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0245 SOUTH MAIN STREET
•F:� n�'1. ".i t.`. -r.: '•;. '.o-, - .* .-,a R� h R � �' �' Q '"'<` t nh..,o 4, v. ti an hr M C !µ V Q ° , o S F f , ° _ t BUILDING DEPT. . ' Application number...J : ......O .. ....... .................. . . .: JUL 15 2020 a-...J.�Fee...................... ............................. TOWN OF BARNSTABLEMAW guildirig Inspectors Initials...w ... Date Issued.....7 .�.......................................... SC �NE® Map/Parcel.....o?e ejF ......................................... TO OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: y� 6=E � . STREET VILLAGE Owner's Name: —5aA Phone Number—23 4✓�7 d/CQ Email Address: Cell Phone Number Project cost$ 13 Check one Residential_ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize `7,— Is, D.t.ac/g-K to make application r&build' it in acc dance with 780 CMR Owner Signature: Date: d 6 fj*E OF WORK Siding ❑ Windows(no header change)# ❑ Doors (no header change)# ❑Insulation/Weatherization ® Roof not applying more than I layer of shingles) ) ❑ Commercial Doors require an inspector's review Construction Debris will be going to Certificate of occupancy with no construction(complete below) Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit) CONTRACTOR'S INFORMATION Contractor's name (C ( r1O C, rq Home Improvement Contractors Registration(if applicable)# ./0�4�1J57� (attach copy) •4w Construction Supervisor's License# S- 6 Q (attach copy) Email of:Contractor 44s2C-a cv ��3ww�tr Phone number —00—-Z--:7 0/GYl' ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY IS/N A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATIONAUMBER *For Tents Only* Date Tent(s),will be erected Removed on number of tents total Does the tent have si s?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Ten X X X f. . Additional tent dimensions can attached on a sep a piece of paper. " Purpose of Event ' Check one: this event is a: for profit n -profit event Check one: Food served Yes No Flame Spread Sheet of each tent in be attached. Pro ' e a site plan with the location(s) of each tent Fuel source being used LP tank 0 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is req d. If food is being serve t your event please obtain a Health Departmen roval between the hours of 8:00am-9:30 a or 3:30 pm-4:30pm. Commercial events may require i epartment approval *WOOD/COAL/PELLET STOVES * ' Manufacturer# Model/I Fuel Type g ab Offsets from combustibles: fr bac left side right side HOMEOWNER'S LICE E EXEMPTION Homeo 's Name: Telephone Number - Cell or Work number I understand my responsibi ' ' nder the rules and regulations for Licensed Construction Supervisor in accordance h 78 R the Massachusetts State Building Code. I understand the construction ins ion procedures, s 'fic inspections and documentation required by 780 F CMR and the T n of Barnstable. Signature APPLICANT'S SIGNATURE a Signature Date All permit applications are subject to a building official's approval prior to issuance. 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)' Address: l0�l��s-I Q City/State/Zip: Phone#: Are you an employer?Check the 4propriate box:, Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.[V 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 corporation and'its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I. Plumbing repairs or additions .m self ' . right of exemption per MGL Y (No workers comp. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.]- Pc.S dw .4-_S "Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi unde he pains and penalties of perjury that the information provided above is true and correct. Si afore:Z Date: 6 Phone#: Can Official use only. Do not write in this area,lobe 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 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that`.`every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required... Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference.number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining�a license or permit not related to any business or commercial venture (i.e.a dog license or.permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: ' The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-871-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.govfdia' eoar�maoouu a�C�/��aaoac%oe Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual RegistrationN Expiration i i�4521 10/18/2021 FRANK DONOVON' FRANK J.DONOVAN 104 CARLOTTA.A�E. HYANNIS,MA 6 A01 Undersecretary ®� Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const,rkjctiari 1S6pervisor' CS-091391 Expires: 10/28/2020 71 FRANK DONOVAN C 104 CARLOTTA�AVENUE HYANNIS MA 02601 Commissioner C14— ACOR® Client#: DATE CERTIFICATE OF LIABILITY INSURANCEo7/os/zoio M rl -11S-CERT417ICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT 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),AUTHORIZE_D REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies_may require an endorsement.A statement on this certificate does'not confer rights to the certificate holder in lieu of such endorsement(s). ' PRODUCER CONTACT , ,Raphael Oliveira NIAAAF �+ PHONE "• (508)771-4600 DISCOVERY INSURANCE tAlc," EXtJ: EMAIL raphaeldiscovery@gmail.com 668 MAIN STREET UNIT#A ADDRESS: HYANNIS 02601 INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A:Burlington Insurance Company INSURER B: „ AFA CONSTRUCTION INC ' INSURER C: , 23 FRESH HOLES RD INSURER D:LM INS CORP HYANNIS, MA 02601 PNSURER'E: INSURER-F: ` COVERAGES CERTIFICATE NUMBER:000015 REVISION NUMBER: r THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED NAMED ABOVE FOR THE POLICY PERIOD , INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO YSUBJECT' WHICH THIS CERTIFICATE MAY-BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT ` TO TALL THE TERMS,EXCLUSIONS AND CONDITIONS OF•SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRI - TYPE OF INSURANCE.'- ADDLI SUBR .RDUCY NUMBER POLICY:EFF POLICY EX. - - LIMITS TR NSR WVD " MMlDDIYYYY MMIDDIYYYY ',. . . r.. A• GENERAL LIABILITY ,EACH OCCURRENCE _ $ 1,000,000 00 ~ ` DAMAGE TO RENTED X COMMERCIAL GENERAL LIABiU7Y , _ PREMISES(Ea ocurrence) $ 500,600.00 LAI CMS- lI .MADE,IX I OCCUR MED EXP(Any ore person) $ 10,000.00 I 735BOO1586 4/20/2020 4/20/2021 PERSONAL&ADV INJURY $ l,000,000.00 —{ GENERALAGGREGATE J+ .� _ -. ' . . - - .. - S 12,000,000 00 t I 4 L AGORE-4?E LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ r 2,000,OOU!)O I' I j X POLICYrj OJECT LOC !z .. +,_ •I•4' —'-YImo' PR COMBINED SINGLE LIMIT 'AUfOMUBILE LIABILITY (Ea accident) _ ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED t • BODILY INJURY Per accident `AUTOS AUTOS • c' ( ) . NON-OWNED • �'� PROPERTY DAMAGE HIRED AUTOS AUTOS (Peraccident).d C /X UMBRELLA I iAB OCCUR I EACH OCCURRENCE. ' '• 1 EXCESS LIAE, CLAIMS-MADE Y r' s AGGREGATE a DED RETENTIONS • ^ WORKERS COMPENSATION D AND EMPLOYERS'LIABILITY V/N ' X WC STATUTORY ER . , - � LIMITS ER �ANY PROPRIETORlPARTP:E-R/E ECUTIVE OFFICEPAIEMBER EXCLUDED? N E.L.EACH ACCIDENT N NIA WC531 S620362019 10/26/2019 10126/2020 $ 1,000,000.00 I(Mandotory in NH) - •'k' r a 1 E.L.DISEASE-EA EMPLOYEE 1,000,000-00 I k II ye_,des<nbe under - DESCRIPTION OF OPEPA.TiONS below E L DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF CPEf IJIONS/LOCATIONS/VEHICLES(Attach ACORD 101,.Additional Remarks Schedule,if more space is required) - - - GENERAL LIABILITY.for regular and usual jobs. r Workers'Compensation. benefits will be paid to Massachusetts employees and contractors.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees/contractors in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(ur,ess theaexpiration date on the above policy precedes the issue date of this certificate of insurance).The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensationlnvestigationsL..The description of the operations are carpentry. 'F CERTIFICATE HOLDER, CANCELLATION SHOULD ANY OF tHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE f a THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN + ACCORDANCE WITH THE POLICY PROVISIONS." �;)tr:;?t3,i.41��±T1:iII COI7i ` RAP14AEL OLIVEIRA ,_ 1'• • # ©1988-2010 ACORD CORPORATION.All rights resv ve¢. V I� ';'�E �L s�►-t_c.L � /S �7�C� CTS � d 4G W y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -7 b Map. Parcel TOWN OF BARNSTABLE Application Health Division Date Issued Z3 h y Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board DIVISION Historic - OKH _ Preservation/ Hyannis Ll Project Street Address, CN75 alaA) M k)I �Sl LIE:Q -, ,,, i yin Owner'Q \t,N 1 1 , 1 • U&T(1 