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0062 MILLSTONE WAY
a '. / gv -A � .. /. /�I� y p .. .. .. .. - � III ., .. ®, T® of Barnstable -Permi �:� �/J� Etpires 6 n! ro sue4e-- Reglllato)i'y Sees Fee . ' 4 =ARPtsrAEt.$ nsAss i639 Richard V.Scali,Interim Director • ♦0 AjED MA't A 'Building Division Tom Perry,CBO,Building Commissioner 200 plain Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 MRESs PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Properry'''Address 4�2 M;j Q11 P ZJAy olokw V i �l [Residential Value of Work S- — Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address KAA(eeenkL-e4kjn ,ondPrL) ((e MA o2_(. ;Z Contractor's Name e j LJ;CC iy,. ;6,,, PP "\i snn Telephone Numberap 1) 2-g-9 k DO Home Improvement Contractor License-.-*.'(if applicable) /73 4� Email: Construction Supervisor's License 9(if applicable) 0 _ Of Workman's Compensation Insurance PER Check one:❑ I am a sole proprietor OCT Q 7 2015 ❑ Pam the Homeowner I have Worker 7OwN OF's Compensation Insurance BARIVS-rABtE Insurance Company Name Argpangut a1n-SU OV1ce— Workman's Comp.Policy T WC ci Z-$p,$3{s2 3 9'-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 9"Replacement Windows/doors/sliders.U Value 3 y (maximum 35)-of windows of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. ..Separate Electrical&Fire Permits required. *Where required Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. "Note: PropertytOwner must sign Property Owner Letter of Permission. A copy o the home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QA1VFPFILES1F0IbN4Slbui1ding permit formsNMRESS.doe _ Revised 061313 " by%MW, T MR1T� Pr�ii4GTA� xc�p['a�� •yy AlODll. . Oil , 4" au „el rYar: [i2�6,�'. �'totac} ;2a9S•F�x�U.R,6$8,fr�i2 ,ura�lea� s4Odrtra,AtR.r i4t p vs�LLe d j Fhynn•r RLLegae��pal�/q{A�ad° a�}E�S7m�+�� aiYeorEd NW Tf LL\LQ�71 AND-I IV/YL1.{�Otilq� - .. x Y _ _.._• JV E G�ria• ., /ter T ..�_ �s1xr• O— - by fv ja io y mid aalllr ageer�ra Padgesc the x - 11 Tb.�p rsro hLr.6er,t__ by�s aF Supthua Z-gimd C SOT➢FPa j �?td/ secvic�s of$aua&crat A' 13n �' brut antl oTi tree attar} ez ti+�di rltk t erT�ixid °1 ,LLC da/z Rmi as 'P on shut "c euveit kh¢,�e,�, i�os,3 � 6mj on t6i Finoa ard:the rI�t_ of 7a4Pt L3 Htetar;�,,fia coned "G>FJ[[�1P. n gsc4hvC E :ta.eCe altithee c1f .• �.tvb - Fi+ianeed ate°�art aS fob� f' Crept pr`Tu arq '• < •.:;i " nMff.ph ll3 of to an .' %F .. fhttaed ASP+ rienC you,m jon y 7 B-414 06 . bra �rcl am 9fP grtP ''°f}pbtairrt•6�p�8Ae,• l any , ' the dYDars-lrh wk.lmkd thire,te+e or mo� no iuial.under nd' to C t_tt�1laexede na�ersF din 6l)' �tb y af� osr t . B : Panes,"it e tpg° f rtJmd�ng tug aye ' Ajx� aad 9 .re p aii$noe tit Buyer raned'tisfBu Pdatlepe C'nnce v"B,ttbedjajs UC apd dated yet* ri�Ete. utel:t . ent bO:NA df[ON, tee o e tlP dgte!'rroe.rrltteq n, and(2);Waa�r udrls§erd Sntia., S CQf RkCT TF TE[�F A$$ANY `1NB:srApm& ' �� bl'r' s�nyoft6e ' You aie TflR$p 2 ooacop yaf0 iat d for th agreed cs d, �Fa�yl3teotheivff } .. ertefltied �,� �ctl.t�e Youg E�ceit e s j1a7�3a1 haft the adsa.wlds�r lbi.ggea�ea�k ana as aa+�u3ovq yu.K m to ori�ar�i a h of the vane to i mes q-F"{4]� iYaa oE]I[r l�aa an dim is m,'eyFeu main,ol�dt a #vur Ti e e9 is Bois Bot 1 1t *epasea is g uasttor ableeemtnr:(5)Yuta mar oaaad!tl� emcit; !f l� afgtied at the 9°a:�6raac�s aE the aBQesi ProvLde.!