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HomeMy WebLinkAbout0222 NOTTINGHAM DRIVE 'mo Y +'fir t. 4 ) b r t { r, z u , i a _ Town of Barnstable Building MaseBAFNWAM ` Post> Cdo m o "sST ymednondsM . " NO 211clll ustbe>Ke t ,Posted Until FinalInspeetlon Has Been.Made z �': .� Where a`;.Ceri,ficateof Oceu an' ;s Re' used sueh�Build,n ='shall;Not be Occu. ,ed until a�F,,n�al,lns ect,'on>has;been.made �� Permit Permit No. B-18-2406 Applicant Name: SWEET,ANDREW Approvals Date Issued: 08/01/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 02/01/2019 Foundation: Location: 222 NOTTINGHAM DRIVE,CENTERVILLE Map/Lot 171-035 Zoning District: RC Sheathing: Owner on Record: FLEMING, RUSSELL S ESTATE OF g Contractor.Name Jon D Walsh Framing: 1 R Address: 222 NOTTINGHAM 2 DRIVE Contractor•License CS 095605 CENTERVILLE, MA 02632 Est Protect Cost: $ 13,407.00 Chimney : Description: roof Penn e: $68.38 t e Insulation: Project Review Req: F Fee Pa,d;4 $68.38 ' final: Date 8/1/2018 �l � k _ Plumbing/Gas Rough Plumbing: BuildingOfficial Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within a- onths afterissuance. Rough Gas: All work authorized by this permit shall conform to the approved application and theapproved construction documents for wh,cht'h,s permit has been granted. g a , All construction,alterations and changes of use of any building and structures,shall be in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or,road(a id shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Off,icials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection " 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 0 o� $ Application number.......t .�.Q..., . PDR �4 = E � Date Issued............. U. . BARNSTABi.E. ................................. JUL 2 5 2010 Building Inspectors Initials.. ......................... 001 0F p T � 7 l 2 L 1RNSTAB Map/Parcel._......:2.......Q�?:5.............................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY WFORMATION Address of Project: 2 Z Z �/��f�1,�,�, ��r• �'e.�'{�r✓�'/�� NUMBER STREET VILLAGE Owner's Name: vn Phone Number q(,;- �/6-i7 z r, Email Address: h�;,(yo n e 'Va A o o.c o rn Cell Phone Number Project cost$ /�, ilo-7 — Check one Residential_� Commercial OWNEWS AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name A,1,�f�,,/ ' PetZ Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# 09 S� 0 S' (attach copy) Email of Contractor Phone number 461- 7IV- 6 3`�9 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. :T APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected I Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent df food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval. "WOOD/COAL/PELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities,under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. Y understand the construction inspection procedures,specific inspections and documentation rewired by 780 CMR and the Town of Barnstable. Signature Date ZAPPLICANT'S SIGNATURE H ClJ RE Signature Date 7—L s /S All permit applicati are subject to a building official's approval prior to issuance it's Home Improvement Agreement: Page 1 Home Depot License Number(s)• Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license info MA: 1077.74, 112785 Salesperson Name: Christopher Read Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or service provider named below ("Service Provider") will furnish, install or--service the equipment listed below at the price, terms and conditions as outlined on this form. salvon bethany New England South 1-660NVRT Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 222 nottingham dr Centerville MA 102632 Customer Address City State Zip (415) 846-1723 1 bsalvon@yahoo.