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I " -�, I,I 1: -- ... �* _', 1 t',� i"i, , �� _ � �i��,�,,�`�,��- I,,I ;"', �, I , � t 'r � . � ��., !� :"', ,,,,�,," I I , ',�� :,`l,� 1"�� " -��`r. �, " " , , " ': , , ��� ,. � � . � � ,� _ "I � - , _ " , � __ �,�lj�: ,�,� .4, % � , , , � - � ;, �_ ,-,, __�";,!, ,�� � r � � _:�� ,� �_��, , I�: " _ " _ _�1, � -�, ": _�,, ", � i .- ,,� �� � , ,� ,-,�IFF.�,,",-�: ,�,� �,-:,,- - - - _ Town of Barnstable Building r,�. fir, tSo'Thati a sible.From-the Street.=vA rovedPlans Must�be�Retalned on.,Job andth�sard Must be-Ke' t :� iPost This Cad t S 1 Posted a Where`�aCert�ficate:of:Oceu anc s;Re aired:such,FBuildin shalF at-be ccu ied`until a Final�lns",ectior/has�been,madeW �rt ._ Permit Permit No. B-17-2843 Applicant Name: SCOTT PEACOCK BUILDING&REMODELING INC Approvals F Date Issued: 09/01/2017 Current Use: Structure - Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 03/01/2018 _ Foundation: Residential Map/Lot 189 097 Zoning District: RD-1 Sheathing: Location: 47 MARIE-ANN TERRACE,CENTERVILLE C t actorAName: SCOTT PEACOCK BUILDING,& Framing: 1 Y REMODELING INC Owner on Record: HILL JAMES H&KRIS L Address: 47 MARIE ANN TERRACE a '� -. `on'traetor�Llcense151853 2 ..; Chimney: CENTERVILLE,MA 02632 Est Project Cost: $25,000.00 Description: Refit Kitchen Permit fee: $17Z.50 Insulation: Project Review Req: Refit Kitchen fee Paid $ 177.50 Final: u e_ Date `r 9/1/2017 _ Plumbing/Gas } Rough Plumbing: Final Plumbing: Pit Building Official This permit shall be deemed abandoned and invalid unless the work authorized�by�t1%permit is commenced within six monA11fker Issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and theapproved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures�shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access sireetorroad and shall be maintained open forpublic Inspection for the entire duration of the work until the completion of the same. x Electrical 71 Service: The Certificate of Occupancy will not be issued until all appli10 11 1�1"Iq cable signatures by, he Bu ngand-Irrr Officials are provided on.this permit. Minimum of Five Call Inspections Required for All Construction Work:, �' Rough: 1.Foundation or Footing U° i•. 1Z �" 2.Sheathing Inspection 4 Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed priorto Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Whe'�e applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: We*shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- q� Pp Parcel Application # - 74 0 BUILDING DLPT. � `I o� Health Division Date Issued 17 Conservation Division AUG 18 2017 Application Fee Planning Dept. Permit Fee TOWN OF BARNSTABLE Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address Igari `e - A-,m Yi Pe.r rq eAE, Village czA/Atr yt 1 e, �a voles '- K n 41,Owner � S 1 Address Lf-7 Ma ree'--)qVIyl T er"►"Ci-e-e-, Telephone (D (p �t(o0 L1'�. V D H A � �3� Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation %�5l COO Construction Type n 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 Kings-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 0 Appeal # Recorded 0 Commercial ❑Yes ❑ No If yes, site plan review # Current Use W Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name J c S C&4+A$ Telephone Number Address d by)c License # CIS- 0I4_'��bc> os*)( Via�� , ' t \ � S Home Improvement Contractor# I C� _ Email S �p��-(' °� _ 1.