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HomeMy WebLinkAbout0105 PARK AVENUE - , y ,� ,, � ,_. .., _a __ ..� .. _. _. �.-- Y _._,._ �, �. . � _ . . r . �. _ � a a .. .� �. .. - �o o r , o . . � '� . ., o r � � ._ � w . . � a . o . - ,� 5 �; � a _ ,� .,µ ., y. � � ,,� .� .. n .. .. o o ., . ,. -.te �.p yl 1 V��.k S p Y• V� K?,. .. �i'� � � 7 �•+w. �� SM S '. sib l' {/ { r - - 1 y Application number... ...................................... h o•P ` Date Issued................Z� .. BAWNSTABLE. ••..• ........ o. LIMAS& 039. `0�' Building Inspectors Initials............ F 1_U 2 0 2i. , .................. TOWNM bNKNS-1_f �� Map/Parcel.......�......o...9.......... .............................. 6' J-ram TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/QVINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY Y OI A ION Address of Project: -c- -- Q `- 06t 4y,.I (-e— NUMBER STREET VILLAGE Owner's Name:�v�es-f ���Cson- / / Z- Phone Number 5 0 Email Address: r-o! t.;a�lCs „ 7c coca 5 � Cell Phone Number Project cost$ /5 O 3C7 — Check one Residential Commercial OWNER'-S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: 5 e- A- a chg-'� 061,A4 Date: TYPE OF WORK ❑ Siding U Windows (no header change)# ❑ Insulatio g ) �_ n/Weathenzatton ❑ 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 Grl a s4e-12jG�� CONTRACTOR'S INFORMATION Contractor's name l�r�un `7Rn�,'sc✓� - —!ZA-ern 4/,J &, (rrncQ Home Improvement Contractors Registration(if applicable)# 17 3 Z-K S (attach copy) Construction Supervisor's License# 0 S`7 07 (attach copy) Email of Contractor OSLJea 9 3 S@ 6 ; 1• C 6nM Phone number q0/- z 2 R -9 XO) ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. ' APPLICATION NUMBER............................................................ U *For Tents Only* Date Tent(s)will be erected 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 If 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 XVV®OD/C OAL/PELLET STOVES x Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXENVTTION 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. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. Renewal Agreement Document and Payment Terms Andersen. dba:Renewal By Andersen of Southern New England Robert &Lenore Jackson. Legal Name:Southern New England Windows,I.I.C. 105 Park Ave RI#36079, MA#173245,CT'#0634555,Lead Firm#1237 -'Centerville;MA 02632 WINDOW RE LACEMERr 1.0 Reservoir Rd I Smithfield,RI 02917 - : - ` H:(508)827-7731- Phone:866-563-22351 Fax:401-633-6602 1 salesOrenewalsne.com' Buyer(s) Name: Robert & Lenore Jackson wContract Date: 01/29/19 Buyer(s)Street Address: 105 Park Ave, Centerville MA 02632 ` Primary Telephone Number: (508)827-7731 Secondary Telephone Number robert.'ackson17@comcast.net Primary Email: 1 ` Secondary Email: Buyer(s)hereby jointly:and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in.this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement. Document,the terms of which are all agreed to by,the parties and incorporated herein by reference(collectively,this"Agreement'). Buyer(s)herebyagrees to sin a completion certificate after Contractor has completed all work under this A reemen t. g g P P g Total Job Amount: $15,030 By signing this Agreement;you acknowledge that the.Balance Due-and the Amount Financed must be made by personal check;.bank check,credit card,or cash: Deposit Received: $5,009 Balance Due: $10,021 Estimated Start: Estimated Completions 8 to 10 week—, .8 to 10 weeks Amount Financed: $0 Method of Payment: Credit Card We schedule installations based on the date,of the sig" ned contract Y and secondarily on • " . . C6sh/Check ` the date in which we complete the technical measurements.-The installation date that we are providing at this time is"only an estimate.We will communicate an official date and time at a later date: Rain and extreme weather are the most common causes for delay. Notes: Depo paid CC, Bal paid by Check.Tax Centerville(Barnstable) Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will.be valid without the signed,written consent of both the Buyer(s).and Contractor. Buyer(s)hereby acknowledges that Buyer(s) 1)has.read this Agreement, understands the terms of this Agreement;and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE.TO BUYER: Do not'sign this contract•if blank..You are entitled to a copy,of the contract at the time you sign YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 02/01/2019 OR.THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.: Legal Name:Southern New England Windows,LW al B Andersen of Southern New Engla dba:Renew nd Buyers) ` Signature of Sales Person. Signature Signature Cory Scanlon Robert Jackson Lenore Jackson x Print Name of Sales Person Print Name Print Name `UPDATED: 01"/29/19 Page 2 / 13. Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement-Contractor Registration Y Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS, LLC`.= Registration: 173245 10 RESERVOIR ROAD Expiration: 09/18/2020 SMITHFIELD, RI 02917 SCA , 0 20NI-05/17 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 173245 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 10 RESERVOIR ROAD SMITHFIELD, RI 02917 Undersecretary 10t 41 Without signature Commonwealth of iviassachusetts Division of Professional Licensure Board of Building Regulations and Standards ., Construction Supervisor kf--"' -095707 = EXp i res: 09/08/2020 RIAN D DENNISON 8 BLACKWELLt DRIVE CHARLTON MA./-01507 Commissioner The Coinntonwealth of Massachusetts Department of Industrial Accidents I Cone ress Street, Suite 100 a Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electriciaas/Plumbers. TO BE FILED WITH THE PER-MMENG AUTHORITY. Applicant Information Please Print Le-ibly Name(Business/Oreanization/Individual): u. 'J�`e r e L O L Address: U Sev Vol r F�:Cl . City/State/Zip:SM[-Hi-6 el ,17- t DZQ 17 Phone#: Are ye an employer"Check the approprtate box: Type of project(required): 1. l am aemployer with 20+—employees(full and/orpart-time).• 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in $: Remodeling any capacity.(No workers'comp.insurance required.] 3.[:]I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my Property. [will 10 D Build'a addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. l2.[]Plumbing repairs or additions 5.711 am a general contractor and I have hired the sub-contractors listed on the attached sheet 1 .[]Roof repairs These sub-contractors have employees and have workers'comp.insurance. / 6.0 We are a corporation and its officers have exercised their right of exemption per m[GL c. 14.ff&er b✓1/t �l 152,§1(4).and we have no employees.(No workers'comp.insurance required.] ^e 1 elgln P � 'Arty applicant that checks box 91 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'camp.policy number. I am an employer that ispr9Wdin;workers'compensation insurance for my employees Below is the policy andjob site information. /� Insurance Company Name: �C'4&w (J�jll1�Q/l °� 00 . of Policy#or Self-ins.Lic.#: iq/C f� � ( 7 L �1 �� Expiration Date: /' —2 D ZO Job Site Address: /0 S— r Li e . City/State/Zip: C fPr .'i Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ation date). Failure to secure coverage as required under MGL c_ 152,§25A is a criminal violation punishable by a fine up to S L,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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certi under the poi d penatties of perjury that the information provided above is true and correct Si ature: ' Date: 2- - Phone#: r-- Official use only. Do not write in dais area,to be completed by city or town official City or Town: Permit/License# Issuing authority(circle one): 1. Board of Health 2. Building Department 3.Cityflbwn Clerk 4. Electrical Inspector 5.Plumbing,Inspector 6.Other Contact Person: Phone#: Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY( 16.� 1 12/28/2018 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 O ACT CoBiz Insurance, Inc.-CO NAME: 1401 Lawrence St., Ste. 1200 IAIC.PHONENo. Ext: 303-988-0446 C No:303-988-0804 Denver CO 80202 ADDRESS: COMail@cobizinsurance.com INSURERS AFFORDING COVERAGE NAIC d INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER B: FlremenS Insurance Company of WA,D.C. 21784 SDuthem New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER C: Homeland Insurance Company Df New York 34452 10 Reservior Rd INSURERD: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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 TYPE OF INSURANCE ADDL SUBR . POLICY EFF POLICY EXP LTR POLICY NUMBER MMIOD/YYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 V1/2019 1/1/2020 EACH OCCURRENCE $1.000.000 CLAIMS-MADE a OCCUR DAMAGER ENTEff— PREMISES occurrence $3D0,000 MED EXP(Any one person) $10.000 PERSONAL&ADV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X PRO- POLICY JECT LOC PRODUCTS.COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 COMBINED SINGLE LIMIT $ Ea accident 1 000000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS N AUTOS Per acc derrt $ $ A X UMBRELLA LIAR X OCCUR CPA3158728 1/1/2019 1/1I202D EACH OCCURRENCE $15,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $15.000,000 DED J X I RETENTION$II $ B WORKERS COMPENSATION WCA315872924 1/1/2019 11112020 X I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEq$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Pollution Liability 7930073340000 1/112019 1/1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate $2,000,000 Retroactive Date 06/20/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE A - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel OOS Application o7�D Health Division Date Issued Z" Conservation Division Application Fee Planning Dept. Permit Fee Coo Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address WS PAf Y_ Village zl ice- t Owner . � T 4- wAM--c-a, Lv_—_Bp9,t:� Address PU fboX 1 'Yl Telephone 15o A, D by S' P�I�IZ�� F�i-�� 1�1A 0;JV;bu Permit Request �11oP�L �� 7Zvc -Q �i�P1�.e.