�vo't�y slsm'a��et�s or beF�ah�: + Yoe ore�a oe> I(�er¢t�teet by pt sorltt�t rnFdaQf cidrodardaar agar the"day*vn s tic$iNe er fltr Ag neon�seladlmg Bnaday and amy hnhd�y nn whlCh eaaildekversp,a=eaaami"L% tice' ai mgaay g Anit's � ('petF3tvi�eda�¢a Kt. Bayes(a}. Prim NasiitofPro&wt3faaager L'crosnru c Pm Nat<ee ;OU IM P Y( N[1EL- )f tTS:T..RA➢II A i} ;AT ANY Ile PRIf�B TO bill3�VtE#�3'It' OF,T :.TFQRD` i[tS�IIFA ,'fi 'r10.�7>!ile .'I'[tdlgltG'1'[� _ 91m"L'AID'i4'1'PACIN07p�C�tp�f.�r�CC .t:ATt(l&fORI►is,` ^ A=& 'I(WI(WIMS BIGFLT: NaTICE vF CArCaza w' NOTICE Of CANCELLATION - - - a#T=Uawn f-: /£/ lhiumty eantdi Data af'TransastJan You may-Cancel; has traniactivnx without any penalty;or o65gaban,aiitloet i. thts tsansiegtipk antfl out'aryr as o6lrgat+on,wtvwt lli 6tttlodss dxt froth Etta de'1Fyo�i cattcet,.arty' thnae bue99 s from t1�above.dode:ud'1a". n�,a'7''ti °taFerC7 ti^aded«4 Pa enbc made by you under the roperey::tiraded.n,any.P*mft ntada by you inter the; :anftr�t air Sale,erid an!n tie ble histrumertt executed ' - ax ee!er Isaltr°_anel bery•n thi411 ms ttsarti exewted t iy you Wng,6m tesu ed wlthm teii lussircess dagry Fellawina bf►yew vAH be ireld�tte+d wt,t ti em busirtcss days folbW61-1 by:t1u Sallow.ai ymnf a.:.ceilat,tn eint.ae,alai isntr rpc.. b N+* !Wfgr aFyvur (latlan atlte.area salt, E£ii ty '.rest a 4'ste$-out,e!"�tke tr3n ttieoe MILD bse 9e uetert.t_-3Tas •Oi o •the taansaction yell be ' arnc¢fad.ffiy U cantol; m rri arllllabao t3 na CAN;, cancebad, fynti cmnnceb u imvst maw avialfa6la eo the SeIAaP, 1 your r�esldlence,6i'su m�allyr aa 'de e,in #snttally as food ion an, whits aeeived,aiy6aode d'elirrrred to you under this;Contiekt or 1 reoeived,:Any atiotli delWii0 d to you utid�th6 Cwitratt or'' t arymu ma If you Wish.rninp$iw7t�i tl+e lecsRructToe9 a he Se®� iS.e At pnnent of+l,a®avde Erne , the Seller reimin cle the return shipntant of the�obds et the aellbr'sj RidiG Itjt4h do tNl(m ttit9 ode allr6la, , Selldr'Icc enss Gird risk �ti rtnake ilie,gahs avaFPabie' a c eFc.e.Seller dca nit plc !Ptem,up vt%f$untln: d and the E.ler acres not p6dti e9st.iip':wlthlm:; tr t rend dabG bf takellation;ou reft n;or twe ay.of tine.date of eanSeMitio rebkm or; [NO& 'a the.gc s rare c r furetle obi •[f'ynu' dl of'r�goods i idiout.any f*it* o�bji�ga�ti�ff gtru, t�3 to malo'n the goods axeilabCe to ffTe Seger;or you agree fad to make ibe foods axi➢able io thr Sv0a5 a if yvF+agrerr_` o raturrt the oohs to the Seller and do*,then you to re4Taiee the gads the seller mild fell to de'so,then yeti enaaGn ItablB:Tot pet6arntani®+aF all clitlgatlions under die recnatln lG a Ior'erfarnaence ofi all otig ittcuvs'tm er th$,' .bntraedTbeatteell-titisb4niiWaiinikirlorddiver.a.ii rted ContraitT6eancalthistramactioiiyrrk"—debvar ae esd's Halo dates:tsar eel tffls eartretlation noBca o< am atieer ,,dwmdil,espy of tlds;®rteelFstfart ribtfce o':piry aLfteur: n-it�nrw4laa,vtrsendlstot .totiatsewzI6jtlladatson'vf writtennoth*oriwWatelsgiiamtglbenewal:by.Ati trsenof �atttlt®nr t�i*E end at 2 �1on Ilalad, ca RI SS, 1UP'em Neer Sii avid at 24 AlbPon Road,L6maln,Nf 02865, Wri L'ATER N'MIDNIOUT OF' f►' ,NOT LAT=T I�IDNtGF1T OF. a � HE� XINCELFFli5A1+95A14N..; FI� Y;Cp►NCLL`i HIS"4'WRATION ' u r mad" '-Gta =•dJ c 91 SLNA Pn..wr Wlwr .J Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts -Depaftrnent of Public Safety Board of Building Regulations and Standards y i License: CS-095707 jF BRIAN D DENNLS6N -- 7 L4N18S POND 6Ht Chariton MA 01507 Commissioner vein, Tpdr�vn?,o�tveu�� a� C�/!