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0041 MAPLE AVENUE
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TOWN OF BARNSTABLE BUILDING PERMIT`APPLICATION Map V Parcel Application # �v Health Division 13U/LD/NG Q�P Date Issued T. Conservation Division MAR 2 Application Fee Planning Dept. TOW 4 2016 Permit Fee "I/ 0 Date Definitive Plan Approved by Planning Board N OF 13A S rA13 LE Historic - OKH _ Preservation/ Hyannis Nd r✓v�,4Z l� Project Street Address Village Div ov,i Li-ip: Owner 5Address 141 /' Apa,7 Auaoac Telephone Permit Request t� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation '+$ +OIL Construction Type 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 ❑ 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 _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other 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 APPLICANT INFORMATION - - (BUILDER OR HOMEOWNER) Name &PEpn—via 1"1'C . Telephone Number Address 0�1)1 lA/� �� License # 0,,& I-P q 6 o J 1--Pp" I M6 D 1 `l 7 Home Improvement Contractor# Email -.�D�D � YP�i�.T�fc�/t� ��1 Worker's Compensation # (A)CIA 013 0 16a c�,f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO (O �-i�i�K/I�"rb (,�F/-1/`- 0158'l SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED , MAP/ PARCEL NO. ADDRESS VILLAGE OWNER 'DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ' ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Tay Town of Barnstable Regulatory Services s_ Rirhmrd V.gad Director Builder Division Tamrerrp,EmIrTfn Camftdssioner + - 200 Main Street Hpani*Ls,MA 02601 wwW town:�arnstable rn2-IIs. k Office: 508-862-938 508-790-6230 Pragerty Owner must - COMP*let'e mad Sign This Sec ''{ ' .. t - ?a.J ��1 .� ?_` Jam- J • . ct prop he�laya o ize G 1�" u9 4 1`0, to act on myb alTf in all math=relative to work aUtboazed by-d s.b emit application for.` • _ f •(Address of Job) 4 't - OjDlfences`and,alaims are rthe response Of t o a scant fools T and not to be filled or 1ii&d befofe fence"is`mstnl a2&Mlr I f inspection are performed and accepted. - Sre Q Pn Name - .' . . ,� nut Name Dain LZ L QFO OWNEUBXMESIDIeOC)IS ` Town of Bamsta-ble _ Regalatorg Service •. EirIiard Y_ScA D' fnr DuHdmg Division. . Tom Pent,Bu7dmg Comm-imdnner i _ 2-00 Mai- Rya s,MA 0260I - �� • .` W�S4 t0�1'II.�Ta]3LcfafiTf ma� , Fa= 509-790-6230 n6MMOWNERLTCWME N JOB LOCAIIOI�L-,_ anmbcg i. y�Iagc •$Of,�E0gT1�R: s7atiC bond CIIRRENT2dtAIL GADT?RFS3:. - slatz zip rock The current exemption f&r,`h meownere =te, to include owner-o cc�ied dwellings of snt imi�or Less and to aIIow homeov�ncrs.toengaLgeanmtEvidnalfor hodomnotpossessalicense,ptoyidedtbattbcawneracfsasst�etyisor_ DYmITIox oggon:EowNM p easan(s)F9&0 o w a p 7 of farad on whit F� she resides or intends to reside,on which there is,or is intended to be,a one or two- ti3mily dweTlin �t a-p o (ached s _ accessory to such use and/or farm stncL =s: A person who cons mcts more than one h n=,in a two-ycgr period :om be ed mheownr Such-inmwwmeel.shall sobmhto foe B-mldiii Official on a fog SGtGptable to the Bm7dmg Official; hesha -be onsinIe fur aI1 such work eifn�c3�dsrtht crmif (Section 109.LI) . The uadczHP'cd`:�omeownm'assti cs n-sp for compliance w¢lithe Siam Bur7ding Cade,and other applicable codes, bylaws,rnIj;S- d=9- lations-" j t Ike dnmgned-hDmaeawnee cmrtfes that om ofBamstablc BlnZdmg Deparfmcnt msp edio7a IIn procedures and regairemenfs and•tiathe[sba Will'c IyWiff].said pm audregirrmexds_ sigaatnc atHamca wnrt. AppM'Yml afBm7d-mgOOrc-31' _ Ooo�vbie feet or wi�lbe to comply . fie StateBmMbg Coda , �eciion f27.0•.Cons vefinn'Cgdfr ' _. $o WNEXIs c ox The G.4de Stales that: aAuy hoLmeovener pe work for which a burZdiag permit is required shall mpt fromtTie provisions of ibis sestina(Sec ran I0I= Li of const�rac ion Supervisors);provided that if the homeowner es a;pers4a($) or bse fado srscf7rk,tbai sash ameowner shall and as supervisor." `}NAug TilS eowncis who`ttse ibis erenipfnn =L are Fhatfhey are asm g fie responsffiMt es of a raperv'sor (see Append Q�Rules Bt_R o funs for Limos rag Ca ' n SIIperaisors;Sechnn Z.L5) Thb lark of awareness oftCa results in serious problems;pjrflcul�rly when the homeowner mHcensed persons. In this case,our Board cannot proceed ag-�st the=rcensed person.as it would wI i a licensed ervisor_ The homeowner acting as Supervisor is uIihaatdy responsible. To ensure$at 5ie ho eowae i�.fffHyaware of his/her rasp Md ,many commmu ties requae,as part of fze P '�apgIicatiam tint thi hameowner cmfify that helshe understands fhe responsibEies of a Supervisor. On$ie Lssf gage of this issae is a;,foi-sm mr-reagp wed hg Feral towers. You may care t amen.d and adopt mclL a formlem Lea on for use in gma eomifiaY - �5�pFIIFOB],�1s�„�rr�I,amitsl��Fcc�e B.eaised 061313 . y M l TTie Geinzrtiarrf�errlt3t off�rrssatlirrse�tts t • . t ' DeparliffeW&frnd sftia1Accide-7rdc Offrre OfIM.aestigatiartxs 600 Wash n Street: ' r ti 3osfan, A 02111 is t • Mr(ir.leers' CGmpensaf ffn Insurance Affidavit:Builiier��ntr;i urs/EIectr cians/Plumhers` Applicant Inf4mafion - r Please.Print Le�i�iIy . Name nesnP�c n � � 6 (B '�g3IIi�tjrmli'nd� � na�� �HT�iKr���l�_�L� 'r"y Address: City/SfaWZip- rn t LFoPz Of 151 Phone-- ', D`1j -- ` 7 3. 