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1295 SHOOTFLYING HILL RD
. .� � . � . . .,. .. t �. ., a �, � -„ s ,. .... ... cr '' 4r �� ,. 0 ,. ....., � r. :, �, n i �t, r e< 4#, ,. _ .y � _ � e I� .h 1' , � .... ... a �A ' L�rl ' 6 f e k i F r o OF THE Tp� Town of BarnstablePerm�t = f` 5��S Expires 6 w2s issue Regulatory Services Fee EARNSTABLE, * / 9� MASS. Richard V.Scali,Director TfD1639. ♦� Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY / `Not Valid without Red X-Press Imprint Map/parcel Number 1�o l�a L` � ; r Property Address_m�,r ( Ch,737,5z- �9/07_ residential Value of Work$ 2 0- 60 Minimum fee of$35.00 for work under$6000.00 _ Owner's Name&Address /1 Z g Zj6kl- Contractor's Name �� �'�/✓,tl /�1/� �_ fC/A�/Q /�l ' Telephone Number ( Home Improvement Contractor License#(if applicable) /3 Email: / /]/� �i/��L ✓ ° /mow. Construction Supervisor's License#(if applicable) g 9� "oran's Compensation Insurance Check one: ❑ I am a sole proprietor MAY Q 12015 RL I the Homeowner M41have Worker's Compensation Insurance TOWN OF BARN STABLE Insurance Company Name - Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Regw5 heck box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers oaof roof) ❑ Re-side g ❑ Replacement Windows/doors/sliders.U-Value (maximum;4 }#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is i SIGNATURE: requ Q:\WPFILES\FORMS\building permit forms\EXPRESS. c Revised 061313 Y IS�1Zd.SZdZng and D n1 , x 1 a dtvis>on of7Constri�ction, Inc. 31-Wanni Circfe: , Centerville, �A 02632 Linda Roche ` _ March 25, 2015 1295 Shoot Flying Hill Rd, , Centerville;°MA 02632 t We are pleased to submit the following specifications and estimates for reroofing: Strip existing asphalt roof Install'8".white drip edge Install ft. ice and water shield ti Install 15 lb. tar paper to remaining roof. F ` Install 30 yr. Certainteed Landmark architectural grade}asphalt shingles 3 Install ridge vent to ridges and round soffit vents to all bays - Clean up and haul away all debris to landfill' We hereby propose to furnish material and labor,-2 complete in accordance with the above specification, for the sum of: Seven thousand eight hundred fifty`dollars..................... ........................$7,850.00 , r , Terms: One-third`deposit required. Balance in fult is due upon completion. . . . All material is guaranteed to be as specified. All work to be'completed in a workmanlike'manner according to standard practices. Any alterations or deviations from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.'All agreements contingent upon strikes,accidents,or delays beyond our control. Owners to carry fire,wind t. . damage and other necessary insurance. RLT.Construction,Inc.carries General Liability.and,Workman's Compensation Insurance. Certificates of Insurance provided upon request. ACCEPTANCE OF PROPOSAL:.The above,prices,specificationsand conditions are. satisfactory and hereby accepted: You are authorized to do the' ork as specified. . ' Payment will be made as outlined above. .Date of Acceptance:,- �:20 j ' Signatur adck �SfIJ dG- Startbate Signatur _ -- Telephone 508.420.5243 and 508.776.8914 'Facsimile 508.420.1776 ' t , J s�. The Canin onrveak h of Massachusetts assachnsetts epartwent of 1idWYtriat Accidents =.:` t ff e of fntmstigations 600 Washinglorr Street Mlorkers' Compensation Insurance Affida-v t: Builders/Contr-actursfE-I tidans/P hers Apphcant Information Please Print Le6bly Name(fat=e&,;Urganiza€ioa11n&vidual): G/ Address: f (ly' City/State!Zp: P/1/_4 R Phone# :ire y an employer?Check the appropriate:b44 Type of project(required): 1. 1 am a. •em toer with 4. ❑ l am ° a general contractor and I employer 6_ ❑ITew cansfiaicfiiori. employees{full and.lor p time).* have lured the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. y- ❑Remodeling slip and have no employees These sob-contractors have g_ ❑Demolition working for me in any c city_ employees and have workers' � y � 9. ❑Building addition. [No workers'comp-insurance comp_insurarlml required-] 5. ❑ We am a corporation and its. 10_.