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC., 2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL The Home Depot I @ customercancellationnortheast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENTS WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS�DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YMIR RI TO CANCEL. Acknowledged by: 06/20/2018 Customer's Signature Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: lincludes all applicable taxes. Excludes finance charges.* Sales Tax: 10.00 (If applicable) *Maximum deposit ONLY applicable In MD, MA, ME(331%), NJ, Wl(99%) Dep. 125.0 % Deposit Amount 13351.81 1 Remaining Contract Balance 10055.44 The home Depot-2455 Paces Ferry Road, N.W. Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 Customer Agreement(C,E,I)(31 Jan.18) v 50.1.2 o f +off $ gg ed r.T--�g,.-a N�V _ A 4 t S z5TO rer .c_ 42 CgLce of Cof=mcrAffairs Bistness-Av9U=Dn §10P� YMPROV+IEW CONTRACTOR RogiSVat onvt16for tndMdJZr U-54 a7Et"')r TYP—c:Susnirrrani;rd be€ofe The Wiratls date U Yound return W.{jlqv 952iEZiAv mrPA of GUrrsurner A—,.Mlrz dRA&,Wnor Firxjcjla.jon !-i-a!,2 15f 7 Ot-*Ashbwtoci Race-3uiks1301 'not valid without signature Under.�zr:ltai^! The Commonwealth of Massachusetts Department of Industrial Accidents - Z Office of Investigations 600 Washington Street Boston, AIA 02111 - - '''M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organ izatiori/Individual): • Address: / k/TIOUln die . . City/State./Zip: PA Phone #: � Sd 9'96 z Are y'ou an employer? Check the appropriate box:. Type of project (required):. 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. [l New construction I employees (full and/or art-time .* have hired the sub-contractors P P. ) 2.S I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑.Demolition working for me in any capacity workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insura-oce 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ .I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No•workers' comp. . c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13:0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners vvho 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 their workers'comp,policy information. I ant an employer that is providing workers'compensation insurance for my employees. Below is,the policy and job site information }Insurance Company Name: . Policy#or Self ins. Lic. #: Expiration Date: Job Site Address: Z 9111 Aa City/State/Zip:_1 ;4 ; '. Attach a copy oi.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 S250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Of lcial use only. Do not write in this area,to be completed by city or town offecial. City or Town: Permit/License# Issuing.Authority (circle one): Board 1• of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone#: r Details 7118/2018 Licensee Details emographic In ormate� n - e�Name: icense ress n ®rma ion L Kingston MA- 02364 e inTormation FLicense _ ,_ _ t .. ;CS-.095605g Licennse Type Construt6n'Su erv[sor Building Licenses Date of Last Renewal 7/16/2018 �Eupira.tion Dafe` ''' =°6/1.4`/2020 Toda s Date: 7/18/2018 s: Active Yeconarycense Type: I Doing Business As: atus ewalChan a as Lcense rerequ'se n ®rrRR �®n No Prere uisite Information Close Window i �+ --" ltc `,� L• 711CIcS I ontaCl (�� ©2011 Commonwealth of Massachusetts � vi https://elicense.chs.state.ma.usNerification/Detaiis.aspx?agency_id=1&license_id=284556& r ur { �: i �; , ff`' f.0 i 'tif Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston; Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22/2019 2455 PACES FERRY RE) C-11 HSC ATiANTA,GA 30339 Update Address and return card. Mark reason for change. El Address ❑ Renewa! O Employment G Lost Card -_-- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE SUDDlement Card before the expiration date. If found return to: Registration Expiration , Office of Consumer Affairs and Business Regulation ' 112785 04l22/2019 10 Park Plaza-Suite 5170 i 0ME DEPOT USA INC Boston,MA 02,16 ANDREW SWEET 2455 PACES FERRY RD C-11 HSC ATLANTA,GA 30339 Undersecretary d ithou signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations s 1 Congress Street,Suite 100 Boston,,K4 02114-2017 " www.massgov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `f Please Print Le 'blv Name (Business/Orgattizariooilndividual): O P J/i ,0 Address: * f g y S y�w `rVANPr Citv'State/Zi : Sh/' +ra M • d/s'/3' Phone#:. ! / Y- o2 rys - o?