71 b6 Are you an employer?Checkthe appropriate bo rye flf project(requited)- 1_El I am a employer With am a genier`a1 crmfrictor and I ? employees(fish andlor part-time).* have hired the soft-caatr 6_ attors [J I.kw. constzuctian 2.❑ I am a sale prroptie#os orpartner- ` f listed outhe attached sbeet 7. Remodeling ship and fie no employees. These sub-cLtradors have �pS. -017emolifion worlring for me is any capacity employees andhave wodcers' coon insuran f �_"0 Building addition [No'rti ariaers'comp.insurance y P' .• 10 Electriczl required] 5. ❑ We are a-coipporition anal its 0 repairs or additions 3 :'`officers have eesere-Ped their _El am.a homeou�er doing all work11_Q Plumbsngrepairs or additions myse.If[No workers'gip_ . Tight of exemption per MGL 1 _❑IZoafrepairs inmzarwe required-]i c.1,52,§1(4k and we have na ' emplayees_[No;vorkes' 1 .❑Othei K t camp_insurance required_j• '' ;Any w5cmtthstcheckshox#ltffist also fuloutthesetBoaberawshowingdmiry Aeleco®pevsatinapoliryinfoimsuom Homeowaerswho submit dus sfgd=m&c tiag dmy axe doing anva t ama dLm him outside contractorsnmst submit a newSMdarjt indicating MdL ' =Contractors dat rhea This box mast attached au addidanst dreamt showing the nmze of the sub-Lntrrckrrssnd state whether ornottbnse eatrtieshave employees.1€thesubtantrwtors1ave employees,theymorstpivui&-their w"orken'comp.polity umber, I airi art siitpi err fltrrt is praizdrrzg rvorkers'.can perisrrtiott insirance for rrr}*enrploy�ees $etowv is fhe policy rc d job site • Insurance Cam.panyName: Expiration Date: j 1 rob Site.Addteas: U 9 , ' City/Stawzip pA 03A Attach a copy of the workers'compensationpolicy declaration page(sliowing the policy nuiuber and expiration date). Failure to secure:coverage as.required.under Section 25A of MGL c 152 c-an lead to the imposition of nrimimal penalties of a fine up to$L500:00 anWor o=--earimp€isonment,as w&as chtil penalties is the fa=.of a STOP STORK ORDERand a flue of up to$250-00 a day against the-violator. Be ad{used that a copy of this statement may,be forwarded to the Office of InresErgations afthe DIA for insurance coverage verffiica#ion I tla Hereby comfy rlitde e •is andpenahYes a.fgerj iy thatflte injor�tzcr€iaii prat +led aboveis barb ar2sdy correct Date: Phone i 50 9 — 4 T3 '1 POP 0.0did use only. Da iiat asreta in dds arerc,ter be cainpleted by city a form ojfrci st City or Tangy.: PermitJLicense# Issuing Authority(&-de fl ): 1.Board of$ealtk -r.Buff diag Department 3.Cityll'own Clerk 4.Electrical Inspector S.Plumbing Inspector ' 6.Other . Contact Person: Phone#: ornmatiana and Instructions Massar hasetts General Laws chVfrr M regnaes all employers to provide workers'compensation for 1Jieir employees. p this stat atq,ail;esaplayee is defined as-"-.every person i a the service of another under any contmart of bile, express or implied,oral or wafirn_" An employes is defined as"an.mdividnal,parfnersh p,associafi.c corporation or other Iegal entity,or any two or more of the foregoing a ngaged is a Joint en 2pnse,and including the legal=preseab&es of a deceased employer,or the receiver or trastee of m i adividnal,paxtnetsh ,association or other Iegal entity,employing employees.. However the owner of a dwelling hoIlse having not more than three aparmeats and who resides therein,or the occagaut of th e- dwelling house,of another who employs perSQW to do maiate= e,construction or repair work on such dwelling house or an the grounds or budding aEPvd il thereto shall of such employmentbe dsemedto be an employer" n MGL chapter 152,§2Sg6)also states that every state or local licensing agency shall withhold$he issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any aPplicantwho has not produced acceptable evidence of compliance With the mcvrance-cove-rage required." Additionally.MCiL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits political subdivisions shall enter into any contact for the perfounance ofpublic wok u as acceptable evidence of compliance with the instuMce.: req=mints of this chapter have Been presented to the contracting aistb ozity_" Apphcan-& Please fill out the worker'compensation affidavit completely, checking the