� Tt�¢✓ Val �'[}-4 �b4v1Nt�� Square feet: 1 st floor: existing 1 0 proposed cc,c2nd floor: existing proposed Total new 11 W Zoning District Flood Plain Groundwater Overlay Project Valuation 1�P,000 Construction Type L'r.\ cvD Lot Size Grandfathered: ❑Yes iJ No If yes, attach supporting documentation. Dwelling Type: Single Family .$( Two Family ❑ Multi-Family (# units) Age of Existing Structure 55 Historic House: ❑Yes N(No On Old King's Highway: ❑Yes )i No Basement Type: A Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) (1►„k Number of Baths: Full: existing_ new 0 Half: existing O new U Number of Bedrooms: oZ existing Priew Total Room Count (not including baths): existing (P new O First Floor Room Count Heat Type and Fuel: A Gas ❑ Oil ❑ Electric ❑ Other Central Air: 21 Yes ❑ No Fireplaces: Existing 1 New V Existing wo_'Olcoal stove: ❑TY,es I No Detached garage: ❑ existing ❑ new size— ❑ existing ❑ new size _ Barn: ❑ xisting �0 neft size_ Attached garage:156 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Z`' rA Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 4 No If yes, site plan review# Current Use lrg,y�yw- *NOT i tr�_ Lc.? 1 o I U Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name t�Ppt,�. -74 d6,—_ Telephone Number Address b o P���� tl ta,.�� �nJ�Y STO A License# 0 2'VD 3 y �YMti�IS , A Oa�.�a0 I Home Improvement Contractor# d O '�PJ Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 5 A, SIGNATURE DATE FOR OFFICIAL USE ONLY j. APPLICATION# • DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE }, OWNER c DATE OF INSPECTION: 'a FOUNDATION - FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ► { GAS: ROUGH FINAL r FINAL BUILDING DATE CLOSED OUT , ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): p)4L ILL t*>N S.� PA rJ Address: Po Pt� \ v S. 1%, Ua t OD I1 City/State/Zip: Wo,ks-%,i�,%1.t= P 1 , N-to3LVhone #: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. g Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.F]Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infomiation. 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:T'(Z f��t✓ S �' mil'` ~P C/�,s.�L �j, b pl�avtti c-!� Policy#or Self-ins.Lic.#: I PJ i�6- 4-7.5Ij Expiration Date: 7. 'LI 7,0IJ Job Site Address: 1 O7 5 IS,\1cN U - City/State/Zip: 40Ntn,_—,L-i 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a n ti o er ry at a information provided above is true and correct. Sip-nature: r Date: Z " Phone#: ' U$• III •U b O'J Official use only. Do not write in this area,to be completed by city or town offieiaL 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#: I CERTIFICATE OF LIABILITY INSURANCE °ATE`MM/DD/YYYY) o8118/2014 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 endorsements. PRODUCER CONTACT NAME: WELSH & PARKER INS AGCY PHONE FAX 131 COOLIDGE ST STE 100 AIC,No,Ezt: AC,No): E-MAIL ADDRESS: HUDSON MA 01749 29FDY INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED INSURER B: OHC INC DBA HOUSE COMPANY, THE INSURER C: PO BOX 1 166 BARNSTABLE MA 02630 INSURERD: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ C DAMAGE TO RENTED OMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one erson $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMPIOP AGG POLICY I I PROJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO 56YSRULED BODILY INJURY Perperson) $ ALL OWNED NON-OWNED BODILY INJURY Per accident $ AUTOS AUTOS HIRED AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY (7PJU6-4759P37-7-14) 07-21-14 07-21—15 X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y/N E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) N NIA E.L.DISEASE—EA EMPLOYEE$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREFO,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF BARNSTABLE AUTHORIZED REPRESENTATIVE 200 MAIN ST HYANNIS MA 02601 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD u Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License; GS-074034 MICHAEL S ROC$WEI L_ 799 LUMBERT MILL'&?1p s MARSTONS M M G48 % Expiration O7/27/2016 Commissioner Office of Consumer Affairs nd Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveri2gnt,C ontractor Registration Registration: 100932 Type: Supplement Card Expiration: 6/24/2016 OHC INC. DBA/THE HOUSE COMPANY* , _ iA MICHAEL ROCKWELL t �� 30 PERSEVERANCE WAY UNIT 28 .: = ' Hyannis, MA 02601 , Update Address and return card.Mark reason for change. Address ❑ Renewal Employment 0 Lost Card scn� 0 2ona-0sri i dI �c�{iarrrrrraarrcaeall�o��curcc�uae� ' ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration 100932_- Type: 10 Park Plaza-Suite 5170 Expiration -6/24/2016 ' Supplement Ward Boston,MA 02116 OHC INC.DBA/THE HOUSE COMPANY MICHAEL ROCKWELL P.O.BOX 1166 BARNSTABLE,MA 02630 Undersecretary Not valid without signature The Mouse Company Jackson Residence, 105 Park Avenue, Centerville, MA 02632 Town of Barnstable Regulatory services Thomas F.Geller,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us t Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section f If Using A Builder We,.