The URL can be used to link to this page

Home My WebLink About0179 PATRIOT WAY 1 r7 o v o ° ° a b o Application number...........`l �.................................... Date Issued................L�.1.Sd o................................. BARNSTABL£�°� Building Inspectors Initials.......... ............................ �FDtNR►"�� J �� i 6 `<� Map/Parcel...... __ -3..�1.. ........................... .... TOWN OJ 8ARNS IABLE �3S TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY EWORMATION Address of Project: _Al — A- K+, J E ./ ST T VILLAGE Owner's Name: al le- f}V/0V Phone Number2y�� J9p.5- Email Address: Cell Phone Number Project cost$ :W,61 Check one Residential Commercial O N W 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: See .A491 .a.aQ Date: TYPF,OF WORK Siding Windows (no header change)# Insulation/Weatherization _ Doors (no header change)11 Commercial Doors require an inspector's review `J Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S FORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# 11 Z 7 8 S (attach copy) I� F Construction Supervisor's License# 67`�2 (attach copy) Email of Contractor Saie�f S�� m a • c cs'Y` Phone number 4"o/- 7 i,1/- (-33 9 ALL PROPERTIES THAT HAVE STRUCTURE OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY 15 IN A HIST®RIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. . v APPLICATION NUMBER............................................................ *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 df food is being sewed at your event please obtain a Health Department approval between the hom-ps of 8:00am-9:30 am or 3.30 pm-4:30pnL Commercial events may require Fire Department approval XW®®D/C®AL/PELLET STOVES r77 Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE 1GXE1V'JLLL JLIO ' 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 APPLICANT'S SIGNATURE Signature Date FUT All permit applicatio drare subject to a building official's approval prior 8o issuance. MASSACHUSETTS SUPPLEMENT WARNING —DO.NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Ida v/aV che I Te 10087csk Last Name First Name Store#/Branch,Name PO(s)or Customer Order# Salesperson's Name (if any) The terms and conditions of this Supplement apply to all Home.Depot,(interchangeably referred to as "The Home Depot") Home improvement Agreements in Massachusetts and are expressly made a part of all such agreements. .In the event of any conflict, 'inconsistency or discrepancy between'the terms of Your Home Improvement Agreement and this Massachusetts Supplement, the terms of this Supplement. shall control. NOTICE TO BUYER You may cancel this Agreement if it has been signed by a party thereto at a-place other than an address of the seller,which may be his main office or branch thereof,:provided You notify the seller in writing at his main office or branch by ordinary mail posted,by telegram sent. or by delivery, not later:than midnight of the third business_dayfollowing the s' igning of this: Agreement. See.the attached Notice.of Cancellation form for an.-explanation.of this right: This right shall not apply to a transaction in which You initiated the transaction and the goods or services are needed to meet a bona fide immediate personal emergency and You furnish the seller with a separate dated and signed personal statement in the Your handwriting describing the situation requiring immediate remedy and expressly acknowledging and waiving the right to. cancel the sale within three business days. t (Customer's signature); TAX IDENTIFICATION'` .NUMBER;FOR,HOMEDEPOT. 58=1853319 NO WAIVER OF RIGHTS: Yourrights-under the Home Improvement Contract Laws (MGL Chapter 142A) and other consumer protection,laws (i.e., MGL Chapter 93A) may not be waived in any way; even by this Agreement. However, You;may be excluded from certain rights if the service;provider'You. choose is not properly registered°as prescribed by law. REQUIRED PERMITS Home Depot and/or'its Service Provider is/are:obliigated to inform You of any and all permits necessaryaO complete the work contemplated by this Agreement, and it is the obligation of Home Depot and/or Service.Provider to obtain.said permits. If You secure their building permits; You :are automatically:excludetl from any Guaranty Fund provisions.of the Home Iiiprovement:C on, tractb Law. WARRANTIES: Home D:epot.may guarantee or provide an express warranty for workmanship or materials.:Any enumeration of these matters 0h which You and Home Depot lawfully agree maybe added to the aerms of`this,Agreement as long.as.theydo not restrict Your basic consumer rights. MA SWa Sup.(Feb.01.2017) Customer ca;60 07.467-2581 { o D The'Home Depot.-i 2455Paces Ferry Road;N.W.Bldg.B-3,Atlanta,.Ge&94 30339 Customer,-,Copy i x :ltriek ➢ittxtfN prtd? tl ri# 'srr ` ootevglat006 Ongopervisom y 4 iT �60 KES[�t■s�P/4ia#ayCv ROAO M MA F} $;F - e' - The Commonwealth of Massachusetts 1=- Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 ' Boston M4 02114--2017 %<;;"'%='`` www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ��lica>at Information Please Print Legibly Name(Business/Organization/individual): ) Address: City/State/Zip: ��:r,.t -:n i�3 -`, Phone#: ,Z� -`ir✓L—�S%�;� Are you an employer?.Check the appropriate box: p } ❑ I am a general contractor and I Type of project{required}: I.El I tun a employer with 4. ,/employees(full and/or part-time).* have hired the sub-contractors 6• El New construction 2-LJ I am a sole proprietor or partner listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g. Q Demolition Working for me in any capacity. employees and have workers [No workers' comp- insurance comp_insurance$ 9- ❑ Building addition required.] 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.Q Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]- C. 152,§1(4),and we have no 12.[]Roof repairs employees. [No workers' 13:❑ Other comp.insurance required.] 'Any applicant that cliecks box rI must also rill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all-work and then hire outside contractors must submit anew affidavit indicating such- 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'comp.policy number. information.an employer that is providing workers'compensation inffo insurance for nzy employees. Below is the policy and job site 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 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 unprisonment,as well t s 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. ' do hereby certa under the pains and penalties of perjury that the information provided above is true and correct -: Siag iature: t-. ` / I Date:! �... ...... Phone#: Offrcial use only. Do not write in this area,to be completed by city or town-officiaL Cite or Town: Permit/License# Issuing Authority(circle one): I.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person,: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents Off tie of Investigations I Congress Street,Suite 100 Boston,AL4 02114-2017 �y www massgov/dia Workers'Compensation Insurance Affidavit: BuilderslConrractors/Electricians/Plumbers Applicant Information Please Print Le blv dame (Bu:sinessKr o&=tionvIndividual): Folne, — Address: 9B ig651 l l/RN��>� clNstaze,Z t�I f. viSYr Phone#:, 7 VY i p: s�,-� M A—'you an employer?Check the _propria ox: Type of project(required): 1. I am a empiover with, 4.?111e I aun a general contractor and I 6. ❑New construction employees(full and/or part-time hired the sub-contractors i I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. E;Demolition i working for me in any caps emaol�ees and have workers' city. 9. ❑Building addition o workers' coin insurance comp.incttrance•. ! 1 �] p 5. We are a corporation and its 10.❑Electrical repairs or additions requir officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. Zlo workers' comp. . right of exemption per i�IGL 12.[D Roof, s r c. 152,§1(4),and we have no insurance required] , e li Other employees. [No workers` comp. insurance required_] I , •:u.:appEcant thai cbzcks box 21 must also M out the section below showing their worJmrs'compensation policy inform 'ou. 