boxes drat apply to your sitoation.and,if necessary,supply snb-co tors)name(s), addresses)and P ne numbers) along wiiji their certt(zcate(s)of i„crtrance. Limited Liao Companies(LLC)orLimitc, T 1Zrty-Partnerships(LLP)withno employees other thanibe members or partnets,ate of reguaed to carry waikers'co nsa-tion insurance. If an LLC or LLP does hate employees,a policy is re Be advised that!i!,ate maybe submittedtotheDepartment of Industrial Accidents for confnmation o ce coverag lsa e sure to siga and date the afbdavit The affidavit should be;rot=e;d to-fhe city or town at the application for pemut or license is b ei ag requested,no t the D epa dment of „ • " 'Acddents. Should you ve any q estions the law or ifyon are rego=d to obtain a workers' compensation-policy,please call apartment at th umberlisfedbelow. Self-insured companies should enter their self-Tn r ce liven e number on the ropriate line. City or Town Officials Please be sore that the affidavit is complete p � legibly. The Department has provided a space at t$e bottom ofthm affidavit for youto fill out in the eventth Offi of Investigations has to coafactyouregardingt3ie applicant Please be sine to fiIlin the pe�idlicensemtmber hi wdlbeusedas arefere =u mlber. In addition,an applicant that must submit multiple permit/license applHitc any given year,need only submit one affidavit indicating c=nt policy in ationf nec (iessary)and under"lob Sit-- �1 s" 1ti e applicant should wate"a1I locations n l�� (dty or town)."A copy of the aiff davit that has been officially ed or m�ked by the city br town may b e provided fa t3he " applicant as proofthat a valid affidavit is on file for g or licenses A new affidavit must be fMed out each year.Where a home owner or citizen is obtaining a lic or ermitnot related to any business or comm.ert ial v&Utoro (Le;. a dog license or permit to bum leaves eta.)said p` on is N required to complete this affidavit ' ke to thank you in ce for y ur cooperation and should you have any questions, The Office of Investigations would 11 please do not hesitate to give us a call. ` The,Department's address,telephone and fax number. 'heCG--. aZf ofI�assach '. Depart nmt 1a'us� ialA009ents Ofucf. 111vestioffo.= MA Q111 Tt,-L 4 617 727-49QO f or 1-977 MASSAFE Fax# 61,7-72 revised 4-24-07gfd?a 7 � aronr�ealCh Massachusetts -Department of Public Safety p ac�cuoel�s ' �\ Office of Consumer Affairs&Business Regulation i3oar.:of SL�1tS��. . I ':IL.Ons and Sta^vards OME IMPROVEMENT CONTRACTOR j. Consti union Suyerwisui i&2 r sEriiiy TExpiration:-,-,4...1 egistration: 110996 Type: j License CSFA-046460 7I:S /18/20}6 Private Corporatioi A. "-;4 CAPERTOWN KITCHEKS iNC - JOSEPH F PERR( E 207 WEST ST �, @t Milford MA 0179/ JOSEPH PERRONE � ' 207 WEST ST i� ` MILFORD,MA 01757 0�,„,,11 . Expiration Undersecretary Commissioner 02/26/2017 •rt < y 03/15/2016 10:05 5084787228 • BRIGHT INS PAGE 01/01 A E) DATE(MMIDDIYYW) CERTIFICATE OF LIABILITY INSURANCE F3/15/2016 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 aY 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 g, PRODUCER RCT Kim Sylveetle Bright Agency, Inc. IN,PHONE (508)473-0556 FAx 6 Congress S t. MAIL f5091478-6700 P.O. Box 424 Milford INSURERS APFORDING COVHRAGE NAIC A MA 01757 INSURED INSURERA:Acad,ia Insurance Company 31325 Capertow,n Ritcheza,e Inc INSURER B ID:CitatiOn Insurance Co an 207 west Street ' INSURER C: INSURER D: Mi If ord INSURER E: MA 01757-2201 INSUR COVERAGES CERTIFICATE NUMBER:CL15101607161 REVISION NUMBER: THIS IS TO CERTIFY THAT TliE 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. INURADDLNUOR .IR TYPE OF INSURANCE POLICY EFF POLIICDY EXP LIMITS r134 NUMBER GENERAL LIABILITY , EACH OCCURRENCE, $ 1,000,000 X COMMERCIAL GENERAL LIABILITY -PREMISES Ida OCCURS e 2 50,000 A CLAIMS-MADE a OCCUR 1 10/1/201S 10/1/2016 MED EXP An one ere0n S 51000 PERSONAL 6 ADV INJURY S GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT gppllEg PER; PRODUCTS-COMP/DP AGG $ 21000,000 X POLICY F1 PRO• LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LI I. Ea ccldo r B ANY AUTO A BODILY INJURY(Pet person) s 50 000 AUTOS X AUTOS SCHEDULED X9573 10/1/2015 10/1/2016 BODILY INJURY(Per ezident) 3 500 000 'X MIRED AUTOS X AUTOS , PROPERTY AMAGE 100,000 UMBRELLA OCCUR COmCBi E 2(),000 EACH OCCURRENCE $ EKCESS LtAB CLAIMS-MADE AGGREGATE $ D RETENTION$ HAWORKERS COMPENSATION S AND EMPLOYERS'LIABILITY WC STATU- OTH. ANY PROPPIETORIP,IRTNF_RIFKECUTIVE Y 1 N T OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT a 100,000 (MnndatoryinNM) CA0134076-21 10/1/201S 10/1/2016 E.LDISEASE-EAEMPLDYE $ 100,000 If es deaerlt pN o under DtZ9f1RIPTI OF OPERATIONS below E.L.DISF,ASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ARech ACORD tot,Additional Rrmarlto Schedule,If more space to required) CERTIFICATE HOLDER CANCELLATION (508)473-7104 SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street HYannf s, MA 02601 AUTNORrCED REPRESENTATIVE Steven Ellis/Y.