hy( Address Telephone Permit Request '" �syo�►n� �� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family W' 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: a/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 QA6(kO)� Telephone Number Address License# S' 0 q 1 :5,? /t Gt n f&A f Home Improvement Contractor# lG eiSot I Email 4AS a6 ( , C_NWorker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO AQ SIGNATURE atm(/ti� DATE ,� " ' I G/ ►r, FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING zil s DATE CLOSED OUT ASSOCIATION PLAN NO. : e Rie Cost mo weakh of Massachmseffs Depar&nez,it of firdustzid Accidents - Office of Investigations 600 Washington&reet Boston, 510—HI wnnv.mass.gov1dia Workets' Compensafilonlnauranr 4Lffidavit:BuilderslContractorslElectriciansMumbers A ppEcant Information Pleasa Print Legibly I�I�(Busro�esslOrganization/fndividnat): ��it���� ZiGti�.— Address: JU eq r1 e, ff6' 14 P v GityfStateIZip: -� Phone� J �'l Are you an employed Check the appropriate bo= T3W ofproject(r u re _ 1.❑ I am a employer with 4�❑ I am a general contractor and I 6_ ❑New construction. employees{full andlorpart-tune)* have hired the sub-contractors 7 I am a sole proprietor or partner- listed on the attached sheet +- ❑Remodeling ship and have no employees These sub-contractors have 8_ ❑Deurolitioa for sae to an capacity_ employees and have workers' working y 9_ ❑Building addition [No workers'comp_insurance comp-insurancel requ6red-1 5_.❑ We are a corporation and its 10-0 Electrical repairs or additions 3 ❑ I am a homeowner doing all work officers have exercised their 11_.0 Plumbing repairs or additions myself [No workers,comp right of exemption per MGL rzt�J Roofrepairs insurance required-]!. . 'r c_152,§1(4),and we ha-.m no employees-[No workers' 3�_.❑Othetr comp_insurance req*e-d-] *Any sppUumt that cheds bm-91=ast also fill out the section below showing ihek via cexs cotugeasatiou police infnrrnition " Hameowners who submit this affidavh ink cstiag they are doing an uudt and then hire outside contzacrom mast submit a new affid.,6 im ira- mch- JcDntmcturs thst-ched r this bos roust itticlied nit additional sheet shosmg the nna off fe its-cogs and state whetter aen Hous e se emiri have employees. if the sub-contractors bave employees,they must provide their-wark�s'comp.pvlicp number I am an employer that is protadfxg tt orke-rs'compeiLwfion irLrurarice for riiy employees Below is fire poficp and job rife info rrfrafron. _ Insurance Company Name: Policy 9 or Self-ins_Lie_4: ExpirationDate: J� Job Site Address: 15 JO l'I t'Ll,�i mA, � !• r'Cify,''StiWzip_ e y ) e, WA���( Attach.a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as regturedunder Section 25A of MGL c. 152 can lead to the imposition o f criminal penalties of a fine up to S 1,500-0a and/or one-year imprisonment,as well as civil pena}ti es in the farm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator_ Be advised that a copy of this statement may are forwarded t a the Office of . Im-estigations of the DIA far insurance coverage verification - and hereby'ce finder the ns andpenaWas ofpedmy fhatthe information prinidid aboue is true and correct Date_ li, G Phone#: 0.Okial use only. Do not write in this area,to be completed by cif} or town offic aL. City or Town:. PermitUcense# Issuing Authority(circle one): 1.Board of$ealtfi 2.Building Department 3.Citylrown Cleric 4.Electrical Inspector S.Plumbing,Inspector 6.Other Contact Person: Phone#" 6 J Information and. Instructions i Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute, an ernployee is defined as".._every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shaII withhold file issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for axy applicant who has not produced acceptable evidence of compliance with the insurance,coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their cerri..ficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required_ Be advised that this affidavit may be submit`ied to the Deparfnent of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit '112e affidavit should be returned to the city or town that the application for the permit or license is being requested, not 1.1he Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a vrorkers' compensation policy,please call the Department at the number listed below. Self insured companies saould enter their self-insurance license number oa the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to:U out is the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitllicease number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address-the applicant should write"all locations in (city or town).