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HomeMy WebLinkAbout0109 OLD STAGE ROAD} 00 ®. r " � v• • r : c. t , n y Y ' n w. r. 4 „ .. .. .. .. .. ,. .- � _ .. a ... .. _ _ y A•.. ... � - � �. Ii ..;, _ i ,. _ .. V ,.. . i� .. r r .. - u ,. .. .. ... .. . :: ., --�+ � � '.: � � �, .� .. �. - .: �. - .. � .. � i �, . ., .. - ,. �; y ,�. .. - ,, �. � .. .Y c Town of Barnstable Building x rasa�arnaa� . Post This Card So That it is Visible.From the Street-Approved Plans`Must be'Retained on Job and this Card Must be Kept . Posted Until Final Inspection Has Been Made. i6s�• Permit p�� a Where a Certificate of Occupancy is Required,:such.Building shall Not;be.Occupied until a Final-Inspection has been made. Permit NO. B-19-3210 Applicant Name: Keith Cliff Approvals Date issued: 10/10/2019 Current Use: Structure Permit Type: Building-Stove Expiration Date: 04/10/2020 Foundation: Location: 109 OLD STAGE ROAD,CENTERVILLE Map/Lot: 208-159 Zoning District: RD-1 Sheathing: Owner on Record: DEWEY,STEPHEN H Contractor Nam�KEITH A CLIFF Framing: 1 Address: 109 OLD STAGE RD Contractor License: CSFA-058557 2 CENTERVILLE, MA 02632 Y Est. Project Cost: $800.00 Chimney: Description: REPLACEMENT OF OLD WOOD STOVE WITH NEW WOOD STOVE Permit Fee: $35.00 INTO EXISTING STAINLESS STEEL LINED FIREPLACE FLUE. 4 _, €' Insulation: Fee Paid:; S 35.00 Project Review'Req: � -Date: .! 10/10/2019 Final: Plumbing Gas Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced withinn siz months after issuan icia Final Plumbing: All work authorized by this permit shall conform to the approved application and the"approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zo tying by-laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. % Final Gas: n this rmit. "I inand-Fire-Officials-are` rovided o t s e he Bw d The Certificate of Occupancy will not be issued until all applicable signatures.by t gp p Electrical Minimum of Five Call Inspections Required for All Construction Work:i 1.Foundation or Footing �� Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue,lining ispinstalled Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical',Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION T 01,,IV qjq Map Parcel, AApplication # "J 3 h;-D-itehsu�d Health-Division 10 Conservation Division ApplicationFe :.., Perrit Fee''.n"Planning,Dept. D: F" Date Definitive Plan Approved by Planning Board T I OKH Preservation Hyannis Historic a.aw treel,A. ddi Project S Address Did kodd- Village Owner /01, Address Old Telephone Permit Request , In CIZI, A,11A 9 71 �9a u 6_X 0/14#140 VK ASP C" Square feet: 1 sl floor: existing proposed '2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 00 0 Constructio Project Valuation /W rQJec n Type Lot Size Grandfathered: Ll Yes Ll No If yes, 'attach supporting documentation. Dwelling Type: Single Family ,". Two Family Ll Multi-Family(# units) Age of Existing Structure Historic House: J Yes Q No On Old King's Highway: LJ Yes LJ No Basement Type:A Full LJ Crawl Ll Walkout L1 Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new 6 Half: existing new 4) Number of Bedrooms: existing Anew Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: X Gas ❑ Oil LJ Electric LJ Other Central Air: LJ Yes No Fireplaces: Existing New Existing wood/coal stove: U Yes LJ No Detached garage: LJ existing J new size_Pool: Ll existing J new size Barn: LJ existing L1 new size Attached garage: U existing LJ new size —Shed: Ll existing Ll new size Other: Zoning Board of Appeals Authorization L3 Appeal # Recorded LJ Commercial LJ Yes Ll No If yes, site plan review# ____,,_Qurrent._Use_SJZr0 Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) CN Name Telephone Number .Address License# C (Y J 6)� Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO m&&h SIGNATUREA DATE ? FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME C&O-712,11tj - - INSULATION FIREPLACE f ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL I FINAL BUILDING F DATE CLOSED OUT ASSOCIATION PLAN NO. ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street. Boston, MA 02111 ,v P www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address:. S'U &J� a. Jea n J City/State/Zip&,� k. /I � p Phone.#: 5DY- V2-9 /&CO ArKya-in employer? Check t appropriate box: Type of project(required): a employer with $V� 4. Lam a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors ..2_0 I am a sole proprietor or'partaer listed on the attached sheet. T. []Remodeling ship and have no employees These sub-contractors have g• '❑ Demolition workingfor me in an capacity.,., employees and have workers' Y P tY`• $ .4. ❑Building addition [No workers'•comp.-insurance comp. insurance. '10. Electrical repairs or additions required.] - 5. ❑ We area corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself- [No workers' comp. right 6f 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. xContractors that check this box must attached an additional sheet showing the name of the subcontractors 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: 6 Policy#or Self-ins. Lic.'A �(, aV S 7/-�( 1 Expiration Date: Jab Site Address: City/State/Zip: y�//�G /� /'�/ 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 crimuial penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of.a STOP WORK ORDER and a fine. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb, ce tify under the pa an a-nd penalties ofperjury that the information provided above is true and correct Si afore: � Date:— w Phone#: I ' [J=1c,=lia use only. Do not write in this area,to be completed by city or town officiaC ty or Town: Permit/License#.. uing Authority(circle one):. Board of Health ,2.Building Department 3.City/Town Clerk 4.'Electrical Inspector 5.Plumbing Inspector Oter-ntact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �...•►� 06/29/2012 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 be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). . PRODUCER CONTACT Ciermanl Insurance Agency NAME:PHONE FAX 908 Main Street c xt 508 428-9194 A/c No: 508 428-3068 IL Osterville,MA 02655 ADDRESS: INSURE S AFFORDING COVERAGE NAIC# r 19SURERA:SAFETY INS CO INSURED • INSURER B Scott Peacock Building&Remodelling,Inc. — P.O.BOX 171 INSURER C: Osterville,MA 02655 INSURER D: Commerce&Industry Ins.Co. 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 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 I ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MM/DDIYYYY LIMITS A GENERALLIABILITY - CP00001152 7/5/2011 7/5/2013 EACH OCCURRENCE $ - 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE DOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 1 - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JECTPRO LOC $ AUTOMOBILE LIABILITY Ea COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE NON-OWNED HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ - $ D WORKERS COMPENSATION WC 005-81-5464 6/22/2012 6/22/2013 1 WC STATU- oTH- AND EMPLOYERS'LIABILITYY/N FP ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) y E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 , DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER `• CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Scott Peacock Building&Remodeling,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Fax#508-428-7625 ' Scott_Peacock@venzon.net AUTHORIZED REPRESENTATIVE - ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo'are registered marks of ACORD oFz�tqk, Town of Barnstable BARNsrABLE, 9� MASS. Regulatory Services TFD 'y s Thomas F.Geiler,Director ~.Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must t ` Complete and Sign This Section - If Using A Builder Z I, v+✓�c' , as Owner of the subject property hereby autho i �� th act on my behalf, in all matters relative to work authorised by this building permit application for: • l aid � Pad Owkwlll���S (Address ofjob) Sig6atilre cif Owner _ Date eft-ep t- 1- Vim' F Print Name QAYvTFILES\FORMS\building permit forms\EXPRESS.doc b Revise020108 •� Massachusetts- Department of Public Sitfet) Board of Building Regulations and Standards Construction Supervisor License License: CS 94500 i JAMES S PEACOCK w.1 PO BOX 171 OSTEVILLE, MA 02632 Expiration: 7/22/2012 Commissioner Tr#: 29233 r C,q ok,,FiYr,777,CLl�coerr,�/� X Office of Consumer Affairs&Busiless RegulationXIJCCC _License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: .151,853 Type: Office of Consumer Affairs and Business Regulation ' F , xpiration 7/7/2014 Private Corporatic+n . 10 Park Plaza-Suite 5170 z - Boston,MA 02116 SCOTT PEACOCK BUILDING &REMODELING INC JAMES PEACOCK €; ' r 1046 MAIN STREET SUITE 7 OSTERVILLE, MA 02655 ''+ Undersecretary' Not valid without signature F F ` t ;�; ��^�.� ,�:_ I tu.a.�r W C, r +--_- �REY�F�S'T ��� tc r •—�y�,t,�3 � X�v -- .- � L �-�-`.L 1 ,r�. P ..�: , P � �� � t XP ERANT Town of Barnstable *Permit# ~ Expires 6 mo rss+ee date Regulatory Services" Fee t A'� ` 12 639 �0 Thomas F.Geiler,Director Building Division 1�0�/N OF < G� ARNSTABLE Tom Perry,CBO, Building Commissioner - 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number P;Residential pe Address i I� Value of Work • Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name 7 �lephone Number 738 q2B Home Improvement Contractor License#.(if applicable) I S1 Ufj Construction Supervisor's License#(if applicable) 1. S ry 1 u korkman's Compensation Insurance Check one: ❑ I am a sole proprietor. I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name �I(j(/ U! d Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit 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 #of doors Replacement Windows/doors/sliders.U-Value �� maximum:44 #of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic;Conservation,etc. ***Note: Property.Owner must sign Property Owner Letter of Permission. A copy?_hp Home Improvement Contractors License&Construction Supervisors License is requi red. SIGNATURE: C:\Users\decollik\Ap D to\Local\Microsoft\Windows\TemporarylntemetFiles\Content.Outlook\QKIH7J6E\EXPRESS.doc Revised 070110 To wn of Barnstable Regulatory Services * BARNSfABLE, • 9 MASS. $ Thomas F.Geiler,Director 1639 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 Oder Must Complete and Sign This Section 4 If Using A Builder. as Owner of the subject property. orize p� Z S to act on my behalf hereby auth , swi in all matters relative to work authorized-bythis building permit application for: . 