__Rgbert.: ore Walsh as Owners of the subject property hereby authorize OHC, Inc dba The House Company to act on our behalf, in all matters relative to work remodeling a bathroom, authorized by this building permit application for: 105 Park Avenue,,Centerville,MA 02632 (Address of job) Signs a of bwnd V Date p �- Print Name Signature of Owner Date Lcc,oc`-S.- W Print Name Pa e9of10 4'- 10 1 /2°' U 6 m N v aoi �N^ o 0 o v 04 t*, O � oc � U U : o 0 N aHr) - O > Co E o ^ o w 0, ,6 40 CDUO N `o 0 m _ 1 e— L D _ 2 � � I m O O O 2 V, a) UQ 0 �5 BUILT ILTfi�' ���. PROPOSED BATH 979VISNd va JO 2/2/2015 r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V Parcel Application # �F A S �}p Health Division 'Dag Qued 0 �3 Conservation Division .;, � - Application Fee Planning Dept. � Uj e Fee Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation/ Hyannis Project Street Address �D�✓ � � V i I I age Owner a S : 1i4L'�� �� ,��'/ Address Telephone Lae Z2 L J) 21 rY Permit Request 2— `V a r ch, x5 ✓ �� ��. Square feet: 1 st floor: existing proposed 2nd floor. existing proposed Total new ,Zoning District Flood Plain Groundwater Overlay Project Valuation .3'a1® , 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 1�11' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ANo On Old King's Highway: ❑Yes e<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/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 d.r - - °Proposed°Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �' �l :�r�/ .� Telephone Number Address T *,/.0,kl l�27Z_ License # /0441;g Home Improvement Contractor# Worker's Compensation # .�D®. ��`��'�� ALL CONSTRUCTION DEBRIS RESULTING FROM�/THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ✓ 4 FOR OFFICIAL USE ONLY , 3' APPLICATION# T , DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER r DATE OF INSPECTION: pFOUNDATIONrt �-&sRw,!,L �a�: t � FRAME •x sINSULATION I,.v;_ .,, FIREPLACE ELECTRICAL:. . ROUGH FINAL �Y PLUMBING: ROUGH FINAL GAS: -- .;ROUGH FINAL FINAL BUILDING s, t DATE CLOSED OUT is ASSOCIATION PLAN NO. �Iirssac IIu set ts - De aarmle t of Puhlic �.rfci� _ l ti t3o;.artl of Building Re'"Ulatlllro ;uttl 'mandard.v Q011stru• tion Supervisor License Liceii -CS 100988 Ay s HENRY CASSIDY � ' r, 8 SHED ROW WES`1 IEARMOUTH, MA 02673 Expiration: 1 1/1 11201 3 , l , iuui. i ru.•r Tr✓r: 7620 G� k - ' - Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 021,16 l-Tonle Irnprovement Contractor Registration Registration: 153567 Type: Private Corporation Expiration. 12/15/2'bl4 Trk 233t1J'I CAPE COD INSULATION, INC HIENRY CASSIDY 18 RFARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address anti return zard. Marts reason for change, Address Reliewal I jUmployment I I Lost Card i`/ 1/r'� ut.nrr ire!t'rc�C�t`C.:i/fi'IJ;1fICN"!Cl,1('�lJ � .4 • Urlir ! ( ousuurcr Alluu s& Busuress Kcgulatiou Lict nse or registration valid for individul use only i t{OME IMPROVEMENT CONTRACTOR befure the expiration(late. If found return to: AM eyistration: 153567 Type:• Office of Consumer Affairs andBusiness1legidartion xpiration: 12/15/2014 Private Corporation10 ParkPlaza-Suitc 5170 Boston,NtA 02116 ' C�;r'i COIi iIV;iULAT'ION,,INC. - ' tu:iVlfY i:A:;Slf)1' I;Rt:At2OON CIRL;Lt 5 __ Sl 1'r\I=;MIiUTti, MA 02664 .------- — --• - -- - ----- - Uridci srcrcrury of var witho re--- '..' f" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A li as cant Information Please Print Legibly Name(Business/Organizationdndividual):-,,,�,��? �� Address: ���"%ice City/State/Zip: Phone#: � Are you an employer?Check the appropriate box: I am a general contractor and I Type of project(required): 4.1.❑ I am a employer with- ❑ g employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ° ship and have no employees These sub-contractors have g. ❑ Demolition F. working for me in any capacity. employees and have workers' [No workers'comp.insurance comp. insuranceJ 9• ❑ Building addition required.] 5 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doingall 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 3a.❑ I am a homeowner acting as a employees. [No workers' r-giber general contractor(refer to#4) comp.insurance required] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensatioti_folicy 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. 