�f.�t Z6�1, ►`'l P� Worker's Compensation # � � d� ��`" �5% ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO \Lavy-�Y , Lo,_�dd� Ll SIGNATURE DATE R , 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 F DATE CLOSED OUT ASSOCIATION PLAN NO. t eiata»yerrvices Mobard V 8"10bectox 200 Mft Sftot,Sya *'MA 02601 - 4 WWv4mMbiim4abIamz.UI c e: 508-862-4038 Paaci'S08-79 6234 Proper er,must C I on�plete �d Sip'�h�s Section in 9" T: 1 ., ,U' OW=of the subjectpropaty 11=67 authOS Ze to b ems; as all xx>z xclat e to work autboxized b wit a oza for. � b'� P PPlica (Add&eaa of Job) *Pool feaces and 4m= are the xesponsibi tq of the appuc=t Pooh axe not-to be Bled or used beforb fencels in ned and an a1 =specti®sts are pod gibd acce�pted: Situze•af Uwwoaes s4a ofAp�aliesot x t.l\Ta o C p ►tN=e � ,. A2te � sro�ooz:� r 6VO wash&g1mwee€ Bost i' 10P iasJ� _ �ct� �e�s Aire-3-au aTtIare. eapPr6eb= _ - arna amploy—ate 4 ❑Zan a g Z -al cflatmctxaudi '' of z°IecF(rr uirec emazc?e (�ilY a,�fo€g��imc � Rehire ffte sir-eo3hz� fi- ❑ 2.Q I a�a sale piuon -cw,oz partaer f15iZC ,ih,aft.,Cr ed �_ s.b' and base as FTn��ee5 `�ese-ab-Cauca=g. a,m o �o$�g i�nre in a 1 ��e wado s,' a- ❑ calal Q - _ �'��- employees rN4 iTL}iL'ErS COIIID_i cnsx,r� camp_MSuMncf d �--Q�rII1�Lt2II�adiffi0 resaLed-T �_ ElWeareato=pa�i=cgs 10-QEletcagrcpaimor �-Q _ -az e 's�piag_ 3 ES g g3pYl'� y�Q� j33IIS QY 8[771� ' sr>crrac�reT2 Lcec1 S c- UR an&ve have na LR—Q�o-:rrepaim eaploye—t'o"-mb S& 13-0 0&ez .. Z:Omti_s'IISL��isQElr�� 6=if EDJR1Q'*+�i�35CCOaG3�Co�Z *Zs}St Elsa nocat -S�SIEIILl.0:106F�r�,n.-v mn,5=BDS]GPti'QUID *?• - �Z�.T":'1�'7J!-i�Fi3D SSi�+1�E2�S E�'70�'-41L i�mrstin.r ��1�DII.. -'Cam-�y�^tca�ti�somc�+ -�`�°�rlE��tL��aa�ir�r,�,,T,,,-:,,,•_,..,,+sv7Qaitgn=-saas�u�-���sa:a - _�ast���E�a1�25�D� san-Ca �s�tt3�ua�m�uaaa�£�prge�sy.� ' eT�_•iuy2�.Lff+Laan,.r�t�,rt,,..= tuna-�af&r: �t'3e c�9taj� p-Qyj�+�'��' r'DLti-ca'.3Z9.�DI1Ls mrmisnr - - - 1 am au 2PP87 5RFYllll�t5 it 7F©7 ��5�cD t!&QE£{d?Y Z�IS?bTdtt':CB�Dpy o� ?r�'OITBILIZDPL t ���eg 33eIDa4 s i�ie�rr$c1,m-�JD�d SZf3 Co�oaawe: CT7 Job Sii:e Addxesz 7 Man -)4nn 1.e r� � CUYjS P: �er4j if tVKOa(03a-, Fa unr �{ ar za peitsa a?�p Fa decla,-atm Me.{�h�thepoTev�3�e*4 and exp�aoF a dua to s eon- 2g -'reg e!luu rSe�art25Aa€Mtff-¢15 cmImjtu,Seehwosif3nrtofcrim{ng-DMalffesoia fine upt--$L50DOQaguera6e-y.ear as Well as-ci peke,.injje,f,,=cfaS��C}R��3IZi3Et�anda� of OtY a d- ag=aku tsolacti� 1 adrssrca a ems; Lrves-d �'�*��be x d O�flmceat 1 eia Ater p c " rhea- Pfims - 1!rjP-7jUz�'a ss u ucprm Bbo4�aiR h;rs r�ir s ect e3}a' iia IT&rrry w'se cDPP,�seted by d rrt-fDio-zs aL t_,.