❑Electrical repairs.or additions 3.❑ 1 am a.hGmeo Amer doing all work officers have exercised their I L❑Plumbing repairs or additions *self o workers co mp-: rxghtofexemptionperN[GL myself.� +�- � 1�,. afrepairs insurance required.];" c. 1.52,§1(4),and we have no eraploy .[No workers' 13.0 Other comp_insurance required.] ',ring applicant Est cheats box#1 also fill outthe section belon,showing their nmtkeis°compensation policy infOrn3 don. I omemimers who submit this.affidzMr uLLcatmg they are daiug all weak and then hire autsicre contractors lost submit a new affidavit iadieatng sack- =Contractors thaT check this box mast suached as addidonsr sheet showing the names of the sub-comracturs and state whether or not those entities have erupkyees. Ifthe mb-contraaors have employees,they mirstprovide their workers'comp.policyninnber. lam Tarr emplaver tliat is pros-idurg it orkers'-congwasalion ins7irrar ce for caay enrpiol'ees. Bedorw is tdrepodicy,rznd job arts inform[rtron. Insurance Company NTame: Policy 4-or Self-ills.Lim#f AA Expiration Date_ Job Site Address: 0 /_ p � /`( City/stateizip: d// Attach a copy of the markers'compensation policy eclaratiara p d.age(showing the policy number an expiration orate). Failure to secure coverage as.required under Section 25A of NfGL'r 152 can lead to the imposition of criminal penalties of a, fine up to S1,500.00 and,`or one-year impisonment,as well as c i+il penalties in the form of a STOP WORK ORDER and a tine: of up to$250_0.0 a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office of . Iravestigatiom of the DLA,for insurance coverage verification- I do hereby . P thv pains and arc ofPedurt,thatthe informationptYrr.�i&d abor a is true.acid correct Sienature:: Date: Phone a: Official arse oni�. Do not tr'rite in this area,to be completed by city or tolvil of ciaL City or Town: Permit/License 0 Issn ng Authority(circle-one): 1.Board of Health ?.Building Department 3.titylrown Clerk. 4.Electrical Inspector 5.Plumbing.Inspector 6.Other Contact Person: Phone#: 6 .acoR�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNM) 0211712015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 01005-006 NAME CT Maurabeth Chilson HUB International New England LLC AI NNo.Ext: (508)394-0946 FAX No.: 265 Orleans Road EMAIL nee.mail@hubinternational.com North Chatham,MA 02650-1161 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 3.3758 INSURED INSURER 13: R L T Construction Inc IN URER C• 31 Manni Circle INSURER D• Centerville, MA 02632 INSURE E 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, gEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE'BEEN REDUCED'BY PAID CLAIMS. I EXP N TYPE OF INSURANCE IANSR WVBD POLICY NUMBER MM%DDYW POLICY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE [_7 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG .$ . ff�OLICY E 0 OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ e acci e t r ANY AUTO' -BODILY INJURY(Per person) $ ALUL OWNED SCHEDULED A TOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS acrid t UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ yyp DEDg p RETENTIION $ V g TTLLC� T $ AND EMPLOYERS LIA TL?.N1l X TORY LIMITS OER ANY PRo PRIET ppR/PgqRTNER/EEXECUTIVE�Y/ E.L.EACH ACCIDENT $ 100,000.00. A oFFICER/MEMBER EXCLu0ED7 - i N/A VWC-100-6019620-2014A 11/74/2014 11/14/2015 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00' DESCRIPTION C/�dOPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Town of Barnstable Attention:Wiring Inspector SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD � .k ,x$ to w.`• a t �` � Coyps #ner A= f3c Etus�ne�sea tray " if-ONME IMPROVEMENT CONTRAC 0 e g istratiori 134256�'� F?a Expiration 10/22/2015 +s Corpta�on ,iR CY)N�STTI►VC DBi4`iSLAND5}DING&R0OF1 y, - o. ma a� ;� r ` � ^ fi Rq{ N4E TA�`LOR r E I 31 MANNI CIRCLE CENTERUILLEMA 02362 w � n�eCe�re any Pass I assett isp a ent.o sib is Ief hoard of I3udding Regu4a#ions aridtar+da,vs # C"ollstriac�10n- t;penis(yr Spc i )tr A Y � F 7 • � trcunse::-CSS�-09991D��, _ � �` r v RONNIELTAYx . 