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0083 PATRIOT WAY
�� F •�a r J� L .;� 'A y t is 0 n 'y aolVouq I THE r� Town.of Barnstable *Permit,# P� y0 Expires issue date Regulatory Services. Fee . _t4t�� + 3nRNsrAsr E 9 MASS. �' Richard V.Scali,Director i639. �0 ' pTED MA't A Efl IT Building Division . �® Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis;:MA 02601 - www.town.barnstable-maxis Office: 508-862-4038 Fax: 508-790-6230 PLICATION - RESIDENTIAL ONLY ZNot Valid without Red X-Press Imprint Map/parcel Number Property Address 63 Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address `'` Contractor's Name cD '79,v�„6� �o��;i�C( Telephone Nurnberg f 2� Home Improvement Contractor License#(if applicable) 1 �1 `'� Email: _ Construction Supervisor's License#(if applicable) (yqg ej ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor Vam the Homeowner have Worker's.Compensation Insurance Insurance'Corn an Name P Y Workman's Comp.Policy# 2-oo I cw 7e 6 Copy of Insurance Compliance Certificate must accompany each permit Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) KrRe-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and.inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pro er t sign Pro Owner Letter of Permission. A c py of ome Impro ement ontractors License&Construction Supervisors License is ieq r SIGNATURE: Q:\WPFILES\FORMS\building permit forms\E)MRESS.doC Revised 061313 I �1ae Ctax��rxx �t��'�assrre�r��s ,. A--p rrtMMt of fluk' sftid Aec-.idetrfs 600 WasT agfbn Street wn�ls�J��gr��r�ir�c orkers' Compensationlnar=nce davit:Bailders/ContractorsMettricians(P'1umbers plicaut Information Please Print Lefibly Name{BrmiresdOjgmtzafionlfndividnal)_ Address-. 'o god (�C6 tfty/5ta& ip- A k e:1 3ZPhans �S c can an employer: Checktl�appropriate baz; _. ._-- _ _ ..- _ T o T°lest(req�re _ _ __ 4. I am a contractor and 1 ❑ 1. I am a emp layer�uitbi_� ❑ i5_ NeYr Constrac6on employees(full and/or pa t-time)* /rave hired the sub-contraciors. �_❑ I am a sore prupiie#ar or partner listed on the attached sheet y- ElR--=deling ship and have no employees These snb-contractors have g- ❑Demolition working forme in any capacity_ ernplayL4m and have woikers' g_ ❑Building addition [NO work is'COn7p,insurance Comp_m�, req Led 1 -❑ We are a corporationand its 10_0 E1ecErical repairs or additions 3.❑ I am a homeowner doing all wort officers hn-e exercised their I I-❑Plumbing repairs or additions nay.9f[No workm'mmp_ right of emmptionper MGL 12.❑Roof repairs c-154§1(4} and we hnna no,insurance required]1 13_0 Other employees_[Nil, comp-Msurance required-] !Any sppfiacat that chec s boa-1 trmst also fill out to section below shnWia their arozicea�Coa3pP m firruf goiirF i Ft�a titm 1 So-meownen orho submit this afhdxvrt it g they am tlomg aI•f truck and ft nhae nufside contacmrs mns#sl it a nea ai d t IDtrarstmg such *tntactors thst check this box must att,3rhed as additional sheet showing the name of&a szdt-eo s and state whether ornot tbnse eatmes hzm mployees- if the sobs-contactors hn-e empIoyee%they Est pnnnde their trarkprO Comp.policy number I am an.empPoyer that ispnn ic}iftg workers'conTenaafioa imutrartor for my employem Belvtr is thegoticy attd job Site informshan Insurance CompanyN me= !G- Policy a or Self ins Limo 4- 20 o K 0/ Expiration Date: f -7 z S I S Job Site Address- 3 .z CityjStat Top: C Attach a copy of the workers'compensation iolicy dedaration page(shoving the:policy namber and eqd ation date): Failure to secure coverage as require under Section 25A of MGL c. 152 can lead to the imposition of rriminai pm-dries of a fide up to;$1,500.Q0 and/or one pearimgiis t,as well as civil pen fti in the form of a STOP WORK OADEI and a fine ofup.to$250_0-0 a.day against the violator-Be advised that a copy of this state�maybe forwarded to the Office of Im e*pttons of t3>e DIA far- coverage Verifrcafion- I do hRt ere-by c erh fy u der t maxis r rlpaaaltier o per ur}�fltatfhe ire onrtar#icrn prmrzded abaue cs rmd correct Simature: Date: 7 Phone#: G 3 e-8 l ro QUECiaL use anty. Io not write is dds area,to be camp&ad by d47 or town of'cia£ City or Town: PermiffAcense# Iss-u_i-ng Anthorily{circle one}: 1.Sward of Health. 2.Bu{1'•ding Dtparta m-t 3.CityffoRn Clerk 4.Electrical Fnspector 5.Plumbing Inspector 6.Other Contact Person: Thane#_ Infa -Mahon and Instructions Massachusetts General Laws'chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an ernployee is defined as"__.every person in the service of another under any contract of hire, express(implied, oral orwriiten L / An emyloyeryis defined as"an individual,partnership,association,corp 'on or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the Iegal r resentatives of a deceased employer,-or the receiver or trustee of an individual,partnership,association or other I entity,employing employees. However the owner of a dwelling house having not more than three apartments an who resides therein,or the occupant of the dwelling house of°another who employs persons to do maintenance construction or repair work on such dwelling house or on the grounds or;�building appurtenant thereto shall not becaus of such employment be deemed to be an employer." MGL chapter 152, §25`C(o7 also states that"every state or local -ceasing agency shall withhold the issuance or renewal of a license otlpermit to operate a business or to co ct buildings in the commonwealth for any applicant who has not produced acceptable evidence of con Rance with the insurance.coveragerequired," Additionally,MGL