-y or Town: reeffi ae� e 4:17 : i ai lkspectur .T- E Contact f e solo ' CCWL30 CERTIFICATE OF LIABILITY INSURANCE DATE, �� 07/10/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Germani Insurance Agency P"oN o E t. (508)428-9194 A/c No: (508)428-3068 908 Main Street E-MAIL ADDRESS: certs@germaniinsurance.com INSURERS AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURER A: SAFETY INS CO 39454 INSURED INSURER B: Granite State-AIU Holdings 000000 Scott Peacock Building&Remodeling, Inc. INSURER C: P.O.BOX 171 INSURERD: INSURER E: Ostervllle MA 02655 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 EXP LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMDDY/YYYY MM DD EFF Y/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ A BMA0022118 07/05/2017 07/05/2018 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JEST LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBER EXCLUDED? ❑-N/A WC 005-81-5464 06/22/2017 06/22/2018 (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Scott Peacock Building&Remodeling Inc ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 171 Ostervllle,MA 02655 AUTHORIZED REPRESENTATIVE Fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-094500 Construction Supervisor JAMES S PEACOCK PO BOX 171 `� "N OSTERVILLE MA 02655:= Expiration: Commissioner 07/2212018 ,� �"��r,.�rvrrrrcnuruen�/�n/�G'jlla�Jac�rrde� ._- 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: ::1-51853 Type: Office of Consumer Affairs and Business Regulation �7 Expiration:_ 7/, .1 Private Corporation 10 Park Plaza-Suite 5170 &`ems Boston,MA 02116 SCOTT PEACOCK BUIL-T!! &:REMODELING INC _ 1 . JAMES PEACOCK 1046 MAIN STREET SUITE 7 OSTERVILLE, MA 02655 Undersecretary Not valid without signature a F� v PAINT GRADE CABINETRY-COLOR TBD Sheet 52k Rev. ' ---------------------- � rs r --------------------------------------r------------------------ -----------------------Ti rr -------,----T W W 5.16.17 l---- ---------------------------------------Lill1 I 1 1 I .CORNER la• y i i " I O ACCE55 , I , 2 . 2 Eng. 1 I I , I I ,. I ....... _ - ...... 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EW583055 2.25 i i Z 1 05.94 x 40 .. 35 x 40 - _ r I I I J 1 1 I I I 1 I j ._. .. ..... �.. .. 10. ♦ - O. - I I ----- • 1 1 � 1 . _ _....__ 37.719X 3073 aAx90." j I -------------------------------------------------------------------------------- - <� 3 51NGLE ADJ 5HEV LG RANGE LAZY 51.15AN c L5E4G 135T ' 37; 30' —254 25•--k c 0 �R q: •. 1. PAINT GRADE CABINETRY-COLOR TBD sheet Rev. 5.16.17 Scale 76, Eng. r F 2'T-29' n I• 744 R29' �i 2-1 _ ........ _....: Q S: z _ zz. z 36' 34�, DI z rE III 51NGLE ADJ 5HELF SHARP 2470A5 SINGLE ADJ SHELF J 29' L 5IN2LE PULLOUT 74 SINGLE PULLOUT -29' J_ S o U' ai i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ® n "` af: 6 Application# Health Division Conservation Division Permit# Tax Collector /=f 4 Date Issued 1 �� Treasurer Application Fee Planning Dept. Permit Fee a- � 6V Date Definitive Plan Approved by Planning Board 2//7/07 Historic-OKH Preservation/Hyannis Project Street Address `4—7 I V a r I -e '— Pi n n e 1rr eA c Village —Ce �"�r U 1 I , Owner ��)(�l -�� 4 K66 L- I'I I Address �� W y e— h yi o Te✓I(C66 Telephone 5006 S 9 2— Permit Request ( Y1 15 6 I I M Y Gi)m a nd Q f ?, %n ! Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District ResfdCI41a Flood Plain - Groundwater Overlay Project Valuation J 000 w�Construction Type Lot Size 0 �a ,� J Grandfathered: ❑Yes �&No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 5?-- Historic House: ❑Yes U No On Old King's Highway: ❑Yes 10 No Basement Type: ❑Full ❑Crawl 1/Walkout ❑Other Basement Finished Area(sq.ft.) .