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HomeMy WebLinkAbout0091 MONOMOY CIRCLE N G4 n TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Cl O Parcel 21 Ll Application # 0)) 400 0 3 Health Division Date Issued j Conservation Division Application Fee S_b Planning Dept. Permit Fee & Date Definitive Plan Approved by Planning Board ak �it�13 Historic - OKH Preservation/Hyannis Project Street Address C, Village Owner _E \Q� Address °\\ MM0 M0,A Telephone Permit Request lace \C� CO- S `1g) (3,(2 A:c �e k o 4�c Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 600 ,oo 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/coali stove: UYes W No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ ,. 1 ✓ C> Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ CIO Commercial ❑Yes ❑ No If yes, site plan review# _— Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C 4(1 Telephone Number '33-R' Address �6 1�04nN-C \30 tn��C License # 10A III 7 JtlA C) 63 Home Improvement Contractor# Worker's Compensation # W 6'�1�16 °� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 0 1 1`3 FOR OFFICIAL USE ONLY 4 APPLICATION# DATE ISSUED y MAP/PARCEL NO. ADDRESS VILLAGE '1 OWNER r DATE OF INSPECTION: FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL s PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING k DATE CLOSED OUT ASSOCIATION PLAN NO. i i The Commonwealth of Massachusetts Print Fa f' Department of Industrial Accidents Office of Investigations 1 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):CONSERVE ENERGY INC. d.b.a CONSERVISION ENERGY Address: 376 ROUTE 130, SUITE C City/State/Zip:SANDWICH, MA 02563 Phone#: 508-833-8384 Are you an employer?Check the appropriate box: Type of project(required): 1.® 1 am a employer with 6 4. ❑ I am a general contractor and 1 employees(full and/or part-time)..- have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor orpartner- listed on the attached sheet. 7. ❑ Remodeling these sub-contractors have` ship and,have no employees T 8. ❑Demolition working for me in any capacity.. employees and have workers' 9 g Buildin addition [No workers'comp. insurance comp, insurance,• _ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself, [No workers'comp. right of exemption per MGL. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no WEATHERIZATION employees.[No workers' 13.91 Other comp, insurance required.] Any applicant that checks box if l must also fill out die section below showing theirworkers'compensation policy information. - t Homeowners who submit this affidavit indicating they amdoing 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: SELECTIVE INSURANCE COMPANY OF THE SOUTH Policy#or Self-ins.Lic.#:WC7956539 Expiration Date:3/15/13 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy'declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and afine of up to$250.00 a day against the"violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage.verification, 1 do hereby certi under the ains and genallies o er u that the in ormation.provided above is.true and correct.. Si azure: Date Phone#:50M33-8384 Official use only. Do not write in this area,to be completed by city or town uncial. City or Town: Permit/License# Issuing Authority(eircle one): 1..Board of i�ealth. '2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing'Inspector 6.Other Contact Person: .Phone#,' Client#:68880 CONSER ✓ ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMODINYM 0 311 5/2 01 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:if the certificate holder is an-ADDITIONAL INSURED,the policyOesj 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 andorsemengs). PRODUCER ICONTACT NAME Rogers&Gray Insurance Agency,Inc. f PHONE FAx - (Alt ao, 508 398 7980 I FAX No ADDRESSt 434 Route 134 EMAIL - _m � South Dennis,MA 02880 I INSURER(S)AFFORDING COVERAGE "Co 508 398-7980 INSURER A:SC'I8Ct1Ya Ins.Co.of tilt South --^—t -- INSURED . ....I_ . . �. �_.._ INSURER a;: Con-Serve Energy,Ina 376 Route 130.STE C I INsuRERc Sandwich,MA 02563. INsuRERo: INSURER E:.. _. INSURER F: - - - COVERAGES CERTIFICATE NUMBER; REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE'POR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT;TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT'TO WHICH.THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. .LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, IR ADDL_SU_BR 0YFF POLICY TYPE OF INSURANCE IN . POLICY NUMBER IMMIDlYYYY I Mopy� LIMITS A GENERAL LIABILITY X S2011299 3M412012 031141201 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL UABILITY pAMq ET ENTEO (� pREMES Eo octane i'S100,000 CLAIMS-MADE I ^U OCCUR MED E P(Any one person)_i_$10,000 PERSONAL&ADV INJURY f 44 "$1 00O 000 GENERAL AGGREGATE '$3 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1 - PRODUCTS•COMPIOP AGG $3 000 000" X POLICY -PRO- LOC AUTOIAOBILE LIABILITY - - - ."