chapteM52, §25C(7)states"Neither the c mmonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work un acceptable evidence of compliance with the insurance requirements of this chapter has Xe been presented to the con sting authority." Applicants Please fill out the workers'compens on affidavit compl ely,by checl�g the boxes that apply to your situation and,if necessary,supply sub-contractors)naA(s),addresses) d phone number(s)along with their ceri_ficate(s)of insurance. Limited Liability Companies(A-LC) or Limit Liability Partnerships(LLP)with no employees other than the members or partners, are not required to car workers' ompeasation in urar ce_ If an LLC or LLP does have employees, a policy is required, Be advised l t this davit may be submitted to the Department of Industri.aI Accidents for confirmation of inc, „ce cove rag , AIs be sere to sign and date the affidavit The affiaavit should be returned to the city or town that the application or e permit or license is being requested,not the Department of Industrial Accidents_ Should you have any questio r larding the law or if you are required to obtain a workers' compensation policy,please call the Department at th number listed below. Seli insured companies should enter their self-ins urance license number on the appropriate lore City or Town Officials Please be sure that the affidavit is complete and printed legit The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Inv gations has to contact you regarding the applicant Please be sure to fill in the permit/license number hich will.be as a reference number. In addition,an applicant that must submit multiple pennitllicense applications in any given y ,need only submit:one affidavit indicating current policy information(if necessary)and under"Job ite Address"the app 'cant should write"all locations in (city or town)."A copy of the affidavit that been offie ally stamped or marke by the city or town may be provided to the applicant as proof that a valid affidavit is on file r future permits or lice A new affidavit must be filled out each year.Where a home owner or citizen is obtainin a license or permit not relat to any business or commercial venture (i_e,a dog license or permit to burn leaves etc_)s d person is NOT required to mplete this affidavit The Office of Investigations would lace to thank ou in advance for your cooperation,and should you have any questions, please do not hesitate to give as a call_ The Department's address,telephone and fax n ber. The CoTnII1Qnwe@ a of Massachusetts \ De t ent Gf Industrial Aceidc:n t Q-:ffire of luvestip. txans �Qf��ash:�tn, an Strut . Bostou_MA G21 I l D—J.A 61 7- 7-49OG W 4-06 or I--a7-7-MASSAFE Revised 4-2¢07 Fax#� 617-`�27-7749 www_mass gay>/dia CERTIFICATE OF LIABILITY INSURANCE DATE(MM/U°'YYY'r' AC 0® ��. 10/07/2013 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 MURER(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: Debbie Mark Sylvia Insurance Agency,LLC PHONE FAX 404 Main Street 508 957-2125 aC Nc:508 957-2781 n o I":mark marks Iviainsurance.com Centerville,MA 02632 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Farm Family Casualty Insurance INSURED INSURER B: D&T Construction,Inc. PO Box 168 INsuRER c Centerville,MA 02632-0168 INSURER D: 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 ADDL SUER POLICY POLICY NUMBER MMIIDD EFF POLICY MMIDD EXP LIMITS LTR A GENERAL LIABILITY 2001XO485 . 7/21/2013 7/21/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE (RENTED PREMISESS Ea occurrence) $ 50,000 CLAIMS-MADE �X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ Included GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X__1 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per a.dent $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION 2001 W7501 7/25/2013 7/25/2014 WC STALIMTT• I X OE H- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? FY] 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/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if mom space is required) Carpentry The workers cornpensation does not provide coverage for Troy A Thomas and Shawn M Doyle: CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE D&T Construction Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 168 ACCORDANCE WITH THE POLICY PROVISIONS. Centerville,MA 02632 AUTHORIZED REPRESENTATIVE „_...: q..._ ... ...._._. .............:... ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD -Siding to be stripped and cleaned of all old sidin -Home to be papered with T g&debris wrap Maibec Grade A white cedars ding to be installed -AZEK PVC trim to be installed on areas discussed -5 Yard dump trailer will be needed on site;and will be removed at co -Contractor will be responsible for all building permits needed at the ropety of the job .. p perty NOTICE REQUIRED BY LAW With the agreement of the contract$500.00 of estimate vis Further payments under this contract are as follows: due. _1/2 of the.estimate due at the start;and remainder due at Balance of all materials and labor shall be a completion of the job. this contract. Payment as agreed upon shall be made wl,upon completion of work described i delayed shall be subjeit to a finance charge of 1.5/ hen due. An n _ The coitractor warranties the work per under Y payments which are year from the datee cotracto w der this contract for a period of o Du`nehe stated warrant one the repair or adjusthe1t,but the contractor shall not be res o Y period the contractor shall be responsible for the service due to abuse, rnisu and or