( Basement Unfinished Area(sq.ft) Number of Baths: Full:existing Z new Half:existing new Number of Bedrooms: existing new _ ,f Total Room Count(not including baths):existing new 2 First Floor Room Count Heat Type and Fuel: ❑Gas 16/0il ❑Electric ❑Other Central Air: ❑Yes °/No Fireplaces: Existing �_ New Existing wood/coal stove: ❑Yes "o 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 .V/No If yes,site plan review# Current Use �0 ,_ Proposed Use., BUILDER INFORMATION Name �U e � � �® Telephone Number 5* 17 • Address ��0 22 License# CS 77 Z 3 I(a & n_'�r y 1 I I-e l 1y� C003 2— Home Improvement Contractor# ►A �2—(p f Worker's Compensation# l�C J ZeaS ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO '.( iabU 1"r Sfev 5S e1Y70V1 SIGNATURE DATE ��/�/® 7 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. i f ADDRESS VILLAGE 1� OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL s GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT . ASSOCIATION PLAN NO. , x r,� y • m : : : : : : : : : : : : : : : : li :Are : : : . . : : . . . - .. D.. ..p .a.r-s. ., : : : 28 New -Stair- a -Treads - -I : : : : : : : : : : , : : I Co N � Teo Wall ,double Bich . . _ . _ _ . . 1 1 Office ,p - If -Fees . . . . _ . . _ _ _ . . . , :9 .5 3 RAY. . . . . . . . . . . . 60x4 -Double I: : : : : 99 : : ; : : : : : : : : . : : :. . . . . . . . _ -Vic N � 2 - . . _- - _ . _ . . _ . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . _ . . . Y• :0T . . . . . . . . . . . . . . _ . . _ . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . _ . . . . . . . . . . . . . . . . . . . _ . _ . . . . _ . . . . . . _ . _ . . - - - .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . _ . . P�oFVE► Town of Barnstable Regulatory Services BMWSTABM ` Thomas F.Geiler,Director Mass• Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence..or building be done by registered contractors,with certain exceptions,along with other requirements. (� Type of Work: ( r" 2 rox ' 'I ; ' Estimated Cost Address of Work: !-) Owner's Name:, .)(/� �. y I s, . Ell Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ElBuilding not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor ame Registration No. OR Date Owner's Name Q:forms.homeaffidav The Commonwealth of-Massachusetts Department of Industrial Accidents 9-3 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): Da U i u / r?& Address: L-e Y,n Ln City/State/Zip: . M r�Z one# ' Are ou a 1 n employer? Check the�appropriate ox: Type of project(required): .Are am a e 4. V am a genera con I l tractor and I mPto Yer with 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet, t ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their. 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11-0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs ' insurance required.] t employees.(No workers" 13.90ther��')i1 ISh qVyRr i y7L 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 tContractons that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Comp any Name: V �� t b' I� V 16 ( n 5 t4 ra�� C v Policy#or Self-ins.Lie. #: �� (� _ 12— 2.5 Expiration Date: 'b 2_S C)0 Job Site Address: 1 1 I V 1 Ja n- " f i► 1 n ly ra ce- City/State/Zip: Ole{f tG ry ilol V 9`0aW Z 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 ce under the pains and pen !ties of perjury that the information provided above is true and correct: signafore: Date: // , O 7 Phone#: ��� ' ?'2�' c8' 9? 