1Contractors 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:���� �/ Policy#or Self-ins. Lic.#: ��b�� �� / Expiration Date: Job Site Address: D A�i/Jrr� /?�� %v_r�;P IleCity/State/Zip: *,,4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A 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 of the DIA for insurance coverage verification. I do hereby ccrtt under the ins a penalties of perjury that the information provided above is true and correct Da el, Ph F l use only, Do not write in this area, to be completed by city or town ofciaL r Town: Permit/License# Auth on8 ty(circle one):rd of Health 2.Building Department 3.City/Town Clerk 4."Electrical Inspector 5. Plumbing Inspector ert Person: ' - one#: . • . - CAPECOD-27 MYOUNG CERTIFICATE OF LIABILITY INSURANCE 1 OAT 7 /YYYY) /8120/2013 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 License#PC-514062 CONTACT Margaret Young - AX Rogers&Gray Insurance Agency,Inc. PHONE F 434 Rte 134 A/c No Ext: AIC No South Dennis,MA 02660 E-MAIL myoung@rogersgray.com INSURERS)AFFORDING COVERAGE NAIC# INsuRERA:PEERLESS INSURANCE COMPANY INSURED INSURER B:COMMERCE INSURANCE COMPANY Cape Cod Insulation,Inc. INSURER C:Evanston Insurance Company - 18 Reardon Circle INSURER D:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 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 TYPE OF INSURANCE D R POLICY EFF POLICY EXP LIMITS LTR 1 SR WVD POLICYNUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CBP8263063 DAMAGE TO RENTED 411/2013 4/1/2014 PREMISES Ea ocairrence $ 100,000 CLAIMS-MADE I X1 OCCUR' MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE - $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PROi El LOC $ AUTOMOBILE LIABILITY - Eaacc,IidentSINGLE LIMIT $ 1,000,000 - B ANY AUTO 13MMBCKVMK 4/l/2013 4/1/2014 BODILY INJURY(Per person) $ ALL OWNED X AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $.. AUTOS PER ACCIDENT) $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE XONJ453512 4/1/2013 4/1/2014 AGGREGATE $ 1,000,000 DIED I X I RETENTIONS 10,000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS. E D ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCA00526904 6/30/2013 6/36/2014 E.L.EACH ACCIDENT - $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) ° - E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Compensation includes Officers or Proprietors. Addtional Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - - ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD OWNER AUTHORIZATION FORM 1, , (Owner's Name) owner of the property located at (Property Address) (Property Address) hereby authorize CA I Cr ti , (Subcon ) an authorized subcontractor for RI E Engineering,to act on my behalf to obtain a building permit and to perform work on my property. ,. a O e's natur Date j 2l2,7l►14 PE eyqN.11'5T .0 7 4 CA COEY INS. ULATION ^I�o P: alp ' lIYYRp4lf ffAMEE55 fYRAT FOAM YUfPINDED - - RAM 4.REYf INYDLAlIpN CEIEINpf 1-800-696:-6611 *y�` I VIS j Town of Barnstable , Regulatory Services Building Division ' 200 Main St Hyannis, MA 02601 fir. l bate: r f Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Perfon-nanee Institute (BRI) inspector. All work preformed meets or exceeds Federal & State Requirements. Pro erty Owner Property Address Village P Insulation Installed: Fiberglass 'Cellulose. R-Value Restricted : Uniestricted Ceilings Slopes Floors O ( ) (�1. ) (, ) ! Walls ICA_, .41��&Jft ! Sincerely z i�! Fie ry E Cas y Jr, President r C• e Cod I ulation, Inc: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel / + Application # �U31 4 Health Division Date Issued Conservation Division `Y : Application Feed .� # 6 Planning Dept. 4 Permit Fee Date Definitive Plan Approved by Planning Board ` Historic:.- OKH Preservation / Hyannis } Project Street Address. 1-0 S � O Village C ��/1'�1ib n, Owner Address Telephone Permit Request w t ovgm Square feet: 1 st floor: existing Improposed 51 6 21n flo r: existi g proposed Total new Zoning District Flood Plain roundwater Overlay Project Valuatio ,5,500,- Construction T Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family , wo F e, ily ❑ �� ulti-Family (# units) Age of Existing Structure I istoric House- ❑Yes Po On Old King's Highway: ❑Yes kNo Basement Type: mull ❑ Crawl alkout ther Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 1.�� Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: k existing _new Total Room Count (not including baths): existing _new First Floor Room Count Heat Type and Fuel: was ❑ Oil ❑ Electric ❑Other ` Central Air: ❑Yes Flo Fireplaces: Existing New Existing wood/coal stove: ❑Yes CKNo Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garageo2kjcisting ❑ new - size _Shed: ❑ existing ❑ new size _ Other: p C Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ N c, CIO Commercial Q. o If yes, site plan review# Current Use _ _ . Proposed-User A w APPLICANT INFORMATION rn (BUILDER OR HOMEOWNER) Name Telephone Number Address' /� � i�+ 'q/`� License # Piyl, yv 1A� Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEB S ULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE fn t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED i MAP/PARCEL NO: 1 , ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME i INSULATION 1 ix FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL I GAS: ROUGH FINAL FINAL BUILDING` DATE CLOSED:OUT ASSOCIATION PLAN'NO. tHE TOWN OF BARNSTABLE � , Bui0ing Application Ref: 200803147 • * BARNSTABLE, * Issue Date: 07/18/08 Permit 9 MASS. 16g9. Applicant: �PECKHAM, STEPHEN M Permit Number: B 20081498 ArFO MA'1 A Proposed Use: SINGLE FAMILY HOME Expiration Date: 01/1.5/09 Location 105 PARK AVENUE Zoning District RD-1 Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 208005 Permit Fee$ 25.00 Contractor PROPERTY OWNER Village CENTERVILLE App Fee$ 50.00 License Num OWNER Est Construction Cost$ 3,500 [Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND OPEN,GAZEBO DINING AREA ADDITION THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY.IS REQUIRED;SUCH Owner on Record: PECKHAM, STEPHEN M BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address:. 2.GREGLEN AVE PMB 410 INSPECTION HAS BEEN MADE. NANTUCKET, MA 02554 Application Entered by: JL Building Permit Issued By: THIS PERMIT'CONVEYS'NO RIGHT TO OCCUPY ANY STREET,ALLY:OR SIDEWALK OR ANA0ARTTHERWjAftHEK`TEMPORARILY OR PERMANENTLY.: ENCROACHEMENTS ON PUBLIC PROPERTY,NOTSPECIFICALLY PERMITTED UNDERTHE BUILDING CODE,MUST BEAPPROVED BY THE JURISDICTION. ON"STREET ORALLY GRADES`AS WELL AS.DEPTH AND LOCATIOF'PUBLIC SEWERS MAY B5O'BTAINED FROM THE'DEPARTMENT OF PUBLICWORKS'.j, THE ISSUANCE'OF"THIS PERMIT DOES NOT TRELEASE THE APP<LICANT,FROM,THE CONDITIONS OF'ANY-APPLICABLE:SUBDIVISION RESTRICTIONS,,, ., MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES.MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6:FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES CONSTR TION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NO STA ED ITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE S UARAN TY UND(as set forth in MGL c.142A). MR, „r 0, V. BUILDING INSPECTION APPROVALS PLUMBING INS ION AP ELECTRICAL INSPECTION APPROVALS 2 2 ,` 2 3 1 Heat' g, nspection Approvals Engineering Dept Fire Dept Board of Health oFIKE r Town of Barnstable *Permit# 08C) Expires 6 monthsfrom issue date s Regulatory Services Fee * �R Thomas F.Geiler,Director MASS, �� Building Division 1.Ow2008 Tom Perry,CBO, Building Commissioner N OF 200 Main Street,Hyannis,MA 02601 BgRNSTABLE www.town.bamstable.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 �" © D Property Address r DResidential Value of Work D Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 4 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ 1 am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to %_I'— ❑ Re-roof not stripping. Going over existing la ers_of roofl � KRe-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: P .ro rty Owner must sign Property Owner Letter of Permission. A y o e Home Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc . Revise020108 t; fS • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers APPUcant Information Please Print Le ' 1 Name(Business/Organizahon/lndividud): City/State/Zip: Phone.#: &D '2 Z-1, 11� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 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, E]Demolition wo for me in an ca employees and have workers' rizng Y PAY• t 9. ❑Buildmg addition in . [NO workers' comp.-insurance comp•insurance• required..] 5. We are a corporation and its 10.❑Electrical repairs or additions 3. a homeowner doing all work officers have exercised their ME]Plumbing repairs or additions nyselL[No workers' CO'mp. right bf exemption per MGL 12 Roof repairs insurance ram]t c. 152, §1(4),and we have no 13.]Other employees. [No workers' comp,insurance required_] *Any applicant that cheep box#1 must also fill out the section below showing their wo i=%'eomrpwm4on policy infamnation. t Homeowners who submit this affidavit indicating they are doing all work aid then hire outside contractors must submit a new af5davit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the sub-cmbuctora and state wbether or not thost entities have employeeL If the sub-contactors have employees,they must provi&their woriccrs'comp.policy mmrber. I am 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.Lie.