=M ACORD 25(2010105) Q 19t36-2010 ACORD CORPORATION. All rights reserved. INS025(2o,oDs).ot The ACORD name and logo are registered marks of ACORD HDU 04 2815 11:29:85 M11115nSional Tech -> S004737104 Page 002 AC6R7br CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11/4/2015 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 poticy(ies) 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 NAME: Kni ht-Gik Ins A c Inc •' 9 Y PHONE .tiX.............................................................. 446 lda4ra St 9th P3 !(yrc,.No, .•••.-_(_508) 753-6353 _ l(nlc No);..(_508) 752-'1764 E-MAIL. ....._.........................— WcregmterMA 01648 A�uf�i"k§...................................................................._..........................................................._..._...........................,............__...................... INSURER(S)AFFORDING COVERAGE NAIC# .........................................I.......... ............_......_......................._............_... ........-_........I.. .................................................................... INsuRERA:Safety Compa.ny.........._... 39454 INSURED (77q;.... .9 ...�ft.9,�............ .... _...... —................... INSURER B: Mar .o Toecano ....._.....a.................... INSURER C; _........__.................................._.................................._...............................................................,................................i................ ........................_. 162 Haaj-1,ton Street INF�URFRD; Worcester MA 01604 IN6URERE: ............................................................................................................................................- INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 4455 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, I.H.96............._...._............._..................................................._....._........-ADD,.!gvur;........................................_..................................._........-.............:..C+OC'tC'Y'Epp-....P'0'LfCV'PXC.....,....,..._......_................................._................................._..........._..................._............ LTR TYPE OF INSURANCE qp:WV POLICY NUMBER MMIDDlvYYY i MMIDDIVYYY LIMI76 A X COMMERCIAL GENERAL LIABILITY _........ EACH OCCURRENCE 11000,000 ............... CLAtM9•MAOC ...x...! OCCUR EMAO023603 5/0/2015 Slli/:+016 ... k N E E 9KtF�nregl.......�,5:................. ..200,,00_�......_... ............: ................ .............................................................................. MEU 6Y.F(Any nne person) s 5,000 _..._..............._...................................................... I &AW IN 1,000,000 C;(cW'L AfiGC3C CtA'E;LIMIT APrlL,IFS PfzR: (XENFkAI,AC3c5r?Fi4,A'I'D..._ is 2,000,000 . . . ...... .....� ........_.._.............._...._................. XPr>LICY II f RO I ... .......... _........................................ _._.... PRO :T8-:OMf'!OG>AGG ?g 2,000,000 DUC ;..._.... ......._............... .................. ._...................._.............................. OTHER.: AUTOMOBILtSI,fAfiIL1Tv CiINdF ?ING,.F 1,Ml II...__ I i fEfl ErCCI @ _ __ .................—E ANY A',1TC) BODILY INJURY(P8r person) ................................. ALLOWNEOfCh1EAULEI7 ........... ............. ........................................................... .......... A!ITOS AUTO: BODILY INJURY(Per accident):S Nlktl?Gu.Yi'tir- NON-OWNED a ...`PROPERTY TY.0 1- ........... ........................_ ._......................... ........... AUTO$ i E S{a(:gJslrnr)1A ....... ........ ... ..... DAMAGE S ...._ .........................._........ ..................... ............................ e , .W...�.�.�.�.�..�.�,..w.�W..,.,�,..W.,, UMBRELLALIAR W ,..,,....... .,.,.,.,.,. W..,.,.,..,... ,.�W...,..WWW.r..............._,WWW....,..,.....,..,...,.W,...,..�,..,.W....�... ............ OCCUR - - 'EAi1Fl=tt::i::LIRRENCE 'a EXCESS LIAO C ......... _....... ....................................................................... LAIM$-MAD ........................... .._......E...... . ................t ............:.._......_..........._....- AC,[,RF,'.GATE bECiRITF,.NTIC)N ._............._........_......._..........._. .r. .............................................................. WORKERS COMPENSATION GEIY 01'H- AND EMPLOYERS'LIABILITY Y/N i ANY PROPRIETgR/f-ARTNF.R;f,At,:I I I tVE i _ OPFiOERrM>MBER EX I,IJDED^ :NIA: :L._............ .......................... .EACI•i.ACCIDLNT S (Mandatory In NH) u nr.,decorit,c u»dnr F.L......-)iSF....FA FNtPL.)YE yy C E S c CRIPTION OF OPERATIONS hclow F.L.C>I$f Ak3F'-I'UIJCY LIMIT L$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Addltlonul Remerk6 Schedule,onav he attached II'tnoree space is requlredl CERTIFICATE HOLDER- CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Capertown Kitchens Inc ACCORDANCE WITH THE POLICY PROVISIONS. 207 West Street AUTHOR17,F0 REPRESENTATIVH Milford MA 01757 O 1996-2014 ACORD CORPORATION, All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ,aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/6/16 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 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: Handy-Apple Valley Insurance A PHONE FAX 508 792-3070 AI No: (508) 791-7294 440 Park Ave E-MAIL ADDRESS: Worcester, MA 01610 INSURE S AFFORDING COVERAGE NAIC# INSURERA:Safety Insurance INSURED INSURER B: JEFF MEADE INSURERC: DBA PRIMARY PAINTING INSURER D: 10 VILLA DRIVE INSURERE: HOPEDALE, MA 01756 INSURERF: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE INSR WVD POLICY NUMBER MM/DDIY MM/DD/YYYY LIMITS GENERAL LIABILITY BMA0019908 9/3/15 9/3/16 EACH OCCURRENCE $ 1,000,000 X COM MERCIAL GENERAL LIABILITY "MA GE TO RENTED IS, $ CLAIMS-MADE F_x]OCCUR MED EXP(Any one person) $ PERSO NA L&ADV I NJURY $ GENERAL AGGREGATE - $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER [PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY _ COMBINED SINGLE LIMIT Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWIED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Feraccidenl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACODENT $ OFFICE RIME MBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Interior Painting CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CAPERTOWN KITCHENS ACCORDANCE WITH THE POLICY PROVISIONS. 207 WEST STREET MILFORD, MA 01757 AUTHORIZED REPRESENTATIVE STEVE R. HANDY/SAFETY INSURANCE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: AC R' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YF0311612016 YYY) N E 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 endoreement(s). PRODUCER CON NAMEA TLarry Cowan Cowan Insurance Agency,Inc, PHONE 978 372-1451 FA't 978 521.4669 359 Main Street Mal la cowaninsurance.com Haverhill MA 01830 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A• Employers Mutual Casualty Company INSURED INSURERS:Associated Employers Insurance Company George Peloso III dba Peloso Flooring&Restoration N R 3 Admiral Street INSURER Woonsocket RI 02895 IN R E INSURER 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. ILTR NSR TYPE OF INSURANCE DDL SUB L CY UMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE 1 OOO 000 A X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 OOO CLAIMSAIADE XD OCCUR 4D70992 0311112016 03/1112017 MED EXP(Any one rson 5 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,0OO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT c ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per aoddent) $ HIRED AUTOS NO AUTOS PROPERTY DAMAGE $ an UMBRELLALUU3 OCCUR EACH OCCURRENCE EXCESS LIAB HCLAIMS-MADE AGGREGATE $ D $ WORKERS COMPENSATION X WC STATU. OTH- AND EMPLOYERS'LIABILITY Y/N B OFFICER/MEMBER EXCCLUDEANY ECUTIVQ� E.L.EACH ACCIDENT 10O 000 (Mandatory in NH) NIAWCC-500-5013899-2015A 09/2312015 09/23/2016 If ea,describe under E.L.DISEASE-EA EMPLOYEEIgo 1 OO OOO E.L.DISEASE-POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) Flooring contractor. CERTIFICATE HOLDER CANCELLATION Capertown Kitchens Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 207 West Street ACCORDANCE WITH THE POLICY PROVISIONS. Milford,MA 01757 AUTHORIZED REPRESENTA E Fax: 508 73-7104 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD Vinyl-Painted Finish Characteristics Cabinet manufacturing facilities, unlike many.homes, are maintained with humidification systems. Therefore, a situation exists where the cabinetry in your home will dry out or absorb moisture. In either event, the shrinkage or expansion of the joints can cause the finish to fracture at the joints. This condition is not in any way considered defective workmanship or material. It will not affect the stability of your cabinetry, doors, or finish in general. Capertown Kitchens, Inc. cannot be held responsible for any of the above-mentioned conditions that may appear in your cabinetry. Purchas 's signature S e s signature Date t� --- ------- ................................. ...................... 48, —36"_/ 251" 25-V 25 36 2 N." 44.1 40-1" 2' 36"--- ...............3 30,......... ........... 