normal wear and tear, p nsible for the normal maint of All , which shall be the responsibility of the homeowner.repair Irranties for the materials supplied by the contractor shall be y be required to register or mail in such warranty card or evidence ownership in.orde�ctivate such warranties. Homeowner failure shall no passed directly to the _ for the contractor _r the warranty of 1 provisions;the choice of repair of replacement shall ate any responsibility discretion of the cgctor. Th IFneowner acknowledges that the form be at the contract are intend comply with the a .'content, and notices co apter nd regulations pr dated there under..applicable event of the Mass. General Law Chaed in this portion shall be inv of any instance of non-compliance,only such d the remainder of this contract shalt be in full force effect. such portion not in liance shall be read and interpreted so a maximum extent al under such law and re In addition, any s to have its intended meaning to the regulation. fined as a sealed instrument on this date: , Da HomeoWn r ntractor �7 125� 539 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,? C 5 - 7) Map Parcel Applica 1 Health Division 'Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board rr�bl Z Historic - OKH Preservation / Hyannis Project Street Address 83 PATRIOT WAY Village CENTERVILLE, MA 02632 Owner ERIN GOVONI Address SAME Telephone 774-9.94-1232 Permit Request PERFORM AIR SEALING MEASURES; INSTALL INSULATION TO THE KNEEWALL AND KNEEWALL HATCH AREAS; INSTALL VENTILATION CHUTES (PROPAVENTS)IN ATTIC. AREA; INSULATE BULKHEAD DOOR. PLEASE SEE COPY OF ATTACHED CONTRACT. Square feet: 1st floor: existing proposed ''-2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation $2307.12 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other ._0 <J g C:2 Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑;Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn:.0 existing l newo size Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# -- '' Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name RISE Engineering A DIV. OF THIELSCH Telephone Number 401-784-3700 UZUU ENGINEERING EXT. 6133 Address -1341 Elmwood Ave, Cranston RI 02910 License# 100459 EXP. 3/28/12 Home Improvement Contractor# 120979 EXP. 3/25/12 Worker's Compensation # 3730961-01 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO EXP. 1/1/13 RI Resource Re ve JO STON I SIGNATURE DATE It Erik Nerstheimer for RISE Engineering l FOR OFFICIAL USE ONLY t APPLICATION# DATE ISSUED MAP/PARCEL N0._ ADDRESS VILLAGE OWNER y f DATE OF INSPECTION: 'j '.`FOUNDATION';' 4 FRAME ' INSULATION' <. i FIREPLACE s ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: -yr' ROUGH y . + t . FINAL r _-;FINAL.BUILDING'-". 17: L k DATE CLOSED OUT �x ASSOCIATION PLAN NO. �i 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): RISE ENGINEERING; A DIVISION OF THIELSCH ENGINEERING Address: 1341 ELMWOOD AVENUE City/State/Zip: CRANSTON, RI 02910 Phone,#: 401--784-3700 OR 800=422-5365 Are you an employer?Check the appropriate box: Type of project(required): 1. %M I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired-the sub-contractors 6. E] New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling shipand have no employees These sub-contractors have 8. � Demolition working for me in any capacity. employees and have workers'. t comp. insurance.$ 9. ,� Building addition _ [No workers' comp. insurance p• 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 11:0 Plumbing repairs or additions myself [No workers' comp., right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0`Othe'r INSULATION comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: THE PRESTON-AGENCY, INC. Policy# or Self-ins. Lic.#: 3730961-01 Expiration Date: 01/01/13 Job Site Address: 83 PATRIOT WAY City/State/Zip: CENTERVILLE, MA 02632 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. r I do hereby certi n r th ains d penalties of perjury that the information provided above is true and correct. Signature: Dater ERIK NERSTHEIMER.FOR RISE ENGINEERING Phone#: 401-784-3700 EXT. 6133 Official use only. Do not write in this area; to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health. 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.,Other Contact Person: Phone#: THIEL-1 OP ID: 27 Aco�o6 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°DIYYYY) 1 01/13/12 TAIS..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 401-886-8000 CONTACT The Preston Agency,Inc. 1350 DIVISIOn Rd Suite 303 401-885-1700 PHONE No Ext: AIC No): PO BOX 810 EMAIL East Greenwich,RI 02818-0810 ADDRESS: Judith A.Wright CPCU AAI ARM INSURER(S)AFFORDING COVERAGE NAIC g INSURER A:Zurich-Amencan INSURED Thielsch Engineering,Inc. INSURERB:American Guarantee&Liability - Thielsch Group Inc. Hi Tech Realty Inc. • INSURER C:Twin City Fire-Hartford Attn:Trent Theroux 195 Frances Avenue wsuREt:D:North American Capacity Cranston,RI 02910 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 - POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYYYYI (MMIDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DA A X COMMERCIAL GENERAL LIABILITY X 3730962-01 01/01/12 01/01/13 PREMISES Ea occurrence) $ 300,00 CLAIMS-MADE FX1 OCCUR MED LEXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERALAGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO LOC Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accident 2,000,00 A X ANY AUTO 3730963-01 01/01H2 01/01/13 BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) HIRED AUTOS AUTOS NED , PROPERTY DAMAGE $ AUTOS . Per acc dent $ X UMBRELLA LIAR X OCCUR - . . - EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE AUC 4857188-01 01/01/12 01/01/13 AGGREGATE $ 10,000,000 DED RETENTION$ ` $ WORKERS COMPENSATION X I T WC STATU OTH- AND EMPLOYERS'LIABILITY Y/N RY LIMIT- ER A ANY PROPRIETORIPARTNER/EXECUTIVE 3730961-01 01/01/12 01/01/13 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ❑ N/A - _ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 C Property Section 02UUNHE6930 01/01/12 01/01/13 Property see belo D Professional Liab DVL000026802 01/01/12 01/01/13 Prof Liab 2,000,0010 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESI(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)- When required by a written contract. CERTIFICATE HOLDER CANCELLATION — TWNHARW .- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, 'NOTICE WILL :BE DELIVERED IN Building Division ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis,MA 02601 ©1988-2010 ACORD CORPORATION: All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD f Page, 1 of 1 ' The Official Website of the Executive Office of Public Safety and.Security(EOPS) Mass.Gov Home Public Safety- :. . Department.&Public Safety.Licensee Complaints t License Type. Construction Supervisor License`#. . . .100459 Restriction. WS,IC Name Erik Nerstheim& City,State,Zip North Scituate,R1,02857 . Expiration Date. 3/28/2012. status Current "auMnplaintsfoW.vd to,tagsLicerzee. Back to Search } 11�y.11llt,N't Oct ui1 cirt ,f u3nstrtac#ru: Ilur tj ul{tli� UW)Iri e. It,1 - License: CS r3 V £�'rr�llt SL < Restricted to: WS 1�459 tier t i rttip.a ERIK NERST . HEINj 228 GLEANED. C EL HAP f . NORTH$CITVA ROAD T E R10285 110 ort:-3/28/2012 .. "100459 a http://db.state.ma.us/dps/licdetails.asp?bctSearchLN=CSL100459 4/2012011 O lce o onsumer aiVa uslnes+se u at lon g 10 Park Plaza- Suite 5170 Boston �#ssachusetts 02116 . Home Improve ° ontraetor Registration —` Registration: 120979- �1 Type: Supplement Card Expiration: 3/25/2012 THIELSCH ENGINEERING _ ERIK NERSTHEIMER - r '1341 ELMWOOD AVE. i H. CRANSTON, RI 02910j Update Address and return card.Mark reason for change. ` \3Af P E] Address Renewal,,Q Employment ' Lost Card " PPS-CA1' 0 60M-04/04-G101216 - - - -` ��ie'-Panvrrcrnuuea/,C�i �,�/�Craeaclzuael7a - . _ -•` . Office of Consumer Affairs&Bu iness Regulation License or registration valid for individul use only before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR - . � •. Office of Consumer Affairs and Business Regulation . Registrations �79 Type: 10 Park Plaza-Suite 5170 Expira 12 Supplement Card Boston,MA 02116 THIELSCH ENdio ` r a: ✓kx ERIK NERSTHE` I 1 1341 ELMWOOD'AITA- CRANSTON, RI 029Yd?:;,`' Undersecretary Not valid without signature f OWNER AUTHORIZATION FORM* ' M0.h(,� (Owner's Name) owner of the property located at " � y z (Property Address) �PP7f ► , Z63 (Property Address), w hereby authorize _ (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work-on my property. .. 6 O s Signature Date ; 1 . TOWN OFTARUNISTABLE R I S EF2 06 Division of Thielsch Engineering,Inc. 1341 Elmwood Avenue ENGINEERING Cranston,Rhode Island 02910 IVI'Su N Thursday, February 23, 2012 Town of Barnstable Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 RE: 83 Patriot Way; Centerville, MA Barnstable Building Permit#: B20120318 Dear Mr. Perry, This affidavit is to certify that all work completed at 83 Patriot Way; Centerville;MA, has been inspected by a certified Building Performance Institute (BPI) inspector. The following insulation was added: ➢ Install 2.25" R-10 FSK faced semi-rigid fiberglass board insulation to 179 square feet of knee wall area. ➢ Install a 10" layer of R-37 dense packed Class 1 Cellulose to 52 square feet of knee wall floor attic space. ➢ Insulate and seal 4 knee wall hatches by installing 2" rigid foam board that meets the sections R-316.5.4 and 316.6 requirements of building code. ➢ Insulate the back of the basement door leading to the bulkhead'with 2" rigid foam board that meets the sections R-316.5.4 and 316.6 requirements of building code. All work performed meets or exceeds Federal and State Requirements. Sincerely, Erik J. Nerstheimer RISE Engineering Residential Installations Department RISE Engineering; A Division of Thielsch Engineering 401-784-3700 •800-422-5365 •Fax 401-784-3710 f Town of Barnstable ;emit# �OFTHF/p�� Regulatory Services �Fees6"'°'t/rsfrnr me $ Thomas F. Geiler,Director rA - F �e �" Building Division Tom Perry, CBO, Building Commissioner -200 Main S-treet,'Hyannis, MA 02601 www.town.barnstab le.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 Property Address r/7 U estdential Value of Work ?B�Ci" Minimum « - 3 fee of$35:00 for work under$6000.00 Owner's Name & Address ,� 1-` Contractor's Nante Da'"nt� � �� Telephone Number ��S 77'—?c) e 3� Home Improvement Contractor License#.