- Are von an employer?Check the 4propriate box: Type of project(required): 1.• I am a empiover with 4. I am a general contractor and I j { � 6. ❑New construction ; employees (full and/or part-time).* have hired the sub-contractors t r—; listed on the attached sheet. 7_ Remodeling 2. I am a sole proprietor or partner- t ship and have no employees These sub-contractors have g• ,Demolition Noriong for me in any capacity. employees and have workers' 9 ❑B��g addition ' jvio workers' comp. insurance cpmp•ir�t'r�nce.� required.] 5. We are a corporation and its 10.E Electrical repairs additions 3.ri I am a homeowner doing all wort: officers have exercised their 11.❑Pl=bing repairs or additions j myself. Tlo workers' comp. right of exemption per�IGL 12.FRIroof repzks insurance required-] t C. 152,§1(4),and we have no empioveez. [tio workers' i 13.E Other ; comp.insurance required.] •v, applicant tba:_hecis box il'_must alsoa out the section below showing their workers'compensation policy information. •' homeowners who submitthis affidavit indicating they are doing aD work and then hire outside conttactnzs must submit a new affidavit indicating sock :Contactors that check this box must attached an additional sheet showing the name of inc sub-contractors and stare whether or not those entities have =piovees. s the sub-contractors have employees,they mtJst 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 sire information. lnsuLrance Company Name: 1.(rJ�"T/fit✓ 2�o/tJQ.� �N��n� r'/!'L �it�S C,'B _ Polio•#or Self-ins.Lic.#: X W �i I l o / Expiration Date: Job Site Address: 2 2 2 11110 l ill 5 City/S-tate(Zip:6? ► e/✓�'!le t-1 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 25 A of MGL c. 152 can lead to the imposition of criminal penalties Of? fine un to$1,500.00 and/or one-y imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S_'50-00 a day ag st a lator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DL9 r ce coverage verification. I do hereby certify un e i at the information provided above is true and correct Si att�e: Date: 7— Sr' t Phone=. ricial use only. Do nor write in this area,to be completed by city or town offusal. y or Town: Permit'Licenseuing Authority(circle one): 1.Ruard of Aealth 2.Building Department 3.City/Town Clerk 4.Electrical lnspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r ACC> CERTIFICATE OF LIABILITY INSURANCE DATE 0212WON BDmrr) 1641� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY.THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 endorsemerrt(s)- .PRODUCER CONTACT MARSH USA.INC. PHONE FAX TWO ALLIANCE CENTER fAIC,No Extl, ac No 3560 LENOX ROAD,SURE 2400 E-MAIL ATLANTA GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIL L CN101642069-H=eD-GAW-16-19 INSURER A:Old R uNicInsuranceCo 24147 INSURED THE HOME DEPOT,INC. INSURER B:New Hampshire Ins Co . 23841 HOME DEPOT U.S.A.,INC. INSURER e:HomeRisk CaDWe Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA.GA 30339 INSURER E INSURER F: _ COVERAGES CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUB POLICY EFf POLICY EXP LIMBS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MWD DNYYYI A X COMMERCIAL GENERAL LIABILITY MWZY312717 0ON1/2018 1030/2019 EACHOCCURRENCE S 9,0DD,000 CLAIMS-MADE A OCCUR A R ED 1.OD0,000 PREMISES Ea occurrenrP S LIMITS OF POLICY XS ! EXCLUDED MED EXP(An one person) S OF SIR:S1 M PER OCC PERSONAL&ADV INJURY s 9p00,C00 GEN•L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9000'100 FTI PR CT LOC PRODUCTS-COMPIOP AGG S POLICY❑JE 9,00C.000 - S OTHER: AUTOMOBILE LIABILITY MWTB312718 031012018 03101/2019 Ea amde�iHSINGLE LIMIT S 1.000.0 D