2 2T 37 ........... ........ HIS ........................... .................... .................... W*............. [77 WC3333L WB3333 inst all new door ......... same opening size N.�� sai Ceiling Height=92.25+- (DUibVV 3DB30 cabirietry set to 87" ............ Cf) M LO lliil Cr double recycle 58368 rp 3DB30 drws 00 CO Bathroom It Remove pantry walls CO new tile floor and ---------- ............................ ...................LI tub walls 66"x 24" En M w, N Table Base L,4 M (a U ........................................... ......... .. . .. ......... .............. (D apatch in wood flooring and refinish 0 3: CMD 2 12 'U.0 0 Refrig increase opening a_ 0 aC\J to 60" N_ ......... ............. ............. .......... .. .................. ............................. .... ... WB30 .............................- 24"de 24" vig M ........................................... 89� ........ ---------- 1 '.1_ ............ ............. 1701 ........................................... .................................. —27 38 89.. 5 7,.—/ L94-- 0 0 '0 CU 0 0 2 1 E C1 - f,, L, All dimensions-size designations This is an original design and must Designed: 1/15/2016 given are subject to verification on not be released or copied unless Printed: 3/2 1/2016 job site and adjustment to fit job le t I"Ott,'11 applicable fee has been paid or job conditions. order placed. fl.ens Brown Cape Horne JAII 1 I No Scale. 2.The standard form of warranty shall apply to the service and equipment furnished(except where other warranties of purchased products apply.)The warranty shall become effective when signed by the Seller and delivered to the Purchaser.The warranty is for one-year materials and labor. 3.The delivery date,when given,shall be deemed approximate and performance is subject to delays caused by strikes,fires,acts of God or other reasons not under the control of the Seller,as well as the availability of the product at the time of delivery. 4. The Purchaser agrees to accept delivery of the product or products when ready.The risk of loss,as to damage or destruction,shall be upon the Purchaser upon the delivery and receipt of the product. 5. The Purchaser understands that the products described are specifically designed and custom built and that the Seller takes immediate steps upon execution of this Agreement to design,order and construct those items set forth herein; therefore,this Agreement is not subject to cancellation by the Purchaser for any reason. 6.No installation,plumbing,electrical,flooring,decorating or other construction work is to be provided unless specifically set forth herein.In the event the Seller is to perform the installation,it is understood that the price agreed upon herein does not include possible expense entailed in coping with hidden or unknown contingencies found at the job site.In the event such contingencies arise and the Seller is required to furnish labor or materials or otherwise perform work not provided for or contemplated by the Seller,the actual costs plus(20%)thereof will be paid for by the Purchaser.Contingencies include but are not limited to inability to reuse existing water,vent,and waste pipes; air shafts,ducts,grilles, louvers and registers; the relocation of concealed pipes, risers,wiring or conduits,the presence of which cannot be determined until the work has started; or imperfections, rotting or decay in the structure or parts thereof necessitating replacement. 7.Title to the item sold pursuant to this Agreement shall not pass to the Purchaser until the full price as set forth in this Agreement is paid to the Seller. 8.Delays in payment shall be subject to interest charges(18%)per annum,and in no event higher than the interest rate provided by law.If the Seller is required to engage the services of a collection agency or an attorney,the Purchaser agrees to reimburse the Seller for any reasonable amounts expended in order to collect the unpaid balance. 9. If any provision of this Agreement is declared invalid by any tribunal,the remaining provisions of the Agreement shall not be affected thereby. 10. This Agreement sets forth the entire transaction between the parties; any and all prior Agreements, warranties or representations made by either party are superseded by this Agreement.All changes in this Agreement shall be made by a separate document and executed with the same formalities. No agent of the Seller, unless authorized in writing by the Seller,has any authority to waive alter or enlarge this contract,or to make any new or substituted or different contracts, representations or warranties. 