-:. Ea eBB LI INEED SINGLE MIT ANY AUTO BODILY INJURY(Per person) -I$ ALL AUTOS OWNED AUTOSULED - BODILY INJURY(Per-' accroenp$ - NON•OWNED. - PROPERTY DAMAGE " HIRED AUTOS AUTOS Paraccldem $ _ $ A uMaREL1A LIAa X OCCUR X S4011299 3114I2012 03I141201 EACH OCCURRENCE S1 OOO O00 XEXCESS LIAD CLAIMS-MADE AGGREGATE- $_3,000+000 _ DED X RETENTION 0 g A WORKERS COMPENSATION WC7950539 s- 'WC STATU• OTH- - AND EMPLOYERS'LIABILITY 311412012 03114/201� I-�RYIJMLTS -__ Eft,-{j_. ANY PROPRIM8ER EXCI I IER/EXECUTIVE nY I N I'E_L.EACH ACCIDENT. T0001000 " OFFICER/MEMSEREXCLUDED7 J NIA -- (AAysWnOatory In NH) E.L.DISEASE-EA EMPLOYEE$100 000 OESCRIPTI N OF OPERATIONS.bebw _ .�, _ ...fir.• E.L.DISEASE•POLICY LIMIT LSSQOiOOO. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Altaeh ACORD 101,Additional Remarks Schedule,it more space is required) " Excluded officers under workers'comp-Conorand Courtney McInerney. Blanket additonal insured coverage applies under CGL. CERTIFICATE HOLDER CANCELLATION Th1eISCh Engineering,1nC: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave. ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,Rl 02910 AUTHORIZED REPRESENTATIVE 0198 .2010 ACORD CORPORATION.All rights reserved. . ACORD 25(2010105) 1 of l The ACORD name and logo are registered marks of ACORD #S788991M78898 DDR Massachusetts-Department of,Public Safety Board of Building Regulations and Standards fnslructiirn:Sup'€rsitr>r Spedilit 5 License:CSSL-102778 ^gg� A CONOR D MC(NgPN-EY 39 SIASCONSET.DRIYL SAGAMORE BEACH MA'0 62 t t� . ems,,. f�.xpir3tion Commissioner 08/19/2014 .mot ✓ L69lZJR�91lL(eCG!(�L O<,.t'!• C�"e '' •f .. - t Office o'.l oosnmer I airs$K$CC llffjlr{gSmess 1(egu.pop License or registration valid forindividul,use only HOME IMPROVEMENT CONTRACTOR nJ. before the expiration date. If found return to: r LL Registration: ,17125T Type: Office of Consumer Affairs and Business Regulation E s�f Expiration 3/1/2014 Partnership 10 Park Plaza-Suite 5170 f Boston,MA 02116 C ERVE ENERGY ,,4 CONOR MCINERNEY l # 376 ROUTE 130 SUITE C SANDWICH,MA 02563 t ..r. Undersecretary , Nat valid without signature { , OWNER AUTHORIZ,ATION FORM, 1, (Owner's Name) owner of the property located at (Property Address) (Property Address) Y hereby authorize e �'_ V11 31 vAl (Subcontractor) an authorized subcontractor for RISE,Engineering, to,act on mybehalf to obtain a building permit and to perform w.rk onYmy property., Owner's,Signature Date t �ov-fw Toivn Of Ba>rnStable �rc)C)S�(q ` -Regulatory Sel-vices. Expires61 rrltrsfomi erinre snxtvsrkHm Fee y pASS. 1619• Thomas F. Geiler, Director $Arai n+AV Building Division ;Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 . www.town.barnstable.ma.us' Office: 508-862-403 8 . Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Nnl Yrrlir/rvillrorrl Red X-Press•Iny�rinl Map/parcel Nurnber q0 2A Property Address 144t 0VI'lr Residential Value of Work A30L, Q Minimum fee of$35,00 for rvor]< under$6000.00 Owner's Name & Address i) Contractor's Name q,_Xad ����a✓� � _Te_lephohe Number Home Improvement Contractor License#(ifapplicable) _ Construction Supervisor's License# (if applicable) ❑Workman's Compensation Insurance Check one: I am a sole proprietor "" S PERMIT ❑ I am the Homeowner v = ❑ I have Worker's Compensation Insurance OCT Z01 Insurance Company Name TOWN OF 6/'tRNTA Workman's Comp, Policy11 Copy of Insurance Compliance Certificate must accompany each permit, Permit Request (check box) { ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed) (not stripping. Going over „.existing layers of roof) Re-side ~ ////❑���` Replacement Windows/doors/sliders. 