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#: Sub Contractor W-9 and Certificate of Insurance �..,.,;, 3 „,F(nsured ,.. ,:,�z,.. ertlfcat�of,lnsurance, " x irationDate Pol c number Ace Arborculture General Liability 4/19/2008 NPP 1082374 X 04-319-4573 Phone: Automobile Liability 10/1/2007 06MMMM9021 025-48-7944 Fax: Worker's Compensation 11/18/2007 WC 844-99-24 Advantage Electric,Inc - General Liability 1/11/2008 BINDER251774 Phone: 508-326-7921 Worker's Compensation 1/11/2008 WCC5005299012007 Fax: 508-394-9620 All Cape Garage Door Co.,Inc General Liability 6/1/2008 168087K26379TIA07 Phone: 508-398-2757 Worker's Compensation 6/1/2008 WCC5002586012007 Fax: 508428-1184 Associated Alarm Systems,Inc General Liability 4/5/2008 CLS1244289 Phone: 508-775-3442 Fax:508-790-2330 Associated Elevators Companies,Inc. X 04-309-3454 Phone: 508-760-3875 Fax: 508-760-2809 Baxter,Inc. General Liability 8/1/2007 SRSGLMA05092 Phone: 508-775-0375 Worker's Compensation 10/6/2006 US3796BB1705 Fax: 508-771-7324 Riggers Coverage 3/29/2008 QT6607344B865TIL05 Belanger,Susan X 020-70-7459 Phone: 508-776-9482 Worker's Compensation 4/25/2008 VWC6007213012007 Fax: 508-420-3568 General Liability 4/27/2008 3600031197 Belanger,Steven General Liability 6/14/2008 BP17034414 020-60-4983 Phone: 508-428-1389 Worker's Compensation 2/4/2008 VWC6002932012007 Fax: 508420-3568 Automobile Liability 7/2/2008 95375400001 Brennick Building System LLC General Liability 2/25/2008 CB4E1820 Phone: 508-775-5111 Automobile Liability 4/1/2008 T39797 Fax: 508-896-7997 Umbrella Liability 10/5/2008 5.16!92 Brian Bolton Worker's Compensation 2/23/2008 UB7254B64A07 Phone: 508-776-3466 General Liability 2/18/2008 MPB90590 Fax: 508-3624129 X Builder Services Group,Inc.-Cape Cod Closets General Liability 6/30/2008 MWZY55525 d/b/a:Quality Insulation&Bldg Prod Worker's Compensation 6/30/2008 TRJUB122D026A06 Cape Cod Insulation,Inc. Worker's Compensation 6/30/2008 WC8962496 X 04-271-5757 Phone: 508-775-1214 General Liability 4/1/2008 CBP9587416 Fax: 508-778-5735 Automobile Liability 4/1/2008 BA9587917 Cape Cod Welding General Liability 9/13/2007 TBD Phone: 508-428-3843 Worker's Compensation 8/15/2007 UB-5520084-1-06 CapeCuts,Ralph Tovar Worker's Compensation 10/6/2008 7019907012005 017-72-6980 Phone: 508-7264176 General Liability 6/7/2008 SCP0558695 Fax: 508-430-0951 X Christopher N.Yerkes General Liability 9/10/2006 MPB72549 231-35-3650 Worker's Compensation 10/15/2006 UB3774B94205 X Cloney,Kevin Electrical Contractor LLC X 04-349-9263 Worker's Compensation 12/17/2006 7015775012005 General Liability 12/16/2006 QB1U7947811 David 0 Nordberg General Liability 5/29/2007 2001XO450 X 010-69-8126 Phone: 508-4284443 Fax: 508-428-8109 DeNardo Home Improvement of Cape Cod,Inc. General Liability 9/10/2008 680883OA359COF X 030-40-3734 Phone: 508477-5574 Worker's Compensation 12/20/2007 UB 0315615406 Fax: 508477-8999 Automobile Liability 1/6/2008 PMC7191293 Downey,Wayne B. General Liability 6/6/2008 53644633 X 021-44-8836 Phone: 