#: Expiration Date: Job Site Address: City/Suftgip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to si etae co ge as egnired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500. o ne-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 day t the violator. Be advised that a copy of this statLmerit may be forwarded to the Office of Investigations of a insurance cov a verification. I do hereby c e pains-and enalties of perjury that the information provided above is true and correct Date: _ Phone 4- — 7 ` l�- Official use only. Do not write in this area,tb be completed by city or town offic&L 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#• 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 le jientity, or any two or more of the foregoing engaged A a joint enterprise,and including the legal representative's of a eased employer,or the receiver or trustee of an dividual,partnership,association or other legal entity,emplo g employees. However the owner of a dwelling hous having not more than three apartments and who resides th in,or the occupant of the dwelling house of another o employs persons to do maintenance,construction or r air work on such dwelling house or on the grounds or building a want thereto shall not because of such emplo ent be deemed to be an employer." MGL chapter 152, §25C(6)also sta That"every state or local licensing agen shall withhold the issuance or renewal of a license or permit to oper +'_a business or to construct bull in the commonwealth for any applicant who has not prodneed•accepta a evidence of compliance with a insurance coverage required." Additionally,MGL.ehapter 152, §25C('n s -,`_`Neither the commonweal or any of its political subdivisions shall enter into any contract foe the performance of p -lic work until acceptable vidcncc of compliance with the insurance requirements of this chapter have been presented the contracting autho 'ty." Applicants Please fill out the workers'compensation affidavit comple ly,by eking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and numbcr(s).along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited LUiab Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'comp n insurance. If an LLC or LLP does have employees, a policy is required. Bp advised that this affidavit y b �surbmitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be s e to si `and date the affidavit. The aff davit should be returned to the city or town that the application for the pe ' or ' is.being requested,not the Department of Industrial Accidents. Should you have any questions reg the law or' are required to obtain a workers' co nsafion policy,please call the Department at the er listed below. insured companies should enter their self-insurance license number on the agm priate line. City or Town Officials Please be sure that the affidavit is complete and prim legibly. The Department has vi a space at the bottom of the affidavit for you to fill out in the event the O ce of Investigations has to contact yo ding the applicant. Please be sure to fill in the permit/license number ch will be used as a reference number. 'lion, an applicant that must submit multiple pmmitllicense appli ns in any given year,need only submit onp vit in current policy information(if necessary)and under"Jo Site ddress"the apglicarit should write"all to 'ons in (city or town)."A copy of the aff davit that has been o cull stamped or marked by the city or town may provided to the applicant as proof that a valid affidavit is on a for permits or licenses. Anew affidavit must b filled out each year,where a home owner or citizen is ob a lice a or permit not related in any business or co ial venture (Le,a dog license or permit to brim leaves etp.)said perso ' NOT required to complete this affidavit. The Office of Investigations would hike to"you in advan for your cooperation and should you have any questions, please do not hesitate to give us a call The Depa�tmenfs address,trlephone•and:'`number. Th�Gommonwealth of chusetts Depa l ment of Industrial ccidents office of Iavestiptf 0 ` 600 Washington S Boston,MA 02111 TO. #617-727-4940 ext 406 or 1-577- SSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.gov(dia \ Town of Barnstable �pF THE tp�� Regulatory Services L swxxszwatt~ ; Thomas F.Geiler,Director 9 MASS. g, 1639• Building Division PTFD I'��a Tom Perry,Building Commissioner . 