'riomeowacn who submitthis affidavit indicating they are doing all work and thin hue outside comracrms must submit a new affidavit indicating such. =Cort ectous that check this box must ailaehcd an additional sheet showing the name of tic sub-con raetots and state whether or not those entities have =pioyees. if the sub-contractazt have employees,they mast provide their workers'comp.policy number. I am an employer dt.at is providing workers'compensation insurance for my employees. Below is the policy and job sire information. jn �j surance Companv dame: (.,trJ 'r/Lt' f y2�7 bNdr� l/N�onI r'1/`G �•tJs 1.e — Polic_v 9 or Self-ins.Lic_#: o I Expiration Date: 3 `7 City/SiateiZi Job site Address: l _ p: Attach a copy of the workers' compensation policy declaratio page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofI-AGL c. 152 can lead to the imposition of crhnbW penalties of a fine uu to$1,500.00 and/or one-y imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day a1"% i a lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA ce coverage verification I do hereby cer tYy tin at the information provided a/b a is and correct S attre: Date: l Phone T: — Official use only. Do not write to this area,to be completed by chy or town offtciaL Croy or Town: Permit/License rr Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone?: =_= Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22/201 S 2455 PACES FERRY RD C-11 HSC ATLANv'TA,GA 30339 Update Address and return card. Mark reason for change. D Address ❑Renewa! ❑Employment G Lost Card — Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE SUDDlement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation i 12785 K22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 f ANDREW SWEET `,Q Ca-- 2455 PACES FERRY RD C-11 HSC ATLANTA,GA 30339 thou Undersecretary d i signature ACC CERTIFICATE OF LIABILITY INSURANCE D021220U 1`� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,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 Iieu of such endorsement(s) coNT PRODUCER MARSH USA.INC. PHONE IFAX TWO ALLIANCE CENTER AIc Not, 3560 LENOX ROAD.SURE 2400 ADDRESS: ATLANTA.GA 3M26 INSURERS AFFORDING COVERAGE NAIL fi CN 101642069-HomeD-GAW-18.19 INSURER A.Old Republic Irwwce Co 24147 INSURED THE HOME DEPOT,INC. INSURER B,New Hampshire Ins CO 23841 HOME DEPOT U.S.A.,INC. INSURER e:HDmeRisk CaDwe Insurance Campany 2455 PACES FERRY ROAD INSURER o: BUILDING C-20 ATLANTA.GA 30339 INSURER E INSURER F- COVERAGES CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF BiSURANCE ADDL SUER POLICY NUMBER MMID�E� P EXP LIMITS LTR A X coMIdERCIAL GENERAL LIABILITY MWZY 31 Z717 0310112018 Imirm9 EACH OCCURRENCE S 9,000,000 CLAIMS-MADE OCCUR PREMISES Eaocnrrrerrce s 1.M0.000 LIMITS OF POLICY XS MED EXP!Any one personj S EXCLUDED i OF SIR:SI M PER OCC PERSONAL S ADV INJURY S 9.000,000 GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 9.000.100 X PRO- �LOC PRODUCTS-COMPrOP AGG S 9,000'a G POLICY❑ JECT OTHER: S A ;AUTOMOBILE UABIIRY MWTB312718 031012018 031012019 COMBINED� tSINGLE LIMIT s 1,000,000 X ANY AUTO BODILY INJURY(Per person) S OWNED ' SCHEOULED I SELF INSURED AUTO PHY OMG BODILY INJURY(Per accident) S OWNED '�SCHEOUAUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE s I AUTOS ONLY AUTOS ONLY i Per aeadenl � S UMBRELLA LIAR OCCUR EACH OCCURRENCE Is l EXCESS LIAB CLAIMS-MADE AGGREGATE is F-TOE. RETENTIDN s s B WORKERS COMPENSAMON WC014122577(AN,NH,NJ,VT) 0310112018 031012019 X STATUTE ER B AND EMPLOYERS'LIABILITY YIN WC 014122578(WI) 031012018 0302019 ANYPROPRIETORIPARTNERIDfECUTn/E E.L.EACH ACCIDENT S S,C00,CCC OFFICERIMEMBEREXCLUDEDI 7 NIA 5,000.000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 0 yes,describe under COnfinued on Addtional Page E.L.DISEASE-POLICY LIMIT S 5,000,000 DESCRIPTION OF OPERATIONS bebw C Excess Auto 297-1-10011-00-2018 031012018 031012019 Limit: 4.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEllED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhegee I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ` AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC'OR�® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSH USA,INC. NAMED INSURED THE HOW DEPOT.INC POLICY NUMBER HOME DEPOT U.S.A..INC. I 2455 PACES FERRY ROAD BUILDING G2D CARRIER ATWITA.GA 30339 I NAIC CODE ADDITIONAL REMARKS eFFecrlveDATE THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liabili Insurance Workers Compensation Continued Carrier.Indemnity Insurance Company of NWh Amenca Pot Number WLR CW83191(AL,AR.FI,ID,IA,RS.KY,LA,},iS.MO.NEN i,ND,,3KSC,SD.TN,WV;AY) Effective Date:03M12018 Expiration Dale:031012019 IEL)Limit Si,000.000 Camer lieu.•Hampshire Insurance Compaq Policy Number.WC 014122576 (DC,DE HI,IN.MD,MN,MT,NY,RI) Effective Date:03/012018 Expiration Date:031012019 ;EL)Lunt S1.000.000 Carrier ACE Amencan Insurance Company Policy Number WCU C64783221(OSI)(Q.CA,IL,NC.OR,VA.WA) Effective Date:031012018 Expiration Date:03/012019 (EL)Limil:S1,000,000 SIR S1.000,000 SIR for the states of AZ.CA,IL.NC.OR,VA,WA Carrier.National Union Fire Insurance Company Pdicy Number.XWC 4595580(OSI)(CO.CT.GA ME,MI.NV,OH,PA,UT) Effective Date 03I01i2018 Expiration Date:0 3101/2 0 1 9 IEL)UmiC 51,000.000 51.00D,0o0 SIR for the states of CO,NE;NV.Ml.OH.PA.UT 5750,000 SIR for the slate of GA SIWQ0=SIR fo the slate of CT Camer.Nabonal Union Fire Insurance Company Policy Number.XWC 45MI(C;SI)(,W1) Effective Dale:03/012018 p Expiration Date:03MI2019 (EL)Limit:S1,000,000 SIR:S500,0CD TX Employers XS Indemnity. Carrierllfinios Union Insurance Compamf Policy Number-TNS C4916693A(TX) Effective Date:03/0112018 Expiration Date:031012019 (EL)Limit-S 10.000.00D SIR S 1.000,COD ACORD 101 (2008/01) ©2008 ACORD CORPORATION: All rights reserved. The ACORD name and logo are registered marks of ACORD i Application number.: �. ...... .........7�+' AUG j�r Date Issued.............9/ 5. ............................. Building Inspectors Initials...... ....................... StARLE . Map/Parcel.....I .......J.... ..............:.......... :..... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTYµINFORMATION Address of Project: /DQ� —ltO7L R C -� -liltr� NUMBER STREET VILLAGE e, Owner's Name: GA a&. IYOr"I Phone Number Email Address: Cell Phone Number Project cost $ Check one Residential V- 11 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: Date: TYPE OF WORK ❑ Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's r.eview EfRoof(not applying more than 1 layer of shingles) Construction Debris will be going to it r CONTRACTOR'S INFORMATION Contractor's name A—,e r id g kvt/4 Gov 1 CA Home Improvement Contractors Registration(if applicable) # ., 2 L/ F6 , (attach copy) Construction Supervisor's License# (attach copy) yAhov WL--t 5W 2go q Email of Contractor OL.©V/,C,4&,!df0, Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT; YOU MUST OBTAIN HISTORIC APPROVAL BEFORE PERMIT CAN BE ISSUED. APPLICATION NUMBER.................................................... ..,... y� *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 dimension`s 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, ' 5 *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date /OPLICANT'S SIGNATURE Signature Date U All permit app 'cation ar ubject to a 'ding official's approval prior to issuance. I A�® CERTIFICATE OF LIABILITY INSURANCE DATE )4/3/2018 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 have ADDITIONAL INSURED provisions or 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 BRYDEN & SULLIVAN INS - NAME: 88 FALMOUTH RD PHONE FAX HYANNIS, MA 02601 -(AC.No Ext: AIC No: E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: LM Insurance Corporation 33600 INSURED - INSURER B: ' BEL ISLANDS HOME IMPROVEMENT LLC 204 CINDERELLA TERRACE INSURERC: MARSTONS MILLS MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 41181950 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 CER'TWICAI-E 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 LIMITS LTR D POLICYNUMBER MMIDD/YYYY MMIDDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE '•° AGGREGATE $ DED RETENTION$ * $ A WORKERS COMPENSATION WC5-31S-615667-018 - 2/11/2018 2/11/2019 STER OT ATUTE ERH AND EMPLOYERS'LIABILITY - - YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500000.. , OFFICER/MEMBER EXCLUDED? a N I A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 000 0 If yes,describe under - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION PHIL RYAN ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 7 HARBOR FARMS RD ACCORDANCE WITH THE POLICY PROVISIONS. EAST FALMOUTH MA 02536 AUTHORIZED REPRESENTATIVE Jon Smith ='%'l C ✓, f ^, t - _,...� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 41181950 1 1-615667 1 18-19 WC 1 n0254981 1 4/3/2018 2:10:19 2N (EDT) I Page 1 of 1 Estimate '� ;; K Date Estimate# L. ISLANDS Home Improvement 7/19/2018 795 Bel Islands Home Improvement 204 Cinderella Terrace nlame/Address Marston Mills, Ma ,02648 `_ Michelle Horen 179 Patriot Way Belislandsroofingandsiding.com Centerville,Ma,02632 508-280-1794 508-364-6909 Terms Project ` I Descnption Qty Rate Total Y system POSSIBLE EXTRA: Any rotted plywood,trim boards,lead flashing or other carpentry , needing replacement will be done and charged for as an extra at rate of$60.00 per hour,plus 15%mark up materials Bel ISlands Home Improvement Guarantees the labor for Lifetime of roof and against Blow-offs for 15 Years. Bel Islands Home Improvement:Carnes Worksman's Compensation and Public Liability Insurance on the above work, certificate available upon request Extra work:(labor/materials) 1,800.00 1,800.00 1.Replace old sidewall shingles(cheeks)and step flashing on the back of the house with new new flashing and new white cedar shingles-$400 2.Supplya and install vented dripedge and ridge vent for proper, ventilation$450 3.Supply and install new Azek rakeboards(2 members)on the back porch-$200 4.Replace old chimney flashing with new led flshing-$350 Permit 50.00 50.00 Dumpster 450.00 450.00 • .ice( ;1(�� %l I� - /'�; � , i('`�� jf Total - $10,000.00 Page 2 « Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standard Constr:vcttgri`S��ervisor CS-111305 w E' ires: 06/01/2021 ANDRE YARMALOVICH 204 CINDERELLO TERRACE `. ` ' MARSTONS MILLS MA 162M, i Commissioner r J � �JIF �rtre�trritrr.