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' � •- E* 1 v .. a - ,.�5 � 15 'ra,. 1s sY ;`' s •� , +v , a. , [ e - '� _ a. ,.' - r , u � - �' e : - :~A � E 3. f cs xY '�Y :•� e X - ] 112661, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 70 Map ` �5 Parcel Oy s_ Application # ( F es Health Division Date Issued Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board f 2)3!/0 Historic - OKH _ Preservation/ Hyannis Project Street Address 7 North West Lane Village Centerville Owner Debra Thibodeau Address same Telephone 508-778-7916 Permit Request air sealing, insulate attic (R-38) , basement ceiling (R-19) , install one thermadome Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3746 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 _o 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: 0 existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site,plan review# Current Use Proposed Use APPLICANT INFORMATION - - (BUILDER OR HOMEOWNER) Name RISE Engineering Telephone Number 401-784-3700 Address 1341 Elmwood Avenue, Cranston, RI License # 100459 Home Improvement Contractor# 120979 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE — DATE 1 r� Erik Nerstheiemr for RISE f r FOR OFFICIAL USE ONLY r APPLICATION# k DATE ISSUED- _ MAP/PARCEL N0. f ADDRESS VILLAGE OWNER. , Stt ; C DATE OF INSPECTION: 'FOUNDATI.ONu ' k n FRAME , E j INSULATION- . FIREPLACE r ELECTRICAL: ROUGH FINAL i � ,I PLUMBING: ROUGH FINAL ti ' f- GAS: - #=s-;i - ROUGH FINAL r. _ i:,itFWAL BUILDING f - DATE CLOSED OUT �`ti ASSOCIATION PLAN NO. RISE ENGINEERING Federal ID#0s-0405629 RI Contractor Registration No 8186 A division of Thielsch Engineering MA Contractor Registration No 120979 CT Contractor Registration No 620120 sp,. 1341 Elmwood Avenue,Cranston,RI 02910 , - (401)784-3700 FAX(401)784-3710 CONTRACT Page 1 THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR WORK AS ' ENGINEERING DESCRIBED BELOW CUSTOMER - PHONE DATE Client# Debra A Thibodeau (508)778-7916 09/01/2010 112661 SERVICE STREET BIWNG STREET LE � � o 7 North West Lane 7 N-west Lnno SERVICE CITY,STATE,LP - BILLING CITY,STATE,LP - Centerville,MA 02632 Centervil,MA 02 S E P 2 0 2010 ul JOB DESCRIPTION RISE Engineering will provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be 7. performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements and other unheated areas(windows are not generally addressed.) This work' will be performed at the rate of$66 per man per hour,which includes materials and testing. 16 man hours. $1,056.00 RISE Engineering will provide labor and materials to install a 11 layer of R-38 Class 1 Cellulose added to 1100 square feet of open attic space. $1,320.00 RISE Engineering will provide labor and materials to install an easily moved,insulating cover for the attic access folding stair. The cover has integral weatherstripp ing to restrict air leakage. $160.00 RISE Engineering will provide labor and materials to install 1100 square feet of R-19 faced fiberglass insulation to the basement ceiling. $1,210.00" RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact offers 75%incentive,not to exceed$2,000 per calander year.also includes all of the air seal;ing costs. -$3,056.00 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF """Six Hundred Ninety&0011-00 Dollars $690.00 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF I%WILL BE CHARGED MONTHLY ON ANY - UNPAID BALANCE AFTER 90 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. - DO NOT SIGN THIS CONTRACT IF THERE AR LANK SPACES A IZED TORE-RISE ENGINEERING C RACCEPTANCE NO IS CONTRACT MAYBE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE - ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE l� SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK DAYS. it AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE The Commonwealth of Massaichusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' COMpensation Insurance Affida.vit: Builders/Contractors/Electricians/Plum bers Applicant Information Please Print Legibly Name(Business/Organization/Individual): RISE Engineering a division of Thiel ch Engineering Address: 1341 Elmwood Avenue City/State/Zip: Cranston, RI 02910 Phone#: (401)•784-3700 or 1-800-422-5365 Are you an employer? Check the appropriate box: Type of project(required): 1. 