(if applicable) `- � t' Construction Supervisor's License#(if applicable) A- SS Imo__- orkman's Compensation Insurance s Check one: AUG 9 2010 �❑ am a Sole proprietor TOWN OF BARNSTABLE L� ` am the Homeowner ❑ I have Worker's Compensation Insurance. Insurance Company Name Workman's Comp. Policy# ,Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over. existing layers of roof) ❑ Re-side #'of doors f replacement Windows/doors/sliders. U-Value _(maximum .35) # of windows f q *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A'copy of th Im rovement Contractors License & Construction Supervisors License is, quired. SIGNATU E: QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 _ x oIla Town of Barnstable P� Regulafory-Services B^ s"SBLE'$ Thomas F. Geiler,-Director 639• orAnts Building•Division Tom Perry, Building Commissioner" 200 Main Street, Hyannis, MA 02601 www.town.barn9table.ma.us Office: 98-862-4038 Fax: 508'790-6230 HOMEOWNER LICENSE EXEMPTION &-Ito Please Print 'DATE: / },,, I/ JOB LOCATION: f t'cCkS number str t .village ,'� •fir , "HOMEOWNER" Vklv5 ke�-llL,Qe name home phone# work phone# " CURRENT MAILNG ADDRESS:~ b Vim'%hv'�✓� �1(®1 r , city/town a state zip.code 1 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 o'r 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 permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for.compliance'.with'the:State Building Code and other applicable.pcodes, bylaws, rules and regulations. / The under ' tomeowner"certi"t t he/she understands the Town of Barnstable Building Department minimum in ures and requi ents and that he/sh will comply with said procedures and requirements. . owner 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 with a licensed Supervisor.-The homeowner acting as Supervisor is ultimately responsible. x 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 form/certification for use in your community, Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 - of THE ray + BARNSI'ABLE, + MASS. Town of Barnstable AlFD Mpr s Regulatory Services 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 Complete and Sign=This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 I Town of Barnstable *Permit /�pp1HE rp� # P p E spires 6 months fLoin issue date Regulatory Services Fee * BARNSTABLE, ' - �� MAC' Thomas F. Geiler,Director 1639. v ! A Building DivisionX-14PRESs PERPAIT Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis,'MA 02601 jUL !9 2010 www.town.barnstable.ma.us , Office: 508-862-4038 TOWN OF BAR TA& 6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not•valid without Red X-Press Imprint. Map/parcel Number 'R z o Property Address ' f'�" O'fa GtfCt, �Pl. o Q/Residential Value of Work 3500 Minimum fee of$35.06 for work under$6000.00 . Owner's Name& Address 11 ��'� L (�.L Contractor's Name Dckml5 /��' g�.C� Telephone'Nurnber '7rX'�c Home Improvement Contractor'License#(if applicable) �G ®� Construction Supervisor's License#(if applicable) _el dworkman's Compensation Insurance Check one: ❑�-,� am a sole proprietor LS t am the Homeowner i [/have Worker's Compensation Insurance:"' Insurance Company Name ✓ UIK / �(� flu uv� Workman's Comp. Policy#_ k1 i;, .166 Q I j% 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 Ve-roof(not stripping, Going over existing layers of roof) ❑ Re-side m #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 of the Home Improvement Contractors License& Construction Supervisors License is SIGNATURE s 0:\WPFILESTORMSIbuildmg permit forms\EX PRESS.doc ` Revised 0701,10 The Conrrrrro rwealflr of M—assaclruset#s r Department of Industrial-4cc-idenis Office of Investigafions �- ' 600 Waslringtorr Street r"d• M T Boston, M4 02111 >Hww.mass gos ldio Workers' Compensation Insux-ance Affida-vit: Builders/Con#ractoe-AILctricL-ins/Plumbers plicant Infoim.aton. P"lease Print Legibly Name(Busmem/0rgau zat on vidual) V11f�1�j C�J` Acidness: LI(P ✓1��Myc/, S . 9w C'1 City/StatPizip- Phone># Are you an employer:`Check the appropriate bon Type of project(required).. 1.111 am a employer . ❑ I am.a general contractor and 1: with 6. E]NevG,construction . employees(full-andlor part-time)-*' have hired the sub-contractbrs 2..❑ Y am a sole proprietor or partner- listed an the attached sheet 7. Remodeling ship and liar*e no employees Thy -contractors hm e„ i S. � Demolition workingfor mein any capacity- employees and have workers' x 9. Q,Buildng.additiou k No workers' comp-insurance comp_insurance.. f . 5 letr e ed. � repairs or additions 3_. I am a homeowner doing all work officers have exercised.their I LE]Plumbing repairs or additions myself. [No worke€s''comp. riglttafexemptionper h1CrL 12-0,koofrepairs instrance required:] c. 152, §1(4),and we have no employees.'(No workers',ers' 13.El Other` comp- insurance.required •Any applicant that.checks box#1 must also fill our the section below,,showing their workers'compemation policy infonnstion_•' _ t Homeowners who submit ibis affidavit indicating they are doing all wcA and then.here outside contractors must submit a new a$ida-t indicating such- Fconrractors that check this box must attached am additionA sheeet showing the name of the sub-couttacto35 and state whether or not those enuties have employees. I€the subcontractors have employees,they mast provide their markers'comp.policy number. I am an emptoyep that is providing tirorkers'compensadoh irts7.4rance for aly ertrlrloyees. Belo IV is tiro pa He,v a►ad1ob si e` informatiart Insurance Company Name Policy A or Self-ins-Lie.9: ' E)pis-ation Date. Job Site Address: City/State/Zip.' Attach a cop} of the workers'cornpeusatiOn policy declaration page(sheiii rg the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 1:52 can lead to the imposition of criminal penalties of a' fine up to$1,500.00 andior 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:D1A f verage verification. . k I do herby a fire pints rand penaltiei rr eiry that the itifar ritntiort prmzded of bol :is tnie rand correct Si• Date: Phone#:'Official use only. Do not.write in this area,to be completed by city or town rtfc at City or Toms is Permit/Ucense lk Issu nL-Authwity(circle ogre): 1.Board of Health 2.Bunching Department 