� /� of"ltc..sizc�ra.e�t� L0_Office of Coasumer A s&Busi egulatiou 999 H..OME IMPR ENT CONTRACIN -0 T, Regis, ti 17247ti T pe: Ex i r►; 71212018 DBA P BEL ISLANDS HO E IMPRO/EMENT ANDREI YA.RIVIALO 204 CINDERELLA TER; MARSTONS`MILLS, 0.648 ndersecretary y,w' , , 5 1 I \ r �e�n��ror�amcuenl/�o�'C��a�acrc�uuel/�. Office of Consumer Affairs&Business Regulation 1 HOME IMPROVEMENT CONTRACTOR TYPE:Individual w Registration, Expiration 1-.2416 "' 01/01/2020 ANDREI YARMALOWCH D/B/A BEL ISLANDS HOME IMPROVEMENT _ a ANDREI YARMALOVICH 204 CINDERELLA TER L. MARSTONS MILLS,MA 02648 Undersecretary *° p Registration valid for individual use only before the expiration date. found return to: Office of Consumer Affair d Business Regul i 1000 Washington Stree ite 710 Boston,MA 02118 IVo i ithout si ure t • 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): Y G Vl' /s I T Address: Gl I1 �%dGBL � C City/State/Zip: tAA9-rf �l�l Phone#: ��C�o Are y u an employer?Check the appropriate box: Type of project(required): 1.91 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, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporationand its 10.❑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 ' employees. [No.workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: / L Policy#or Self-ins.Lic.#: �—�! S U Expiration Dated 2 Job Site Address: �/ '© / City/State/Zip: . Attach a copy of the workers' compensation policy declaration 11ge(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 thW ' lator. Be*advised that a copy of this statement may be forwarded to the Officeof Investigations of the DIA for insce coverage verification. I do hereby certify,uwder the ins and penalties of perjury that the information provided above iss true and correct ' Si ature: Date: hh Phone#: V 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#: Information and Instructions Massach efts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to is statute,an employee is defined as"...every person in the service of another under any contract of hire, express or im lied,oral or written." An employer is efined as"an individual,partnership,association,corporation or other legal en' ,or any two or more of the foregoing ngaged in a joint enterprise,and including the legal representatives of a dece ed employer,or the receiver or trustee f an individual,partnership,association or other legal entity,employing ployees. However the owner of a dwellin ouse having not more than three apartments and who resides therein, r the occupant of the dwelling house of an ther who employs persons to do maintenance,construction or rep ' work on such dwelling house or on the grounds or b Ming appurtenant thereto shall not because of such/ea n a deemed to be an employer." MGL chapter 152, §25C also states that"every state or local licensingll withhold the issuance or renewal of a license or pe mit to operate a business or to construct buie commonwealth for any applicant who has not pro uced acceptable evidence of compliance witrance coverage required." Additionally,MGL chapter 1 2, §25C(7)states"Neither the commonwealf its political subdivisions shall enter into any contract for the erformance of public work until acceptablef compliance with the insurance requirements of this chapter ha been presented to the contracting authori Applicants Please fill out the workers' compens ion affidavit completely,by ch king the boxes that apply to your situation and,if necessary,supply sub-contractors)n e(s),address(es)and phone ber(s)along with their certificate(s)of insurance. Limited Liability Companies LC)or Limited Liabili Partnerships(LLP)with no employees other than the members or partners,are not required to c workers' compens on insurance. If an LLC or LLP does have employees,a policy is required Be advise hat this affidavit y be submitted to the Department of Industrial Accidents for confirmation of insurance cove e. Also be s e to sign and date the affidavit. The affidavit should be returned to the city or town that the applicati for the pe it or license is being requested,not the Department of Industrial Accidents. Should you have any quesh ns regar g the law or if you are required to obtain a workers' compensation policy,please call the Department at e n er listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials �1 Please be sure that the affidavit is complete and p ' ed le 'bly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the ce of vestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license numbe which will a used as a reference number. In addition,an applicant that must submit multiple permit/license applic ions in any gi en year,need only submit one affidavit indicating current policy information(if necessary)and under" b Site Address" a applicant should write"all locations in (city or town)."A copy of the affidavit that has bee officially stamped o marked by the city or town may be provided to the applicant as proof that a valid affidavit is o file for future permits r licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is o ining a license or permit of related to any business or commercial venture (i.e. a dog license.or permit to bum leav etc.)said person is NOT r ired to complete this affidavit. The Office of Investigations would lik to thank you in advance for your ooperation and should you have any questions, please do not hesitate to give us a cal The Department's address,telephon and fax number: The Commonwealth of Massachuse Department of Industrial`Accidents Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 vvww.mass.govfdia s Application number... .. .I....... 0. .L�3 Date Issued................... .�.i. 0 163 �� Building Inspectors Initials....�Fo��a� JUL 0 5 2010 ®�� -- - Map/Parcel............ .?... ...l. ..7..................... NOF8A APS-FABLE TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: /r� �fi^,o1� c✓a,� �P� �r"l�� NUMBER STREET VILLAGE Owner's Name: Mr'�ti2!/2 i/�o,/ Phone Number 77W LlgR S Email Address: Cell Phone Number Sbk-,2 1?2 Project cost$ Z 77 9 — 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: Ser zc(ac 4d cam--k-� Date: TYPE OF WORK Siding IE Windows(no header change)# 2 Q Insulation/Weatherization 0 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 MA CONTRACTOR'S INFORMATION Contractor's name_: -t e[e — G,/ti�.a�,l Wo Home Improvement Contractors Registration(if applicable)# 02 S (attach copy) Construction Supervisor's License# 07 Z.7 7 Z-. (attach copy) Email of Contractor Phone number 7 9'1 — q S Z- q?O 5 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. y APPLICATION NUMBER............................................................ *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 df food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type _ Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date LICANT S SIGNATURE Signature Date All permra�ons are subject to a building official's approval prior to issuance. Window World.of Boston MA H►Nummberbar- regon / of d"&Showrooms, N ✓ 188025 O 15A Cummings Park O 295 Old Oak Sheet Federei ID# Wobumi MA 01801 PembrokeMA 02359 B2 4g9gg32 (781)932.4805 (781)826-6281 www.WlndawW 0dc1cfEIostorLcam mer.Custo •�-' LL€ r�YLOy Phone(h) �T7 Install Address:/ Phone City GiI �L� State:MA Z E-mail WINDOW WORLD !, GLASS OPTIONS _1 o00 Series Single-hung All-Weld $199 7' SolafLons Elite-Ouat Pane 5119 2000 Series DH Mach/Welded Sash $215 —TIJOb Pane/Krypton $ 4000 Series DH All-Weld $240 ("3er(as 5000Onty} -secs Sertss DH:AIFWetd $260 WINDOW OPTIONS / �2 LitaSlidef $374 ✓ Gless Breakage Warre*(4000/6000):$15INCLUDED 3UleSlider na+A+) ,rev $515� l2Screens $gINCL1iDE0 _Picture/Fixed Lice 40.83 UI). $365 darn lnetaiatldn cn Jambs and_Head:$11►NCLU LPiettue/FIx9dLiDa-(�F130Uq 63 �:. �ouiNe.StrengthGlass(4000/6000) $131NC6UDED Awntn - $31U $$.INCLUDECI g.. QoiaMe locks(7 28') �gose nenl,.:<,..;.. $334__. :. : . 2 LAO Casement 5545 Foil Screens $2S. �3 Ute Casement,na ra?w•.n(5 r2+W 10_, :•4�Colonial Gridsrv(Gontoured/F10), $� '.;43d 1?r$InaGdds, S75 Bes2matat Hoppec ,�-.- .,�Bay�Windov�.•;SolfiitMounkl�NSSeaLS2860 �r,SbnWeYetl�rVlded`l+te�� $1e2 T. LI>}43 4cit 3dfst Ao(tr{f/ksisdot$2T6$'' a - . :to %'�,,,..��?1,9�fPri'6w`k` �. . ,,. :�Qbsr=ut?�S6)$s�`FBS�R"�) •. ,$75 , ,.. _day;Bow( rr rf oveess '( i 09'uy$97S Oriel Style(A)fitl ex 86/4% Vs - Beige/Almond �rFoartl,EnfleFlt}eti FYeme $3.5.. �detlirain Inreribi'(Sedasuddi06641$t00' (UghtOal=OaklCherryI Fox Wood PRE'i97BWWr140MES(EPALRDSAFERENOVATIO/h RrEmMePm) _Lead 9afaPractices Required Sao 8iormFAerforWch.Brome/Amekp.nli•md)St00 W HOME WAS BUILfINlHE ' 7•YEAA nil(d' 0asigner Color Extorter $175 MISCrtLLANEOtfS- `Specialty'Nin/dJ/w.:� r§� _Custom Exterior Aluminum Cladding. Window Color LLB—/ i�F. O Textured$90 Q 88mooth$90 $� Facing color- --- ::! : Metal wlr:aow Remove[' � $16 NON CiJ70AA.10 .111i S. NevrCnttstrucEenVlrntRemoval $175 vtnyt Ranfro Palio.geer,6R or sfr. $t09S. _�Speda*%-Andovi'.8dedor Trim $ ,_vlrryf Ao@ing petio'Ooor•.ett $1195 Mull to Form Murd Unit' $30 Ado to bue'prtce for Custom Rdl'mg Patio Dam$1260 --Install ir"riorlExterior Stapp $5ol. itenEf>R00',Slidrpgl'ago:gacrB,ILarett..:,81985�_ ^'InslaAtnteriorCf;sirig Starts At $05 �Freneh tiait'$pdJng PA4d;t7aortlR• .: Stass tnsulate•Weight$oxes $ FrsncltiRait3llilU�gPatlo"tSoor9it St5g5 _ m6xieiior GtaBding $300 Rodtfar eaylBow Windows $500' 3pjrd flrf�Coasb. . sws / 6dsting New Coast::,Ext:Rain)Fit $150� _Cuslo . $2t0 RemoVatof'&istinoSay/Bow $2501 sse5 _Repair SIN.J"or('eplaaesill nosing M - 85es _Full'SubSlll(Singld)replaaement $173 tiorf)eslgnAtGfatoes . "TT:tin6rlbrCealnq-100 3+E 5275 T— 2 11uli1n Removal 0 $ `�Bay/Bt)w>'onvef910r k RatM fit $450 ' �..