0 I am an employer with 4. 0 I am a general contractor and I 6. 0 New construction employees(full and/or part time).*_ have hired the sub-contractors 2. 0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.1 9. 0 Building addition required] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption perm MGL 11:0 Plumbing repairs or additions insurance required] t c. 152,'§ 1(4),and we have no 12. 0 Roof repairs' employees. [no workers' comp.insurance required) 13. M Other Insulate Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach 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: The Preston Agency ' Policy#or Self-ins. /Lie.#: 3730961-00 Expiration Date: 1/1/11 Job Site Address: 7 (Mmym wtsf--� 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 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 $250.00 a.day against violator.Be advised that a copy of this statement maybe forwarded to.the Office of Investigations of the DIA for coverage verification. I do herby certi and fhe ins enalties ofperjury that the information provided above is true and.correct. S nature: _ Date: Print Name: Erik-Nerstheimer Phone#:(401)784-3700 or 1 800 42 165 x 1 3� 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: AconD. CERTIFICATE OF LIABILITY INSURANCE ' �10PID 47 DA1E(MMlDDY1(Y)PRODucER HIEL-1 04/13/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Preston Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1350 Division Rd Suite 303" HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, East Greenwich RI 02.818-0810 Phone: 401-886-8000 Fax:401-8857-1700 INSURERS AFFORDING COVERAGE NAIC INSURED INSURERA: Zurich-American Ins Co. Thielsch Engineering, Inc INSl1RER B:. Jln.rdc.n Cuarant.• c Llibll [y . Thielsch Group Inc. INSURER North American Capacity Hi Tech Realty Inc, - 195 Frances Avenue INSURER Cr Hartford Insurance Company Cranston RI. 0291.0 INSURER E: ' , COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY'PERIOD'INDICATED.NOTWI-fNSTAI•IDING ANY RECUIREMENT,TERM OR�IZONDITION OF ANY CONTRACT OR OTHER OOCLIMEKF WITH RESPECT'TO WHICH THIS CERTIFICATE MAYBE ISSUED OR WtiY 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. IFULI LTR INSRCTAPE OF INSURANCE POLICY NUMBER DATE(MM/DONY) DATE( m LIMITS _ I GENERAL LIABILITY EACH OCCURRENCE - 2 1,0 0 0,0 0 0 A I X COMMERCIAL GENERAL LIABILITY 3730962-00 04/01/10 01/01/11 pREMISES (Ea occuence) R300,000 CLAIMS WADE FX I OCCUR' MEO EXP(Any.one person) s 10,000 PERSONAL&ADV IN.:URY . s 1,0 0 0,0 0 0 GENERAL AGGREGATE -s 2,0 001000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPhO AGG $ 2,0 00,000 POLICY X JEa LOC Emp Ben. 1,OQ0,000 AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT s 3730963-00 04/01/10 01/01/11 (Ea accideni) 2,0 0 0,0 0 0 ALL OWNED AUTOS — -- s. SCHEDULED AUTOS BODILY INJURY(Per person) HIRED AUTOS " NON-OWNED AUTOS BODILY INJURY (Per ecclda.nt). . PROPERTY DAMAGE s (Per accidenil GARAGE LIABILITY AUTO ONLY-EA ACCIDENT s ` ANY AUTO OTHER THA.M EA.ACC s AUTO ONLY: AGG $ , EXCESSIUMBRELLALIABILTTY EACH OCCURRENCE $ 10,000,000 B X OCCUR F CLAIMS MADE UMB 9 2 6 3 6 3 7—0 0' 0 4/0.1/10 01/01/11 •.AGGREGATE s 10,000,000 DEDUCTIBLE X RE.TEN'rION s 10,0 0 0 s WORKERS COMPENSATION AND EMPLOYERS"LIABILITY X TORY LIMIT$ ER - A ANY PROPRIETOR/PARTNER/EXECUTIVE 3_730961-00 04/01/10 01./01/11, E.L.EACH ACCIDEIIT s1,000,000 OFFlCERMEMBER EXCLUDED?If yes,eesefibe untlaf E.L.DISEASE-EA EMPLOYEE s 1,000,000 � _ SPECIAL PROVISIONS boloN EL.DISEASE-POLICY LIMIT :{ 1,000,000 OTHER CiProfessioaal Liab DVL000026800 04/01/10 04/01/11 Prof Liab 2,000,000 D � Leased/Rented Eqp 02UUNT056'78 04/01/10 04/01/11 Equipment 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER, CANCELLATION SHOUCO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION . DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE"TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL .- IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESE V ACORD 25(2001/08) @ACORD CORPORATION 1988 ells 1 "'�a tza laL?�. _a.,i e�r4f:..„� ef�p?!tEs� : �� ° +h z�.�.i .r N 1 S 1 sr.!7 rr f {' l .E Y i�{I�SAs�dM-�A N,.`.E+_� syliTEP IOj < ©4s�/12/10 ....�i..i"s[': .,.r�.'. . ,.... a.. . .. Also for RISE Engineering, a division .of ThielBah Engineering,. Inc'. Gaskell Associates.; a division of Thielech Eng.ineering, .Inc. BAL Laboratory; .a division of Thielsch Engineering, Inc. ESS Laboratory, a division of Thielech Engin..eering, Inc. ALCO Engineering, a division of Thielsch Engineering, Inc. Water Management Services, a division of Thiels.ch Engineering, Inc. 91te Offtice o nsumer alb; an usm�eguon o 10 Park Plaza - Suite 5170 Boston, ssachusetts.02116 Home Improve ontractor Registration _ Registration: 120979 Type: Supplement Card z J ' w Expiration.: 3/25/2012 _ THIELSCH ENGINEERING M ERIK NERSTHEIMER 1341 ELMWOOD AVE. CRANSTON, RI 02910 Q 0y Update Address and return card.Mark reason for change. ❑ Address n Renewal ❑ Employment n Lost Card DPS-CA1 qr- 50M-04/04-G101216 ,per �1ze 'Coanvnwouuea�! o�./�,aaaac�u�aeCta - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ° Registrations 79 Type: 10 Park Plaza-Suite 5170 Expira 12 Supplement Card Boston,MA 02116 THIELSCH EN(At ERIK NERSTH 1341 ELMWOOD CRANSTON; RI 029 4r= Undersecretary Not valid without signature i ra9ei0z1 �l 'The Official VYebsite of the Executive Office of Public Safety and Security (EOPS) Mass.Gov Home 1 Public Safety Department of Public Safety Licensee Complaints License Type Construction Supervisor License#/ 100459 Restriction WS,IC Name Erik Nerstheimer City, State, Zip North Scituate, Rl, 02857 Expiration Date 3/28/2012 Status Current No complaints found for this Licensee. Back To Search Board of 73iiildino Regulations and Standari:5 1-•a,.- <. Li.eense or registration varid-ifor individiil use only i �i HOME IMPROVEMENT CONTRACTOR i. before the expiration date. If found return to: Registration:. 120979 Board of Building Regulations and Standards 1 Ezp.tz_ati:o:o;:=3 25/2010 One Ashburton Place Rm 1301 =TYRe i pPtemeni Card T; -SIQ 1,h a. 021-08 IELSCH ENGiNEEhqING,y IK NERSTHEIM.ER=-- =-; i1 ELMWOOD-A�!E = ANSTON, RI 02910 Admin.isti::i[or Not valid without sign-1�re ;.:.. hrtp:Hdb.state.ma.us/dps/licdetails.asp?txtSearchLN=CSL1004.5 __ _ F. NAT-24531 -- 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# ab�l Health Division Conservation Division Permit# 6-1 Tax Collector Date Issued Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board v?1)1/o? Historic-OKH Preservation/Hyannis Project Street Address '7 OU o Village OwneP r ta --1 1`4 A Address rU® r��-1 tee-zSt Telephone 8 7 7 7 —// 1/. Permit Request G� V -c— d ,v 0 �► [ 'e_ Square feet: 1st floor:existing LO proposed 2nd floor:existing proposed # Totaf�ew Zoning District (�Ati S Flood Plain Groundwater Overlay w Project Valuation 700. Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting cementation. Dwelling Type: Single Family Plr-' Two Family ❑ Multi-Family(#units) ' N) w Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Hi way: neS "'❑No Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing C new Half:existing new Number of Bedrooms: existing 3 new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes XNo Fireplaces: Existing New. Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 36No If yes,site plan review# Current Use ��� Proposed Use BUILDER INFORMATION Nam �a c, �CA w,�� Telephone Number . Address* S�/ .