`�z��acfuul� , Office of Consumer Affairs d Business Regulation 10 Park Plaza-Suite 5170 Nil" Boston,Massachusetts 02116 Home Improvement Contractor Registration - Registration: 173245 Type: Supplement Card - Expiration: 9/192016 SOUTHERN NEW ENGLAND WI'dWS LL DENNISON BRIAN 26 ALBION RD _-- LINCOLN,RI 02865 Update Address and return card.Mark reason for change. _ SCA1 G ans.osnt - { 3 Address !Renewal L' Employment ❑Last Card _ 44 ItIceo1 Curve r:llfairs K Rusine"Reeulafion License or registration valid for individul use only -F7ME IMPROVEMENT CONTRACTOR before the expiration date.ir found return to: - it Registration: 173245 Type. office of Consumer sRairs and Business Regulation 10 Park Plaza-Suite 5170 Expiration: 91IM016 Supplement:ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. -- RENEWAL BY ANDERSON - DENNISON BRIAN 26 ALBION RD Q _ r LINCOW.R102865 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' > 0I Congress Street, Suite 100 Boston,MA 02114 2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone #:401-228-9800 Are you an employer? Check the appropriate box: �... Type of project(required): 1. I ate a employer with 20+ 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑'New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These sub-contractors have g. n Demolition workingfor me in an capacity. employees and have workers' Y P tY• ,. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no = / employees. [No workers' 13. Other i� fr e comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. Policy#or Self-ins. Lie.#:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: " 6 2 ;ffs4 City/State/Zip: e,0Aer.1;1(e 1"1 4 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-af-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 urance coverage verification. I do hereby certok under the ' s and penalties of perjury that the information provided above is true and correct. Si ature: Date: v Phone#: 4.012289800 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#: SOUTNEW-01 PARKERNATHCO A�o�►t`© CERTIFICATE OF LIABILITY INSURANCE . �$11312016 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 j BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED ` REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER 1 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 endomernent(s)_ PRODUCER cT Willis Certificate Center Millis of New Jamey,Inc. I PHONE P45-73T8 $$0 457-23T8 c/o 26 Century Blvd I Lan S,Ear.(877) IAIC Not{ ) ` P.O.Box 305191 1 Nashville,TN 37230-6191 ADDRESS: --- INSURER s AFFORDHiG COVERAGE I NAIL it i INSURERA.Selective Insurance Company of Southeast 139926 j INSURED INSURER B:OneBeacon Insurance Company 21970 Southern New England Windows LLCI INSURER c;Argonaut Insurance Company 19801 T D/B/A Renewal by Andersen t INSURER D 26 Albion Road Lincoln,RI 028N !INSURER E: I INSURER F- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO V*itCH THIS i CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 11iE TEttvz. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE i POLICY EFF POLICY DCP 1 ! LTR l POLICY NUNSER M= LIARS A X I COMMERCIAL GENERAL LABILITY EACH OCCURREWCE S 1,000,OOt 1 CLAIM&MADE v OCCUR ! x js 2029459 08110/2015 i 08/10/2016 i 100 ,PREMISES(Eaocamalne) S � MED ExP"i ona perm) S tN11r0�,0(q ` 4 PERSONAL&ADVW.AJRY S 1, , GEML AGGREGATE L1WT APPLIES PER: GENERAL AGGREGATE t£ 3,W0,0Ibj PO1tCY®jERCaT C I OC PRODUCTS-COUPIOP AGO j$ ;Mow OTHER- I S AUTOMOBILE LJAatLtTYGLE LIMIT 5 Ea accaient Illm000 —Xi ANY AUTO j X I S 202UM 0811012015�0811012016;BODILY INJURY(Per Person) s ALL OWNED SCHEDULED t IAUTOS AUTOS i I ' I BODILYINAIRY(PeraecMent) S • HIRED AUTOS X AUTOSED 1 i I ' PROPERTY DAMAGE $ peraccdent) i r I 3 i UMBRELLA tdAS OCCUR i EACH OCCURRENCE s I r EXCESS t L4t3 CLAIMS trADE AGGREGATE I S j DED RETENTIONS j g WORKERS COMPENSATION i PE3a ;OTl•F B jAND EMPLOYERS'LIABILITY Y/N 1 i X STATUTE i ER ANYPROPRIETORIPARTNERA7CECUTWE Dooms=z OFFICERAAEMBER EXCLUDED? M 1 A `08121/2015?Q8/2112016 EL EACH ACCIDENT S 1,000,00 �kS i lmamtdaw in MF{) E.LDISEASE-EAEMkOYEE S 1,000, 't under OExRiPT10NOF OPERATIONS ha[ow ! i EL DISEASE-POLICY LIMIT s 1,000-nmI C Workers Compensation i ; WC92BOM52M . 08121/20f5108/2112016 See Attached DESCRIPTM OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remffihs Schedule,may be attached I more space Is required) THIS CERTIFICATE VOIDS AND REPLACES THE PREVIOUSLY ISSUED CERTIFICATE DATED:Stil/2015 Auto Policy includes additional insured When required by written contract/agreement as per policy form. I! HSS Holding Corporation,kec.and anysubsidiaries are included as an Additional Insured as respects to General Liability when required by written contractlagreement as per policy form i I CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i THE EXPIRATION DATE THEREOF, NOTICE vwLL BE DELIVERED Im ACCORDANCE wrrg THE POLICY PROVisioms_ i j I AUTHOROM REPRESENTATIVE J ©1M-M14ACORD CORPORATION. Ali rights reserved. ACORD 25(2014l01) The ACORD name and logo are registered marks of ACORD r Town of'Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee. S /T • snxrtsrnste, • MASS. $1659. Richard V. Scali,Director �� gEOMAY� . Building Division Tom Perry,CBO,Building Commission yt 200 Main Street,Hyannis,MA 02601 P R M T www.town.bamstable.ma.us Office: 508-862-4038 JUN Fax. 508-790-6230 EXPRESS PERMIT APPLICATION - RE SID , n-' LMNrL�- TA B L E Map/parcel Number U' Not Valid without Red X-Press Imprint J b Property Address Residential Value of Work$ Ild / U Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address c��h�t CG. P -�, Contractor's Name /GN (���C�ti�; Telephone Number Home Improvement Contractor License#(if applicable) d Email: �°�Z��d (� 7�C'0� tie f . Construction Supervisor's License#(if applicable) 10039 3 VgWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor v. ❑ I am the Homeowner (� I have Worker's Compensation Insurance - r r Insurance Company Name Workman's Comp.Policy# 0 0 U y — 3 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 ✓`'�GU� ❑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: . ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is require . SIGNATURE: - Q:\WPFILES\FORMS\building permit orm XPRESS.doc Revised 040215 } RX- CAZEAULT\' aFl NG REPAIRS PROPOSAL Proposal No. 14-736 Sentember 6.2014 } To: Kathleen Needham Work to be performed at 62 Millstone _ Y �vannis:MA' We hereby propose to furnish the materials and perform the labor necessary for the. completion of: , �wv untiF 1. Remove existing shingle roof ' a 2. Install new aluminum drip edge ' TrP a W%ter-bar-r-ir r-first-2ft_ al 1.skvli alit s and oenetrations 4. Cover roof with 15 lb felt 5. Re-roof with 30 yr architectural