'R 3i MAi<IIVI UR'CUl y CENTTRYII.LE'MA 026 10/28/2015 = } • 1 �P JL-7Ocy r . CAP E COD . , OWN OF 8 ARNSTAftr*. i INSULAT10N ❑�� MIA. MAY fie% IIYlY Yu3S 3tAMl[33 fPYAI fPAM 3p3P[ND[p YAKS 311R[YS INSp[A[ION C[IIINPS "' 1-800-696-6611 _ {¢ f t7 't own of Barnstable Regulatory Services Building Division 200 Main St Hyannis, N4A 02601 Date: De,Lr 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 Perfonnance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. { Property Owner Property Address Villa�e } 4)14 4 0V 4D Cew�c.�ur i, M/1 lrisulation Installed: .Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings (X—) Slopes !i h100rs Walls Sincerely Fle y L Cas, y Jr, President C. e Cod I I ulation;.lnc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel D Application # 0 7 o� Health Division Date Issued $h y Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Str et A]d�dr�esfs IJ It Village ttiV b�c/ Owner v` Address Telephone '22 Permit Reque W V h K4 : 10Z Ile VIC !b VA�f& �I Square feet: 1 st floor: existing proposed 2nd1floor: existing proposed Total new :Zoning District Flood Plain Groundwater Overlay Project Valuation b�' v" Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ 'Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of AppealYN thorization ❑ Appeal # Recorded ❑ Commercial ❑Yes o If yes, site plan review# Current Use Proposed Use C �jj APPLICANT INFORMATION GS OU;'J,� i} LDER OR HOMEOWNER) 175, , � � Name Telephone Number Address License # av m t, Home Improvement Contractor# �:✓ S6 Email Worker's Compensation #W cpDU V1 qo l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PRO IT aA_� BE TAKEN TO (Ay, ICA SIGNATURE DATE r FOR OFFICIAL USE ONLY - APPLICATION# I fI. DATE ISSUED i MAP/PARCEL NO. is ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' ' FOUNDATION F Y FRAME INSULATION T• FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 4 GAS: ROUGH FINAL L FINAL BUILDING k DAT&CLOSED OUT c• A$S,OC7 -ION PLAN NO. i . .Massachusetts -DepattmOnt of t5pblic Safety ,Board of Buildinig Regulagons end Standards Construction Supervisor " License: CS-100988 HENRY E CASSIDY 8 SHED ROW s WEST YARMOV"TH k2' r . `J.4.- �J ,� �,��' Expiration Commissioner 11/11/2015 ` �r Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 021�16 a Home Improvement C6atragtor Registration Registration: 153567 Type: Private Corporation - Expiration: 12/15/2014 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE t -- SO. YARMOUTH, MA 02664 - Update Address and return card.Mark reason.for change. l Address 0 Renewal -E]-Employment ❑ Lost.Card SCA 1 0 20M-05/11 - CST e�Liiz�rracyrciceczlt`i a�F%l/lcc:i�ac�tu�et� -,, ` Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: .1$35' 67 - Type: Office of Consumer Affairs and Business Regulation xpiration 121.1-5120.14 Private Corporatioli 10 Park Plaza-Suite 5170 , 4 € Boston,MA 02116 CAPE COD INSULATION,I INC1 F HENRY CASSIDY 1 18 REARDON CIRCLE. ��voT SO.YARMOUTH,MA 0266 IJndersecretar - y Atvalwitho t nat re Tile C,olrrrrtoriivealth of Alassachusetts Deparunent Gf'IrrdustrzalAccidents n r - Ojjice of Inve's4g,7dorrs 600 Washington Street Boston, MA 02111. �t'tww,rr"laSS.�P'Gv/(�Xa ' v�tyri:cYs cup-UfyrC:Yats"ttiou YUsurance A:ffid:ilvit: B"denlCo tractors/ learic-Y i�tr"s1 `Ya xzibe�s il,lt.':atYt i9Yiorulat-Yuklt4 ���t'lEtti Prt.C.1t Lx Y.tiwy . .,tttc �Uw,ne�>lie)rl;u.Llixiitiort/)_ndivitltrul , r Vic' �� / � I t Phone arc fr;i, lae .tytPloYeli•2 (-heck the ,appropriate box: "t'yp orpro' Ject (requjl .ed):�. I -u,l.1 c'.Ittt;,li,ycr W ll.la- Lana a general contractor and f pluy�.c, gull unci;of f)atrt.-time).* have hued the sub-contractors 6. E] New constructiliu ptoprictOr o1 pa.r-tzucr- listdd on rho aaacbcdsheet. 7. Q lzeLxaucleling ;hip and hµve r]U etaapluyees These sub contractors have 8. El DemoIItioki"� vurktu; fur uln L'11 tiny capacity. employees and have workers' stir, .v,rkt:ls' comp. w urancc comp, instuance.t ). ] Building. addition. ylurt:cl.j 5. [] .We arc a,corporarion and its f 4.Q Electrtc.al repairs or add,nons hurtaao�vtaer doing Fill work officers have exercised their 1.M1,;C7 Plurnbtxtb repairs car addtuons . ,,,y:relf. [No .vorkcrx' con-ip. right of exemption per NIGL t c. IS2 1 , toad we have no 12,[' R.00f repairs l tl;itllail�e l4"I,U.UGd.) , § (') uul a hotncowucr acting as tit employees. [No workers.' 