3.,Cit}/Tolim Clerk: 4.Electrical Inspector 5.Plumbing Inspector 6.Other Coa.6ct Person: Phone#: 1 V 1/Al V1 LLL1 11J{.N."iV X �� TME Regulatory Services uRrrsTAst Thomas F. Geiler,Director , HASS. 039 ,e� Building Division ATED MPy a . -Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.bartistable.ma.us Office: 508-862-4038 Fax:, 508-790-6230 HOMEOWNER LICENSE EXEMPTION " i Please Print DATE: 1 I� 'I 6 JOB LOCATION: p ✓ 1 tno4e. f• number T�ehnl5 L�^street village "HOMEOWNER": ���G L�L,C, `W �� ��77 ���S J name home phone# work phone# CURRENT MAILING ADDRESS: l( C<'111 bZj4 L.1 L/t/l city/town state zip code units or less and ` The current exemption for `homeowners was extended to include owner-occupied dwellings of six t urr P P >; 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 permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department - m' t ins e uirements and that he/she will comply with said procedures and req ents. nature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to corriply with the State Building Code Section 127.0'Construciion 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 with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt'such a form/certification for use'in your community. Q:\WPFILES\FORM S\homeexempt.DOC TOWN OF BAARNSTABLE BUILDING PERMIT APPLICATION " ` Map lqd Parcel �� Application# Health Division Conservation Division Permit# Tax Collector Date Issued /`Yk 7 " Treasurer Application Fee i oo i Planning Dept. Permit FeeZS bD Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address (r)� Village eC n1 lh tk Owner r r2oda�&o A �A (,p��"G� Address cc)� �fi' �rJ� UJA4 Telephone �� ho 2- o Permit=fie uest I�JA� �- 1 4 !1'l ` `4' it J Square feet: l st floor:existing l proposed RQZ 2nd floor:existing proposed Total new `Zoning District V Flood Plain Groundwater Overlay project Valuation 00•0 0 Construction Type Lot Size Grandfathered: ❑Yes o If es, attach supporting documentation. Y pp 9 Dwelling Type: Single Family X Two Family ❑ Multi-Family(#units) Age of Existing Structure 9,ee�T?C 9c> Historic House: ❑Yes U4o On Old King's Highway: ❑Yes VNo Basement Type: JdLFuIl ❑Crawl ❑Walkout ❑Other easement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) =, Number of Baths: Full:existing new O Half:existing_�, new- Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor RoomzGount Heat Type and Fuel: ❑Gas ❑Oil 1 Electric ❑Other c Central Air: ❑Yes 1 No Fireplaces: Existing New Existing wood/coal s ove: )(Yes ❑No Deta6hed-gar@ge:❑existing ❑new size I:❑existing ❑new size ©© ❑existing ❑new size Attache arage:❑existing ❑new size ShedAexisting ❑new size Other: 2 Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes X•No If yes,site plan review# Current Use G`'I P Proposed Use #00110 BUILDER INFORMATION ` i Name` " COD' 4" Telephone Number " LI Address p v,(01 W A. License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS REg"ULTING FROM THIS PROJECT WILL BE TAKEN TO f 7 P/ SIGNATURE �— `_"l .— - `—"`�---'_`_ _` DATE J-� (` P FOR OFFICIAL USE ONLY i PERMIT NO. DATE ISSUED MAP/PARCEL NO. f ADDRESS VILLAGE ►- OWNER r DATE OF INSPECTION: FOUNDATION FRAME i INSULATION ,) FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL a , FINAL BUILDING i x DATE CLOSED OUT ASSOCIATION PLAN NO. �f- The Commonwealth of Massachusetts y Department of Industrial Accidents Office of Investigations 600 Washington Street y Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): c! �o C1 C0Sfip Address: �iR �,i 0 1A1 r City/State/Zip: Ci?-A'L l lei —AA4 Phone#: " Z� 2— 0(0 0 l� 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 $ ? 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. insurance 5: ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.pQ 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.] # 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 tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration pag wing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 cari lead a 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 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. ,F I do hereby certify under__the pains and penalties of perjury that the information provided above is true and correct: Signature: JU ��- C � � I Dater o o Phone#: � ` 7 12 — A Offccial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: z Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the leg 1 representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or oth legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenan e, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not beta a of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that"every state or loc licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to c nstruct buildings in the commonwealth for any applicant who has not produced accepts le evidence of co pliance with the insurance coverage.required." Additionally, p MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall � enter into an contract for the performance of public work til acceptable evidence of compliance with the insurance Y „ requirements of this chapter have been presented to the co tracting authority. Applicants Please fill out the workers' compensation affidavit®o pletely,by checking the boxes that apply to your situation and,if. necessary, supply sub-contractor(s)name(s), addres ( ) and phone number(s)along with their certificate(s) of i LP with no employees other than the insurance. Limited Liability Companies (LLC)or L ted Liability Partnerships(L ) members or