shingle 6. Install ridge vent 7. Flash all.pipes and penetrations 8. Remove all rubbish from project Labor and Materials $10,100 All material is.guaranteed to be as specified,and the above work to be performed in accordance with the specifications and completed in a substantial workmanlike manner for *hP awim of Ten Thangand and One hundred Dollars,$10,100 with payment as follows: Five Thousand-and-FiftY.Dellars$5,050.Due with acceptance of proposal and Five Thousand and-Fifty Dollars$5,050 due upon Completion Respectfully.su Richard P.QWmult,Jr: RIC#168607' CSL#100393 198 Five Corners Road . ; Workman Comp and Liability with Centerville..MA 02632.; _ Mcshea Ins Ost Acceptance of Proposal No. 14-736 The.above prices,specifications and conditions are satisfactory and are hereby accepted. Yoh,:pr a,rthori�.ed to do the Work#s sv_Wfied..Payment is outlined above. . ignature Date The Caminam waUh of Massachusetts Deparhnmt of Industrid Accidarts Office of.1amtigations 600 Washington Sfreet. Boston,CIA 02111 , nwumas&gov/dia Workel<s' Compensation Insn><ance .davit: Builders/Contractu s/Eiectricians(Plambers Applicaiart Information Please Print 1,- -bI Name 1): //G C�Zeay � g ����(�Y f Ate: I f U Covn t---,r c� awstatelZip: re /'upl�e Phone## �- Are you an employer?Check the appropriate box: 1.PI am a employerwith 4. ❑ I am a.general contractor and I Type of project(required)- employees(fa il and/or pact-tame have * have hired the sub-comtmctors 6. ❑New construefibn 2.❑ I am.a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors hate S. ❑Demolition working for me in any:capacity. employees and have wodcers' 9. [No Ywodams'comp.iovxsmce, comp-insa ater-1' ❑Building addition mod-] 5. ❑ We area corporation and its 10-0 Electrical repairs or additions 3.❑ I am a homeowner duing all work ofom have exercised the i L❑Plumbing repairs or additions myself[No workers'comp- right of exemption per MGL 12..❑Roof repairs joirance required_]j c-152,§1(4X and we have no employes-[No workers' 13_❑Other comp-insurance required.] ;Any anlic=Ahat checks boa#1 mast also fill out the section below show*flu&woders'com4measafionpolicy ir&zmatian. Hcmiammers Who submit this affidavit itubcstmg they are doing all wak sad dies hue outside contractors must submit a new affidavit indicating such. f Caatcactors that check this boa must attached z additional street showing the—of the sub-camtructors and state mhether ornot ffiose amities ham employees.Ifthesub-cantnctarsbave emplayees,8wynstprovide their workers'ramp.polity number. lam.an emp i7j-er tliat is proiiding workers'conrpertsadon insurance for my employees. Beidow is fife poUcy an d,iob s►tf iRformadon Insurance Company Name:G Policy#or Self-ins.lic.#: C -V `c -O U 0 3� / � (r,? $�iration Date: 7 � /// Job Site Address: ( l(S �, l/"�^�' CitylState/zip: �e- ` ✓(�! Attach a copy of the workers'compensation policy deciarati page(shaving 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 andlor one-year impaisonmeut,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 statem�&may be farwarded to i�Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder d and ponab'ies ofperjun.,th ttlte inforrrtationpro ided above is true ar car .ct:: Sienataw. ! Date: Phone#: J b ���-(J ,-Gr' 0 �- Ofj`icial use only. Do not write in this area,to be completed by city or tolm off:at City or Town: Permiff kense# Issuing