�- S-F�-� ,-t— License# O-2 ©S Home Improvement Contractor# Worker's Compensation# ce.> 6- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1A SIGNATU DATE �� 6 t FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER • P DATE OF INSPECTION: FOUNDATION ' Y FRAME INSULATION i FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL i FINAL BUILDING i DATE CLOSED OUT f; ASSOCIATION PLAN,NO. ' r •b. The Commonwealth of Massachusetts Department of Industrial Accidents = Office of Investigations , d ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia 0. Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): . �v ►�+V^� Address: 2 /V O GI—)CA City/State/Zip: C-�NfiY-r-c�'; t M Pr Phone.#: AZ re an employer?Check the appropriate bog: Type of project(required):. 1fiJ I am a employer with 4. I am a general contractor and l 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.: 7. ❑Remodeling ' ship and have no employees These sub-contractors have' g, �Demolition working for me in an capacity. employees and have workers' g 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 l l.❑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 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. ;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: l� -�— Policy#or Self-ins.Lic.#: 17 1 417 Expiration Date: - / S d 7 Job Site Address: City/State/Zip c_,ctrzr 0, ►t z r'1 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 the 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 her under t and penalties of perjury that the information provided above 2-2, ue 7,, correct. Si ature: Date: �i � � Phone#: � i� — 6 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Perm it/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#: 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 hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the oin mP of the foregoing gag e� rp g g . P � rece;vPr nr trustee-of an individual partnership,association or other legal entity,employing employees. However the owner of a dwellfng.house having not more than three apartments and who reside therein,or the occupant of the dwelling house of another who employs persons to do maintenance,constructio or repair work on such dwelling house or on the grounds or building appurten\t thereto shall not because of such emp oyment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing a ncy shall withhold the issuance or renewal of a license or permit to'operate a-business or to construct bull gs in the commonwealth for any applicant who has not produced,acceptable evidence of compliance wit the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwe nor any of its political subdivisions shall enter into any contract for.the performance of public.work until-acceptabevidence of compliance with the insurance requirements of this chapter have been presentedto the contracting auth rity." Applicants Please fill out the workers' compensation affidavit completely.,by c ecking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),address(es)and phone umbers)along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liabih Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compens n insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit ma b submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sur to si and date the affidavit: The affidavit should be returned to the city or town that the application for the permi or lice is being requested,not the Department of Industrial Accidents.