11. The Seller retains the right upon breach of this Agreement by the Purchaser to sell those items in the Seller's possession. In effecting any resale on breach of this Agreement by the Purchaser,the Seller shall be deemed to act in the capacity of agent for the Purchaser.The Purchaser shall be liable for any net deficiency on resale. 12.The Seller agrees that it will perform this contract in conformity with customary industry practices. The Purchaser agrees that any claim for adjustment shall not be reason or cause for failure to make , payment of the purchase price in full. Any unresolved controversy or claim arising from or under this . contract shall be settled by arbitration and judgment upon the award rendered may be entered in any court of competent jurisdiction.The arbitration shall be held under the rules of the American Arbitration Association.It is hereby agreed that such dispute shall be referred to one arbitrator for arbitration and his or her decision shall be final and binding on said parties. gq 70& Town of Barnstable *Permit#- , ,4 Expires 6 months from Ume date sRegulatory Services Feed -40 • �. g rY %63 Thomas F.Geilert Director Building Division Tom Perry, Building Commissioner X-PRES S PER 200 Main Street,.Hyannis,MA 02601 1� Office: 508-862-4038 MAY 2 1 2115 Fax: 508-790-6230 EXPRESS PERNTr APPLICATION - RESIDENTT M&MF BARNSTABLE Not Valid without Red X-Press Imprint 4ap/parcel Number 'ropertyAddress y���a�l,�' �l/� (?��7@41 UZ Residential Value of Work � `,/17J� Minimum fee of•$25.00 for work under$6000.00 )wner's Name&Address ;;1 1V11—) �D Contractor's Name ,�.PPl/1�� Telephone Number 77J—,;K Vi�� Home Improvement Contractor License#(if applicable) /d4 J Construction Supervisor's License#(if applicable) ` ❑Workmen's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Named 11�A?ll5, 'S Workmen's Comp.Policy# // 914VU ZF,Z?.Z . Copy of Insurance.Compliance Certificate must be on file. Permit Request(check box) C'l eReroof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers.of roof) ❑ Re-side ❑ Replacement Windows. U-Value- (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. Home Improvement tractors License is required. Signature QForms:expmtrg Revise063004 b F r .. The Commonwealth of Massachusetts Department of Industrial Accidents —_ Office of Investigations _ a 600 Washington Street, 7`h Floor Boston,Mass. 02111 g Workers'Com ensation Insurance Affidavit:Buildinig/Plumbing/Electrical Contractors "W! {;sT2 'r1.0�:spm��v _ - •: , 'hcninforatbh .* a'- ?�. name: address: city ��/ f' .fG stater zin•42g6 :U ph ne# i/7i5_—_.'?% work site location full address): ' ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction Remodel ❑ I am a sole proprietor and have no one working in an_X capacity. ❑Buildint. Addition TTKKu�t,,i�••ra.�.y„i;+"`ni. "`.r,�•955�^T.s✓o-':Fai;"!v.,�iXxep,"r 3y�sw: iF� n-�r�,;a�^i{,a,,. sr •�..•,ir.' rr;. :;:t q[?:Y]., R. �yy. oi.n .,�:�'ry ` ';k. .-SAL',*" �:w•G-.�:9�,.�i:i:'^ n',e.. .....,"f?''«: .. •...k:. ::�........t'i,.;�i'f`.�....,.,t:,�r.�.',.r� .. ..: :IF':t'•..•.:���t �+' .�n::. \ I am an employer providing workers'compensation for my employees working on this job. company name: address: city: X l�h phone#: 7_7c3`���� / insurance pc,o. policy# •.:li:i:•Lie'SYe:i 4•�T.;.iX•A'(('�N a`!rl�R�•ie...k. :S'•"fi::' 1?:: "+{::^ .lp..- ..•1'..". a+':£r ki{(6 aM.m. 'a....b;c=.'�.�'Eini..F':J.$,>c�i+IL•:a^:.T•,.�a.... , :;�F,`,.:; •:v . '.2�:�::.�d.�:...�a.;. �•..•.2.�:.�:arr.,r. ��..mt�'�.rL;�!:::;'.u:Wa�?.,�'!�a:e"i�a`o '�.>.': ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name P address: : city: phone#: insurance co. policy# ,t . . ..�•a.'�i .. ....n.r,6�';:-.r..ii,'rg,... ...� -� ."�Pvr::" ,2�..:. .: fliti','.=i•N:� :.:... ..,. «.ice. .. n. ...,i..71: ..A;:ri.,.� .. .:.. .. ,..lyd:� 'company name address: city phone# insurance co. policy# ^� r. I h a aElk� ddih 41a1':h�t_i t�r-� d o e. •nec sa a r i d.. a �ErYti;"�:A.:�.31�.7��.�...�w,Ta�,•'n�i?�". ,r:'n' i; r� .. .��i.�a[..;.eta��sa�.as,._?a+�:�7e...+X":�s€�'�;,;'y'"�; ",:r.,�r��' ' Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1400.