^�I2r�Bs9t'•t7pt1014S � . . (New Siding Will Not Malchl / PE DaOFColor, rnsM WAsrda Cusopser sc�tr�gsp{vvra .art�ltndeataCt4spai(ttitt an arg� r uedl rxl R r: . FltAGIAIIdEB�Cuslamei.fstesDotdibfet8r`.tlle{d6atrlyd:acanaecbairwh{tifi{s'smlieM:PdIdiOAStaiciiig,'gWd► LilidUC�ectlt9sbFliiact'�,idEinDYEinfilipesin• e>teaser'S25Otf,I�tpeowtutmdorDdndoAstodiIJ6Appml Kdod@DWCtAOWouL City ol00donperul -$St walk Pimp fees in No IUITNA WORK IF NOT IN wpfTlNGI CUMOmer agrees to the terms Of payment as o ows: Extra Labor&Materials i 7rb310- Z/925— Slte.Sat 11p,p"%OGposal&Delivery Fses 9 000.00 i Tatel Anid6t:1 chi Custom Order Dept $LMCk# s!±if►-C Zf r 'r; �861drifi8'Pald to lnstaAar U00 t3ottipibtfdri :-:�'r..;>5P^.'."•.i-.. .. y:n:v�^,:;'r;'.d: • A"FirtanCed' tNfnE(sw'WSIgot64steRanAlaA�esarGllDtldsvmdrnm. s endbe{dpss4santiaAycom!>temdlrl� da1s 3eaudgrUur@atiYes�No Ar1YCeAoaittkatdiilgktadvaR e�rbofgbtw.Wk 3.1/99Gdt10elM1}tmla?etpd4a4rlbroart(uat4�tstankmatadaFaf:eg4rolned(Na s➢seasprdele W�ilrR � Whl!i LCordatS piths ttdClhekvodtrlaesSUfetlUt$r9WPlE4twlFp►ae@> oassq@dUfe r7 OgalPeYmeA1 �Iteictrielmil drnt6ltkp lsCom te(CU�9Sfie d balhpetlies s {kt:rila ItnOtbirgmat8 eoJiiras�rsadd`stntt`d't:m'rs skill b�rapiSteredanU that atrylitAt�a'S shad a f6tiaa�dl'lUflcon0atmr rt�l6fp io a reAls$sbYd 9hoold6e dttsetadtw omaa/'Cerayeter Altalte.and,Bsrlrt mg Rapplift tint puk Plan,suite silo a@/toe,10102f1a,Pkm(511)913•tll0o N rys�a�bbie� �qa�toth@rAydttB . cdn atA IiplWthbowt faomorol. ct tp/ irP�ildffiSas�l uaderyttSnifi➢tP 1421tAtaQenat$tlawsWreto f)Ca�Sfirtpdpn trperCil(ssWtlEaaWCddof 9tril8ttSh5(�110 deAOtetff9§phbsN[Sdof tftt+eaamrde$onfrs.in,fta9ieeiieMoi pff, JJ ap4Aet # Ihortfes9►lOdNiduats. N@uda9dtM_SvnGludEA(BD�niM(r(,oOrr4tttlit�ufrldlefedpdriUitpfprl4ewoilade�dEakt� rlfga:t6Arunm9tirefracbtdrutbrs, the PURC,otsEUZ-160061VidkiaafAatKIRIF.+q ofedi(OOEe.Wd�tlfeWt'.npepaVMWU EaP)l ^ WlgifoTbeamdledram7kraelolmcr ealleotlan hatn goarangr ptAtkadeathbett !S43It, .: CU: tl U9 �lQ.,• a4•dlIIS� q'•Q tlrl 'ill n,•I d 1. Ae¢3:8va and..: {q.,'. 1- 8 a ptli N�rm.:Et11tEtlllaltd11�110�b4 ip:Wlhtn�.p9f31naik@d tso(ftrr.Ulan millnlpktnttfte.isltawteglhlrJ•�t�ssday. TI awtiW:N" Inc..uoQor cs vFa VCaRp epaw a D nHMrrnuea ank •anar, notat9 Any bi Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstruCtfon`Supervisor CS-072772 E P ires: 04107/2020 t� JEFF C STEELE ,k 24 SHERWOOD AVE DANVERS MA'01923 > Commissioner �i[r �am;xnr�tierr�t�i iJ/r;'��idr Cicftt�sr�J' Office of.ConsumerAftairs&Business Regulation HOMEMPROVEMENT CONTRACTOR TYf:LLC Reglstrati�" Egoiration ,7:68025x� 04/11/2020 WINDOW WORLD OF Bi7STON.'LLC. jIF, y JEFF C.STEELE 15A CUMMINGS PARK WOBURN,MA 01801 Undersecretary I The Commonwealth of Massachusetts Department of Industrial Accidents I Congress.Street,Suite 100 Boston, AM 02114-2017 www.mass.gov/dia Workers, Compensation Insurance Affidavit:Builders.ContractorsTlectricians/Plumbers. TO BE FILED WITB THE PEPMITTLr1G AUTHORITY. Amplicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: jS_A Can,..-..'r,�s r K CityiStatelZip: n Phone#: �g 1 —q 3 Z Are you an employer?Check the appropriate box: Type of project(required: 1.�I am a employer with��employees(full and/or part-time). 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. I❑Remodeling any capacity.lNe workers'camp.insurance required.] I 3.D I am a homeowner doing all work myself.(No workers-comp.insurance required.;' 9. C Demolition ' 4.❑1 am a homeowner and will be hiring contractors to conduct all work or,my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions •proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance. 5.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�ther tom,I n t 0 f 152,§1(4),and we have no employees. [_No workers'comp.insurance required.; ,— J j ( Syr e4"f S I 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.i 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'camp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: FA re Tn s J RA f�C S Cep . Policy# or Self-ins.Lic..#: Z Z- W/i` C L ,�-2 5 Expiration Date: 1— Z 7— / Job Site Address: lo Gt/li Cit_y!State/Zip: C.Pit ferr//f'P Attach a copy of the workers' compensation policy de aration page(showing the policy number and expir tion date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this s tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi lion. I do hereby cer under to pair erjury that the information provided above is true and correct Signature: ' Date: — Phone#: — 3 2-- 05 a use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i CERTIFICATE OF LIABILITY IN DATE�ilDOryyyyl St3RAIVCE THIS CERTIFICATE 15 ISSU018 ED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE'NOLDER.THIS CERTIFICATE DOES NOT AFFIFMATfVELY OR NEGATIVELY AWETV, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS Cl_R1lFlCATE t?F INSURANCE DO>:S NOT CON A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATWE OR PRODUC)CR,AND THE CERTIFICATE HOWER. j iMPORTAN7; Ef the certiTcaYe hoEdct is>an ADD1710NA17NSUREfl,the policyr(lles)must havp,4DD1�ONAL INSURED prorisioe�or be endorsed li If SUBROGATION IS WAWM,subject to the 3emrs and cond;>; s-of•the this ceetitricate does not con#er lights to the Im1CY,Ce"n PO Ncies my require an endorsement A statement oA 9 certitfcate holder in fieU of such endorsementls). PRORlUCI3R Marsh&McLennan fi4wcY LLC >uaije CM1 VUItcher,CtC,CtSRR CB1A 3525 N.Elm St. PHco° •336-544-685p Greensboro NC 27455 a raalc Fax wo:212-6p7-6516 Ap Ess: Carf€.VlAtc, marshmrm.com INSURERS)AFFORORNGC0v RAeE NAIL$ 1NSUREfl ?:RIJDOQ INSUM RA:AlimeRaca Financial Seridt 34534 Wndovv World of Sostoll,LLC vauRER B;HartiOrB Fire Insurance C a ? is682 Nor Shaver Street EMIRc.Massachuseft ' ,Insurance Corn North►.�lilkesboro NC 23659 223DB INSURM D-, ('SURERE: COVERAGES INsuoREPF: THISCERTIFICATE r7lllYlf3ER 104r(?95T/2 RI:VfSI0Ir1 hiU{IABI=? INDICATED.IS D CERTIFY HSTA D POLICIES OF)NSURANCE'LIS7 ED'BEZ01N fiIAVE 13MI ISSUED TO THE DSURED NAMED ABOVE FOR THE POLICY PER;OD CERTIFICATE NOThV"ii HSTANDLNG AP Y P.EQUIREMEPJT,TERM OR CONDITION OF ANY CWITRAC7 OR OTHER.D000MENT VwT}i P.ESPECT TO VI�1J,^,H THIS CERTtFTCATI MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HM;T=`I IS SUBJECT TO ALL THE TERMtiS, �JtCLUSlONS AND CONDITIONS OI SUCH('OLIfeICIES.�Mn SHC N N. MAY HAVE BEEN REDUCED BY PAID CLANS. 1 TYPE OFLRANCE L!StIBR POLICY S�F POLICY EJGP C'OIISMERCML GENERALLRA Mny ODiTTS02x""7 dffiDDJYY RSd7DD. UMITS f 41]R�18 4PE2019 EiACHOCCiR�RENGM 01.1l00,000 CUNMS bL8][ a O^CUR J I PRE O EDl ED f �IIf' a u 8590090 Ell r rAE�E(P(AAy gM 11ett Ofl) n 5.000 i I tGENLAGGP.CGATEUdd1TAPPLIEEPER: `PER90A1AL8gDyli�LIURY $?.UUgDU� POLICY Ci J�ECT j LOC , G'cN1cR+11AC3G�CATE _ S2OW40M � i (OTHER I 1 PRODUCTS-CCAMPABG ( 2000.G00 A 'AUTOMOBILE UAB&M , •S --7a ANYAUT O I 3 I AU1J6B757R`fb W162017i e"8=0 R RE SINGLE UNfTxl � i$e -0 00 OWNED ^ SL'HEDULEC 1 r SOMLY114AJP,Y(PerFerep)� 1.�I AUTOS ONLY _ I AUTOS 111 I— HItEXCE-SSLUJAR ED �1LY '�UOI�.*-OVYNED � 1 !�EO>�:LY NjuRY AlJ7Y)S�� j 1 - PRG'P`W DAWAL -- ! ) Pa cciden C A UAg' 'X S OCGJR ; 3 01�7'-�`-+�7 2I1PZM7 WV101E EACH OCCURRENCE yZ,-0DO.i� CLAIMS-0dAIF_ I ONS AGGREGATE 52 DOD.000 B 7 TtOg GOPJIPBNSASIOt, AMUEMP 5, - i 221,Ya'RJ2$9'o $ LOYER�1.1ABILITY 1/27T20t8 'I V27!<0'19 j 1'ER ER F�s OPRIETOr�/i°AF F-W0=LyTIVE ! iP.IM RE7LCLUDEB? p71A ELEACHAOCIDE TToryin NH) escribeunder i E.L.MSEASE-EA EMPLOYE :55M(MD IPTIOPR OF OPERAnrwc re1aa ( ELWSFASE-POLICYIJW S.L"7C•000 ) DESCR1PT70NOFOPfRA7IONS/LOCATIONSIIIE€#IC4E$(ACORD9rP}_Add�mlalReapar_7�Sch9W_re,r��¢q}��h�dbmoRs!>ac�iyaequfrod) CERTIFICATE HOLE)r=R CANCELLATION SHOULD ANY 0F7HEAB0VE-DESCFjBEAPOLICIESBECANCELLEDS I THE UMATION BATE THEREOF, NOTICE WILL 13E n.ELIUk'P.ED IN ACCORDANCE WITH 77'IE POLICY PROWSIONS. AOR�OMREPI SEWA?IVF . ©ISM2016 ACORD CORPORATION. All rights reseried. ACORD 26(2016/!?3) The ACORD name and logo are registered narks of ACORD i c . " TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION . Map l 9 3 Parcel ! �- E - !8 Application`# ' / G"� Cq Health Division yl�j ('y�y Date Issued: Conservation Division Application Fee Planning Dept. _ 3 Q Permit Fee Date Definitive Plan Approved by Planning Board ' Historic - OKH _Preservation / Hyannis Project Street Address I ti' It o� Village C P n4err 1 (�� Owner l vti o Address sCk'm e Telephone 0 8 a9 3341 Permit Request A� a r� is ��nsr�`a��n +he ha.s,f,mcr1b, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3$00 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 Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new .size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 1 li c� 4 koLog-SK,/c�TfIc, Telephone Number �D 8 3� D3 9 8 Address _D 4w*'I it 14 ir6_ License# L US, ' an Pf Home Improvement Contractor# 3B� Email Worker's Compensation # 4 ® � ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO ��nn►o#A SIGNATURE DATE Lt i FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. k - ,t '4 ADDRESS VILLAGE OWNER `r DATE OF INSPECTION: >, FOUNDATION a. FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. HOME OWNER WEATHERIZATION WORK PERMIT.'