0-Value #of doors (maximum .35) #of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. historic,Conservaiion,.etc. ***Note: Property Owner must sign Property Owner Letter of Permission; A cop e.Rome Improvement Contractors License &':Construction Supervisors License is. `i require IGNATUI2E: 4PFILESIF0RMSlbuilding per forins\EXPRESS.doC :vised 072110 The Cavni roirivealtlr ofMassachusefts -- -- - DepartinenI ofIn dusirial.4 cciden Is Office of Ilnve'sd$ga 0fis. 6 600 Washbigton S'treel { � , Bosion AL4 02111: N•'1!'nI inass.govldra `Varkei-s' Compensation Ins-urincP Aff da-vit: Builders/Conti actoi-s/EleCtI'IC1 tllS/Pl:tliilbePS Applicant Information" 1'1e.ase Print Le 'bih Na1�le (Busiuess�Orgauizationdndividual): Address: Mot )nil%/ C,.r�A C1ty/Stat&Z1P: er-�// X Pii iie #: a`37410 Are you an employer?Check the appropriate boa.: Type of project (required): L❑ I arm a employer with 4. I am a general contractor and I erz7ployees{fu11 andlarpait=.time). have lrised the sub-contractors 6•"'❑New.constnrc.tion 2.. I am a sole proprietor or partner- listed on the attached sheet- 7 .Remodeling p�Pri P slu. and have no employees .The:se sub-contractors have P8. O.Detuolition ,vork-ing :far me in any capacity. en ploy'ee:.s and have workers' [No workers' comp.insure,qce comp;insurapce..1 9. �.Building.addition retlaired.] 5. El We are.a emporation:a.nd its 10.El Electrical repairs or additions tafB.cers have exercised their 3.❑ .I am a.homeotiimer doing all work : 11.0 Plumbing repau-s or addi.ti�ans myself. [No workers'comp: right,of exemption per l-IGL 12.0 Roof repairs* insurance:required.] T L 152, §1(4-),and.we have no. employees. [No workers' 13.0 Other cinyp :insurance req,rir•ed.] •Any applicant:that checks box#1.must also 5ll.nttt the!section lielma shozring heir workers'cotvpeirss:don policy inron=tion_ l Homeontners who submit this.affidavit inditatiug they are doing all-work and than hire outside contractors must submit a uew a>fida"it iLcating such. ' =C'ontraclors that check this:box must sttachexl an sddition$l:she.et showing the:nameof the su:b-cmrtmc.turs sn.d stste whether ar not'those entities have employees. Ifthe mb--con1ractors1AN-e euxployees,lhey,umst provide their workers,'comp.pol cynumber. I alit all etnpl yer flint is Providing nwrkers':contpensahon insurance for ttay-employees. Below 1s thte policy and,hob s& il[for r atiVIL Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration.Date s Job Site Addrmis: city/state/Zip. N Attach a copy of the w rkers'compensation policy dieclaration page(s11011dng the policy number and expiration date). Failure to secure coverage as required under Section 25A of NfGL c. 152 can lead to the imposition of criminal pemki ies of ii fine up to$1.,500.00 an&or one-year imprisonment,as well.as ci%il 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 D.IA for Mi surance coverage veriEcation: I ado hereby certi rxrr.,d tPte prriris crud pettnlh'es gfpedntr that the ii fortnation prm idid xa.b6va is truo.and correct: Signature: y - Date: Phone#: O�frial use:on&. Do not write in this area,to be completed by city or town official City or To}'i'n: Permit/License# r. ,Issuing Authw ity(ch-cle one): L BoarMd of Health 2.-Ruilding Department 3. Caty/Toti;-i Clerk,A,Electrical Inspector S.Plunmihhig Inspector 6.Other. Plra,fi 'Contxct.Penon: ne# <:.: Op THE Tp�y + BARNSTABLE, ,KASS, s6Sq. Town of Bar�nstable ♦� �rfD MA'I A Regulatory Services , Thomas F. G,eiler, Director Building Division Thomas Perry,-CBO Building,Commissioner 200 Main Street, Hyannis, MA 02601 wrvw.town:barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 . Y , Property Owner Must Complete and Sign This Section If Using _A. Builder I Coo as Owner:of the subject property hereby authorize l -to act on my behalf, in all matters relative to work authorized by.this building"permit application/for: U M O r►n vo J vl E' vti erW (Addre s of Job) C.cxc. /v /u Signature of Owner Date Print Name If Property Owner.is applying for permit, please complete the Homeowners Licen"se Exemption Form on the reverse side. QAWPFILES0 RMSIbuilding permit formslEXPRESS.doc „ r '•" s s ,-'` a Revi.ePri n721 10 � rt. 0 Town of Barnstable r�ti y'`' ' Regulatory Services M « gAhJAM, Thomas F. Geiler, Director g,ArQ ..A,b Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rnsta b le.ma.us Office: 548-8624038 Fax: 