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0191 SOUTH MAIN STREET
0 0 . � 4 ., `p .. � p 3 a 0 . `� s - 1 � � �. _ .. _ - m � w 0 V i, '� r Town of Barnstable Permit x—/7—�w Expires 6 months from issue date Regulatory Services Fee sn8risraars. • �'(' Richard V.Scali,Interim Director Building Division Tom Perry,CBO,Building Comm 200 Main Street,Hyannis,MA 0260 1 www.town.bamstable.ma,us Office: 508-862-4038 Nov 0 .8 48-790-6230 EXPRESS PERMIT APPLICATION - TIAh ONLY Not Valid without Red X-Press Imprintt AN/�y�r ,- Map/parcel Number ? 0_/ e u� Bu - Prop drty`-Addy&ss`/ 7 S 'Aid, [Residential Value of Work S 5 (off S Minimum fee of$35.00 for work under$6000.00 , Owner's Name&Address It gi S Contractor's Name )�r)-A l*71y-63fd ,� OTLo ' Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) [ Vorkman's Compensation Insurance 66 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance ! Insurance Company Name /y JTT W L— 1 / 10 N A/ /b S • Workman's Comp.Policy# S� 5 S I Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) side ❑ Replacement Windows/doors/sliders.U Value • 2 Gf' (maximum 35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.. Separate Electrical&Fire.Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i:e.Historic,Conservation,etc. 1 ***Note: ope wner must sigh Property Owner Letter of Permission. o y the Home Improvement Contractors License&Construction_Supervisors License is it SIGNATURE: Q:1WPF[LES\F013MS1huilding pe f�XP7W. Revised 061313 ! f Home Depot Contractor License Numbers: MA: 107774, 112785 Salesperson Name and Registration Number: Janice Campbell : R-1-073-13-00016 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions.as outlined on this form. Customer Information: Bob Melley [New England South 10465120 First Name Last Name Branch Name Lead# 191 S Main St Centerville MA 02632 1 KENTERVILLE MA [02632 Customer Address City State Zip [(508) 726-1968 Home Phone# Work Phone# Cell Phone# kamkarr@comcast.net Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip, or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged b • X 10/24/2017 Customer's 5 gn re - Date ' u> ° UN AN �� r^p p Y ,t,i, '; k"i 4.1, ;.{'t;:7 f.9. 'a t,r ,k k I ,i; t ( `r 1�:.;•'r)t b..+1 �.:b :.r 6 S ., cl ( Y � F��O.,BOX 67.3 r y the CGMnWM7'fWArh t OP&MWh eft 119 Ir �. 690 Washhgion met BastoY4 MA DZH Workers' Campenixtim Iasurauce f davit eIS��`-t f *�..�.�,Lr-i��n ere ApplicaidTufbinmfiou Please Prime .Na= Addge= tom_O t�C ur73 Giigf � jtt`�t Qrl7ah �1A 6T,�6 Phowt'k- -Qb7'-69Yz Are you au=player?Checktheappropriate bay Type of project{reqused}: L❑ I am a emplaym Witk 4 0 I aax a bpemmal ronfsctar and I (fall andfor part-time).* hwe hired-Me�- E.0 New c=structim.,V '' Z. I am a sale propdetcr or partner- Tilted on.the attr�sheet 7. El RemadetPag and havens 1 s Txesesub-conract=hava , �P� f $ ❑Demolition wodfiag for me many capacity aadhave wadoxe 9. ❑ ai�iva. [N4 camp. cnsanre ca 1p-kLMr 1c $ -1 5.El We are a cmporafim and its 16.Q Elechical repairs or anus 3.❑ I am.a homeownw&ing au work officers have eYRrdsed thek 11-0 Phmrbingrep=or addidmis mpset€[No w06ae6,comp- Tifflit of emmvficm per MGL 17.❑Roofrepaics rFT7tTF+a]i c-152,§1M andwe have no emplayees(NOwodoe& 1312offier Camp,insma„ce Vie-) �A-ap spg€��stc5ecks SoYl IDms2 elw�amEthe sechioa heTawg�atva�tes'��•m6�••po&eyiQo� 1EMneDwamsw1w suit dm xMd8@g �g��aSg�a�c and@1ea14Ie 6St9dECOII S�St subffit mama Edzeftm surTi. fCantrat�rsfazt AkIr this box n8est attsCLed mt 2114wmd sit sb—ing&a—of the sub-cauftzo wand state wheam canot*use urm employees.Tff8M&C Ada-b—MgAq--%t ley P-V de rbek =mmP-FOi-."I" Ian[rut snig��r Si�ispranria�iig tr�crkers'ca�errsatirrrr irtssraaas,�nr�*emgta}�es $efary is eta prritep and je&bite . ir�ar�rzrrlinra, - N Iusua=e ComgaIIgitEai . 