. PLEASE COMPLETE AND SIGN.THIS FORM AS THE APPLICANT HOMEOWNER. .m I f_ ll `hereby consent,to„and'agree that weatherization work, may be done by the Weatherization Program of Housing Assistance Corporation on the property located at The weatherization work done will be based on programmatic priorities and-availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic&basement insulation;,exterior wall insulation; ventilation measures In consideration of the weatherization;work to be done at my home I agree to the following: 1. 1 give permission to Housing Assistance Corporation the property with such equipment,' and materials as may be necessary to perform weatherization. . 2. The Housing Assistance Corporation reserves the right to inspect the*fuel or utility bill for ` the weatherized unit on an ongoing basis for no more than five (5)years after the weatherization work is completed. have read the provisions of this agreement and give my consent. Home Owner(ssgnare) Home Owner email: Date:' .r x . Agent:(signatura) ; 1 Date; Weatherization Contractors: a Adam-T Inc C All Cape Energy,9Y, ron ier, nergy Solutions ' Alternative Weatherization ` :, ., Lohr Home Improvement Building Science Construction Resolution Energy Cape,Cod Insulation , Tupper•Construction — Office of Consumer Affairs and Busmess:Regul a tloli. J 10 Park Plaza Suite 5170 Boston;:Massachusetts 02116:._ Home Irr provern.nt Contractor Reg'$tratlor r ,.. Registration 171380 r ,.: Type Corporation. # ,e Exprmon 3%14/2018 r# 419291 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE ; SOUTH--YARMO:UTH MA 02664 g '� * 'Update Address and-return card Mark reason for change. " Address ❑4enewal ❑ Employment ❑Lost card; sea 1 0 20M-05/11 c�/Irc�a�t�»trntcuetrll�a�C�/�/las:tac�cc�e Offiee of Consumer Affairs&.Business Regu►ahoo License orregistrat�on valid for individul use only. HOME IMPROVEMENT coNTRACTOR before the expirat'Ion date =If found return to — Registration 171380 Type: Office of Consumer Affairs'and:Business Regulation 10 Park Plaza-Sutte S1Z0" Expiration 31a4/201�8 Corporation. Boston,NIA 02116 CAPE SAVE INC. d t . 4 1 .. 1 WILLIAM McCLUSKEY 7:-D HUNTINGTON AVENUE, i SOUTH YARMOUTH,MA 02664 undersecretary Not valid- i 'signature .. Massachusetts -Department of Public Safety Board of Building Regui:ations and:Standard8 n..._ n._.__ n_ 1.1/111Ci UltIt111 Jtjll ClVlll/1 JI/C1/A74V' License- CSSL 102776 W,LLL4m J MC lgtU 37-NAUSET ROAfl 119, Dip West'Yarmouth MA Expiration Commissioner 061=2017 1 n .6 ACCO& CERTIFICATE OF.LIABILITY INSURANCE DATE(maamorrwv) 4/12/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION.ONLY AND CONFERS:NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES. BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,.AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)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 Inaieu of such endorsemenE s. PRODUCER - M" NaME Risk Strategies Company Risk Strategies Company uHCD N E : (781)986-4400 FA�No:(781)9`63-4420 15 Pacella Park Drive y ,: aDDREss:randolphcid(risk-strategies.com Suite 240 , • ± .-- •* , INSURER(S)APFORDINGCOVERAC•4 ° NAICB Randolph MA 02368 lNsuRERA:Selective Ins. oF,America INSURED 4 :. .INSURERS Allmerica°Financial Alliance Ins Co 10212 Cape Save, Inc i iNSURERC:Star Insurance Co r. . .` 7 D Huntington Ave " . _ • INsUriERD: INSURER E: 1 South Yarmouth 2dA,a 02664 iNSURERF:' COVERAGES CERTIFICATE NUMBER:CL1641211375 "=' "' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED.ABOVE FOR THE POLICY,PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WrrH 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, EXCLUSIONSANUCONDITIONS OF SUCH.POLICIES..UMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.. INSR - D - POLICYEFF POLICY EXP - .-. .... .. L•R_ TYPE:OF:INSURANCE • , POLICY.NUMBER... :.MMIDD MIDD F, LIMITS ,•+l X COMMERCIAL GENERAL LIABILITY: .,- r EACH OCCURRENCE $ _ 110.010 0.0 DAMAGE TO RENTED A CL.AIMSMADE OCCUR PREMISES Ea occurrence $.. 100,000 -- - X S1994480 ^- , 10/16/2015 ioy16/2616 MEDEXP An ones person) $ 10,000. . s t Off:: a. N , • PERSONAL&ADV INJURY` $ °1,000,OOD GEN'L.AGGREGATELIMITAPPLIES:FER: r �, .. GENERAL.AGGREGATE $ 2,000,000 ❑PRO- COM POLICY X �C7 LOG _ * x x p~i ., -3 PRODUCTS—GOMPtOP.AGG $ 2,O,D0,000<- OTHER`.. AUTOMOBILE,LIABILITY _ c k a„`K a , Eea BINED ccidenE NGL LIMIT $ ANY AUTO I' ` x ( ' i ' BODILY INJURY(Per person) $ B AUTOS OWNED X SCHEDULED `t 3 A13SA4.6796600 "' _ 31/6/015 11/6J2016 BODILY INJURY(Per aa;ident) $ X HIREDAUTOS X N01WOV44ED t y, .,.c+�. �: T.�: 1. ROP TY'DAMAGE G $ AUTOS t Perae�adent Ai X UMBRELLALIAB X� OCCUR .�.� °:. EACH OCCURRENCE $',=+^. 1 000 ODO EXCESS LIAR. CLAIMS . e• A. e 'i. g:tx ' " AGGREGATE t $s. . 1 000 000 X 91994480 10/16•/2015 10/16/2016 DED IRE 6IL F $WORKERS COMPENSATION, - officers Included fox4t s*:,r" r;rs X PER OTH- AND EMPLOYERS'LIABILITY,- < -YIN .+ • - STATUTE :ER _• _ ANY PROPRIETOR/PARTNERlEXECUTIVE NIA - coverage ° tr ° - E.L.EACH ACCIDENT $ 5.00 000� OF:RCER/MEMBM EXCLUDED? N❑ C (Mandatory In NH) .� ,; : 14f-, , HC085540700 : 4/9/2016 4/9/2017 E.L:DISEASE.AEAEMPLOYE $.. -a.<., 500,000 It yes,desaibe under �,, •+� q.. .-- ., ....:., - DESCRIPTIONOFOPERATIONSbelovi s c"_ _ .' ue•' t E.L.DISEASE-POLICY LIMIT. $ a -500 000 ., r Y' [ t): .• ,:*y. s r � r s "' "a�° a` a .. t .:�Yti- vk "� - '� c °"� tr'... .. a �; ;,,tG... " x•.s;; .,i -C f..Yl,.,a i - .+ .a T.e.S _ •c. National Grid Corporate Services LLC .d/b/a National Grid, Action Inc, eisrequired)' •' "''"DESCRIPTION'.OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 7111,.Additional Remarks Schedule,may be attached if,more Spac rp Colonial Gas Company"and NStar° Electric are. all included as AddiiioAil' insuteds with'resgects to the General Liability coverage of named X. insured as required by written contract: 5 71 CERTIFICATE HOLDER. CANCELLATION £ R SHOULD ANY OF THE.ABOVE DESCRIBED POL ICIES BE CANCELLED BEFORE' HO11S1IIRJ'Assistance_Corporation,' P` ,V. a T' R, THE EXPIRATION DATE THEREOF, NOTICE .VNILL .BEr7 DELIVERED IN" Cape Light Compact ACCORDANCE WITH:THE POLICY PROVISIONS. -Barnstable Count 460 Nest Main Street ""a ` r` ' ` i 1 �v ° '. AUTHORIZED REPRESENI'AT1VE ,a.�l. s•'" w c •• ' -- Hyannis, bA 02601 ' Michael Christian./CLG ®1999-20.14 ACORD CORPORATION AII)ti_gh4!s raserved. ACORD 11,2014/01) »_ r The ACORD name and logo are registered mar6 of ACORD' IINS025(201401) x • a , , The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02H4-2017 y� www massgovLdia N orkers'Compensation.Insurance Affidavit:Builders/Contractors/Eleetricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):Cape Save Int Address:7-D Huntington Avenue City/State/Zip:South Yarmouth-MA 02664 Phone# 508-398-0398 Are you an employer?Check the appropriate box: Type:of project(required): L:✓�I am a employer with_._15 employees(full and/orpart-time)_ _ 7. 0 New construction 2. am a so le proprietor or partnership and have no employees working for me in ❑I 8. 0 Remodeling any capacity.[No workers'comp.insurance required'.] 3.Q I am a homeowner,doing all,work myself:[No workers'comp.insurance required.]t 9 0 Demolition I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10.E Building addition 4 ensure that all contractors either have workers'compensation insurance;or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5,❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees:and have workers'comp.insurance.'- 6.❑We area corporition.and its officers have exercised their right of exemption per MGL c.. 14.❑✓ Other Insulation 152,§1(4),and we have no employees.[No workers'comp.insurance required:] *Any applicant that checks box#1 must also fill.out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must.submita 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 policyand job site information. Insurance Company Name: Star Insurance Co. Policy#or Self>ins.Lic..#i WC085540700 Expiration Date; 4/9/2017 Job Site Address: 179 Patriot Way City/State/Zip: Centerville Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL-c. 152,§25A is a.criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,M 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. .I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.. Signature: Date: 4/25/16 Phone#:508.