1�.�Othee U �,.:.� r �� •.•;tu/ �'L.1l Cl al CUIl Cr'aCtla.r (r-CfC'x- to tf}) - comg insuruce required;) .t it,{,i,cwt tllnt chct ks lwx IFl i111L1t else, till out the 3CC600 below 9howlllg thclrw0cim,cotnlacmttlodiko1icy inftari,ilitiou. _ tu,ttcvwil�,)whr,-b-it aii3 aff1CWyit itad.tcaung they uxc doing all work-ad Lhcn hire uuL9lde cOgq'JC[ol-3 must sub"L tl ncW 11f7111,i1vit W[!ll'iltltlh 9lIlI,thin box Lau-it urWLcbcd an LLdt1 6()Li:il ShcCE showing the nunta Of the xub i ogtisttoly nn�t yt3te w aoctter or qoc d,aYc anutica t,avc :uq,t i;cca It Lo�ulr-4untrru turx huvc ett,t:,luyccx, they must provide,their work-3'comp.policy number. t wu uri calployer that kv pre<<Ydrrrrg worke m compensatiurt lruutanCC fUr my i?17ypll)yCCs' GiQW r9 tlxG Policy urrd ob,iirc '�lfcirrrru(tuvt. P y 1. ,a:iu,u.u�cl'ulllpluzy N:i11]�:�;%r�.��i/G /eft✓1�/Zc`-i/� . . C x trdClOq f'at�:T ���� /�,/ 6 /MVtVCity/statezip- X/v�" t/V1 cufiy of late rvork,ers' cumpetrsultluu pratiun page(showing the policy utimbe.r an expiration date). 'atlui�(U snt;ulc'cuverugo as rcquirrd under Section 25A of MGL e. 152 can lead to tbo uM ,p "t>ot] of clijai ittl peUalties of a PI inc ul;t„ S1.5W-UQ and/or ane-year Lmprisonrnent, as well as.civil penalties in the form of a STOP WORK ORDER and a tirre i Lip w S—)O 00 it tiny against the violator. Bc advised that a copy of this statement may be forwarded to th,4-,Office of 1,�cynPLI01is ofthc DIA for 1MILLITwce coverage verification: u'u deretly<'crrz +�j(n,a(�r lh ttN lend penalties of peijury Thai the information provide ab We rs frrrc and currct:4 I utc Curtly. Do not write in Ihi.Y area, to be compleleJ by city or town offrcia2 city or l'unrz: 1 93rrlli9.-turrrority (circle orate): ----------- I." Ard of ficulLlt 21 Buildl11g Depiartrraent 3. City/Tuwu Clerk a, Efectrfcal Inspector S. Plumbing,.ftaspectol, o. Other Phone#; CAPECOD-27 CVANGELDER ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 4/1/2 D/YYYY) 4/1/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONT_ CT NAME:- Cape Cod Commercial Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 Alc No End): A/C No:(877)816-2156 South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company INSURED INSURER B:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURER C:Evanston Insurance Company 18 Reardon Circle INSURERD:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 INSURER E: INSURER F: - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR TYPE OF INSURANCE POLICY NUMBER MMIDD� MMIDD//YYYY LIMITS POLICY EXP LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR CBP8263063 04/01/2014 04/01/2015 DAMAGE To RENTED PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL BADVINJURY $ - 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY a JJECT LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident B ANY AUTO 14MMBCKVMK 04/01/2014 04/01/2016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 1,000,00 AUTOS AUTOS X N PROPERTY DAMAGE $ HIRED AUTOS AUTOS UTOS NON-OWNED Per accident X , X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 C EXCESS LIAB CLAIMS-MADE R/O XONJ453512 04/01/2014 04/01/2015 AGGREGATE $ DED I X I RETENTION$ 10,000 Aggregate $ 1,000,00 WORKERS COMPENSATION STATUTE EPERORH- D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCA00525904 06/30/2013 06/30/201.4 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBEREXCLUDED? NIA , (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE- EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i + , s OWNER AUTHORIZATION FORM a . (Owner's Name) owner of the located at property (Property Address) C Py �"�°�-"� �Ire /UI % G Z� �'Z • (Property Address) hereby authorize LC , (Subcontract - an authorized subcontractor for RIS Engineering, to act on my