'Policy¢or f-ia€Ii��`_ I�piratioaDafe= • Job Site Address: CO/StafeMpq Af€ach a copy afthe warka-e compensationpolicg declaration page(showing the policy number and expua-tion.date. Fare to serum coverage as requiredunder Sec€ion 2 5A,of MGi.a M can lmd to the imposition of cIImimal peuabi of a fine up to$1,50D OQ mWbr one-ymrimPnsosimoit as W&as civil penalties st the fa=of a STOP V OKK ORDERamd afore of up to$25O.Fl0 a sap ab�ast the violdnc Be.sdvised ffkd a copy ofthis statementmaybe ceded to the Office of Imr inms of the DIA,for coverage v ca Ida herv6p cgrfiry carder dlispaim 4PfYM jWY bia HIS iNfanua€iaaprm &£abmw is bus and cored .Dale Phone rkDer 96Z-b yy1i OBZd d arse wjfy� Da not wrHe in fWs tic,to be cwnpfefi d by city rarlbirn offidal City or Town: Pe rmitUcesse ff Iss�agA�tarttF t�r►ne�: - f L Board of Real& r. Departznemt 3.fdj;rown Clerk 4 Ekch ical hmpectoa- S.,Phanbing luq=tar Confard kerson: Phow 9: The Commonwealth of Massachusetts ` Department of Industrial Accidents 'Y ®ffce of Investigations I Congress Street, Suite 100 ' K4 02114-2017 = =� Boston, www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Please Print Ledibly AppIicant Infoa-mm�ation The Home Depot At-Home Services Name (Business!Oreanization/Individual): Address: 908 BOSTON TPK City/State/Zip: SHREWSBURY. MA 01545 Phone 4: (508)942-6942 FAre you an employer? Check the appropriat ox: Type of project(required): ' lIama employer vt�th 200+ 4• 1 am a general contractor and I 6_ New construction ave hired the sub-contractors employees(full and/or part-time)-* listed on the attached sheet. 7- ❑ Remodeling -❑ I am a sole proprietor or partner- These sub-contractors have 8. Demolition ship and have no employees employees and have workers' 9. Building addition working for me in any capacity. comp. insurance. [No workers' comp. insurance We are a corporation and its 10-❑Electrical repairs or additions required.] officers have exercised their 11- Plumbing repairs or additions -❑ I am a homeowner doing all work riabt of p exemption per MGL myself. [No workers' comp. p 12•❑ Roof repairs c- 152, §1(4),and we have no T 13.[/Other t/1 0- insurance required.] employees- [No workers' ✓� /F comp- insurance required-] l ''An} applicant that check box�1 must also fill out the section below showing their +orkers'compensation polio'information. Homeo��mers 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 subol�nntractbe and state whether or not those entities have employees. if the sub contractors have employees-they must provide their workers comp.p compensation insurance for fray employees. Below is the polies and job site I am an employer that is providing workers' information. • NATIONAL Insurance Company Name: UNION FIRE INSURANCE COMPANY 03/01/2018 Policy#or Self-ins-Lic.€: XWC 65831 45(QSI) Expiration Date: n Job Site Address: �� ,YI City/State/Zip:ea/✓i l �r'1 � �- 4 Attach a copy of the workers' compensation pt�on�aeclaration I A of MGL cpage(showing the- 152 can lead to theolicy number and expiration date) unposition of criminal penalties of a Failure to secure coverage as required under Sec ORDER fine up to$1,500.00 and/or one-year imprisonmenL e that a cll as opy of this statement the an,es in be forwarded toof a STOP the Offic of d a fine of up to$250.00 a day aga a violator. Be advns R. Investigations of the D Sance coverage verification. E r u that the information provided above is true and correct I do hereby eertifi'un, he ains ar d tPe I ry , ` Signature: ( ` Phone _ Official use only. Do not write ui this area,to be completed.by eiht or town 0 is. ` r' Permit/License# City or Town: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6-®tiler Phone#• Contact Per son- ���t ��{ L�L�f,�]C-�9'r.