-'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is oa file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining,a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affida dt. The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commanwealth of Massachusetts Depattma,at of Industdal Accidents office ofkvest gatxans 600 Washington. Strctt Boston,MA G2111 Tel.A 617-727-4900 W 406 or 1-977-MASWE Revised 4-24-07 Fax#617-727-7749 VINM-Ma S-90VIdia I 9 Massachusetts -Department of Public Safety -Board of Building Regulations and Standards C ns"ir''u.taitm Supspi.*)r FRANK DONOV,�T , 500 OCEAN ST#9r s Hyannis MA 0260 1 _ ✓ � � „ �� �" Exoiration Commissioner 10128/2014 ain;eu2ls;notlilm en;o tie;a�aaslapnn ;.Z£9Z0 dW'3lll/�2i31N30 NIHW'OS 54Z ;. 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Details Page 1 of 1 Licensee Details Demographic Information Full Name: FRANK DONOVAN Gender: Owner Name: License Address Information Address: Address 2: CRY: Hyannis State: MA ipcode: 02601 Country: United States License Information License No: CS-091391 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/5/2014 Issue Date: Expiration Date: 10/28/2016 License Status: Active Today's Date: 12/11/2014 Secondary License: Doing Business As: Status Change: License Renewal Prerequisite Information No Prerequisite Information Discipline No Discipline Information Documenturn i http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=2803 3... 12/11/2014 163q KAM Town of Barnstable Regulatory Services -Richard Scali,Director Building Division Thomas Perry,CBO ,Building Commissioner 200 Main Street, Hyannis;'MA.02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230. ' Prope;rrty Own r Must Complete and Sign This Section If Using A Buildr� as Owner of the subject rot e l p petty hereby authorize 6� to act on nay behalf, -Y1 in all matters relative to work authorized by this building permit application for: (Address of Job) JA 11� Signature 4f Owner Date Af Y_V Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. t QAWPFILESTORWbuilding permit fonnslsmokecarbondetectors.doc Revised 050412 - 'i,own.of Barnstable '7 Regulatory Services otr Richard V.Scali, Director Building ]Division s,►texsr�srs, : Tom Perry,Building Commissioner KAM 039. � 200 Main Street, Hyannis,MA 02601 www.town.barnstable,ma.us Office: 508-862-403.8 Fax: 508-790-6230 HOMEOWNER LICENSE ON Please Print DATE: . JOB LOCATION: number stree village "HOMEOWNER': name me phone# work phone# CURRENT MAILING ADDRESS: /ofd ty/to state zip code The current exemption for er ' was extended to include o r-occu ied dwellin s of six units or less and to allow homeowners to en ' 'dual for hire who,does not posse a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcn which he/she resides or intends to reside,on wht ere is,or is intended to be,a one or two-family dwched or detached structures accessory to such use and/or farm structures. A person who constructs morhome in a two-year period shall not be considered a homeowner. Such "homeowner"shall submitlding Official on a form acceptable to the Building Official,that he/she shall be responsible for all such woed under the building permit. (Section 109.1.1) The undersigned"homeowner assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations: The undersigned"homeowner certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. ' r 'Folk . . �z�ki � . - gR C I Vl0d - , .. "-�;'�' � . . / 11 .. . .l...—F.I I . , ` r. . . . 4F as ,�y 2. 6 ,; 1. .. 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(E k E I f I j } . .. { )t t ! � 4 f ! , . a I . {r o . I 11 S r 1 _ _ I` . �� 2.1 I i. .. .r IJ .. CAPE CO® TMNN OF 5- PNSTA-5Lr- INSULATION 7011 APR 12 AN 8: 18 K®®® PIKER GLASS SEAMLESS SPRAT FOAM SUSPENDER RATTS GUTTERS RVSUEATION CEIUNOS 1-800-696-6611w'. Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: 31a0 '13 Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed& completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Villa e U Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( } ( ) Slopes ( ) ( ) ( ) ( ) ( ) Floors V3 QUA+�k oo) Walls �O M,•I p o �� ar► �air d 9 Sincerely hECasJr, President on, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel e�tion # Health Division Date Issued t 3 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation /Hyannis Project Street Address 245 '5P t (A,�• Village '���•L� Owner Ak- Address Telephone r'J� -770 ���✓ Permit Request Guy b AJ e �? ' lit: VAM.44 ��u 5 atie_. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 6001 Construction Type_LK4 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 I Total Room Count (not including battik): existing new First Floor Room, Count 99 Heat-Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other r , Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stoves❑Ye ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing E6new�4ize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 0 o If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name CL Telephone Number 017 AddressL�9AXIC4-A 4 License # Ve"K,6yd-e , Home Improvement Contractor# �✓6� �j p J K Worker's Compensation # U444 ALL CONSTRUCTION D11BRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE A2DATE 3 ` FOR OFFICIAL USE ONLY APPLICATION# F , DATE ISSUED MAP/PARCEL NO. _ ( ADDRESS VILLAGE ~- OWNER _ r DATE OF INSPECTION: w FOUNDATION = 4 FRAME r INSULATION - FIREPLACE ELECTRICAL: ROUGH FINAL 4 PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL x FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Nlassachusetts - Department of Public Sal'ct\ Board of Building Re,ulufiuns antl titandards Construiption Supervisor License - Licenr- CS 100988 r .a HENRY CASSIDY 8 SHED ROW WEST 1JARMOUTH, MA 02673 Expiration: 11/11/2013 ( uuutissiuner Tr#: 7620 J. Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration I Registration: 153567 Type: Private Corporation Expiration. 12/15/?-tl4 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY - ---- ---- 18 REARDON CIRCLE _--------- ---._ - - S0. YARMOUTH, MA 02664 Update Address and return card. Mark reason for change. Address ❑ Renewal Employment I Lost Card ' �e.r, l('o/If/1/.01"/lCf:rl(Cil c L!'((r4Jnc/ZtrJ0ffj s\ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only r tftOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: t[[[lfffe ration: Office of Consumer Affairs and Business Regulation � 9 153567 Type: g S;Expiration: 12/1'5/2014 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATI0N,�1NC:. HENRY CASSIDY 18 REARDON CIRCLE.- _-SO.YARMOUTH,YARMOUTH, MA 02664 Undersecretary ^� 4vaho t t - The Commonwealth of Massachusetts Print Form -�- ° fo Department De Industrial Accidents • it-• ;.: ----- ,- P - t Office of Investigations « , I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ' a llddress:_l City/Stale/Zip: Ut/4L A, Phone Are you an employer? Check.t e appropriate box: Type of project(required): I. 1 am a employer with 00 4. ❑ 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for n:e in any capacity. employees and have workers' insurance.+. 9. ❑ Building addition comp.l No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ME] Plumbing repairs or additions mysel F. [No workers' comp. right of exemption per MGL 12.0 Roof re a rs insurance required.] t c. 152, §1(4), and we have no pj hrs if ` employees. [No workers' 1.3.� Other W k / ho comp. insurance required.] 'Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t i lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such._ ',Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees- If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ``�� fnsttrance Company Name: 6vt C, Polk #or Self-ins. Lic. #: WcA�Q,5 2 5�,7 f y l � `I 01 Expiration Date: �' �f o- Jib Site Address: ��• �- City/State/Zip:C 4kwiAUt 1V19 a��2_ s / 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 tine 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 ofthe DIA for insurance coverage verification.. I do hereby certify^`n�ler the ains rind enalties of er'ury that the information provided above is true and correct. Si mature: �` ' 3 5:Date: Phone#: (� /• i' 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/.fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: GlIellW:4597 ,-;4CO CCINSUIL RD- CERTIFICATE OF L. ABILITY INSURANCE CIA,[(NI141I)t1i) I 07/02120,1TM 2 WN CNLYANO CONFER8 NO RtGHT!3 U -17—E—RTIC-1(-,A vil.j.00. -GATIVELY AIWI�fl,EXI"END OR ALTERTHE CQVCRACQ AFFORDED UY Tili.