behalf to obtain a.building permit and to perform work on my property. Ail? Owner's Signature Date Town of Barnstable Regulatory.Services a .Thomas F.Geller Director MAW ` .,Building Division 039. Tom Perry,Building Commissioner , r 200 Main Street,'Hyannis,MA 02601 ' - www.town.barnstable.ma.us Office: 508-862-4038 M,' r, - F' s Fax: 508-790-6230 PERNII 0 Iba ,FEE: $ . SHED REGISTRATION • r • 200 square feet or less Location'of shed(address) Village - ° ocjp Property owners name Telephone number , IVA9 Size of Shed ' Map/Parcel#J1_ Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District•Commission jurisdiction? /�/ (/• ° _.. _ + Conservation Commission(signature is required) +' Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION, FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. r THIS FORM MUST BE ACCOMPANIED BY A` . -PLOT PLAN Q-forms-shedreg REV:042911 �a 12/10/2009 05:19 15088888667 TOM PONTBRIAND PAGE 01/01 [0 r rto 113 AC K /ja i. szoe ���oP�R Y �5 28 27 zs 120.00 LOT 2.1 NEIGHBOR USING YARD IN THIS AREA. NO. 0 1293 O 20 Ln o eq vi 22 STONE SHARED —�3- DRIVE 120.00 SH00TF'LYING HILL RD . MORTGAGE LOAN INSPECTION f ML13937 SAGAMORE SURVEY ASSOCIATES SCALE: 1 IN.= x P.O. BOX 28 DATE: pEC. 7, 2 0 9FT �,�� 741OFR4 3 AGAMORE BEACH, MA. 02562 508) 888 8667 �' a? T. LMAs: y� PTO CERTIFY TO CAPE COD FIVE CENTS SAVINGS BANK v ONT3RIAND ¢4 HAT THE LOCATION OF THE BUILDING SHOWN HEREON CONFORMS No.343t4 THE ZONING OF THE TOWN OF BARNSTABLE a� I CERTIFY THAT LOCUS DOES NOT LIE WITHIN, THE FLOOD HAZARD o sUFjq ZONE AS DELINIATED ON MAP 0015C COMMUNITY N0. 250001 FLAN ;REFER,ENCE: BARNS I A REGISTRY Of DEEDS REGISTRY OW BOOK/PAGE: LC NO 30545—A, SH 2 LOT NO.: 2.1 PLAN BY CHARLES N. SAVERY, CO. BUYER: DATEDs NARiGH 1, .1960. THIS INSPE :TON NOT MADE 'fRO A S RUME Y AND IS NOT T BE S D FOR FENCES, HEDGES OR TO ESTABLISH LOT LINES. FOR USE OF BANK NLY. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map o Parcel v Application #tAD I Health Division Date Issued 1.5a� Conservation Division Application F Planning Dept. • Permit fee 4\ Le Date Definitive Plan Approved by Planning Board ,5l2n)it Historic - OKH _ Preservation/Hyannis Cr ject_Str_eet_Address O�' L i►'V , Village COw er-` � �. 6 GHQ Address 12 5L i i f - �Telepfione =—P-ermit RWquest� cl now Uajt-�)rnotl" 0 r% /-1"J�V,n i S Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay P_r_oject-Valuation `l i 000; 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 .0 new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other per' Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If p ,es site Ian review # Y CO t � -- Current Use . _ _ .. _v <-:- Proposed Use , APPLICANT INFORMATION (BUILDER OR HOMEOWNER)--,f CNa e k"a I• C cz)g f= Telephone-Numbe_ r`56%' CA61- /IA S� Add`w"ress�`lT-L S l 00-b' License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIG AA U i G DATE ��' � fb . FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED ► :} MAP/PARCEL NO. ADDRESS VILLAGE OWNER i DATE OF INSPECTION: I FOUNDATION FRAME ?�ItD li INSULATION FIREPLACE a ELECTRICAL: ROUGH ? FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 101 Z 11 LAC IzJL5-)I DATE.-CLOSED OUT ASSOCIATION PLAN NO. 1 t _ E 't The Commonwealth of Massachusetts t Department of Industrial Accidents h � Office of Investigations 60t? Washington Street r; Boston, MA 02111 r� www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 99 Please Print Lefxibl g ) �e� !1 C.YI NaI11e Business/Or anizatron/Indtvtdual : Q. Address: ` S�O cr+ �t (� r Odd Ci /State/Zi �" n` P /ItEY'i�i � � .Z(o3.2Phone #: S(U�• ��� `L�� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.0 I am a sole proprietor or,partner- listed on the attached shedt. 7. 0 Remodeling shipand have.no em 10 ees These sub-contractors have P Y 8. .0 Demolition working for me in any capacity, employees and have workers' comp. insurance. 9. Building addition [No workers' comp. insurance P• required.] 5: We are a corporation and its 10.0 Electrical repairs or additions I am a homedwner doing all work officers have exercised their 1 I.El Plumbing repairs or additions myself.