�'�jf C.�r l�J�`r�.��:• 4�l �1 k �Z.��e1'l.J(.'`y 1F C C..�-�Yf,"�.'.°' I Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement'Contractor Registration Type: : Supplement Card Registration: 112785. HOME DEPOT USA INC, Expiration: 04/22/2019 2455 PACES FERRY RD C-11 HSC ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑Employment ❑ Lost Card _ Office of Consumer Affairs&Business Regulation - HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation = 112785 04/22/2019 10 Park Plaza-Suite 5170 4iOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET 2455 PACES FERRY RD C-11 HSC ithOu Signature ATLANTA,GA 30339 Undersecretary IVYYYYI ACo CERTIFICATE OF LIABILITY INSURANCE FDATE0217017 17 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 AU OLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), THORIZED 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 fights to the certificate holder In Ileu of such endorsement(s). CONTACT - PRODUCER NAME: FAX MARSH USA,INC. PHONE TWO ALLIANCE CENTER 35M LENOX ROAD,SUITE 2400 ADDRESS- ATLANTA.GA 3D= INSU S)AFFORDING COVERAGE NIUC 0 100492-HameD-GAW-17-18 INSURER A: db�l� � P4147 INSURED INSURER B:A9"General Insurance Company k2757 THE HOME DEPOT,INC. New Hampshire Ills Co 123841 HOME DEPOT U.S.A.,INC. INSURER C: 2455 PACES FERRY ROAD INSURER D: BUILDING G20 INSURER E: ATLANTA,GA M339 INSURER F COVERAGES CERTIFICATE NUMBER: ATLa374M--14 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CH THIS CERTIFICATEMA NOTWITHSTANDING ISED OR MAY PERTAIN, INSURANCE AFFORDED BY THE PPO OR CONDITION OF ANY RACT OR OTHER LIICIES DESCRIBED HEREIN SS LIB ECT TO ALL WITH RESPECT HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iL SCR I POLICY EFF P011CY E%P �n TYPE OF INSURANCE POLICY NUMBER MNW MMrGD A X COMMERCIAL GENERAL LIABILITY MWZY MOD22 03JD1/2D17 MMV2018 EACH OCCURRENCE S 9,D00,000 t PREMISEDAMAGE S Es oeaurrerx�O RENTED S 1.00(1,OOD CLAIMS MADE ':X;i OCCUR EXCLUDED LIMITS OF POLICY X5 MED EXP(Ark orta person) s OF Sot S1M PER OCC PERSONAL 8 ADV INJURY s 9.000,060 GENERAL AGGREGATE S 9'OOD'OOD GENT AGGREGATE UMT APPLIES PER: - - o I Pya i PRODUCTS-COMP/OPAGG S X POLICY_'JECT _LOC 5 OTHER: 18INEDSI UM A AUTOMOBILELIABILITY MWT831OD21 03l01f2D(7 D3101@D18 Eae s . 1,DOD,000 BODILY INJURY(Per person) S X ANY AUTO BODILY INJURY(Peraaidem) S. A OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS PROPERTY DAMAGE S NON rosmED Per aedtlerd HIRED AUTOS AUTOS S I UMBRELLA UAB OCCUR EACH OCCURRENCE S I EXCESS LL48 CLAIMS-MADE AGGREGATE S - S DED RETENTIONS B WORN RS COMPEr�rnDN WIR C49112300(TN) D31 IM17 MA1112D11 X PUTE OTH- I AND EtV1PU7YERS LIABILITY Y r N WC 423102423(AIGNH NJA 103101017 031DV2018 E L EACH ACC►DSro S 1,000,000 C. ANY PRBPRIETdA1PARTNERIEXEOUrJVE.. .N NIA 1,OOD.ODO C OFFICERIMEMBER EXCLUDED? WC M102424(III) I031D7i2017 D3i01Y1018 E L DISEASE-EA EMPLO S (Mandatory in wHi t,00D,OD0 Ifms d1�0 under oP OPERATIONS bNOw Continued an Additional Page E L DISEASE-POLICY LIMIT I S [EVIDENCE ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 107,AddHlonat Remake Schadulo,may be attached It more apace Is I'DWA ed) . OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEIJ EC'BEFORE HOME ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PAGES S FERRY RY ACCORDANCE WITH THE POLICY PROVISIONS. . AUTHORIZED REPRESENTATIVE _ of Marsh USA Int ManasN Mukherjee �CavAse�-- ©19BB-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ; iF J f f . AGENCY CUSTOMER ID: 100492 LOC#: Atlanta ACC ADDITIONAL REMARKS SCHEDULE Page 2 of .3 AGENCY NAMED INSURED MARSH USA,INC. HOME DEPOT U.SA.,INC. DIBIA THE