-398 0398 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#: r The Commonwealth of Massachusetts _ e Department of Industrial Accidents d 1 Congress Street;Suite 100 '. Boston,MA 02114-2017, www mass govLdia tVorkers'Compensation.Insurance Affidavit:Builders/Contractors/ElectrieiansTItimben.' TO BE FH.ED WI.TH THE PERMITTING AUTHORITY. Ammlicant Information Please Print Legibly ' Name(Business/Organization/Individual):Cape Saye'inc Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 Phone4.508 398-0398 Are.you an employer?Check the appropriate bog; t Type of project(required): 1. ✓ I am a employer with. 15 employees full and/or art-time ' e ❑ ( part-time)." _ 7 .0 New construicrioit 2.Q I am a sole proprietor or partnership and have no employees working forme in 8• Remodeling any capacity.[No workers'comp.insurance required.] F' I am a homeowner doingall work myself. - s 9. El Dem6liti6 y [No workers'comp:.insurancerequired.jt . , 10 Q Building addition ; 4.❑I am a homeowner and will be hiring contractors to.conduct all work on my property. I•will ensure that all contractors either.have workers'compensation.insurance;or are sole 11.❑Electrical'repairs"or additions proprietors with no employees.. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13�Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.. 14. Other Insulation.'" 1.52,§1(4),and we have no employees:[No workers'comp.insurance required:] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation`policy information. t Homeowners who submit this affidavit indicating:they are doing all work and then hire outside contractors mustsubmita.newaffidavitindicating 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: a I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site . information. Insurance Company Name: Star Insurance Co, Policy#'or Self:ms.Lic.# WC085540700Expiration Date: 4/9/2017 . Job Site Address: 78 Stoney Cliff Road City/State/zip: Centerville Attach a copy of the workers'compensation policy declaration page.(showing the policy number and.expiration date). . Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a.fine up to$1:,500:00 and/or one-year imprisonment,,as Well.as civil penalties in the form of a STOP WORK ORDER and'a fine of up to$250.00 a day against the violator.rA.copy of this statement may.be forwarded:to the Office.of Investigations.of lie DIA.for insurance coverage verification. , I do hereby certify under th pains andpenadties of peuryahat the information provided:above.is true and correct , Signature: Date: 4/27/16 : Phone#:508-398-0398 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..P.lumbing.Inspectora 6.Other Contact Person:.. -- Phone;#i DATE(mMIDDNYYY) ACoRV CERTIFICATE OF LIABILITY INSURANCE 4/12/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)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 csrtlflcate holder In lieu of such endorsements.. PRODUCER .._ _ o A. .Risk Strategies C NAME: g -Company Risk Strategies Company HO Nd E (781)986-4400 FAC No:(181)963-4420 15 Pace la Park Drive E-MAIL ' randolphcld@risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# Randolph MA 02368 P INSURER A:Selecti:ve Ins. of America INSURED INSURER BAllmerica Financial Alliance Ins Cc 10212 Cape Save, Inc INSURERC:Star Insurance CO 7 D Huntington Ave INSURER D INSURER E: l.South Yarmouth MA 02664 1 INSURERF: COVERAGES CERTIFICATE NUM9ER:CL1641211375 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED.ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR.MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES .DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND.CONDITIONS OF SUCH.P.000IES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. INSR hDDL SUBR POLICY EFF POLICYEXP LTR TYPE OF.INSURANCE POLICY.NUMBER M MMIDD LIMITS X COMMERCIAL GENERAL.LIABILITY EACH OCCURRENCE $ 1,000,060 DAMAGE TO RENTO A CLAIMS{v1ADE OCCUR PREMISES(Ea occurrence) $ _100,.000 X 91994480 10/16/2015 10/16/2016 MEDEXP(Any oneperson) $ 10,000 PERSONAL.B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES;PER: GENERAL AGGREGATE $ 2,000,OO O POLICY-a',ECOT ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000' OTHER: $ AUTOMOBILE LIABILITY Ee BINEnlSNG 1 . $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED- ADVA46796600 11./6/2015 11/6./2016 BODILY INJURY(Per eocident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS Peracddent $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS-LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X J RETENTION.$ NIL S1994480 • .10/16/2015 10/16/2016- $ WORKERS.COMPENSATION q Officers Include STER Ad for t � `.�, -]{ TA OTH- AND EMPLOYERS'LIABILITY Y I.N _ TUTE ER_ ANY PROPRIETORUPARTNERIFECUTIVE ge NIA C Covera E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? Fil{MandatoryinNH) T. WC085540700 4/9/2016 4/9/2017 E.LDISEASE-EAEMPLOYE $ 500,600 Ityes,descnbe.under DESCRIPTION OF OPERATIONS beloiv E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I:LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more.space le required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the GeneralLiability coverage of named insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Ccupact ACCORDANCE WITH THE POLICY PROVISIONS. Barnstable County 460 West Main Street AUTHORIZED REPRESENTATIVE Hyannis, I& 02601 Michael Christian/CLC 01980-2014 ACORD CORPORATION. All rights r®served. ACORD 25(2014101) The ACORD name and logo are:registered marks of ACORD INS025(2014011 Town of Barnstable Regulatory Services �nss Richard V. Scali, Director 039 AIEo,�,+A 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 November 17, 2015 } Michelle Horen Ivaylo Pavlov 179 Patriot Way Centerville, MA 02632 Re: Apartment Dear Ms. Horen and Mr. Pavlov, This letter is to inform you that you may currently be in violation of Barnstable Zoning Ordinance 240-11; any use other than a Single-Family home is prohibited. You must contact this office by December 7, 2015 to arrange to bring the above address into compliance or be subject to fines of$100.00 per violation,.per day. Sincerely, Robin C. Anderson Zoning Enforcement Officer Parcel Detail Pagel of 3 sn '� s a-�004.1 TAB , , 7s1R5f ON �"'� �App i J"` y vY a Logged In As: Parcel Detail Tuesday, November 17 2015 Parcel Lookup Parcel Info Parcel _ , Developer -.. ID -193-197 Lot LOT 25A&25 Location 179 PATRIOT WAY Pr 108 I Frontage I Sec -.- Sec Road Frontage Fire Village CENTERVILLE ( Dist i t C-O-MM Town sewer exists at this Road--- address No —::] Index11220 r6' Asbuilt Septic Scan: Interactive Map ? 193197_1 Owner Info ......... ......... ................ ............ ..................................................... ...........................:. ........ ....... ......... ......... ........... ......... Owner H�OREN, MICHELLE&PAVLOV, IVAYLO K Owner Streetl 179 PATRIOT WAY Street2 City CENTERVILLE State MA Zip+02632 Country Land Info Acres 0.42 _J Use Single Fam MDL-01 Zoning RC Nghbd 0105 Topography Level Road Paved r Utilities Public Water,Gas,Septic 1 Location FN __,_.___.. Construction Info Building 1 of 1 Year 1979�°µ� Roof Gable/Hip w Ext Wood Shingle Built Struct Wall Living 1948 m»r» ,� Roof A p%F GIs/Cmp-� AC[None ,�,-re , j Area Cover Type Style Ranch Int Drywall Bed Wall Rooms 3 BedroInt Bath oms»» Model esidentiah � Floor Carpet Rooms 2 Full-1 Half A Grade Average Heat Hot Water Total 7 Rooms�� Type Rooms Stories 1 Story Heat Oil _ +Found- Poured Conc. Fuel J ation Gross http:Hissgl2/intranet/propdata/ParcelDetail.aspx?ID=l3959' F 11/17/2015 Parcel Detail Page 2 of 3 Area 4128 � Permit History Visit History Date Who Purpose 8/26/2015 12:00:00 AM Nancy Finch In Office Review 10/27/2014 12:00:00 AM Geraldine Clark In Office Review 10/27/2014 12:00:00 AM Pamela Taylor Change of Address 8/14/2013 12:00:00 AM Jeff Rudziak Sale Review 12/10/1999 12:00:00 AM Paul Talbot Meas/Listed-Interior Access Sales History .... __.... ............................. _ ......... _................................. ................ ......... Sale Line Date Owner Book/Page Sale Price 1 5/8/2013 HOREN, MICHELLE & PAVLOV,IVAYLO K C200280 $246,000 - 2 5/8/2013 LYNCH, MARGARET P #D1220734 $0 3 10/31/2007 LYNCH, DAVID M & MARGARET C184502 $250,000 P 4 4/18/2006 DESOUZA, ALX-SANDA C179811 $350,000 5 2/24/1999 HOLDEN, JANE M #D757243 $0 6 4/9/1979 IHOLDEN, EDWARD P & JANE M IC77746 1 $0 Assessment History .......... ......... ......... ......... ......... .................. ......... ........... ........................ Save Building Land Total Parcel # Year Value XF-Value OB Value Value Value 1 2015 $124,000 $35,900 $1 ,300 $107,700 $268,900 2 2014 $124,000 .$35,900 $1,400 $107,700 $269,000 3 2013 $1361600 $39,600 $1,400 $107,700 $285,300 4 2012 $136,600 $39,300 $1,200 $107,700 $284,800 5 2011 $174,500 $3,300 $0 $107,700 $285,500 6 2010 $174,400 $3,300 $0 $107,700 $285,400 7 2009 $172,600 $2,600 $0 $144,600 $319,800 8 2008 $201 ,000 $2,600 . $0 $150,700 $354,300 10 2007 $199,900 $2,600 $0 $150,700 $353,200 11 2006 $188,600 $2,600 $0 $154,500 $345,700 12 2005 $171,700 $2,600 $0 $140,200 $314,500 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13959 11/17/2015 r P&Fcel Detail Page 3 of 3 13 2004 $139,600 $2,600 $0 $119,200 $261,400 14 2003 $126,400 $2,600 $0 $46,700 $175,700 15 2002 $126,400 $2,600 $0 $46,700 $175,700 16 2001 $126,400 $2,600 $0 $46,700 $175,700 17 2000 $92,600 $2,500 $0 $31,900 $127,000 18 1999 $92,600 $2,500 $0 $31,900 $127,000 19 1998 $92,600 .