� CERTIFICATE ATF 001i;F, NUT AJ-;FIwvjAj-jVEl_y OR NE 1".:It' 1 -,-1�; A-ti A MATTE14 OF INFO;4";�l 1-11�i CLRTII`--ICATC OF INSURANCE DOES NO"CONS 11111 IF A CUNI-"CT HEMLIEN]iiE I A I'IVI:: HqUDLIUFF1, ANG THF-,cERTII-ICAfL 116L.LQK, 1*�WING IMSURI:A�(�i),AU I HQKULL) TriQAL IN,�URt Il,the puliCy(les)must be—N Y, II ROGATION1 cI)IkkAI(IkAlI,4 of fil(;pullc Q1 VLJk;Ij oil'111!�ck"lil:'C:I'l4! CI far nyJlu•1 t"Illc Whlliz Mau U�q�u u ;IAy Uolklltt� �1 — e� 508-760A602 PA A L)�,'tj U k�.I(i I)I F-Mi"I - ALIDII I 333 I M"U RC c Adwilic INS LI I'm ICE MA 026ot INJkJR[- U",_,U"_R r: .................. IIAI;i IF IC NUMUER, N17VISION I LAVEULENISSUCP V,'l t I�'.i I A NI)I N(' 1-011(E IKU NAMCD ABOYL III` H I HL IIOHCYK-1,100 . I Qp, C,,jj,jj AI 10111 OF ANY CONTRACTOR OTHER L)O(,U&11- 11. NIAV Bi-- C)p ---NI WITH 1-1t, K",Y 1-11�---'RIWK ME 14URAN -�311[-(�j 1-(.) kvilIGH 11111; WSICflLIWS AND -�'ONL) '�L by THE POLICIES DESCRIDED 14--RE-IN Is suk),IL7- .111ONS Of- SUCH POLICIES. Lui's sHcj'vvN fI,,-,V`NAV9 LIEEN REDUCE.[) BY PAIL! CLAIMS. 1 10 All 11W IWNI��. &noL��p "10-IF 110UHANGL n/yy:ya ------- !zp,�,=g,Y,—!, y v- )y YY) A-Lli- ' - I- cc. i,;I-NII-flAt.LIAWLIly I(;W&I IT110 ADV IN A.110' a''I 000 000 (AcllLt-�J�L A0014iiclAi f:1 s4uo(l 000 111111 APPLWil PgH- MOOLl TYWRIT6!)SINGLE. LI k I I T 'I 2MMBCKVIVJK 4/01/20'12 04/U'i/2U , Uzi zir.cldc ji (101) ............ in UQL)(LV w1juRy If,- X Au I ul" N C1) A PROPERTY bjkm 00 XONJ4535 121 1012 04J0,IJ2U'l` EkCi 0M—-------- _ .4�1 000 Dou = u � .1410'0 _r_ WCA002buki2, x (IN NIA 12 01'1 ACI'01' 000 Nil) 11,q.H91--............ L L L c, PROPERTY Q�Ens - 00-4V. i- stomj000L- - , ururlcale IIC' dt-1 i3 f1lQICldi;d fl!j t4j) 4LI(litiallal illsLif0d LAILIU1 (4111(,ijal Liaoility wtioli 170(11.11rod by written 01, qj I,eej Ile,It. ——----- CANCELLATION GQLJ ll l julallutt lnc 9HQILILO ANY015 THE AOQVI 0E-'.JCRIrJiLW f1QL.IQIki%i Ph 4ANk-KI,0'V)Uhl Oil; THE EXPINATION DATE THEREOF, NOTICE' WILL Hi: UftlVkl\Ctl IN ACCORDANCE WITH THE POLICY FROVInION:1. ........... of, 2070 ACO)"M CORF'(;NA I ION,All I 1911 IU naallvti. U/vti) 'I 1110 ACORL)namn and 1000 ant rfjUkitorod markii;ofACORD W"y sp ..OWNER AUTHORIZATION FORM Ll ( f Owners:Name) owner of the property located at 5, SNAT�� MA)'11 M�J ue (P.roperty Address) � (Property Address) hereby.-authorize ..( ._ — (Sub tract an-authorizedsubcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property._. Owner's:Si nature 1 �. Date CA E COD BA11 INSULATION •$ 2 4 AUG -- All t 5 om• 2.14 nit.OIASi 3t-,55 SPRAT{OAM SUSPENDED BATTS GUTTERS INSYIATION CtNINOS 1-800=696-6611 � - D -AID Town of Barnstable L Regulatory Services i LZ Building Division 200 Main St Hyannis, MA 02601 Date: Dear Building inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property.listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Pro e�rty Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes { i ) w ( ) oO ( ) Floors Walls (X) ) (f ) ( ( ) Sincerely He y E Ca sidy r, President Ca e Cod sulation, Inc. 1 � ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma P Parcel A pPlication l# 03 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 6h/12- Historic - OKH _ Preservation/ Hyannis ' Project Street Address 'Y4 Village Owner � ��b��� � �/ Address Telephone Permit Request z T Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �f iT Construction Type6� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supl:rfing docQ, enta4on. � . Dwelling Type: Single Family tr' Two Family ❑ Multi-Family(# units) .,..g ... Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑rYes z31No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other f Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) �, Number of Baths: Full: existing new Half: existing nevv, �i 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 tea/ Telephone Number ` Address �5���,� � .�� License h�or !w"/& Home Improvement Contractor Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE_ DATE /f//Z--, f FOR OFFICIAL USE ONLY B'APPLICATION# ` DATE ISSUED d' MAP/PARCEL NO. - i ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION, a FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH ,n FINAL ;FINAL BUILDING s. DATE CLOSED.OUT t ASSOCIATION PLAN NO. 