partners, are not required to carry worked compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that th's affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the applicatio for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any ques ons regarding the law or if you are required to obtain a workers' compensation policy,please call the Departure tat the number listed below. Self-insured companies should enter their self-insurance license number on the approprie line. City or Town Officials Please be sure that the affidavit is complet and printed legibl . The Department has provided a space at the bottom of the affidavit for you to fill out in the evfnt the Office of Inv tigations has to contact you regarding the applicant. Please be sure to fill in the pemut/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license plications in any give year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"th applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or rked by the city or town may be provided to the applicant as proof that a valid affidavit'' on file for future permits o licenses. A new affidavit must be filled out each . n business or commerci al venture license or permit of related to a year.Where a home owner or citizen is�Obtaining a p Y permit to bum leaves etc. said person is NOT r ired to complete this affidavit. i.e. a do license or ) ( g The Office of Investigations would lik to thank you in advance for yo ooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Elie Commonwealth of Massachu efts Department of Industrial.Accide s Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia 'tHE Town of Barnstable �p�C ti Regulatory Services STAB SS. Thomas F.Geiler,Director y ivn � 0390 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 Permit no. Date AFF)AVi T HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which are adjacent to such residence or building be done by registered contractors,with certain excep6;ons,along�dth o*?per requirements. Type of Work: �• w aLL Estimated Cost 0..o0 Address of Work: UJ A 4 Owner's Name: Q0 JU co a Date of Application: Os I Z a 00 G I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law Wb Under$1,000 MBuilding not owner-occupied "--EOwner pulling own permit Notice is hereby given That: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. • SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Signature Registration No. OR o_t,SEQ bo, C 0 V tl- Date Owner's Signature Q:wpfile0bmis:homeaff day Rev: 060606 F ZIME . Town of Barnstable Regulatory Services Thomas F.Geiler, sAxtvszasi.a, + ,Director 9 MASS. �A 1639• Building Division lfC MA't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 4 2 1N I O 6 JOB LOCATION:_ 0 l0 Ali, C��) 1 'jmuK n ber I street village "HOMEOWNER':— d'L(C—<O C C��t� Ia L4 _ � name 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 permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,by aws,rules and regulations. The undersigned")meowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspectip cedures and requirements and that he/she will comply with said procedures and requ' A' Sign 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 with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:fonns:homeexempt s ���•r ,� -Cam. ->.1^�� .l. �� ; •'• - . �•,, , � �r _¢ . .yam _ PO esawy. °'w'�Yy"a 4 t'„ �j�t`,tb-�'•L,� a � �t'� �' i+r'{�' � so so Mr C 1 mac. -` '•�.• �' _ . -. fit' ..L*��^'r��K - y�r^ i r•�''y �� _ �, ,.*. • _ yr • -.: .• �_� : �' Fin c C r ,C ':mow. -'•.aT � R •�•% ',. •{, S �! .•a a�, r• C ALL \ - i - .� to �J .,1�\ ��..:..ati. � .� p�1 vc- f.',c..� yC�'�s'•gyw.i��- �i� _�� , a. r . «� L - .k" �� � � �1Y1li! ANY _ i• ns, � _�� }s. ��� ��1 \, l `'( maw 6K�y♦-< < _ ay . Fy S. saki r r i { 33 Patriot Way, Centerville 11/06/06 °EVE Top, Town of Barnstable Regulatory Services ss j E ni Thomas F.Geiler,Director E%6 9aa10� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 October 7, 2004 Marcos Campos 83 Patriot Way Centerville, MA 02632 RE: 83 Patriot Way Map : 192 Parcel : 220 Dear Property Owner: It has come to the attention of this office that the above address has a bedroom in the basement that is not in compliance with the state building code. You must contact this office and obtain a building permit to either : a)remove the bedroom. b) renovate the bedroom to comply with the state building code. You have until October 22, 2004 to obtain a permit or further legal action may be taken. Thank you for your anticipated cooperation in this matter., By Order, J auzon Local Inspector Q:zoning5 5EF 30. 2004 (FRI) 07:41 CENTERVILLE FIRE 5067902365 FAGE. 2 Y CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT DEPARTMENT OF FIRE-RESCUE& EMERGENCY SERVICES 526 1875 Route 28•Centerville, MA 02632-3117 ,08,790.2380•FAX:508-790-2385 John M.Farrington,Chief ,glen S.Wilcox,Fire Prevention Officer Cfalg E.Whiteley,Deputy Chief Martin 0'L.MacNeely,Fire Prevention Officer September 30, 2004 TO: Building Department Jeff Lauzon Town of Barnstable 200 Main Street Hyannis, MA. 02601 in accordance with MGL 148, Section 28A, the Centerville-Osterville- Marstons Mills Fire/Rescue Department brings to your attention the following potential violation(s) of 780 CMR: Massachusetts State Building Code for your review and/or interpretation of same. NAME/BUSINESS: Residential — Mark & Isabelle Campos ADDRESS: 83 Patriots Way, Centerville OBSER1IANCE: Illegal basement bedroom. Basement room used as bedroom, emergency egress is small casement window Thank you, artin cNeely Fire Prevention Officer C.O.M.M, Fire Distr `�We- -- 1 t�l�f�w In9ev.