavit indicating they an doing all•work and tier hire outside contractors must submit a new affidavit ibdica3iug inch .ontm;.t s that check this box must attached an additional sheet.showing the name of the sub-conuactb�i�s and their workeml, Amp::policy information. am Ian employer that is providing workers compensation insurance for my employees.'Below is the policy and job site. iformation. is=ce•CompanyName: .< =1 n/I • -- _ --_ olicy#or Self-ins.Lia#: Expiration Date: A Site Address:_ City/State/Zip. attach a copy of the workers' compensation policy declaration page(showing the policy number and•eapirataon date). ailure to,secure coverage as requited under Section 25A of MGL c. 152 cmilead to the imposition of arimmalpenalties of a ine up' to$1,50Q.00 and/or one-year=Vnsommmn as well as civil penalties in the form of a STOP-WORK ORDER and a fine sf up to$250.00 a day'agai ast the violator. $e advised that a copy of this statement may to forwarded to.the Office of nvestigations of the DIA.for insurance coverage verification. r do hereby carer der the p ns " p allies of perjury that the Information provided a4eve is true and correct 3k tare: } Daft. a Phone#: �O 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 ones 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other CoatactPersom Phone#i qa Board of Bud►ng Cegulations,and Stan �v HO.IffIE IM;PROVE�VIE[JTaCONTRACTOR { egistra Qtf,:.�140475 , ExP t .: �tca�tl•`o�n �12l2008 � ,. 14 E1 L S I COtvSI fttr ER4'C Ei ELSEN k( T IAl �RD �GG i I ' i I of'IKE Town of Barnstable °^ Regulatory Services sAxNs�►aie, ' Thomas F.Geiler,Director' 9 MAN. fo�,. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section If Using A Builder as Owner of the subject property hereby authorize_ � f� 1"���.� to act on my behalf, in all matters relative to work authorized by this building permit application for: 919 (Address of Job) �d Signature of Owner Date Print Name Q:FORMS:OVR4FMERMBSION t TOWN OF BARNSTABLE Permit No. ____-_. -------- Building Inspector �wrun Cash -- - wa �Oy►Y�\ OCCUPANCY PERMIT Bond -.----_-.-_-__.-------- Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ................................................ . 19............ ..............I................_... ..................................................................... Building Inspector s i' > .} o o TOWN OF BA RNSTABLE BUILDING DEPARTMENT _ I%RNSTAUTOWN OFFICE BUILDING rua �°� i639• �� HYANNIS, MASS:02601 MEMO TO: Town Clerk FROM: Building Department DATE: May 28, 1985 - An Occupancy Permit has been `issued for 'the:building authorized by ` Building Permit #. ..... .2 7451 Bayszde Building Co.;.... ... .. . .. ...... ... . ........ ..... .. ......... ,issued to ............................................._.. .................. ..... .........» ............ ... . Please release the performance bond. �� �i•. tit �$` C�1 ��` � - � .�• 'S i 41 0� IV 7 " l.« S 4�3ACb �� 1 �f � � r }a r #•... >ta A st E t» lux 4 4a f JRw �s. 07 to 4 r`t , •'�1 + 1-.`i' •1 ,"�"'�� ,.S`'�'• '�vWj£ J S ?xI x° t� J tt E .✓ ���t y4 r 1 i • a x¢ �x$�,- ll i po'1`'S rp Ic » CERTIFIED r PLAN LpT t4 Lv/17/3,ER7—S'/1-1/L.-L 1ZP ti0 ELURE _t IN. a R � H fie'' �a�z''"`� i^t` ✓. r F °r t + °' .�� � � , ux 4 <.. E: SCAL 3 p DATE s a p,-w 13�� CERTIFY THAT THE �. CL19 T ex AR T R J REGISTERED � " `.. .�'... " SMOWN <®N THIS 'PLAN IS IOCAT D r� vgagw L: NC t �4� ¢ SON.':T'HE`GROUND AS ''INDICATE�► �' a,, ,tt ' PIQIHEER $URYEY®RIr -.COI �SRI►�IS T® THE ,, CNIND L AIpB OR:�iYe _�_ QF BARN:�TAPL I� SS ` L. �j T t 2 N164 I N S T`R E E T3 4 CHI► $H ET �I�^ 0 TE RED. LAND �s�,�aa777777 SURO/EY4�t Assessor's map:and.-lot number /..........I..................... S PTJ THE Sewage Permit number .'P.. ..��.�......... O IPLIAWITH � r t v 8 "E�' Z BASBSTYDLE, i. 'House numberY� ... :...... ........ 4.;... "VIRO ENTAL CODE �y 90 rAsa r r TOWN p�L�p g� t639. ,F ` TOWN, OF.. BARNSTABLE . :: BUILDING INSPECTOR 'APPLICATION FOR PERMIT TO ,- ................ TYPE OF CONSTRUCTION ......: ....,.��1 (.................. ................................................. w �1... .....1.: '..............190... TO THE INSPECTOR:OF. BUILDINGS: . � /� y The undersigned-hereby applies for a per mif according to thhelfofliwing inf�oorrmatioh Location ........ .............1............... ......... ..... . ... ...... ProposedUse /.. !!.c .i .................................... ............................... :..... ......................... Zoning District ........ .. .16............ .......................:.......Fire District .... .0�.. ��..� Name of Owner .�I?' .f:,�t/.. ;...... Address .......... ..::...S..r ...................:. .. i Name of Builder ....... " .. �...... ............ .Address ................+ ,n ..:.:.................. :. .. Name of Architect "... � S C .. ...................Address Number of Rooms .. ................Foundation . ... ....... Exterior ... .1. . ?:... .�?.Y/�.."