HOME DEPOT POLICY NUMBER - - - - 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA.GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE Certificate of Liability Insurance Workers Compensation Continced: Cartier.Indemnify Insurance Company of North America Policy Number.WLR C49112294(AL ARFL.ID,IA,KS,KY,LA,MS,MD,NE NM,ND,OK,SC,SD,WV,WY) Effective Date:03101IM7 Expiration Date:030018 (EL)Limit S1,9D0,0OD Carrier.New Hampshire insurance Company Poky Number.WC 023102422(DC,DE.HI,IN.MD.MN,MT,NY,RI) Effective Date:03101=7 Expiration Date:001018 (EL)Limit:S1,000,00D Carrier:ACE American Insurance Company Policy Number.WCU C49112282(OSI)(A7,CA,IL NC,OR VA,WA) Effective Dale:03I01=7' Expiration Date:0310112018 i (EL)Limit S1,000,000 SIR$1,0D0,000 SIR for the states of A7,CA,IL NC,OR,VA WA Carrier.National Union Fire Insurance Company Policy Number.XWC 6M3144(OSI)(CO,CT,GA,ME.MI,NV,OH,PA.UT) Effective Date:03MI12017 Expiration Date:03I012018 (EL)Limit:51.000,oOD S1,000,000 SIR for the states of CO,ME NV MI,OH,PA,UT S750.000 SIR for the state of GA S350,000 SIR for the state of CT Carrier.National Union Fire Insurance Company i PoTrcy Num era.XWC 6583i45(OSO(MP) V / I EHeclive Dale:031012017 rn Q �i/1 Expiration Dale:03ID12018 IELj Limit 51,000,ODD SIR S50D.ODD TX Employers XS Indemni fy Camerllfinios Union insurance Company Policy Number.TNS C48613202(TX) Effective Date:03N72017 Expiration Date:0012018 (EL)Lint$10.000.000 SIR S1,000,000 r ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424 10/18/2016 Form of Notice of Casualty.Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 BARNSTABLE BUILDING COMMISSIONER 367 MAIN STREET HYANNIS MA 02601 Re: Insured: ROBERT.&ANNMARIE MELLEY Property Address: 191 SOUTH MAIN ST,CENTERVILLE,MA 02632 Policy Number: 1281132 Type Loss: Water Damage:Plumbing Systems Date of Loss: 10/17/2016 Claim Number: 409705' Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143 section 6 to be applicable. If any notice under Massachusetts General Laws,Chapter 139 Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. MPIUA Claims Division tZ7 1 Q ' -� c CMA00021 AJ 8 ':' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �$ Parcel 05_1 Application # 7J Health Division Date Issued I III, Conservation Division Application Fee Sv Planning Dept. - Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 111 Sam-r4�, 4!4^1 N 5-r Village C e-AJT-/2 Vi C_L E Owner PA L LE'�:J Address 1011 so MAi.y Telephone So ir z%0 77'7cv Permit Request giWmo%/4g- nloN l��pt�c �vG c.✓�L� Oti+ LSf�t.om2 -cam rwLir cc� .Square feet: 1 st floor: existing a-)/ proposed y 2nd floor: existing proposed Total new o Zoning District Flood Plain Groundwater Overlay Project Valuation cc Construction Type ws> F'✓Lftvrc—, Lot Size L Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Uf Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ,9'No On Old King's Highway: ❑Yes !'No Basement Type: ;dFull ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) t000 + Basement Unfinished Area (sq.ft) 1 +- Number of Baths: Full: existing 3 new Half: existing new Number of Bedrooms: b existingX new E _77 To4al Room Count (not including baths): existing new First Flood om Cou t .1 h/4 Heat Type and Fuel: ArGas . ❑ Oil ❑ Electric ❑ Other T' r Central Air: ❑Yes ArNo Fireplaces: Existing New Existing woo ,/coal stove: ���.Yes JWNo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing '❑ n6Q size_ Attached garage:Oexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: .yy Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use r , ' -APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name S.,,v a.i s c Telephone Number 79!