508-760-2091 Worker's Compensation 8/19/2008 6KUB692K742207 Finnemore,Joseph R. General Liability 8/6/2008 MPS30346 X 20-3902628 Phone: Worker's Compensation 1/1/2008 UB-1323C97-1-07 Fax: Forest Keepers X 25747-0515 Phone: 508-790-1620 Fuller Electric Company,Inc. General Liability 9/22/2008 MPO80356 04-228-2361 Phone: 508-775-0030 Worker's Compensation 9/22/2008 WCO80356 X Fax: 508-775-6977 Confidential 11/13/2007 Pagel r / Sub Contractor W-9 and Certificate of Insurance .,." Certif nce> x �c?ttonD�e bPpttc nunnbe W9,,,,,,gym Jci'"er ID Gardner Concrete Forms Inc. General Liability 4/4/2007 1680346CC154 X 861141815 Phone: 508-759-5630 Automobile Liability 4/4/2007 92079400002 Fax: 508-759-5091 Worker's Compensation 5/1/2006 WC6700475 Govini,Peter X 043250384 Phone: 508-420-9195 General Liability 5/31/2006 20011-6220 Fax: 508420-9195 Worker's Compensation 9/20/2006 WC006804404 Gray,Ian General Liability 7/24/2007 PX7843 X 014488938 Phone: 508-477-7696 Worker's Compensation 6/9/2007 OBWECJN0285 Fax: 607-724-7759 Gregoire,Frank General Liability 4/l/2007 BH003 52484287 X 043458812 Harvey Industries,Inc. General Liability 3/1/2008 710012316 Phone: 508-775-7788 Worker's Compensation 1/1/2008 WA71 1 D254242037 Fax: 508-771-3217 Hickey Construction Company,Inc. Worker's Compensation 1/17/2008 WC8934821 X 042913741 Phone: 508-771-4128 General Liability 4/9/2007 16801595B907 Automobile Liability 4/9/2007 BA1944BO5A Hill,John General Liability 2/9/2007 BP17041543 X 018381622 J.C.'s Concrete Floors,Inc. General Liability 11/18/2007 NC 500373 Phone: 508-775-8371 Worker's Compensation 9/20/2008 AWC 7019708012005 Fax: 508-534-9050 Jesse Davies dba New Image Flooring General Liability 12/15/2006 HJP371 Phone: 508-385-3727 Fax: 508-385-3496 JFM Flooring General Liability 5/1/2008 GL3326473 Phone:508-771-1608 Worker's Compensation 6/28/2008 6ZZUB-7982B18 Joyce Landscaping General Liability 11/15/2006 8500029622 Phone:508-428-4772 Automobile Liability 3/15/2007 BA0837W91606SEL Fax: 508-428-4707 Worker's Compensation 4/7/2007 WC8954116 Kevin McBride Plumbing&Heating Inc x 20-477-1754 Phone: 508-778-4556 General Liability 5/2/2008 08 SBA PJ8726 Fax: 508-778-2549 Worker's Compensation 11/19/2007 08 WEC KJ6536 Laferriere,Kevin X 013466674 Phone: 508-737-2454 General Liability 9/29/2007 MPP83469 Worker's Compensation 5/15/2007 WC8945433 Lawrence Robinson Masonry Inc. General Liability 9/7/2008 CB 7E 32 32 Phone: 508-524-1426 Worker's Compensation 9/6/2008 76 WEG NQ5620 Miguel Tatara Neto General Liability 3/14/2008 BP00008250 X 919724275 Phone: 508-360-8365 Worker's Compensation 6/24/2008 7PJUB7744A71203 Michael Mongeau General Liability 12/12/2007 MPS57527 Phone: 508-778-9797 Worker's Compensation 3/4/2008 UB480X760907 Fax: 508-778-9797 X 030401009 New England Landscape&Development Corp. General Liability 12/19/2007 994ED5128 X 043016608 Phone: 508-420-5188 Automobile Liability 1/27/2008 BA-2660C60A Worker's Compensation 3/1/2008 Wcc5001933012007 Northern Sealcoating&Paving Inc. General Liability 10/1/2008 CLA019849410 X 042742821 Phone: 508-398-9474 Automobile Liability 10/1/2008 MAA019849510 Fax: 508-394-0955 Worker's Compensation 4/1/2008 WC6836971 Paul J.Cazeault&Sons Roofing Inc. General