- Should you have any questions regarding a law.or.' you are required to obtain a workers' compensation policy,please call the Department at the numbe listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed le ly. The Department ha provided a space at the bottom of the affidavit for you to fill out in the event the Office of vestigations has to conta you regarding the applicant. Please be sure to fill in the permit/license number which be used as a reference n er. In addition,an applicant that must submit multiple permit/license applications in given year,need only submit e affidavit indicating current policy information(if necessary)and under"Job Site Ad ess"the applicant should write" locations in (city or town)."A copy of the affidavit that has been officially s ped or marked by the city or town y be provided to the applicant as proof that a valid affidavit is on file for fu a per or licenses. Anew affidavit t be filled out each year.Where a home owner or citizen is obtaining a lic a or permit not related io any business or c mmercial venture (i.e.a dog license or permit to bum leaves etc.)said pe son is NOT required to complete this affidavit. The Office of Investigations would like to thank you' advance for your cooperation and should you have y questions,- please do not hesitate to give us a call. The Department's address,telephone-and fax numbe W f J`heComm m ealth a Massaehusetts , Dep m of IndwWal accidents j OM a of Investigation 600 Washington Street: B.3 ston,MA 0.2111 Tel.#617-7-27-4 .0.0 ext 406 or 1-977-MASSAFE F #617-727-770 Revised 11-22-06 .rnass.gov/dia r 1 . I '1 V Y11L Vi i.XKaAAV74a. "A%; REgulatory Services Thomas F,Geiler,Director 9�''ass. �$ • Building Division Tom.Perry,Building Commissioner .200 Main Street, Hyannis,MA 02601 www.town.,bzrnstable,m2..us ace: 508-862-403 S Fax: 508-790-6230 permit no. Date • AFFMAVIT 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 ceataiu exceptions,along with other requirements. Type of'Work— � ►."0 v'1_ stimated Cost Address of Ydork. 9 Q )^ Owner's Name: (�` `��r-.A �� v A L Date of Application I hereby certify that: Registratign is not required for the following reason(s): ❑Work excluded by law D7ob Under S 1,000 []Building not owner-occupied ❑Owmr.pulling ownperrnit Notice is hereby given that OVnRs PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT FORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTYFUND UNDERMGL c,142A, SIGNED UNDER PENALTIES OF Ptpmmy I hereby ap ly for a permit as the a ent of ' Z' Date Contractor Signature. RegistrationNo. OR Date Owner's Sipatme Q,wpMes.br s,homeaff'dVY Rev: 060606 �t 0 d Standards ltin � '�anzrruns and J Board of Building R eN. or License Construction Sup 3. CS 74205 License "1213111956 Tr# 9128 sit tb ig eE-A tr n 1?13112008 t Restt�ictton� DAVID L DADMU � r, t7� 51 POND STREET 02670� z Commissioner WEST DENNIS,M _ --------- ,f� ✓!e-C000�vnwouueal�i o��'l�Gaaaacfzuoe�6 \ Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: j Board of Building Regulations and Standards Registration 128718 One Ashburton Place Rm 1301 Expiration 6/9/'2009 Tr# 129197 Boston,Ma.02108 Type DBA;• D.L. DADMUN CUSTOW BUILDERS; ` DAVID DADMUN ;. 51 POND ST ,� p as -` Not valid without signature - W. DENNIS, MA 02670 Administrator - FROM <TMU>JPJM 21 2007 23:45/ST.23:4S/No.75143813SG P 1 Sep 13 06 07: 38p p. l Town of Barnstable.. $ Regulatory Services ' 'Z a�� Thomas F.(�eiler,Director Building Division TomPerry, Bmlding Conm&doner 200 Main St<ed,Byinnis,MA QM I www.town,barnstable aLu Office: 508461-4038 Fax. 508 790-6230 Property Owner Must Complete and Sign, This Section If Using A Builder as Omer of the subject propenY hereby authorize A�1 to act on my behalf, is all matters relative to.waic authorized bytbis bwl&g permit appl uo on for. . Address of job) ' � as -off ignatsue of Owner Date P�Name Q�DRr�S:0�7�F1tPEi��SICN . THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / �C(�'J LI DATA OF LIABILITY INSURANCE DATE( M01YYYYI 04/12f2007 �n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOMMATfON eryices ( ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ,- HOLDER.THIS CERTIFICATE DOES NOT