-9 S S- Si Z S-� Address ro 11ox f 6Z License # C S - o25c7 7 F . SAVV0 r✓u--W Home Improvement Contractor# )6 o0 3 7 Email Pv�,� „� G.o,.,.G�s,. iv�T Worker's Compensation # 4 z2H Q Yw6?y)•7-IV ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 3�ac.� c�rL UH.-i��7an,r SIGNATURE DATE I FOR OFFICIAL USE ONLY APPLICATION# r "DATE-ISSUED S MAR/PARCEL NO. ADDRESS VILLAGE OWNER a DATE OF INSPECTION: FOUNDATION FRAME INSULATION r " FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL FINAL B,UIWING: f DATE.CLOSED OUT - ASSQCJATION PLAN NO. d E _ . Tfle Commonmealth of Massachusetts Department of Iirdmsaid Acc idents Ira five ofbWest��60ns 600 Washirigfo;Ft&reet Boston,M 4 02111 WtC m ynass�goF-ldia Workei-s' Compensaf on Insurance-4ffidavit:BiulderslContractors/Electriciansmu-mbers Applicant Information Please Print,Legibly Name gkujoe9s Oxpnization&dividnal)- S 2%i G ��z��'f1,KT1er1 Address: Q G SOX $0 Z CitytStatr/Zip: E 5A-yvPW-v—" Phone 47 '79/-,m s- fare you an employer?Check the appropriate b Type,of project r aired.- 4_ I am s general cntra tar and 1 1_❑ I am a employer with o 6_ ❑New contmctm employees(full and/or part tine)* have hired the sub-couxraciars. �_❑ I am a sole proprietor orpariner listed on the attached sfieet 7-��Ade�g strip and have no employees These ee contractors have ship ❑Demolitioa w for me in an c ci � employees and have,workers' orkrng y apa. t5_ 4_ ❑Building addiuots [No workers' comp_insurance camp_itisuratx�_1 5. 0 We area corporation and its 10..0 Electrical repairs or additions rt�nired_] 3_❑ I am a homeoi6m-er doing all work officers have exercised their 11_.0 Plumbing repairs or additions myself [No warkera'comp- right of e mmptioa per MGL 12-0 Roof repairs insxanre required_)1 c_152, §1(4),and we have no employees [No workers' 13_.D Orher comp_insurance required_] _ *11aysp Uomlthat checks boaWImost Aso fill out the section below showing iheirwoxlten'con.pensationpolicyinfarmatiau_ Homeowners who submit this affidavit indicsting they an doing all xmik and then hire o=de contractors nmst submits uzwaffldavit mdicct r mx:h- tractors ths6 check this box must sttached an additions!sheet shacking the nme o€the s;Ub-ors and state whetber ocnot those en ices b ve eimployees. Ifthe sub-contmctars hie empIogees,they must ptuvide their warkers'comp.policy number_ Iam an employer tIrrrtisFrr»idixrg rt orkers'comllelLsrrlinn insrtrrucc for rstl Rlrtpinpees. Selosr is Srega7ic}ac3rl}ob site infor matlolL Insurance Company Name: 2 H R t C-H -A Mcr-►c t V Polley 9 or-self-ins-Lic-4: to 2 Z N'b V 9SG P V 7 Expiration Date: 1 1-2 Ri-/.1r Job Site Address: l r1 1 S., nA a 1,v CityfState/Zip: CWxt j7y i c.4d Attach a copy of the workers'compensation policy declaration page(shoving the policy number and e_Tni nation da.te). 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.Oa andlor one-year imprisonment,as well as cizal penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office of Iun,estigations of the DIA far insurance coverage verification_ I do hereby c,erh;fyzin L-r the pin unrl penaLFiie fury that the information pratided abm e is Inca and correct Signature= Date.: Phone 4,1 _ Of j7cial use only. Do-not writs in this Area,to be completed by clip or lawn officiaL City or Towa:. PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.City fown Clerk 4_Electrical Inspector S.Plumbing.Inspector 6.Other Contact Person. _ Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iegal 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 shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealt'a for ally applicant who has not produced acceptable evidence of compliance with the insurance.coverage requ.ir ed." 