$2,500 $0 $31 ,900 $127,000 20 1997 $102,800 $0 $0 $21 ,300 $124,100 21 1996 $95,600 $0 $0 $21,300 $116,900 22 1995 $95,600 $0 $01 $21,300 $116,900 23 1994 $87,800 $0 $01. $31,900 $119,700 24 1993 $87,800 $0 $0 $31,900 $119,700 25 1992 $99,900 $0 $0 $35,500 $135,400 26 1991 $101 ,400 $0 $0 $561M0 $158,200 27 1990 $101 ,400 $0 $0 $56,800 $158,200 28 1989 $101,400 $0 $0 $56,800 $158,200 29 1988 $78,400 $0 $0 $21,200 $99,600 30 1987 $781400 $0 $0 $211,200 $99,600 31 1 19861 $78,4001 $0 $21,2001 $99,600 Photos ........ ...... ..... ........ ......... .. ......... ... . ° http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=l3959 11/17/2015 YOU WISH TO OPEN A BUSINESS? r 77 For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) 1.}f 1eI1 DATE:/ /Vo Fill in please: iitl!•1.�5,uli'I:�P i11 n t»`EIF�9,i''r� 6A,!:.. ,�;T.;, ir,.s., w APPLICANT'S YOUR NAME/S. Xi�Z Qh?/ZJZ e �1 yl / C7 i a fV y c��fli 1, z, •Isq, ' �i'' ` '7.3 ! t ?'r?dF BUSINESS YOUR HOME ADDRESS: /7°1 /s9'7'R i o bVy C vl U i I J'11 TELEPHONE # Home Telephone Number -` NAME OF CORPORATION: ES&'- / - OC C NAME OF NEW BUSINESS Do U - Y\ '1,z0A n ek✓.d C i2 TYPE OF BUSINE S c=l rt�><4 �So>�o11'S'acI 5�9��ic� IS THIS A HOME OCCUPATION? YES NO . ADDRESS OF BUSINESS /' i I� % vi c r�ie�Vi d A MAP/PARCEL NUMBER. " fAssessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you-may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business siin'this town. 1. BUILDING COMMISSIONER'S OFFICE /( This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this Ztype of business. V� Authorized Signature** COMMENTS: IV- 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) /� '(. \11✓ This individual has been informed of the licensing requirements that pertain to this type of business. • Authorized Signature .COMMENTS: ,.£ YOU WISH TO OPEN A BUSINESS? For Your'Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do byW G.L.-it sloes not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 'I"FL., 367 ` - Main Street, Hyannis,'MA 02601 (Town Hall) - DAT :/, i 20/ Fill in please: t I' APPLICANT'S e YOUR NAME +�A/ZR e - D i o V (r.r l �ra[r(nGI fir, M rk e �� MA �� Isrr z is BUSINESS y YOUR HOME ADDRESS: / `� l�4 R i'© 1Pcr,4Y �e�� V i 1 TELEPHONE # 'Home Telephone Number R NAME OF CORPORATION: op J on /i�l ` NAME OF.NEW BUSINESS e U l v� �4ri rt �>^ C ',e TYPE OF BUSINE S C-Azae;k4 4 +S�,�oRs'Qil 5-9�1 ;c� IS THIS A HOME OCCUPATION? , 'r' YES NO A®®RESS OF BUSII�IESS"L' 1 d� /' `vr c ,7 ieiUc MAP/PARCEL NUMBER (Assessing} When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. .This form,is_intended to assist you in obtaining the information you may,need. You MUST GO TO 200 Main St.-- (corner of Yarmouth .,. _ Rd. & Main Street) to make'sureyou have the ap�propriate'permits an licenses required�0 9egally_ap�erate y®ur:business in this town: " 1. .BUILDING COMMISSIC R'S OFFICE �* 3 {' '; . Thisiindividu j. been dnforfn d f: y p rmi requirements that pertain to this type,of business , } ,; ;" �" i .°>-- MUSTCOMPLY.WITHtHOME 000UPATION w` -Aut. rized ign'to- _' D REGULATIONS.- 1=AILURE TO . -RULES AN COMMENTS: f,:. T 0 t 77 cy- �.2. -BOARD-OF HEALTH. µ,= This individual'has been informed of.�theppermitrequirements'th at!pertain to this type of business Authorized Signature* s y * Y { F - , sue♦ . # ! . - �. . '�N `'� 3 CONSUMER AFFAIRS (LICENSING AI1. ORITY� IATC1 �. This individual,has been informed of the licensing requirements that pertain to this type-of business y ` - r Authordzed,Sd nature* COMMENTS. li�l l r ' t' �i ; Y,-: :'•_ - Y ''� y. A tia Davis i .e• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a Map Parcel A licatio � pp Health Division Date Issued Conservation Division Application Fee " Planning Dept. Permit Fee Date Definitive Plan Approved:by Planning Board Historic.- OKH _ Preservation/ Hyannis Project Street Address �ZT �T�Z>�;� Village Owners✓,� Address Telephone f 7f 7 9L-4. Permit Request �oZ (rZM_d ,/ 4 �_ I Aa.s-�' /Z" X42 zx:� A l4-- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total r e',v Zoning District Flood Plain Groundwater Overlay ? Project Valuation Z) Construction Typea� _ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting 'docJmentation. Dwelling Type: Single Family 1� Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes *No On Old King's Highway: ❑Yes VNo 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 Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nameaezf �'� , , 5��` rx''�� Telephone Number vj7 J7;75`2,`5' Address / �� l�Z� License # f Home Improvement Contractor# Worker's Compensation # Z!,z ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO e y�� SIGNATURE DATE e S� T ' FOR OFFICIAL USE ONLY I APPLICATION# k —DATE,ISSU.ED_ MAP/PARCEL NO. 5� ADDRESS VILLAGE OWNER ,k DATE OF INSPECTION: t3 F0:UNDA�TI.ON!i,`Hr;s t,,1'1l-*iF.L,L:°I 41�:. �..A-...m.,�__._ - FRAME -- - - - - - • . INSULATION.r�,�?��n`�,1l..r�$��.-:��,+aE .. r FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t FINAL BUILDING' - DATE CLOSED OUT ASSOCIATION PLAN NO. t lire (,'ommonwealth of Massachusetts I . 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 Annlicant Information Please Print Legibly Name (Business/Organization/Individual): �• �� G, �� . _ t Address: City/State/Zi 1, o` �Ahone #: Are you an employer? Check the appropriate box: 1. I am a employer with 4• ❑ I am;a general contractor and I Type of project(required); employees (full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g- ❑ Demolition working for me in any capacity, employees and have workers'-`- 9. Building[No workers' comp, insurance comp, insurance,# ❑ g addition required:] "S. [] We are a corporation and its 10.❑ Electrical repairs or additions 3•❑ I am a homeowner doing all work officers have exercised their . I I myself ' ' ❑Plumbing repairs or additions y [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' 13•R Other/.L'1 i_�%AkJ general contractor(refer to#4) comp.-insurance required.] — *Any applicant that checks box#i must also fill out the section below showing their workers'compcnsatioepolicy 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'comp.P Y olic number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information, I Insurance Company Name:_��,(/T� �� ! , Policy#or Self-ins. Lic.#:__ f Expiration Date: Job Site Address: ` Attach a copy of the workers' compensation policy declaration� City/State/Ztp;,/�� P po y 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. do hereby cerdfY un the pains and penalties of perjury that the information provided above is true and correct/l r Sizna Date: Phone#: Official use only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspectorf ' 6. Other Contact Person: Phone#: I j r .• $ i z C v A C)PRI—D" CAPECOD•27 ' �KLIGETT � -- CERTIFICATE OPLIASILITY INSURANCE' RATE(MMIDDIYYYY) THIS CICATEGATE IS ISSUED AST MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE'HOLDE R,THIS 014 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,pollcy(l)S)must be endorsed, .If SUBROGATION IS WAIVED sub ec the terms and conditions of the policy, ce nt s policies may require an endorsement,..A statement on this certificate does not confer rights cvrtlficats holder In Ileu of such endorsements w g he PRODUCER - "' r. �ogers&Gray Insurance Agency, In CONTACT {34 Rte 134 NAME: Barbara DeLavvrence' PHONE iouth Dennis, MA 02660 ralc.No,Ext .' At No: 877 818-2156 E•MAII ( _ ^T s ADD ES bdelawrence ro ere ra ,COm — _ INSURER S AFFORDING COVERAGE T NAIC p j — — INSURERA Peerless Insurance C NS RkA -' an c ompy _ II INSURER 8:COMMERCE INSURANCE COMPANY .Cape Cod Insulation Inc INSURER C:EVanston Insurance Company jJ 18 Reardon Circle -f INSURER D;ATLANTIC CHARTER - South Yarmouth, MA 02664. INSURANCE INSURER E, ,Q ERAGES INSURERF; 1 — CERTIFICATE NUMBER: ' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NREVIA A p A OIVEEOR THE POLICY PERT INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS �RCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, .THE INSURANCE AFFORDED BY THE POLICIES,DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, C�U510NS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY•HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLIO EFR POLI Y X COMMERCIAL GENERAL LIABILITY POLICY NUMBER . MIDD Y M I p Y ------ r 1 _ -LIMITS S_ _....I CLAIMS-MADE L X� OCCUR CBP8263063 r % EACH OCCURRENCE $ 1 000 000 - R. - r 04101/2014 04/01/2016 E TO-RN7 -- �> PR MISES Ea occurrence) $" 100,000 IVIED EXP Any on�ars—on) — $ 6 000 —'—_ G N'L AGGREGATE LIMIT APPLIES PER " PERSONAL&ADV INJURY $ 1,000,000 POLICY._ PRO• .. i. GENERAL AGGREGATE T s 2,00.0,000 OTHER g PRODUCTS•COMP/OP AGG $ �2 000 000 c AUTOMOBILE LIABILITY p 00 Si E SI G E LIMIT l ANY AUTO 14MMBCKVMK ` ' a a cidenl $ ' 1;000,000 ALL OWNED X SCHEDULED ," O4/01/2014 O4/01' 016 BODILY INJURY(Par per $' s AUTOS' AUTOS n b r _ HIRED AUTOS X NON-OWNEDBODILY INJURY(Pae�l) $ AUTOS PROf�ERTY DAMAGE Per accidenl $ X UMBRELLA LIAR X OCCUR EXCESS LIAR CLAIMS•MADE +. XONJ463814 y EACH OCCURRENCE' ,$ 1,000,000 DED X RETENTION 1O OOO O4IO1I2O14 04/01I2016 AGGREGATE r WQRItERS COMPENSATION A r0 ate - $ — AND EMPLOYERS':LIABILITY O g $ 1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE;Y!R WCAO0626904 " STA JUTE ERH• OFF)CER/MEMBER EXCLUDED? N/A ;, l)6/30/2014' O6/30I2016 E.L.