200 Main Street, Hyannis,MA 02601 www.town.barnsiable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: J�. lot,0 V t .. JOB LOCATION:— `r number street ` village "HOMEOWNER": name c home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends 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 structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building hermit. (Section 109.1.1) The unders' ed"homeowner"assumes responsibility for compliance with the State Building Code and other applicable d s bylaws,rules and regulations. The and "homeowner"certifies that he/she understands the Town of Barnstable Building Department m e Rion procedures and requirements and that he/she will comply with said procedures and re Signature o omeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states 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 homeowner 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 would Huth 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 t amend and adopt such a fomm/ccrtification for use in your community. ' M oFtHEr�,,,, Town of Barnstable Regulatory Services vRARNSTAEM f IEMASS. Thomas F. Geiler,Director / 019. Building Division Tom Perry, Building Commissio r 200 Main Street, Hyannis,MA 0 01 www.town.barnstable.ma s Office: 508-862403 8 Fax: 508-790-623 0 . ; 1 a Property Ow r Must Complete and Sigf This Section If Using A{ uilder I , as Owner of the subject property hereby authorize to act on my behalf, in all,matters relative to work au th rize.dA this building permit application for: (Addres f Yob) Signature of Owner Date Print Name 1 If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. :Q . Assessor's map and lot number ......:. r THE Sewa�e Permit number ....��GLd,y:..,QrJ.�.l f4��c 1 SEPTIC SYSTEM MILS �/ /� G NSTALLED IN COMPLI STdIILE, • House. number .... .. .... ................................................. w LE 5 ° "e a �� � EI11�/!¢;Oj11A9 N ITT ��c war aye TOWN of BARNs ft CODE'I� BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..L�� ��hiLlt' .....`1r.... �d..40.......................::................................. TYPE OF' CONSTRUCTION .....&/PvGG............................................................................................................... /. .,J...................19.(��. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...1A: . . ld!4. . .�',.UE.......... '.?Y °tF' .......................:.................:........:... ProposedUse ..../.:v Q. ... /��`. ..............................................................................................................I......................... ZoningDistrict ........................................................................Fire District ............,...................................l..................................... Name of Owner ................Address ,le� �! ' :..,4..P�!` E�!G ...................... Nameof Builder .....Address. ............................................................... .................................................................................... Nameof Architect ....... ....................................................Address .............rrr-.— .......................................................... Number of Rooms ........................................Foundation .. 'N..e ................. ....................................... ........... ...... Exterior ...........G4 ...................................................Roofing ........��� .. .............................................. Floors .............G% .. .................................................. .. ..Interior .............................................................. Heating ...................... - ,'.......................... .,. ................Plumbing .. ............................................................... V �1.... .............................,........Fireplace ..................r .. . .................................................Approximate Cost I Plan Approved by Planning Board ________________________________19________. Area �.. .5 .� . ............... Diagram of Lot and Building with Dimensions Fee . ............... SUBJECT TO APPROVAL OF BOARD OF HEALTH l I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name`P 4: .... RUSSELL, WILLIAM H. '• No Permit for ...BUILD.................... - :........�'.QOJ�..SHED............................................ Location .1D.a...P.ark..Avzriue............:.......... , ..........- .Genterui.11,e.................................. y ; r . . William H. R - Owner u�se.11 Type of Construction ;••Frame .................... ................................................................... ........... ' Plot ... .................... Lot ............................... . 4 April- 13, 01 r= Permit Granted Date of Inspection .....19 Date Completed .......... ........ .. ............19 - '4 HERMIT REFUSED ......... . . ...... . ............................. 19 , :..... ............................................. ...........i w. ............................................ ...........i ., : ................................:......... _ r .......... . b ..................................... tV L. Approvedjr..........t.................................. 19 ........................................................................... ...........::.................................................................. t