1.01 0 (Address ofJob) Si nature.of ,per Date Print Name QkRMS:OWNERPERMISSION V Acr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) �- 07/06/2011 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Germani Insurance Agency PHONE FAX 908 Main Street c o (508)428-9194 tAIC, No: 508 428-3068 E-MAIL ADDRESS: Osterville,MA 02655 PRODUCER CU O E I #, INSURERS AFFORDING COVERAGE NAIC# INSURED _ INSURER A: SAFETY INS CO Scott Peacock Building&Remodelling, Inca wsuRERe: P.O.Box 171 Osterville,MA 02655 INSURER C: INSURER 0: National Union Fire Ins.Comp. 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 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 I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYY MM/DD/YYYY LIMITS A GENERAL LIABILITY CP00001152 . 7/5/2011 7/5/2012 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY - DAMA - RENTED— CLAIMS-MADE PREMISES Ea occurrence $ F—IOCCUR a - MED EXP(Any one person) $ PERSONAL&AOV INJURY $ • - GENERAL AGGREGATE $ .2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ POLICY F1PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ " SCHEDULEDAUTOS BODILY INJURY(Per accident) $ _ ' PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB 1_1,CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ D WORKERS COMPENSATION WC 5815464 6/22/2011 6/22/2012 WC sTATu- I OTH- AND EMPLOYERS'LIABILITYI TOR LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N ,; E.L.EACH ACCIDENT $ 1 OO,000 OFFICER/MEMBER EXCLUDED? ❑. N/A (Mandatory in andNH) -4 - - E.L.DISEASE-EA EMPLOYE 100,000 If yes,describe under � _ DESCRIPTION OF OPERATIONS below - .'E.LDISEASE-POLICY LIMIT $ 500,000 [7T, DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required( CERTIFICATE HOLDER CANCELLATION Scott Peacock Building&Remodeling,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE, DELIVERED IN Fax#"508-428,7625 ACCORDANCE WITH THE POLICY PROVISIONS. - - - AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09). The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts' s Department of Industrial Accidents f^ ' , J Office of Investigations 1 w r :s 600 Washington Street ; �. Boston, MA 02111 =h r s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly G Nalne (Business/Or(,anization/Individual): P_eo� Address: tbq.b r"U TJ '. s� n l City/State/Zip: IU V l Phone #: ' AW10am u an employer? Check the appropriate box: Type of project(required): I. a employer with 4. ❑ I ain,a general contractor and 1 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• El Demolition ' working for me in any capacity:, employees and have workers' 9. ❑ Building 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 I 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' 13. Other 11 1UWS - employees:[No workers comp. insurance required.] `Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infonnation. 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. lam an employer that is providing workers'compensation insurance for my employees..Below is the policy and job site information. !nn nn C Insurance Company Name: VI t VU' 1 ��� R� Policy#or Self-ins. Lice Is q(�qq Expiration Date: Job Site Address: Old skoc City/State/Zip: �,M 62�3. �T Attach a copy of the workers' com pensa tion�policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o kthe DLA for inSLIranA coverage verification. I do hereby cer i v u he (tins an penalties of perjury that the information tu provided above is true and correct. Signare: ' � � Date: V Phone#: _ 7i�j l 6600 Official use only. Do not write in this area, lobe completed b y ciny or town official. - City or Town: Permit/License#� Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 1 N''lassachusetts- Department of Public Safety 7 Board of Building Regulations and Stantl;ir•ds Construction Supervisor License License: CS 94500 JAMES S PEACOCK PO BOX 171 { OSTEVILLE, MA 02632 ,,v �% — Expiration: 7/22/2012 ('uuunisiuncr Tr#: 29233 ` Zx. �O'III�/2(1/GCUP"CLGCiL /JL �iJdlLl.'>7�b(:IL6 - . - Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only !il HOME IMPROVEMENT CONTRACTOR' before.the expiration date. If found return to: ��I t Registration a1.51853 Type: Office of Consumer Affairs and Business Regulation Expiration 7/7/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston MA 02116 SCO1T PEACOCK BUILDING 8 REMODELING INC i JAMES PEACOCK 1046 MAIN STREETASUITE 7: - OSTERVILLE,MA 02655- Undersecretar Y Not valid without signature � r • Town of Barnstable emit: Regulatory Services ate: 1112006 Q, Thomas F.Geller,Director BAWMABM Building Division Fee: MASIL &639.a�� Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us �r Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: Phone: Install at: f d Village: 16- Map/Parcel: 20 NO % � Zvo(. Stove , A. New Used B. Type: radia)n /Circulating r C. Manufacturer: Lab.No. D. Model No.: `���, moo✓ F ry Chimney C A. New xisti (If existing,please note date of last cleaning c B. Flue Size C) C. Are other appliances attached to Flue? o SR `"" 10 D. Pre-fab Type and Manufacturer -„ E. Masonry: Lined/Unlined o -� Z Hearth `•'� c�:� A. Materials: o ram, B. Sub Floor Construction: Installer Name: �� �i�vwrn�f �� Address: ty/1_a /K4 02� Phone: So,f- J-Z d� - ¢3 t q Location of Installation: APPROVED BY: Please make chec payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 122801 Y o4' '9R% 'rcmm9'Iny€,rc�g8ae��'r r I .r E'