Authority(circle one): 1.Board of Health 2.Bugling Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 1 CERTIFICATE OF LIABILITY` *INSURANCE DATE Zi 35 THIS CERTIFICATE IS ISSUED-AS A MATTER'OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE "OLDER. THIS CERTIFICATE—DOESNOT 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: N the certificate holder is an..ADDITIONAL INSURED,the Policy(ies)must be endorsed. P SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endortgmem A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRDDULER s" CONfACt McShea Insurance NAME: Berkle Ass ned Fmk Service, PHONE 1550 Fy�imoutfi Rd RT 28 Ste 2 E No.a 800 634-4589 AlNn %6 215-8118. Centerville,MA 02632 ADDRESS: PoReySeMcm@berkleyrisk.Dom . '. IERAGE .'NAIC6 INSURED .. .INSURER A R zea ichard Cault Jr ' INSURER A 198 Five Comers Road INSURER c - INSURER Di Centerville,MA 02632 INSURER E QiStRER F: F=� COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INUIIRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR WHICH THIS OTHER DOCUMENT WITH RESPECT TO CERTIFICATE MAY ISSUED OR.MAY PERTAIN,-THE-INSURANCE-.AFFORDED 13Y THE POLICIES DESCRIBED-HEREIN IS SUBJECT 1 O ALL THE TERMS, EXCLUSIONS AND 00NOMoNS OF SUCH"POUCiES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.1 SR TYPE OF INSURANCE D L SUER POLL - ►C - LTR INSR WVD POLICYNUMt R- (MWDDfYYYN3 r81/DD L UYRS AUTOMOBILE LIABILITY WORKERS COMPENSATION' WC STATU OTH' AND EMPLOYERS'LIABILITY YIN - ` ." " . - WC LnSTS _ ER "ANY PROPRIETORIPARTNERIEXECUTIVE A OFFICEIMEMBE R EXCLUDED7 NIA a WC-20-20•a03093M OW04MI5 02104=16 . Et EACN ACCIDENT 5 SM.= - , IMandatory In NH) - -. If yea,describe under - a -. E.L.D E SEA 91PLOYEE $ •� DESCRIPTION OF OPERATIONS bell* - . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101'.AddIWnai Renmks Scbedute•P more - --DI -P�ICYUYR �O.00D ' " - mace is regatad). - Coverage Elecbm Category Elect Status Name Sta6e(S) - Ali Ent*0es/taratitonS , Sole Proprietor Exdude Richard CazeauR]r14ACazeauit Jr 198 Five Comers,Road Cente"rolls MA02632_-----"-- CER7IFICATE HOLDER CANCELLATION S MOULD ANY OF THE ABOVE DESCRIBED POUCI ES-SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE"WILL BE DELIVERED IN Town of.Barnstable :', ACCORDANCE WITH THE POLICY PROVISIONS. -y >A OR R PRM Building Deft • :,, NIA IVE N 200 Main St Hyannis,MA 02601 Si` gnature = ACORD 25(2010105)" . t `. SRAG 3139 Mass ElllJsef s artm.ent Eif P- ti �naaa-�caacitoettV ciff.��Lry.J.tgc/rrc3e��:I-- office otConsnmerAffairs.&Bnsih Regulation Conseructton —_ _ g€ — NIE IMRROVEMENT CONTRAdTOR :cam se CS-100393. -_registration: .168607 Type: DBA •� ' µExpiration 3/8/2017 RICAARD P CAZ UEOR 198 Five Corners Road s CAZEAULT ROOFING&REPAIRS Centerville MA 02632 � , RICHARD CAZEAULTT 198 FIVE CORNEFIS 6fG` CENTERVILLE 11M(Y2632 Undersecretary t mMissinnex •. n • � •I a yl.a� �� • r' wu • e{'rertimmmds Dntreach Tra�nmg routYesas an orezntau644 ram,uQ- -I Fire --�a�'{�tahL foc7aor.�czrs 8'art.apat6un•tt�wtuntarg{{o4.6e sass s�'eet<e add Lo1f Y+ ming on'';profit•hnsrds o/thdr toh.Thu murse tin chart z idoWnot zipire - s� ,c a } , ^ 5 arfitnhtr,ofocmahobseeanr�vzbsneatwwwmhs.eovJn ireaeJrhtml�,,.. yoFTHEtp�° TOWN OF BARNST.ABLE • 31MUSTAU63 9- Z. 0 mum 1 0 Al BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO ....... tow .............................. TYPE OF CONSTRUCTION .........: ....................... ............ 