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 Nvih the insurance requirements of this chapter have been presented to the contracting autho ity.7' Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(cs)and phone number(s)along with Neil-ceri_ficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with.no e_,.rl.oyees other than the- members or partners, are not required to carry workers' compensation inSnrarnce_ If an LLC or LLP does have employees, a policy is required_ Be advised that this affidav7t may be submitted to the Depaj-i went of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date he affidavit. '1$e affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Deparm-ent of Industrial Accidents. Should you have any questions regarding he law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Sell 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 he 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 applitations in any given year,need only submit one afiid_.vit 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 bum 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 Conamonw--an of Massachusetts Deparimeat of hidustrial Accidents office offaavest gafians 6.00 Washington Street: Boston_MA 02111 TeL A 617-727--4900 w 406 or 1-&77 MAS,'Wr E Revised4-24-07 Fax# 617-` 27-7749 viww.mas.3-gcv1dia Rightfax .N2-2 12/17/2014 6:-19: 47 AM PAGE 2/002 Fax Server ' DATE(MM/DD/YYYYI CERTIFICATE OF LIABILITY INSURANCE 12/17 T. "" " TIFICATE 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. THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: THE INS AGCY OF CAPE COD PHONE FAX P O BOX 960 (A/C,No,Ext): " (A/C,No): E-MAIL EAST SANDWICH,MA 02537 ADDRESS: 77GBG INSURER(S)AFFORDING COVERAGE NAIC it INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY SUNRISE RESTORATION COMPANY INC INSURER B: INSURER C: INSURER D: P O BOX 802 INSURER E: EAST SANDWICH,MA 02537 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMkDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: r' ENERAL AGGREGATE $ POLICY 0 PROJECT❑LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS, BODILY INJURY $NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR []OCCUR EACH OCCURRENCE Is EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-4956P477-14 11/29/2014 11/29/2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ " 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE- BUILDING DEPARTMENT" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 MAIN STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR "..: ... A.`VE > ': HYANNIS>MA 02601 .:• ; ' ...L'.." ::.. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. . �- �c•�ar,e�»aizaue��tl�a�f��lciucrr�rr,clt Mee of Consumer Affairs&Business Regulation r ME IMPROVEMENT CONTRACTOR egistration =160037^ Expiration =;8i,19120.16"' Supplernc`�t SUNRISE RESTORATION COMPANY `t PETER MEOMARTINO; -P.O.BOX 802 _ -- iH.SANDWICH,MA 02537 Undersecretary r # Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-025077 PETER C MEOMA O- 29 BOARDLEY RD Sandwich MA 02363 i el �y •- . ,I 11A Expiration Commissioner 04142 016 , �"ME Town of Barnstable Regulatory Services BAMSTABy MASS, Richard V.Scali,Director a.19. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:'508-790-6230 Property Owner•Must Complete and Sign This. Section If Using A Builder Lby�� / �� ,as Owner of the subject ro. e • J P P rtY hereby authorize. «�Z�is� ` s 7�2�q--?` to act on my behalf, in all matters relative to work authorized bythis building permit application for. (Address'of Job) "'Tool fences and alarms are the responsibility of the applicant. Pools ; are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature of r 19I atur of App6cant . Print Name Print Name - Date k - • , ' QTOW&OWNERPERMISSIONPOOLS i Town of Barnstable Regulatory Services ��°F TOtyy Richard V.Scali,Director Building Division RARNSMABIZ Tom Perry,Building Commissioner MASS. 1659. 