[No workers' comp. right of exemptiori per MC 12.0 Roof repairs insurance required.] t c.,152, §](4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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. 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. 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 num-ber 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 floe up to S 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_,yerification. !do hereby c tify under the pains and enalties of perjury that-the information provided above is true and correct_ -imn Lire, Phone# Official use only. Do not write in this area, to be completer)hy'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 S. Plumbing Inspector 6. Other Contact Person: -Phone#: Information and Instructions. Massachusetts General Laws chapter IS2 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 t' or other legal entity, employing em to employees. However the receiver or trustee of an individual,partnership, association g ty, P Y 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 theboxes 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 tha'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 prinEed 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. PIease be sure to 611 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 (iftiecessary) and under-"lob 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'rkot hesitate,to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts . Department of Industrial Accidents +� Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#.617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7744 Revised 4-24-07 W �TVJ� ,mass.gov/dia i Jown'of Barnstable -tHE Regulatory Services B LF_ Thomas F. Geiler, Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-962-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Jl Please Print DATE: numbers t/r`ert . village G FfOMEOWN_-ER'.. Ck 3 VO 9�/n' _2,1C/_5_ T— na— m�e'1 home hone#. work phone# CURRENT—MA-TUN7-ADDRESS:—/ city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a:parcel of land on which he/she resides or intends to reside, on which there is,or is intended to ' be,a one or two-family dwelling;attached or detached structures accessory to such use and/or farm structures.,A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,'that he/she shall be responsible for all such work performed under the building permit, (Section 109.1.1) The undersigned"homeowner"assumes responsibility-for compliance with the State Building Code and other applicable codes,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 witlr•said procedures and r uirements. o e - 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. 04 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 supeivisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities ofa supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results insserious 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 ofa 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 fon-Jccrrification for use in your community. Q;forms:ho mcex empt a f f f &LHNSTAHLE, p$ 16,59. ,�� Town of Barnstable Regulatory Services Thomas F. Geiler, Director Building.Division Thomas PerryzBuilder CBO Buildingr 200 Main Stree 02601 www.town .us Office: 508-962-4038 Fax: 508-790-6230 Property Ost 4 Complete and SSection If Using a I as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by thi boil permit application for: (Address of ob) Signature of Owner Date Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. C:\Users%decollik\A Data\LDcaf\Microsoft\ i W ndows\Tem ora hte c pp p ry � m t Files\Content.OutlooklDDV87AAZ\EXPRESS doe Revised 0721 10 2 { _ 5 r � p : • II Y r' r - , • i e a i4^M � d. C i r _ z —; D � _ t f' t' �„� a ` r "'� a �.,. ,cw .1 't. •� `R"' � _ _ E.-�µ _.-.� -..+ _. ` � � .1.. _1«-r r e y,: st"'t." 5... L _! ��.-• �.rt � } - , , L ! - g •�}} �i' � ,�' �� 4Av. � � t � �. 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