(Mandatory In NH)r EACH ACCIDENT a t u yvs,avacribe under $ 1 r000,0�0 DESCRIPTION OF OPERATIONS below E.L.DISEASE•EAl;MPLOYEE,$ :. 1,000,000. E:L.DISEASE..•POLICY"LIMIT $'.. - 1,000;000 IRIP710N OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is requ)ratl). -r Serq Compeneatlon includes Officers or Proprietors,' Ys IQ al Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certif icate Holder, r ITIFICATE HOLDER f CAN CFit ATION 1, Massachusetts -De artnis'nt4of P btic Safet p U y = n, e 3oard of Building Regula;Eons ptl Standards Constntction 5upemsor r: K License; CS-100988 HENRY E CASSIIIv 8 SILP,D.ROW = Vj-12 WEST YA1t1Y'f0[1`111 � tz-4,- --41 ,I ro Expiration Commissioner, 11/11/2015 Office of Consumer Affairs and Business Regulation ;. 10 Park Plaza - Suite 5170 Boston, MassachLIsetts 021.16 Home Improvement CQ ragtoi' Registi:ation' Registration; 153567 Type; Private Corporation . r �.• EXpil'dtIQI1: 12/15/2014, TiYI. 23383'I CAPE COD INSULATION, INC HENRY CASSIDY - 18 REARDON CIRCLE —.-_-.� ._ ...._ ............._.... r SQ. YARMOUTH, MA 02664 t;,,'"a ,''• .t F'Update Address and return card. Marlc;rausun for change, Address 0 Renewal Cj Employment LostCnril c; sul�l uon I I,...� License or registration valid for iudivid 1)Itice ul'l'onsunu r Afrnirs& Business Regulnriolt } ` ul.use only, OME IMPROVEMENT CONTRACTOR before th i e expiration date. '.t•found return to: ".' egistration: 153.567 Type; Office of Consumer Affairs and Business lZogulation . xpiration: 12/1-5/2014 Private Corporation . lU Park Plaza-Suite 5170 nr� �•.. Boston,MA 02116 E(OD INSULATIONIIilo IRYICASSIDY EA'DONCIRCLE YA NIOUI I.I. MA 02664 UndersecretaryAtr vitho twt—lt ' — OWNER AUTHORIZATION FORM 4-- chei le- P-av lov (Owner's Name) _ F owner of the property located at a 'l , (Property Address) �� (Property Address) . I 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. Owner's Signature 04 Date CAPE COD rm* vF7 _,. INSULATION , d 21t9 r�� (f 9 6 f f1YSY YlAfS SLAML[Sl fr¢T fOAN fYSPWD\P MRS YY MR% It"U"IL9N CSILINYS 1-600-696-6611 D . 1`own of Barnstable • - Regulatory Services Building Division 200 Main tit Hyannis, MA 02601 .Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & complefed 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 Performance Institute (BP1) inspector. All work preformed meets or exceeds Federal &,State Requirements, ('�'upe�ty Owner Property Address Village p4Vo / /7 l . P4114,yof 4-)d ('r4, • r lusulation Installed: Fiberglass Cellulose, R-Value Restricted Unx• stricted Ceilings Slopes V loors > . Wallis f-+hl ,Sew/i✓S . . • - ,., M Sincerely _ ? He ry L Cas: y Jr, President i' e. Cod I ulation, Inc. MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Roston,Massachusetts 02108-1904 (6171723-3800 Ma Only(800)392-6108,FAX(8001851-8424 .11/29/2012 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 BARNSTABLE BUILDING COMMISSIONER 367 MAIN STREET 367 MAIN STREET HYANNIS MA 02601 Re: Insured: DAVID&MARGARET LYNCH Property Address: 179 PATRIOT WAY,CENTERVILLE,MA 02632 Policy Number: 1042190 Type Loss: Fire(including Fire caused by Lightning �= r Date of Loss: 11/28/2012 Claim Number: 308018 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. MPIUA Claims Division CMA00021 1 ``��•""'.e TOWN OF BARNSTABLE Permit No. ----- —-------------- 1 VA"n.0 Building Inspector Cash ...� --------------—------- -- �aVIX 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 Suffolk Rea?.r17 Trz.c;t Address 179 Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department 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. .....................................................1 19...... _ ..........................................: ......::............. ~ .... « :..._._.. .�._. Building Inspector Assessor's map and lot number � �. ............. 6 ` ' .` S STEM N"UST 13E L • is.� Sewage Permit number ` "' � `''` ANCE ... ...........�...,3.................... �I 1-4 ARTICLE �` I S NITA �� Cam.- TOTE Pyo�THEro�o TOWN ®F B A R N S TAB;(E�iE-01�S �_� TQ>n,� i BARBSTABLE. "6 9 D M Or•, ; BUILDING t INSPECTOR � PY � " APPLICATION FOR PERMIT TO ...�. Suffolk tRealty Trust ....... .. . ..... ........................................................ ................. TYPE OF CONSTRUCTION ...,,,,,single familXO°r"esidental,,,,,,,,,,,,,,,,,;,,,,,,,,,,,,,,,,,,,•,•,,,,,•••,,,,,,,•,,, March 1 ; 1979 „19........ TO THE INSPECTOR OF BUILDINGS: �� The undersigned hereby applies for a permit according to the following information: Location ..................Lot. ... .... # 25. ...Patriot. . . . ...Way. ...........Centerville,. . . . . ... ........ MA 0.26.3.2.......................................... .... .. .. .. .. .... .. .... .. .. ..... .. ............ .. .... ..... . ...... .. .... .. .. IM Proposed Use .....single..XX :..family..residential. .................................................................................. Zoning District ,••single family residential Fire District ......Centerville - Osterville ............................. ........................................................... Name of Owner •, Suffolk Realty Trust Address ....P.O. Box 308 Centerville ................................... .... ........................................................... Name of Builder .....••• same ,•••.,,,,Address same Nameof Architect ..................................................................Address .................................................................................... Number of Rooms seven „Foundation ....�?oured .concrete ............................................................. .................................................... Exterior cedar shingles .,....Roofing .......,.asphalt shingles,,,,,,,,,•,,,,,,,, Floors carpeting over underlayment Interior .skim coat plaster,,,,,,•,,,•,.,,,•,,,,,,,,,,,,,,,,•,,,:........................................................................... Heatingf.o.rc.e.d...h.ot...wa.t.er....by• o ................... ...............PXq............................................................. .. .... .. .. .. .... ..... .. .... Fireplace brick & block „•,,,•,,,,,,,,,Approximate Cost ............$35,000. 00 ............................. ...............,............ Definitive Plan Approved by Planning Board -----------_------_-----------19_______. Area ........15.847�r...........:.. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH j I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam !IAt�'�� ............. . . - . ` � ^- � Suffjk Realty Trust �ami l ---------.—.—.-.-------.--.--- ) Location .............l7g...............................Pa Wav______ / �o� , ___,____~_ le___._..~___ Owner �folk Beal �ruot -----~--------.^------. � Typo of Construction -----..��----. �--.-' .. ... . .—.. � . ---- . . ---------..--.. Plot ,�-.------. Lot ................................#25 -, / . . Permit Granted ........Msu:cb''2.................Tg 79_ ~ ' Date ofInspection ------------lA Dote Completed ................................... � � kwMIv REFUSED ----...—, .........................................;,19 . ~ ...—. —.---.-.—......— ' '' ' —'' ��—~'' ---"' t � . . '. . . —'.......-....�~..--_-......,..--....._- � ...—. .............. ...........................................---. ^ � � ~ ` —.---.--..--^~--.--.—~.—..---~— . ' . ' ^ . . . ^ Approved ................................................ lQ ^ � � . ^� � �--------.-------~..--..----- . - -- ' '. ---. �---.----.------....... .. . ` j-O 1-4 m L oT 30 - "r D ire c , e_ L 07" • PoessP W. p)J v v aell 1-44 zs • 7 E5 T- 14OL 06fI'h// t1/`7 OU11- AIC SET GK REQUl REMEh.lTS .5/ZD i' 1 W xi ,tt T ;v 8 E �-O 0� ?"i.D C kl E J£'_f3 DI SIG^1 r�L�L4' ��d �� C I ID�q y f-•f-c G7 DES/ tV �Q F'�1 NG /5 o s F-D , -� P)e0/7 QED L Ef3C ,. SEP 7"/42 5 S TE r`'1 �,`J'ST�E' UC T: fl n✓ 5. ,'F�3 L-". C 0 /`9T;0J111l T S T PE-5 UL Ts •�,' 2 •Il ��1VAJ:sTl?� �CF7� 7"f-� 'EGC/a' A?/�C3,4�15'.1 SILL. C.LE.V. TC7 .-] „�` 7f r?r�fi/�~ G`7�.. o),:; 4 j r-tAh/1toZ avv� ro 7`o Exr6,AJZ> , 'I� r^U5 C�tr ,� ., .... k//Th/>`f / C3F �1N1SN€b Cs`,E'RDE �J '�N 1NFld_7-E'�}T,'��(� ' r � � • . MX1�1tMf1M + /4'/"1//�/;M U/`-1----� 57"OJ�✓,� � " O/= � .Tad,. „ n - :, / lia / J,• I ox _;; f,'f , �.:: Ics,.Mrh/• C, P. Y `"/moo or GF L Lihl !vf�S H Z� 60 �f-} L.f1�J /niIV, ,er `'�` f'iT '� R�-� UAJ 7a yet, n l} r. M X- t gi,, fBUD /F?TZD �2 EL.EV: 'A«'' .'L ; $ :1/.1 • G97 2S / 1. ' . HC1G✓A/ v G1F1 URt3 v' R k C.'' ,fe.=? ;E Z?; 1 V 7W. 3i4, ?tia'- Flo.6Q3 /1 / y~ n' y, � "i #$ 4`t?:1. 'll, �✓ -� .¢ 7" ! 0Af b E D,5 '�FG1 S i ERti tiA' in �4 A N`27 T l C "Trl l�.t /, Q T`i- / .lam'J-f3 f+.l I S F ' C�/`1 , 0(,:h✓ Z� 7-1G1 T"Jul8 G A 6 UI! J..n /d�, �S H0411CKIRGE 4.r 3. /U,6 7" ' PJ �. (� Cif 'M I lC�tf,1R, C1 _. Z?/T•�`{"� J^ 7"`_ ; �e k ,,e.&Q U l ram','- 7`/-"z 77 /C-�s7w,& SUR �Z37"�. J r9 J�c'.7?Q 1= .�--1 L � L Tk1