AMEN),EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NNC# o: INSURER A AIG DL Dadmun Custom Builders 191 A Main Street INSURER e: g INSURER C: : Vllest Dennis,MA 02670 INSURER D: • INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE01 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 APKORDECI BY THE POLICIES DESCRIBED HEREIN 3 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR AMO TYPE OF INSURANCE POLICY NUMBER DA E IY A LINIT$ GENERAL UA OTY EACH CCCURRENCE S COMMERCIAL GENERAL LIABILITY PREM E rrEa accure ecl S CLAIMS MADE ❑ OCCUR MED EXP iAny one persvrj S PERSONAL A ADV INJURY S GENERAL AGGREGATE S GEN'L AGGREGATE LMIT APPLms PER:I PROCUC"-COMPIOP AGG E 17.POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO I COMEIp SINGE;LIMIT g f Ec Anil ent) ALL OvINEO AUTOS ' SCHEDULED AUTOS I IBPODILLYY INJURY $ WIRED AUTOS NON-OWNED AUTOS I BODILY INJURY t %PerecadaM, I PRCPPERT DAMAGE OARAOE LIABILITY AUTO ONLY•to ACCIDENT a ANY AUTO OTHEP.TWAN EA A00 $ AUTO CNLY: AGO $ EXCES5IUMORELLA L"LITY EACH OCCURRENCE IIIOCCUR CLAIMS MADE EACH S DEDUCTIBLE SS ggRETppAAENNTION 5 $ EOYER�LuLgINL�RYN AMO ✓ TORY LIMITS ER Al ANY PROPRZTORMARTNERIEXECUTNE VVC1764667 12t1212006 1211212007 .E.L.EACWACCIDEN7 s 109,000 OFFICERIMEMSER EXCLUDED? If Wy� ditu"Under I P,,L.DISEASE•E?EMP.t R S 100.000 SPEL�{AL PROVISIONS Delav E.L.DISEASE POLICY LIMITI SLRAFPTI 500,060 OTHER v CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE A90VE DESCRIBED POuC;B3 BE CANCELLED BEFORE THE EXPIRATION 200 Main Street DATE THEREW,THE ISSUING INSURER WLL ENDEAVOR TO N.ML 15 DAYS wRITIEN Hyannis, MA 02601 NOTICE TO THE CERTIFICATE 1404DER MAMED TO THE LIFT,BUY FAILURE 10 DO SO*HALL IMPOSE NO OBLIGA"ON OR UADILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR P.EPRESENTATNq, AUTMORIUD REPRESENTATIVE ACORD 26{3007lOB) ! ®ACORD CORPORATION 198a h Nw o o 6 f iIS� F�145: m S Do v 's-t,� lo� l K M l ` --24........... _ 27.. _.1• _.____.__.....--54" __._._.._ ,._..24 __.X: - 30"..._._.......1:' ._...27" _-�:=12" { _._..._.._._.-_.__..gg•._..- -- -.,..._..,._,1 • i ` Y i I N W2730 I- ff I W2430 W3012 W2730 WEC4,' i6R N I � o 0 3DB21 2'4.DISHW J'y (G 3DB21 C `'�I .................. f-~ ......... O�G^ ....................... I) ,. _ BLVDFF34.5 BLVDFF34.5 BBCP08FF BBOP06FF a N'— � I 0. TILL FV36 - ) ' co I LL Q O a -12 :' .24"—t 18" i N ........... —casm qzmL SSbZ>3aZ ls�s coio f I MCC..-- -- ?� sa42JI( - } BP4896VG -- SMCORBEL_._.-_. I ................ ......................................... . ....................... ........ ....... ............ of„ r Town of Barnstable *Permit# 'gyp Expires 6 months from issue date + EARNSfABI.E, � Regulatory Services Fee5� 9� '""S& i63q. Thomas F.Geiler,Director ♦0 A'FD1A0'`p Building Division Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w �V ® ��S PERMIT. Office: 508-862-4038 /� �" LFax: 508-790-6230 ,JUN 2 9 2001 OeP_ EXPRESS PERMIT APPLICATION Not Valid without Red X-Press Imprint TOWN OF BARNS-T.ABLE Map/parcel Number zsy Property Address //�dr �� r� "T" L✓� g eT7j7,!17.j11 1 z g3lResidential. OR ❑ Commercial Value of Work Owner's Name&Address_MQaze4? lt//✓�,E�?l?���� Contractor's Name G�/ �.t�.L Telephone Number 7 2 5"! j�— Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner Whave Worker's Compensation Insurance Insurance Company Name 51'e,5 4,7 Y Workman's Comp.Policy# Permit Request(check box) WRe-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature expmtrg a HOME IMPROVEMENT CONTRACTOR d Registration: 100497 Expiration: 06/18/2002 Type: Individual DAVID R. COX .i David Cox 7f' 9/LAVENDER LN ADMINISTRATOR Y. YARMOUTH MA 02673 I f i t I ✓�ie �omnw�uuea� �✓�aaeac�waella BOARD OF BUILDING REGULATIONS License:"CONSTRUCTION SUPERVISOR Number:-CS 063537 g Birthdate: 10/15/1953 Expir+es:10/1b/2001 Tr,no: 7365 Restricted To: 00 DAVID R COX _ PO BOX 401 S YARMOUTH, MA 02664 Administrator