508-790-6230 ---------------------- HOMEOWNER LICENSE EXEMPT N Please Print DATE: JOB LOCATION: number stre village "HOMEOWNER" name home phoi N work phone N CURRENT MAILNG ADDRESS: city/town st e zip code The current exemption for`homeowners" was extended to include owne - ccu id dwellin s of six units or less and to allow homeowners to engage an individual for hire who does not possess a lic rise, rovided that the owner acts as supervisor. DEFINITION OF IIO EOW ER Person(s) who owns a parcel of land on which he/she resides or intend to reside, on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm tructures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Su "homeowner shall submit.to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible f r all such work formed under the building permit, (Section 109,1.1) The undersigned"homeowner"assumes responsibility for complia cc with the State Buildin Code and other applicable codes, bylaws, rules and regulations. The undersigned"homeowner"certifies that he/she understands e Town of Barnstable Building partment minimum inspection procedures and requirements and that he/she will comply with s d procedures and requirements. Signature of Flomeown.er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the S e Building Code Section,127.0 Construction Control. FIOMi;OYYNER S EXEMPTION The Code stales that: "Any homeowner performing work for which a building permit is required shall be exempt from the_provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeow�her engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." ' Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it woul' with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care l amend and adopt such a form/certitication for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 Boer -� License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 152991 Board of Building Regulations and Standards Expiration,1;0/23/2610 Tr# 275069 One Ashburton Place Rm 1301 Iy aF ie Indirvidual Boston, Ma.02108 Typ nF MICHAEL G CRQTEAU _ =� MICHAEL CROTEA J U 7 279 MONOMOY CIRCLE } `f ;. CENTERVILLE, MA 02632; - '' Administrator Not valid without signs Nlassachusetts Department of Public Safetc ~ Board of Building Rc,, ulations.and Standards Construction Supervisor License License: Cs 86639 Restricted to: 00 MICHAEL G. CROTEAU - t 279 MONOMOY CIR CENTERVILLE, MA 02632 a , Expiration: 10/30/2011 ('ununissiuner Tr#: 5679 f Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee2 ws F.Geiler,Director ilding Division . 7 2opm Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601 `i OWN OF BA T M w.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY c� Not Valid without Red X-Press Imprint Map/parcel Number L Q � Property Address Residential Value of Work ddO , 6v Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address %/ G�-io�� �,_C.4 A Contractor's Name Telephone Number Sid Home Improvement Contractor License#(if applicable)/ 6 2 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner U-116ve Worker's Compensation Insurance Insurance Company Name /1`12 �/YS Workman's Comp.Policy# *t� i v C 7 ® O 9 1 / 3® J a o ,j, Copy of Insurance Compliance Certificate must be on file. Pemvt Request(check box) �]Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (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. copy Jofftthe Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 ACORD CERTIFICATE OF LIABILITY INSURANCE DAToi25/2006' TM. PRODUCER Phone: (508)987-0333 Fax: 508.987-0063 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION OXFORD INSURANCEAGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P 0 BOX 370 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR OXFORD MA 01540 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: A 1 M Mutual Insurance Company LIBERO MOLINARI INSURER B: DBA MOLINARI HOME IMPROVEMENT INSURER C: 11 SHEEP PASTURE WAY EAST SANDWICH MA 02537 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRE DATE MMIDDIYY DATE MMIDDIYY GENERAL LIABILITY NONE EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES(Ea occurence) CLAIMS MADE OCCUR MED.EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. $ PRO. POLICY JECT LOC AUTOMOBILE LIABILITY NONE COMBINED SINGLE LIMIT ANY AUTO; :.. (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ y HIRED AUTOS #'.9+ BODILY INJURY - NON-OWNED AUTOS _ (Per accident) $ PROPERTY DAMAGE I$ (Per accident) GARAGE LIABILITY NONE AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY NONE EACH OCCURRENCE $ CCCUR CLAIMS fVA0E AGGREGATE $ DEDUCTIBLE $ RETENTION$ $ WORKERS COMPENSATION AND AWC7008113012006 05/21/06 05/21/07 TORYTATU LIM TS OTHER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,000 A ANY PROPRIETORIPARTNER/EXECUTNE OFFICERIMEMBER EXCLUDED? • E.L.DISEASE-EA EMPLOYEE $ 100,000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION COMMUNICATIONS LINK SERVICE CORP. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 15 TECH CIRCLE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE NATICK,MA 01760 TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. FAX: 1-508-650-5124 AUTHORIZED REPRESENTATIVE Attention: Joseph E.Anastasl ACORD 25(2001/08) Certificate#_ 36643 - ©ACORD CORPORATION 1988 Page No. 9 of Pages MOLINARI HOME IMPROVEMENTS.: PROPOSAL 11 SHEEP PASTURE WAY EAST SANDWICH,MA 02537 PH/FAX 508-888-3750 508-771-5266 TO. 7 / A "PHONE ra.. r.>... e,i r ; i h'!s�^ .ram .. ._ .... ' .h1(.» ^• DA TE Ca i M- n m +I M,-j V JOB NAME/LOCATION"- JOB NUMBER JOB PHONE `We-,,hereby submit specifications and estimates for: rYtrrr t,,:r7ci •I.4 1 !:, t �., t'C I !a K"rW (:'+,+'`r c';T r,r)n r:' Ai•Z 'TAIC''1"!'t7 C7'rnr' .'. "rAI I t t n trrl -I--., , ,,...,._ :..._,:..,_. . ....,.. ztj r r. E J.Iu;xca i s r ; G`r•tl r_'I f+,<7 b *"h i r': !,C,r`.I I t,I . . •,,, .,a r--.7::,r:° - 'r ill -r S ."d r '•,Ci r'1.4 T"a�' . I�t:' t•:!:,"7 C:r'"i'C:'t'1 ,\,' r 7 I t•I( -"1 °, 1^ .,�.. 1,7...Fir� •7CJ ::�" �I.�.. i. LeG:, 4, C)t:': r,`i"'r'Att.., .f'ri •T'L,JG.' �+ u ... Y..ICP ,, i 411,G'7 ,.�.C.'I�.+�r1 t;4 P. 'i-C'hi n 0 ttM1 r:,'+rl("i C'< > r•...:: , , 7 ,3 rG't1 .c n.r. 1'.11")0Vt,a/`,a,7c::7.! rc) rcli.',t '>I, ."t• 7^ A: 'TI--I`rn'ry: Vr:'r.r„7 I.;I. h1"I"YG'I.JYr•.!r". G"!."` - ;:, ; . .dC .r7 II. ",' t 11t,.-�.IiLt:�•1 r� u.,�Vt\H6 hi_. t"f"s_hLlFat t Y7 vn7� i -Ti!. tv We Propose hereby to furnish material and labor-complete in accordance with the above specifications,for the sum of: •...,-. r ,...:, ::,.: ..... ._.. . __._... _._. _..... ....._ _ dolfars($ Payment to be made as follows: L O ,Yr1 7 ,i`.)(Aid / r.rit . :.:. ,. .,,, .. : .,..... GI•r1r:'ni'T 'rQ ff't47i:" .yn, C)It' 'Tit,: rr!'•! /`-.t,7r^C 1'r'. {:ti' I hit`' r�,rr I Inrthl t ( y!r.)i !"r ,,.. All material is guaranteed to be as specked.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over Authorized \ �� and above the estimate.All agreements contingent upon strikes,accidents or delays beyond Signature our control.Property owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by Workmen's Compensation Insurance. Note:This proposal may be withdrawn by us if not accepted within { i.' r days. Acceptance of Proposal -the above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized f / :o do the work as specified.Payment will be made as outlined above. Signatuyet_- L�`��✓ ✓ ✓�l�t- /E�?L`�'f )ate of Acceptance: "'�� Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A_pplicant Information Please Print Legibly Name(Business/Organization/Individual): T hh ,/ r nsy A r ( I O /1R 7�(/Ji�zry Address c�t!" w City/State/Zip: ,G SH,yJ�v� �� �/ Phone.# 6-6.f 6� 3 '2 Are di an employer?Check the appropriate box: Type of project(required):. 1.LSLI I am a employer with 4• El am a general contractor and I' 6 �New construction.. -time).* have hired the sub-contractors employees (full and/or part listed on the-attached sheet' 7. ❑Remodeling 2.❑ I am a'sole proprietor or partner- These sub-contractors have ' ship and have no employees 8. ❑Demolition employees and have workers' working for me in any capacity. 9. ❑Building addition o workers'co insurance comp.insurance. [N comp. 10.❑Electrical repairs or additions required.] 5. [] We are a corporation and its 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. oof repairs insurance required.]t c. 152, §1(4),and we have no employees, [N o workers' 13.❑ Other Yees, comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: A /-V O t U 14 L Policy#or Self-ins.Lie.