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type:' Private Corporation Al Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC � � HENRY CASSIDY tMi 455 YARMOUTH RD. HYANNIS, MA 02601 n JtrUpdate Address and return card.Mark reason for change. K " Address Renewal Employment Lost Card DPS-CA1 0 50M-04/04-G101216 Office o�` mer Affairs Bus ne s tte ul lion License or registration valid for indi��id ! °e^.^.!, HOM j*��'wrea Y�7Cdelta before the expiration date. If found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 •OD INSULATION 1NC_:__ 4w ,.' E� HENRY CASSIDY° 455 YARMOUTH HYANNIS,MA 02601 :r =;;; Undersecretary Aalid ture - Mftssatchusetts-:Departntent of Public Safetl Board of Bu5ldinty Regulations and Standards',. Construction Supervisor License License: CS' 100988 HENRY CASSIDY 8 SHED ROW. WES�T jARMOUTH'`MA'02673 Expiration: 11/11/2013 Tr#: 7620 The Commonwealth of Massachusetts Department of'Industrial Accidents Office of Investigations W 600 Washington Street F , �a Boston, MA 02111 www.mass.gov/dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly t Name (Business/Organization/Individual): r e Cod ei e, , t Address: r City/State/Zip:�xa l/1 d77 (S_ eA 016 G Phone#: 7176 ' Za,1c__Zq Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with I 4,❑ I am a general contractor and'I have 6. ❑ New construction x employees full and/ a•- ' hired the sub-contractors listed on( or p r t time). _ 7. ❑ Remodeling the attached sheet.f 2. ❑ 8. ❑ Demolition I am a sole proprietor or partnership These sub-contractors have and have no employees working for employees and have workers' comp. 9. ❑ Building addition me in any capacity. [No workers' insurance.[ 10. Electrical repairs or additions comp insurance required.] 5.E] We are a corporation and its officers have exercised their right of 11. Plumbing repairs of additions 3• ❑ I am a homeowner doing all work exemption per MGL c. 152§(4),and 12. Roof repairs myself. [No workers' comp. we have no employees. [No workers' 13. Other i insurance required.] t comp.insurance required.] e(`izlU F *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.If the sub-contractors have employeesi they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: /0 � Policy#or Self-ins.Lie.#: WrA 0 A 15 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 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 ma e forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here c under the ins and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 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): a.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . Date: 4/19/2012 Time: 10:13 AM To: Cape Cod Insulation, Inc @ 1508-778-5735 Rogers & Gray Ins. Page: 002 Client#:4597 CCINSUL ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE9rzo�2YYY� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS 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 lieu of such endorsement(s). PRODUCER CONTACT NAME: Margaret Young Rogers&Gray Ins.So.Dennis H(AI NE E:t,508-760-4602 �AkX No: 508-258-2102 434 Route 134 ADDRESS: youngma@rogersgray.com P.0.Box 1601 PRODUCER.CUSTOMER I D South Dennis,MA 02660-1601 , INSURER(S)AFFORDING COVERAGE NAIC# _ INSURED INSURER A:Peerless Insurance 18333 Cape Cod Insulation Inc INsuRER B:Ohio Casualty Insurance Company 455 Yarmouth Road INSURER C:Atlantic Chanter Insurance • Hyannis,MA 02601 INSURER D:Commerce Insurance Company 34754 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP POLICY NUMBER MMIDDIYYYYI (MM/DD/YYYYI LIMITS A GENERAL LIABILrn . CBP8263063 04/01/2011 04/01/2012 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMA E T RENTED PREMISES Ea occurrence $100 000 CLAIMS-MADE I OCCUR MED EXP(Any one person) $5,000 ~ PERSONAL&ADV INJURY $1,000,000.. GENERAL AGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG- $2,000,000 POLICY PRO- LOC - $ D AUTOMOBILE LIABILITY 11MMBCKVMK 4/01/2011 04/0112012 COMBINED SINGLE LIMIT ANY AUTO r (Ea accident) _$1,000,000 ALL OWNED AUTOS BODILY INJURY(Per person) $ , X SCHEDULED AUTOS BODILY INJURY(Per accident) $ . - PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X.NON-OWNED AUTOS 5 $ r. - $ B