X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY Per accident) S AUTOS ONLY AUTOS 1 'i -HIRED NON-OWNED - + - PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY - Per accdeni S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR .CLAIMS-MADE I AGGREGATE _ _ S DED RETENTION S S B WORKERS COMPENSATION WC014122577 (AN,NH,NJ,VT)" 0310112018 03101/201S X STATUTE I ER TH R AND EMPLOYERS*LIABILITY YIN WC 014122576 W)I DWM/2018 03101/2019 E.L.EACH ACCIDENT 5 - S.CDO,000 ANYPROPRIETORIPARTNERIEXECUTNE ( OFFICER(MEMBEREXCLUDED1 NIA S 000 000 (Mandatory in NH) ._ E.L.DISEASE-EAEM PLOY E S I yes.describe under COnfinued on AdditiDnal Page E.L.DISEASE-POLICY LIMIT s 5,00D.000- DESCRIPTION OF OPERATIONS below - C Excess Amu 297-1-10011-00.2018 031D12018 031011201E Urttit: 4A00.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,maybe attached it more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION 7T24155 ME DEPOT USA,INC SHOULD ANY OF THE ABOVE OESCRIBEiD POLICIES BE CANCELLED BEFORE PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ILDING C-26 ACCORDANCE WITH THE POLICY PROVISIONS. LANTA.GA 3033E AUTHOR¢EDREPRESENTATIVE of Marsh USA Inc. - ManashiMukhegee �Lauoo� 1 ©1988 2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD !AGENCY CUSTOMER ID; CN101642069 4 LOC#: Atlanta AlC®' � AGENCY ADDITIONAL REMARKS SCHEDULE page 2 of 3 MARSH USA.II-IC. NAMED INSURED THE HOME DEPOT.INC POLICY NUMBER HOME DEPOT U.S.A.,I1,11C. 2455 PACES FERRY ROAD fBUILDING C20 CARRIER NAIC CODE ATLANTA.GA 303,N I ADDITIONAL REMARKS EFFECTIVE DATE: m THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of LiabilityInsurance Workers Compensation Continued: Carrier.Indemnity Insurance Company of North America Pdicy Number WLR C64763151(AL,AR,FL,ID,Ih.KS•KY,LA,hiS.MO•NE Nfa.ND.OK,SC;SD,TN,WV,'1VY) Effective Date:03f0112018 Expiration Data:031012019 (EL)Limn:S1,000,000 Carney New-Hampshire Insurance Company e Policy Number.WC 014122576(DC.DE,HLIN,MD,MN.MT,NY,RI) Effective Date:03/012018 Exoiralion Dale.01,0112019 (EL)U. 51:00D.ODC Carrier:ACE American Insurance Company , Policy Number WCU C64783221 IQSI)(AZ,CA,IL,NC.OR,VA.WA) Effective Dale:03/01/2D78 Expiration Date:03/012019 (EL)Limit:S1,000,OOD SIR 51,000.000 SIR for the stales of AZ.CA,IL.NC.OR,VA,WA Carrier:National Union Fire Insurance Company Pdicy Number XWC 4595580(QSI)(CO,CT.GA NE,MI,NV.OH;PA,UT) Effective Date 03/012018 Expiration Date:031012019 (EL)Limit:SI,000,000 S1,000,000 SIR for Iheslates of COME NV,MI,01i.PA,UT S750.000 SIR for the stale of GA S350,000 SIR for the slate of CT Cartier.National Union Fire Insurance Company Policy Number XWC 4595581(QSI)(.MA) Effective Date:031012018 Expiration Date:031D12019 Ilk (EL)Limit:51,000,000 I l,//-4� SIR:S500,OOD Tx Employers XS indemnity: CBIris"Illinics Union Insurance Company Policy Number TNS C4916693A(TX) Effective Dale:03/012018 Evpiralion Date:03/012019 (EL)Limit:SIQDDO.ODD ` SIR:S 1,000,COD XORD 101 (2008101) 2008 CORD CORPORATION: All rights reserved. The ACORD name and logo are registered marks of ACORD L, TOA OF1ARNSTABLE BUILDING PERMIT APPLICATION Map ��� Parcel o � 5 Application Health Division Date Issued 512: (o Conservation.Division Application Fee Planning Dept, Permit Fee Date Definitive Plan Approved by Planning Board , Historic- OKH _ Preservation / Hyannis �mPru S Project Street Address c.,�. N o-*1 A,�w m f C Village CeA+trVtlle Owner 4, , 11 Address S�m� Telephone 5 d R L4 q RU 51 Permit Request an ±0 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 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 BUILDING DP:PT Basement Finished Area (sq.ft.) Basement UnfiAished oAreaO�(ssq.ft) PR ZNumber of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new TOWN OF BARNSTABLE Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing '❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes >(No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION - -- - _ (BUILDER OR HOMEOWNER) Name 1I . C /(�p % Telephone Number _SO$ Address --� I�wn�r�n A A-V'Q, License # ZT-Ic 101 4;�G �RUn 0��c {�Ow l Home Improvement Contractor# I 3R a Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO r SIGNATURE DATE l b FOR OFFICIAL USE ONLY s APPLICATION # - + DATE ISSUED t - MAP/PARCEL NO. 4 ADDRESS VILLAGE r %►OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE t ELECTRICAL: ROUGH FINAL i PLUMBING: ROUGH FINAL ti GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents , 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass govldia. . tN orkers'Compensation.Insurance Affidavit:Builders/Contractors/Electricians(Riom6ers.' TO BE FILED WITH THE PERMITTING AUTHORITY. Auolicant Information Please Print Legibly Name(Business/Organization/Individual):Cape Save Inc Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 Phone#:508-898-0398 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am'a employer with .15 employees(full and/or.part-time);*' ❑ , 7.'.[]New construction 2. I am a sole proprietor or partnership and have no employee's working for me in ❑ l & ❑Remodeling any capacity.[No workers'comp:insurance required.] III am a homeowner doing all.work myself[No woikers'comp'•insurance'required]t• ' 9. El Demolition , y 10 0'Building addition 4.❑I am a homeowner and-will be hiring contractors to conduct all work on my property. i will ensure that all contractors eithethave workers'compensation insurance or are sole I I.Q Electrical`repairs or additions proprietors with no employees. - 12.❑Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors.have employees and have workers'comp-insurance.. 13.[]Roof repairs 6.❑we are a corporation and.its_officers have exercised their right of exemption per MGL c: 14.n✓Outer Insulation 152,§1(4),and we have no employees.[No workers'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 anew affidavit indicating such. lContractors 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: , lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: . Star Insurance Co. Policy#or Self--ins.Lic.#: WC085540700 Expiration.Date: . 4/9/2017."� Job Site Address: 222 Nottingham Drive city/State/Zip.-Centerville Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under,MGL-c. 152,§25A is a criminal violation punishable by 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:A copy.of this statemen(may be forwarded:to the Office of investigations of the DIA for.insurance coverage verification. I do hereby certify under fh pains and penalties of perjury that the information provided above is true and correct Signature: Date: 4/19/16- Phone#:508-398-0398 Official use only. Do not write in this area,to be completed by city or town of)'ic al - - City or Town; Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A 62a DATE(MMIDDA YYY) +,..-4 CERTIFICATE OF LIABILITY INSURANCE /12/2016 THIS CERTIFICATE.IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcypes)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 endorsements. Cr PRODUCER _.. .. ._ __. . NAME: .Risk Strategies .Company Risk Strategies Company a„c°N E : (781)986-4400I FAC No:(101)963-4420 15 Pacella Park Drive E4D% randol hcld@risk-strata ies.com AnDREss: P g Suite 240.. INSURER(S)AFFORDING COVERAGE NAIC9 . Randolph MA 02368 INSURER Ins. of America INSURED INsuRERB Allmerica Financial Alliance Ins Cc 10212 Cape Save, Inc INSURERC:Star Insurance CO 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02664 INSURERF: COVEPAGES CERTIFICATE NUMBER:CL1641211375 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED.ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY E F POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER.. NN/DD MNI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMSv1ADEFiO OCCUR DAMAGE TO RENTED—PREMISES Ea occurrence $ 100,000 - X 91004480 y -10/16/2015 10/16/2016 MED,EXP(An oneperson) $ 10,000 PERSONAL&ADVINJURY $ 1,000,00:0 GEN'L.