#: ,�O Eo2 o69 Expiration Date: / Job Site Address: 1�/ �'�-a Gt City/State/Zip: a 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 thq violator. Be advised that a copy-of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify rider the pains and penalties of perjury that the information provided above is true and correct. ' Si afore: ,Tc Date: Phone# � FBoard nly. Do not write in this area, to be completed by city or town officiaL n: Permit/License# ority(circle one): Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person; Phone#: Information and Instructions : Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for.their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under.any contract of hiie, express or implied,oral or written." / Anemployer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more , of the foregoing engaged in a join enterprise,and including the legal representatives of a deceased employer,or the Teceivor trus dividuallpartnership.association or other legal entity,employing employees. However the owner of a dwelling house having n t more than three apartments and who r'sides therein,or the occupant of the dwelling house of another who empl ys persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurte ant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licens''g agency shall withhold the issuance or renewal of a license or permit to'operkte a business or to construe uildings in the commonwealth for any applicant who has not produced�accepi#ble evidence of complian a with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) taies"Neither the comet wealth nor any of its political subdivisions shall o an contract for.the performance of ublic work untii•ac a table evidence of co liarice.with the insurance enter into y p p p n4 requirements of this chapter have been pres ted'to the contrac ' g authority." Applicants Please fill out the workers' compensation affi it comple ly,by checking the boxes that apply to your situation and,if' necessary,supply sub-contiactor(s)name(s),ad, ess(es) dphone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC) Limi d Liability Partnerships(LLP)with no employees other than.the members or partners,are not required to carry wo ker compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that -s ffidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the applicatio f the permit or license is being requested,not the Department of Industrial Accidents.. Should you have any ques ons egarding the law or if you are required to obtain a workers' . compensation policy,please call the Departure t at th number listed below. Self-insured companies should enter their self-insurance license number on the approp ' te'line. City or Town Officials Please be sure that the affidavit/ab ple 'and printed le ly. The Department has provided a space at the bottom �'�.. of the affidavit for you to fill oue e ent the Office of vestigations has to contact you regarding.the applicant. ~'•Please be sure to fill in the perm number which will e used as a reference number. In addition,an applicant thatmust submit multiple permiapplications in.any gi n year,need only submit one affidavit indicating current policy information(if necessaryder"Job Site Address" a applicant should write"all-locations in (city or �tevVn)."A copy of the affidavit s been officially stamped o marked by the city or town may be provided to the applicant as proof that a valid ait is on file for future permits r licenses. Anew affidavit must be filled out each year.Where a home owner or c is obtaining a license or permi not related fo any business or commercial venture (i.e. a dog license or permit to baves etc.)said person is NOT re uired to complete this affidavit. The Office of Investigations woke to thank you in advance for yo cooperation and should you have any questions,please do not hesitate to give us . The Department's address,tele hone•and fax number; The Commonwealth ofMassach etas epaxnemt alnustzal Aeciclen Office,of InvestigatiQns 600 Washington Street Boston,MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAH Fax#617-727-7`�49 Revised 11-22-06 wv­w,mass.gov/dla -O Town of Barnstable Regulatory Services i aAxMASS. ` Thomas F.Geiler,Director 16- 6. 