UMBRELLA LIAR X occuR - 0001254514645 04/01/2011 04/01/201 EACH OCCURRENCE $1 OOO OOO EXCESS LIAB CLAIMS-MADE AGGREGATE - $1,000,000_ DEDUCTIBLE- X RETENTION 10000 $ `+ WORKERS COMPENSATION - WCAOOS259OZ 06/30I2011 06/30/201 X WCSTATU- OTH- - AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA _ E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in If yes,describe a under E.L.DISEASE-EA EMPLOYEE $500,000 under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Comp Information Included Officers or Proprietors " CERTIFICATE HOLDER CANCELLATION _F SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ` THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN * ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ' }' O 1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD #S80552/M68179 MEE OWNER AUTHORIZATION FORM ' J()KY)Sd (Owner's Name) { owner of the property located at - (Property Address) Leh��-✓-'/fie /�� (J z,b3� .� � - (Property Address) 1� T- 4's hereby authorize l q, (Subcont ctor) .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 nature DaY SE M AY.1 12 2412` i` ComplainvTmquiry Report Date: f Rec'd by:--- /tom— Assessor's No.• r Complaint Name:m4 Location ��� �---.-- - �-- -� Address: _ - i NUP Originator Name: Street: vim: Stag zip: Telephone:WE - Complaint Description: Inquiry Desaiption: yO�'-a IFO S7� For Office Use Only Inspector's Action/Comments Date: t - o y — 6 2L n Inspector. � ), \6N SS �01 A o i (nn Follow-up I ' Action . 7�_tZ �� &,Pt C r-- 7w. Additional Info. Attache , apj•Diseikdon: WVa-Deparunent File Yellow-Inspector y a Vail, Town of Barnstable ° Regulatory Services 8"xr ASS, Thomas F.Geiler,Director ` MASS, _ 9q'pr 1639. ►•`�D E g Buildin Division . ' Peter F.DiMatteo Building Commissioner 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLEASE FORWARD THE ATTACHED PAGE(S) TO: TO: z4 ATTN: FAX NO: FROM: DATE: PAGE(S)c " (INCLUDING COVER SHEET) Complaint/Inquiry Report f Rec'd by: Assessor's No.: Complaint Name: Location Address: M/P _Originator Name: Street: vllape: State: ZtP•�— ` Telephone:D/E "c Complaint ❑ G�7�� Description: Inquiry ❑ �5'0� a O <S7 Description: For Olfice Use Only Inspector 's . G s Inspector. � Action/Comments Date: Ilk LL G2 ` 11 Follow-up Action lo Additional Info.Aaaciied Z%� Cop),Distribudion: White-Dep==cnt File I,CBOw-Inspccw, A*.I-- TncnPCCO! (Ret=to Osce Manager) Town of Barnstable Approved Regulatory Services �Ig� d Fee Thomas F.Geiler,Director Building Division Peter F.DiMatteo,Building Commissioner 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 A j�� Home Occupation Registration Date: I' "` ( Name:_ f(I't Alum n Phone#: .CT Address: �� dcef� m i n S f• Village: �nrJWe � Name of Business: (���l e / DU t 1 l,ui n f Type of Business: �Q�el'Worh inc). —56TVlLe. Map/Lot: 2o7V6 INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the following conditions: The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. No traffic will be generated in excess of normal residential volumes. The use does not involve the production of offensive noise,vibration,smoke, dust or other particular matter, odors,electrical disturbance,heat, glare,humidity or other objectionable effects. There is no storage or use of toxic or hazardous materials, or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation, and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the.Customary Home Occupation, other than one van or one pick-up truck not to exceed one ton capacity, and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: Date: Homeo oc Town of Barnstable Approved a� Regulatory Services �Ig� Fee 0 Thomas F.Geiler,Director Building Division Peter F.DiMatteo,Building Commissioner 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 f�A Hoene Occupation Registration Date: f dFi ti Il (,fi(a Phone Name: C ) Address: ��7 ! 000 / �m�� S t" Village: �n�r✓� ��e Name of Business: nooLeM w4 e �1.Ui n t 171 Type of Business:PQperworA inc)- -Sery(Ce. Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors, electrical disturbance,heat,glare,humidity or other objectionable. effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the.Customary Home Occupation, other than one van or one pick-up truck not to exceed one ton capacity, and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: Date: Homeo oc