46.iu........................................ .......... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ..............11 ... Location ................ ............................................... .. ...... .......................................... S11I6.4 - / �`,77 Z .... Proposed Use ................................................... ... .....................;...........................................................................................Zoning District ............I... . .. .—I..........................................Fire District e: //.....�.- .//v............. Name of Owner Z ............................................... ddress ......................... Name of Builder ... ddress ......................................... .............A Name of Architect ...................................... .......Address 2J .,� M.... ............... ................... Number of Rooms .............. ...........;....................................Foundation .......lz::�e L7,:5),,V C7-4�ff 7�s ........................................................................ Exterior ............ 1-9,5 lc�,9& 7- ........................................................... Roofing .................................................................................... Floors ....... P.6.r....................................................Interior ...................................................... Heating .......1��7- 6019�7-6�C 7- ............................... ..................................Plumbing ...... ............... ---.9 Fireplace ............ .............................................................Approximate Cost ............. ............................. Definitive Plan Approved by Planning Board --------------------------------19--------- Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH Sd Cal z 10, 1 10. C) z I -- 40 co • 4C �C.) —W -j Q Al AV N ilk co La I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. NamA . . ................... Archambeault, Lionel R. 16180 one story No ................. Permit for, .................................... single faraily dwelling ............................................................................... YAllstone ��y Loccit n Centerville ................................................................................. Owner Lionel R. Archambeault .................................................................. Type of Construction ...............f.......me....ra ................ ......................................... ....................................... Plot ............................ Lot ......... .................. Permit Grantedr...........A 3.9.............19 73 1 Date of Inspection . ....!.�..........19 Date Completed ........ ...28 -1...19 PERMIT, REFUSED .................................................................. 19 ................................................................................ ................................................... 2- ............................................................................... . ............................................................................... Approved .................................................. 19 ............................................................................... ...............................................................................