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,.000 POLICY�.JECOT FI.LOC PRODUCTS COMP/OP.AGG $ 2.,000,000 OTHER? _ $. AUTOMOBILE LIABILITY Ee accident LIMIT $ 1,000,060 B ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS X SCHEDULAUTOSED ANNA46796600 11/6/2015 11/6/2016 BODILY INJURY(Per accident) $ X HIREDAUTOS X .AUTOS PeracadTentDRMAGE $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE i AGGREGATE $ 1 000 000 DIED X RETENTION.$ NIL 81994480 10/.16/2015 10/.16/2016- $ WORKERS COMPENSATION - -, Officers Included for t- r; X]STATUTE I ERH AND EMPLOYERS'LIABILITY r YIN ANY PROPRIETOREPARTNEREE ECUTIVE Coverage, J E.L.EACH ACCIDENT $ 500,000 N�NIA OFFICEREMEMBER EXCLUDED? C (Mandatory In NH) IPCOSS540700 4/9/2016 4/9/2017 E.CDISEASE-EAEMPLOYE $ 500,000 It yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION:OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace Is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial. Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of named insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. Barnstable County 460 West Main Street AUTIiow2rDREPRESENI7AnVE Hyannis, M 02601 Michael Christian/CLC 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are,registered marks of ACORD INS025(2101401) Office of Consumer Affairs and Business Regulation 2 10 Park Plaza- Suite 5.170.' Boston,-Massachusetts,02116;_: . . Ho me.Improvement.COntractor Reglstratlor - ._.�� Registrat+on 171380 . ' I —� Type Corporation ` 3 y ` Expiration 3/14/2018 Tr# 41:9291 CAPE SAVE INC. s`. WILLIAM 'McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH=YARMOUTH'; MA 02664. Al s Update Address and'return card Mark reason for change. Employment (� Lost Card: SCA 1 %1 2OM-05/11 J e`�a.�runaa�rcgetcll/e a�P/�l�cr�acf cued " Office of Consumer Affairs:&Busiaess Regulation License or registration valid for indi*j4uli use only (r HOME IMPROVEMENT CONTRACTOR before the expiration date If foundreturn to Registration -1713gp Typei Office of Consumer Affairs°:and Business Regulation Expiration 3A4/26-1 Corporation. 10 Park Plaza-Suite 506 — Boston,MA 6 116 CAPE SAVE INC. v ;. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE- SOUTH YARMOUTH MA`02664 Uhdersecreta va .ry Not lid signature Massachusetts -Department of Public Safety Board ofBui)ding Regulations arid.Standards h..__ C_. C_ Imo. �.�m�tiiifu6Ti ouTre�tinoi vnCc�a�u" License: CSSL 102776 WILLIAW MC CitU 37.NAUSETROA� j ,z West Yarmouth NSA �.•G.••�11 •s Expiration Commissioner 06/2812017 4 Apr 1316 07:04p Russ Fleming 781-721-0306 p.2 HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE"APPLICANT HOMEOWNER. 12i i�2�et( -r-'116VA t M hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather slipping; air sealing; attic&basement insulation; exterior wall insulation;ventilation measures In consideration of the weatherizabon work to be done at my home I agree to the following: 1. 1 give permission to Housing Assistance Corporation the property with such equipment and materials as may be necessary to perform weatherization. 2 The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work Is completed. I have read the provisions of this agreement and give my consent Home Owner(sig rr�) yok Ce Home Owner email: Agent:(see) Date: Weatherization Contractor's: Adam T]no Cape Save Ali Cape Energy Frontier Energy Solutions Altemabve Weatherization Lohr Home Improvement Building Science Construction Resolution Energy Cape Cod Insulation Tupper Construction Cape Save Inc. 7-D Huntington Avenue # OF '�� T, BI South Yarmouth,.MA 02664 � z r M 3 :' Tel: 508-398-0398 Fax: 508-398-0399 5/7/16a7.t ' Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permit B-16-990 TO: Building Inspector(s), This affidavit is to certify that all work completed for 222 Nottingham Drive, Centerville has been inspected by a third party Certified Building Performance Institute(BPI) Inspector. All work performed meets or exceeds Federal and State Requirements. ' Sincerely, William McCluskey r t