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, ,as Owner of the subject property hereby authorize Z to act on my behalf, in all matters relative to work a horized�y°this building permit application for: ( dre of Job) Signature of Owner Date Print Name Q:FORMS:OWNERPERMISSION .. -,_.._ ' a Board of Building}t - e . egulations and Standards HOME IMPROVEMENT CONTRACTORLicense or.regtstrat�on valid for i r Registrt o bgfore the ex 1 102322 a. piration ndwrdul.use on! /1/2008 Bdard of.B date. If found a•eturn to. Building z —�r„ g kegulations and.Sts,mdards r1, ype ©�A f One Ashburton Place Rm 1301 MOLINARI ROO I {`; B.ostorMa 02103 � I S Libero Molinari 4 � F 11 SHEEP PASTUF EAST SANDWICH, E A 'f �✓P MA'02537 Deputy Administrator ` of valid-withoutSignature f �� - - � . .� �� �� � �� .,,, � �' � �� -� ! � z� 'j 32' � � / oA /" * . �� /" ,�!'� :�s- ,� �L� a � � 4 �� /�� � �� __ 1 sors map and lot number .lCr k-n...� ......� / " V' INST SYSTEM MUSS` 13E svnc ,S lad commupLIANCE Sewage Permit number 1........3........................................... VQI11 E;r:TI�LE II STATE /� N p�6(�',IT�A�R(Y CODE AND TOWN 4QyO�7HEtp�0 TOWN N OF IV- MAM TADLE, i VR M039. �•� BUILDING INSPECTOR O�0 tlPY�`' �J �x APPLICATION FOR PERMIT TO ....... .................:................................................................ TYPE OF CONSTRUCTION � " "?-�.�a "` F„ .................. ....... ..... .....19 . TO THE INSPECTOR OF BUILDINGS: ., The undersigned h eb plies for a permit according to the following informati w. Location ....... �'. ......�� .r am. . ' '' I. ProposedUse ....... .. . . . . ........................... .. ................................. ... .............................................................................. ZoningDistrict ...................................A..................................Fire District ...... ..... ................. .................. fya Name of Owner ... . .................. !. :..:.....:........................Address ........... »�... .......:.:::-..... .::....... ................ Nameof Builder .......i.f........................................................Address .................................................................................... Nameof Architect ............. ....................................................Address .................................................................................... AV..4 Number of Rooms ...... , ` a ................... .... ..................... .... ..:..... , .. . :. ; .............;.......... Exterior ............ ... . .... . . . . ....... ..... .................................Roofing ........ ................. ...... ............ Floors :...................................................Interior .............. ..... ..... ....... .'... ,... ..:.....:.x.......................... ci� Heating .............. ?..... ..R... ...............................Plumbin ................. .......................... 9 . ... Fireplace o ®.Y . ... ...+..... .. . ...........................Approximate Cost .............. ........................... Definitive Plan Approved by Planning B,ard ________________________________19________. Area /........ ............... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r„ rding the above construction. Name ..... .................. ................................................... Small, Alan y ?y� 16826 permit for one story - tii!F_ ................. ............................. .........sin le famil.. dwellingi ^ . . ...... ...................... . .................. ................. Location .{. . Monomoy Circle ..........................Cemervlle............................ e - Owner Alan Small ' I Type of Construction frame F .............................. Plot ............................ Lot ............. 9............ Jamary 4 74 Permit Granted .......... Date of Inspection .. 8. 7. ............. f Date Completed /..1. .., G.........19 PERMIT REFUSED ................................................................ 19 ............................................................................... 1 • i ............................................................................... a� f ............................................................................... Approved ................................................ 19 i ............................................................................... ..................... ......................................................... I