8' 200 Main Street, Hyannis,MA 02601 �Fb MPt www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: - JOB LOCATION: number sheet village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_ DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or fans 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 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 Iicensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit foims\EXPRESS.doc Revised 061313 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION IJ Map d Parcel Ub v Application #a 1 T ""' f� Health Division . Date Issued Conservation Division Application Fe' Planning Dept. Permit Fee ����( � C�7 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 19( So m A„v sf- Village G&-ArTEQ - \/t L.c-g Owner RoA-%- .-r M ya�,c c-7 Address J91 so, mA„v s- - c-An% rickyy-d� Telephone .So S -7 Z G- /94c l) , Permit Request 1 \A!A1VA— 2CMQv6 F-ft-fa-' Gw4 X'Fu y (,*lr7o~ t b\EP c.g cd F�.4�6ww,�vT Ic�k,t,P o.,,T (�,�avr,wr Ta �'it M�a't M b vt�'.► .�irn�„y� �¢a� a fr 13 ns�sr� Square feet: 1 st TIoor: existing�aoproposed 2nd floor: existing proposed Total new 759so 4 Zoning District Flood Plain Groundwater Overlay Project Valuation —Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family If Two Family ❑ Multi-Family (# units) Age of Existing Structure 3 - Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: X Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) U7 Basement Unfinished Area (sq.ft) IS Z Number of Baths: Full: existing 3 new Half: existing new Number of Bedrooms: y existing —new Total Room Count (not including baths): existing new First Floor m Count, y� M Heat Type and Fuel: N(Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes A No Fireplaces: Existing 3. New Existing woad coal stove: ❑ s .9 No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ xisting 0 nj size_ Attached garage:X existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ 0 Commercial ❑Yes X No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION OR HOMEOWNER) Name Perm MthoMAgtn WC) Telephone Number 781- 953-8tZS Address 4o Fber 86L License# 01 CO Eks� S. w«. ozsC3 Home Improvement Contractor# /(.oo 37 Email P0Mg5b ,Q ea td-" At-C-r - Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 4 Ip !, FOR.-OFFICIAL USE ONLY i APPLICATION# L DATE ISSUED MAP/PARCEL NO. !; ADDRESS VILLAGE j' OWNER r DATE OF INSPECTION: .+ FOUNDATION v, FRAME INSULATION `t - FIREPLACE ELECTRICAL: ROUGH - FINAL PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT '; ASSOCIATION PLAN NO. - _ . •: ; ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ' www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Si& -acyu*A-�\, o�1 Address: Po '9,ox- SoZ f, sA-yyowte.%-E M A oz5/.3 City/State/Zip: jE t+ M,& Phone#: 7 8/ -cl S3- S�IZS Are o::a n employer?Check the appropriate b : Type of pioject(required): 1. I employer with 4. neral contractor and I have hired the sub-contractors 6. ❑New construction employees(full and/or part-time).* 1' . 2.El am a sole proprietor or partner- listed on the attached sheet. 7. Z 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.❑ I am a homeowner doing all work officers have exercised their l 1.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have, employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: MMc9t 1c-A / 7 t Ri cli Policy#or Self-ins.Lic.#: td M Vd)Sf,P y'77-13 Expiration Date: 11 Job Site Address: 4 011 !