� � s i�: ^ro Q�� cVti "Commitment to Our Community" �f '� { ),fit tt>•1 ' tr3� ^ t N �'yr t'}r ram;}�3.'.1� t. \ � ♦ `kt s r ( f 1 - r qr; M1r ,I 2.j s'3 i r'pp D.0 — T L o 9 � ri s t r ^f Vol 5 Qr Y i t n t r g���¢ *�-j•' ' r'4tt Fkt ' F>,! f, .. } ,g 5Z .�1 i ;�yt t :, 7YJ,aa '4.;.} ift f�i' / i;f "iL�1 °;c a'�';S-e ;:"P"". �,�b .'z., n.�'e""-T"� �°�i"�----tir•-3'y=€ a''&.++ 4atba� +4� �.�-.'+.1. r •.! � R v �k ) SL i 1 4 Y r( �. j i Y { It•��, t j.s, 7a�tr F 9 Z 6 + fix., .F; F Y, '_7`� 1 L_ � �/O��/ , p '�.•r r 1 Y� -q y k `f I i „ � r '�Y •c � I�I F!{Sit r,S' - �ft� - - a �4 4���a � , No.64"0 J e. tt t 00 tt W � CERTIFIED sTt- PLOD' PL'A� � ¢t ;Y Lo 7 9 y,�+ 7'�f G T w.� �! �{ I�E 'CQNSTRUCTION ONLY k 1ea "F®UNDATION I� FEET •��E -LOW POINT OF ADJACENT. AS-IfA SCALE: -50 DA�'f Qt�ED(�E Ei�lGfAlE'ERP��C: .C®.�lV Wcen(e-rz I CERTIFY THAT THE _ _ CLIENT _ " P Vi.r Y -- —` - --'-- SHOWN ON THIS PLAN IS-1�.00ATC�D � fa: ;� s t®•I'S`TERED REGISTEREDr CIVIL ` LAND JOB NO-;7L/! ON THE GROUND AS INDICAT�� a� I R BY: �; /ij. CONFORMS TO THE ZONING LAB"� ENGINEERS, SURVEYORS DR ®F. �ARNST E , M 'S. t. �_ CH: f�Y ;I 5 , ., t ys MJA,IN . ST 712 MAIN ST. �/p/� /f�,�J 1✓ SU/ ,YA0 0UTK, MASS;' _HYANNIS;JVI4Sq SPIEw.-. vi^ �='OF,.�""_'` `" '0A:TE;�-- REG..�.LAND ,SU y®�' �Yr�� Assese THE -7 If,2 --Z,7 o (:�,rl -map and lot number ......... 1* SEPTIC SYSTEM MUST Sewage Permit number ............................................. INSTALLED IN C01101-i 4 14-- INITH AF,'Tl%r"-'-E 11 STATE 33AWS LELE. Housenumber .....................7.V....NJ................................... 1639. SANITARY COD,' AND TOR REGULATIONS. TOWN 'OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...... ............................ TYPE OF CONSTRUCTION ...............(k.3c)rn.-b...... F........................................................ ................ ............. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ...... -17 .. Location .......... .......... .....U- ....... ............... ProposedUse ................wZ. .1. 4).(::,. ................... ............................................................. Zoning District ......................RIC,......................................Fire District ....Address ........4004N Name of Owner ...... ................... Name of Builder ............... r?1.e..........................Address ..............................C.:E.....;.. mom.. ........................ Name of Architect ........................... . ............................/\J/. ,�n..................................... . .........................Address Number of Rooms .............F�K...........................Foundation ....f �......3 Exterior .77 "J.l .../. LIX) ........Roofing ............z Floors ....... . ......V.LAX'l ..............Interior .............. Y. ............................ Heating ... Plumbing ...Q.j.n.P.PzA.../..-k z.................... Fireplace ..................... ...............................Approximate . Cost ................. . . ........ Definitive Plan Approved by Planning Board -------------------------------19--------- Area ............. -Az Diagram of Lot and Building with Dimensions Fee ...........c�3......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 4, I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding th above construction. Ina, Name ....... . ... . I .... Leader Construction Co. v � ~' . _ - l I/2�o Permit for -------.—. '.. . .................. ' ' �Location ........... ....................... � ----..---.[eao/3liuer---------.. ' Owner ............... "ea.der..[.QVIpt���tiou..Co.. . � . of Construction j��u�� ^ Type ----- ----- ' . . ` ...........................................................:................... Plot ............................. Lot ..........!.#9............... � - . Permit Granted ---- 'l5_lp 79 � Date of |n ....... Dote Completed '--J� � . . . . ` PERMIT REFUSED � ____—~—_------.�------. lV - . � --------..------....---------.. � —.~-----.---~.-------------.. . . —..------.—.—..---~..--.—.—..---- ----.---.—~—...----~.—...----- ' - . Approved � � ' ~ ` ___------------- lQ ' . ' -- ..�_--'-------..._.-------.. ' - � --' ' --' '--' `w--^—^—^' � TOWN OF BARNSTABLE permit No. _______21C42 s' Buildmg`-Inspector VARITTan Cash OCCUPANCY- PERMIT Bond "No building nor structure shall be .erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to JAade r Construction Address Norwell, 14A lot #9 83 Patriot May, Centerville Wiring Inspector r Inspection date Plumbing Inspe`tor y Inspection date Gas Inspector Inspection date P (Engineering Department �� f'� �e -/ Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS., l ................ f�. .�...�, .....�eBuilding Inspector r ' s c. F Above-Grade Building Sketch (Page - 1) Borrower Client DaCosta Rodrigo p PropertyAddress 83 Patriot Way City Centerville Coun Barnstable State MA ZI Code 02632-1513 Lender First Horizon Home Loan Corporation Dimensions are Approximate Bedroom Bad' Kitchen O NFirstRoor Xing Living Living Room Room 32.0' Bath O ' N Second Floor Bedroom Bedroom `— «� 32.0' 1 ilu _ Sketch by Ap"I\r' - - COfTUf18nt5: -" E LIVING AREA BRrJEAKD AREA :CALCULATIONS SUMMARY BreakdownNet Totals First Floor768.00 768.00 GLA1 First Floor 424.00 24.0 x 32.0424.00 GLA2 Second Floor Second Floor5.0 x 8.012.0 x 32.0 . _ s i i, i TOTAL LIVABLE (rounded) 1192 3 Calculations Total(rounded) 1192 I Form SKT.AGSkl—°TOTAL for Windows-appraisal software by a la mode,inc.—1-800-ALAMODE