� ,r..........................Roofing ............... .... ` Floors &S1Z` .......:.....1.......: ... '...........................Interior .........C/ .�?�1........1/.:.Gv ( ... .............. Heating .... .. -4.:......I ... �._... ".................Plumbing ........... .... ...... ..r .........I :X.... 0 41 /..2-.%.......: :... !.!'. Fireplace .......46,2 C....0...............Approximate Cost ....... .. CL`.. ..... ' .. ... . ... ..... .. Definitive Plan Approved by Planning Board _____________'___ • % (p YL - - - ---• Area ..................... .... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTHO IUD ��9 t t'• `' { OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to.conforn to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...... d�4.......�......... .. .............. r Construction Supervisor's License ........ea.. .6..(... .1 `B%t-ZSIDE BUILDING CO. 3 No 2745 ' Permit for .... l�..Stc�x�t............ - _ •_ i; y...Ixvel g�lg_.................. 04 Location ..�,C? ..14 .9$..L,umbert• 13�} w .•' ? r - ,' Centerville . ' I Y Owner Bayaide:U:Llding•cer 4 =TYPe,of:.Construction ......Fr......... r /'�- • _ _•� ' g' t �,. t„'ay�.. M`r_. a s'� �' � ,�, ` J'�'• r , � n.'��+ �.w - - .t. 7 I {�"�.�.� ��' �i Plot .....:...................... Lot- ............... ' ........ +' Ja Permit Granted nuarys 2l, n .85 ...................... ....... .......19 k. Date of Inspection ..................'19i Date ,Completed `: .. ". rt9 17 • . . -+ �"S;`°. �. • M to (' •' 1 '" r. '-t'ti 'I '� -'' "' oer'i'� ' _ ° , '�.. ` - • 4{ ' r Assessor's map,and lot number ......................................... YNe • .. Bpi Tp�y Sewage Permit. number �� ...9C�.........9...................... `al C t Z EARNSTODLE. i Houle number r '' MAB6 039. w TOWN OF BARNSTABLE - - I BUILDING INSPECTOR APPLICATION FOR PERMIT TO .. ...u. ?�<f........ ................... �-- TYPE OF CONSTRUCTION ........ ��.�:.........�1 .................................................................................. j ............./ ............. .................>I9�r�f i TO THE INSPECTOR OF BUILDINGS: w� 206 r The undersigned hereby applies for a permit according to the following information: / � � Location +�G� �.;. �-�� ,�......... , C 'J6///.,r ?......................:........ ............ ........... /............. -- . ProposedUse /.././'F�l� ....... .. ...........:........./................................ .....................I.....:.................. ZoningDistrict ...... . .... ...................................................Fire District ......!... ......................4............. Nameof Owner .......� '!I �.(,.:� ..................................Address .................. p. a.. ?.................................................. Name of Builder .......�!:?.- //,,..... �.1 ..............................Address ................ P.::.. .................................................... �+ v Name of Architect ..... (I...... �?. ��L..?...................Address ......................Sy....................................................... f V Number of Rooms -� ..........................................Foundation ..... /4J� l%Jst, /�, ........................ ......... ........... ................... X � I Exterior ... ..........�........... ..........................Roofing ...........�. y !. r......r� :..... Floors ......c(x. j...P...............................`. ..............................Interior ............. ... .......... Heating ....... ...1`/............%..! �.,?..........................Plum.bing ........... .....64f.�..........( ( ✓ �� .......................`...... . Fireplace ....... 6.2 Z....... .....1...>./!. ..................Approximate. Cost rfi U" U ............................. Definitive Plan Approved by Planning Board --------------------•---------19_______. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD, OF HEALTH } �f lilt OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulgtions of the Town of Barnstable regarding the above construction. � • Name ..... . G�.r.. .... .... .�.............. .. ...................... -. Construction Supervisor's License ........ ., ..��.7..?.. BAYSIDE BUILDING CO. A=16 106 A=1 6 0 Nb ... Permit for ....9!� Sto .. ......... ............... .........S.i.ncfle Famijy..P��j i 9. ................ ............. ...... . Location ......Lot 14, 98 Lumbert M-111 Road .......................................................... Centerville ............................................................................... Bay side.-Buildiag..qq.�.......... O�vner .................................. Type of ConstructionFrame................If ............ ...................... ....... .................................................. Plot ............................. Lot ................................. Permit Granted ........J.anuaxy...21,.........19 85 , .. ............. .... Date of Inspection ....................................19 Date Completed ....................................19 42W ti