Liability 4/30/2008 BINDER255115 Phone: 508-428-1177 Worker's Compensation 8/10/2008 UB0095B64AO7 Fax: 508-420-4555 Richard A.Roser Jr. X 043500552 Phone: Residential Development,Inc General Liability 7/25/2007 CTR0006825 Phone: Automobile Liability 10/17/2007 1628696 Fax: Worker's Compensation 1/12/2008 WCC5004174012004 Shaw,Jeffrey P. X 018365674 Phone: 508-776-2347 General Liability 1/23/2007 BH00652460711 Automobile Liability 1/1/2007 ZB142789 Shorey manufacturing Co.,Inc General Liability 12/1/2007 CPA130142815 Phone: 508-760-1070 Worker's Compensation 1/1/2008 WC0008556 Fax: 508-760-5716 Automobile Liability 12/1/2007 MAA130144015 Top to Bottom Chimney Service,Inc General Liability 7/3/2006 PAC6506144 X 043508281 Phone: 508-394-7986 Worker's Compensation 9/29/2006 7010131012005 Fax: 508-398-4328 Confidential 11/13/2007 Page 2 L 1 Sub Contractor W-9 and Certificate of Insurance G ate af,lnsura ce �xpitat a i.,Date, 3, ai _um b c qer mplayer ID# Tuckahoe Turf Farms Inc. General Liability 12/31/2007 ZDN4934142 Phone: 401-364-4020 Worker's Compensation 12/31/2007 MDA0274608 Fax: 401-364-6423 Automobile Liability 12/31/2007 ABN4934084 USA Painting-Andre Luiz Costa Lessa General Liability 5/27/2006 CPP0708740 X 919724280 UTS of Massachusetts Inc General Liability 5/1/2008 MPA7J2232 Phone: 781-438-7755 Automobile Liability 5/1/2008 BA8569B622 Fax: 781-438-6216 Worker's Compensation 2/2/2008 3102800710 Winslow Plumbing&Heating Co.,Inc. General Liability 12/1/2007 CBP9919974 X 042846193 Phone: 508-394-7778 Automobile Liability 12/1/2007 8218494 Fax: 508-394-8256 Worker's Compensation 12/31/2007 1554A Wright,Richard X 135347631 Phone: 508-246-1452 General Liability 10/14/2008 MPB75769 Worker's Compensation 10/26/2008 7017064012007 ty Confidential 1 111 3/2 0 0 7 Page 3 Daniell" Braman, P.E. .� AQtG to �G�Z.� 189 Harbor Point Rd Cummaquid, MA 02637-0361 2.5 ► �3`��Q.�� �� td - V5-o7 C a �li�Q-\J 4 t .L 0 hDl A 02.(O3').. �SLC .o 1. T2.ycTL:�24 --LTC.l-t 13-kK CL _ Vt 1 v5.x L 541 ¢5.�� cl is p �-z. 4 ®A� IA , ♦ 4t�.6��. r..e + s f Q ys u.,. , V •., 5 } OF no +� 5 e � �''ca :�.` TAG Eia Tfie Board of Building Regulations and Standards Construction Supervisor License License: CS 72866 Birttti 5/6/1951 WO n 502009 Tr# 13670 Y�� i� �ion Ob:_ _ • DAVID A SAURO 163 TERN LANE CENTERVILLE,MA 026 -2 CommissionerT" 7 • 1 . , 4 �--e A' J Board of Building nations and Standards One Ashburton Place -. Room 1301 Boston, Mas �chusetts 02108 Home Im rovemer strctor Re at ion Registration: 148201 Type: DBA. N u Expiration: 9/13/2009 Trlt 133017 DAVID SAURO/ CONSTRUCTIO DAVID SAURO = U 163 TERN LANE - CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change. Address n Renewal Employment Lost Card DPS-CA1 fS 5OM-07/07-PC8490 Town of Barnstable Regulatory Services ` sn ASS. Thomas F.Geller Mass. � Director M , 9�AlEDN1A�°, 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 Property Owner Must Complete and Sign This Section If Using A Builder I ��Qs as Owner of the subject property he authorize)CA V I'd x � {�(� to act on my behalf, in all matters relative to work authorized by this building permit application for: . p (Address of Job) Signature of Owner Date 4 Print Name Q TORM S:OWNERPERMIS S ION