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under t pains andpenalties ofperjury that the information provided above is true and correct x Signature Date Print name_ �_I/.el�/J�• � Phone# Elnonly do not write in this area to be completed by city or town official : permit/Ucense# i, ❑Building Department immediate response is required ❑Licensing Board ❑Selectmen's Office son: phone# ❑Health Department 03) ' Clothe rN i Information and Instructions Massachusetts General Laws chapter 152 section 25 requires,all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under.any contract of hire,express or implied,oral or written. . An employer is defined as an individua, art nership, association,corporation of 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,asso 'ation or other legal entity,employing employee . However the owner of a dwelling house having not more than three ap ents and who resides therein,or the occu nt of the dwelling house of another who employs persons to do maintenanc construction or repair work on such dw ing house or on the grounds or building appurtenant thereto.shall not because f such employment be deemed to be employer. MGL chapter 152 section 25 also states that every s to or local licensing/nthe 11 withhold the issuance or renewal of a license or permit to operate a busines or to construct buithe commonwealth for any applicant who has not produced acceptable evidenc of compliance witurance coverage required. Additionally,neither the commonwealth nor any of its p itical subdivisionter into any contract for the performance of public work until acceptable evidence of mpliance with tnce requirements of this chapter have been presented to the contracting authority. '^,.�,"" � t .s +,.�-u ;i• ��e,�p�. ,4.,.,, 4!fi:1..; •3e'7 :�; L'9�:�t�� �._.E.C:k ?ti:: .':1. .. jr., �.._ :v:.� � ^:vr��':'•',:'�f•Sr'..P• !1.'".:: ���.• `..z-4 ., .ki, :: •o-w:: �� '".,•' ''da! .. '!c nt1. ..81:k37�w •ca'3"." » a: 'o:LL�€e..d2ere:3.'::J:si:ftc?r1:i."�'„�r`. .N.,�i.. :. :'vl '4 Applicants Please fill in the workers' compensation.affidavit completely,b chec ng the box that applies to your situation. Please supply company name, address and phone numbers along with a erti cate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirma 'o of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or own that the application for the permit or license is being requested,not the Department of Industrial Accidents. Sh you have any questions regarding the"law"or if to obtain a workers' compensation policy, le c 1 the Department at the number listed below. you are required P P Y P rtw�'rr «y.. .h D:riA$T°"';.•r•^z<,r..�Yi, .r:T.`+''_??frv'.i ..�' 'a. i;?7 F'1Ft. .}.�. ^�•' `tiP�:'.;T ar 1. ..(, v zi �v,v ..'+f ice'. .Tc�•P. .Sy;'•�d:.;.t.',:�+' s��� '+,t.a'�Cs. iF.'. y a:'R!4;.'a;ort. :+:.,•: i;•+�•; .ti•`.��`.`•� ?F.,�. .I:, s"�'?.t.>r,:'/f, :•Au,..�:.b , -ii'x 24'.'. .�-'k' r{!q, -ten"•.ti?tn •'_fe>' ;'S';�F'J .t:' :':Uia:. 9,., ^.,.t., ast >:` 'i:- #+.: u �,d.; rr $'�' .:7r,. :�,_ vo:h. '�$.� ..t. ,,..,.�y .,�,,": w :?03. `!� :en•`�.:�s[,W.^"'d�' :e:.�kt..'*:ky .s.:';t.+�K.`�,'..:i0 t •R y. i ;rYar..^'>:vr�'aAK.�.1{r.:a ru.,1;+w'.tYc.:'tzsr..w:rhw:e: .,., cis. :4.:�F,�kR4n::.v. -•.'.?t' _ `t^•s,.r.: ..-x..r:t-;.^:.._,._.a:.�:,'-r' ::e',:S.G:6 0:�¢. �`at:.i-r City or Towns Please be sure that the affidavit is complete and printed le bly. The De utment has provided a space at the bottom of ea 1 t for you to fill out in the event the Office of estigations ha to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be sed as a referen a number. The affidavits maybe returned to the Department by mail or FAX unless other arrangeme have been made. The Office of Investigations would like to thank you in dvance for.you coop ation'and should you have any questions, please do not hesitate to give us a call. .,,.,::y.. _ r '�'.' :•Sk'. °a-,Y.Y - S•G: - `HS.Y4. `��`'.: 'rf.>•:,�pr,:n:'.F.!':,"Sc:• >ya§f..c? :r(,rvG `- n r'> b.�'... 'FA•Jer,.T'•..it« '3�..z�;:�.4�,t; m ,�3r•�il�''. ^.'.rs, .��i., .;�.'*`�,a 'S' ,f}: 'ii�' :t .�: 'f�xc y,+t,•.iY:•., rn..�A.t.. .t.. �. ►c.,J .�. :trC. A'..f.- •ri'u .tK.. .:ti: ..u°''� ^) ?.?:�. ::�i.'? Y -- �y:. 9.� dw1....7 .. .' .ta:ya"#iw... .i$1.-r..�le'tr.1i-'.. .r=U_ 4F:� P �� .�..:Ki'�..�; L _ ..�4__ tt•..?7..`:rnt ,Ft;r�er.':^a3:_':.. •.r_':Y.3�'t:_ShLv.5h.:� The Department's address,-telephone arid fax number• The Commo wealth Of Massachusetts- 'Industrial Accidents 0 ice of Investigations 600 ashington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 ' • • oft ro�ti Town of Barnstable' �.� Regulatory Services sr�nrisrr,8 vplomw F.GeUer,Director , q 'e3 �,•�' Building Division �'°ren n�►►'� tomYerry, Building Com=issiouer ' 200 Main street, $yam,MA 02601 wwwAown ba=stable;ma.us Fax. 508-790-6230 ' Office: 508-8624038 property owner Must Complete and Sign This Section If Using ABuilder ® ,as Owner of the subject property ' to-act on ary behalf; 'hereby authorize m all rriatters relative to work authorized by this building Permit application for.• � duress of ob W } f' •_ ate. Print I�Ta� , lee�o%rrvmaozcu y J Board of Building Regulations and Standards . ' HOME IMP.OVEMENT CONTRACTOR E, .. Registralwm\100497 2006 j p = y to Corporation DAVID COX,IN David Cox 19 LAVENDER LN r W.YARMOUTH,MA.02673 C.G ✓J �:,;: Administrator i