%&-LIU MAmi s r- City/State/Zip: ccye�e_v�oc,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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains d penalties of perjury that the information provided above is true and correct Signature: Date: 16-2-14 Phone#: t F k/- 9'S 3_4/2 5- Official use only. Do not write in this area,to be completed by city or town official 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#: F r ram-, 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 Iicensing 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-contractor(s)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 bum 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 Office of Investigations 600 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 wwwjnass.gov/dia I Rightfax N2-1 944/2014 1 24 11 'PM PAGE 2/005 Fax Server o. �DATEM/DD/YYY.Y) CERTIFICATE OF LIABILITY INSURANCE TI¢ r� .N RTIFICATE IS ISSUED'AS A MATTER.OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON;THE CERTIFICATE THIS CERTIFICATE DOES"NOT.AFFIRMATIVELY-OREGATIVELYAMEND"EXTEND OR ALTER THE COVE RAGE AFFORDED BYTHE POLICIES BELOW. THIS_CERTIFICATE OF INS URANCE.DOES NOT CONSTITUTE'A CONTRACT,BETWEEN THE.ISSUING INSURER(S);-AUTHORIZED. REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate hold evis-an ADDITIONAL INSURED,the"policy(ies)must be endorsed. If SUBROGATION IS-WAIVED subject to he terms and conditions.of the policy;certain policies may require and endorsement A statement on this certificate does not confer rights to he.certificate holder in lieu of such endorsement(s).. PRODUCER CONTACT NAME:. ; THE INS AGCY OF CAPE COD' PHONE • ,,; FAX P O BOX 960 .:.- - - (A/C Nq Ext) „ ---- - _(A/C,_No) - - - - E MAIL :.". _EAS.T SANDWICH,MA'02537 ADDRESS 77GBG. INSURER(S)AFFORDING COVERAGE NAIC q .' INSURED HINSURA INSURER.A:: AMERICAN ZITRIC INSURANCE COMPANY ' SUNRISE RESTORATION COMPANY INC INSURER B:;s INSURER Cr INSURER D: d,. P O BOX 802 •. ,- .. : ;. INSURER E:•.,.. ., .. FAST'SAND'A ICH,MA 02537 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 CONTRACTOR OTHER DOCUMENT WRH.RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY -PERTAIN. THE INSURANCE AFFORDED.BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS_AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED"BY PAID CLAIMS. INSR - ADD SUB ' :' POLICYEFFDATE: POLICY ADD . : LTR - TYPE OF INSURANCE L -R POLICY NUMBER :,(MMMD\YYYY) _:.(MM\DD\YYYY)'. LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISE S(Ea occurrence) , ED EXP(Any one person).;: I$ PERSONAL&ADV INJURY Is . GEN'L AGGREGATE LIMITAPPLIES PER. GENERAL AGGREGATE, Is POLICY, a PROJECT r LOC PRODUCTS.-,COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS " - BODILY INJURY $ SCHEDULE�AUTOS (Per person) - HIREDAUTOS BODILY INJURY $ NON-OWNED AUTOS (Per.accident) PROPERTY DAMAGE $ (Peraccident) UMBRELLA LIAB I I OCCUR $ EACH OCCURRENCE EXCESS LIAB- CLAIMS MADE $ `AGGREGATE DEDUCTIBLE — -- -RETENTI..N-$-: - — � -° - --- - - - -- --- - $ �----- - WORKER'S-COMPENSATION AND ,, _. t wcsTATuroRv OTHER EMPLOY.ER'S LIABILITY. Y/N . UB 4956P477 13 11/29/201' 11/29/2014 X t LiMITs ANY PRDPERITOR/PARTNER/EXECUTIVE - NI/A 10.0,000 OFFICER/MEMBER EXCLUDED? - E.L.EACH ACCIDENT (Mandatory in NH)- _ E.L.`DISEASE-EA EMPLOYEE, $. 100;000, ; __ iFyes descrioeunder • — DESCRIPTION:OF OPERATaONSbelow — EL DISEASE PQLICY LIMIF DESCRIPTION - . THIS REPLACES'ANY:PRIOR,CERT[FICATE:ISSLTED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.. IZ 01 _ _ _ y -CERTIFICATE.HOLDER— — _ _ :CANCELLATION _ " 'TOWN OF.BARNSTABLE - -SHOULD-"ANY•OF-TME:ABOVE DESCRIBED:POUCIES:BE:CANCELLED- •" =BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 367._MAIN ST JN.ACCORDANCE WITH THE_POLICY,PROVISIONS.' AUTHORIZED REPR T E HYANNIS;MA'02601 I, 9 u Massachusetts -Department of Public Safety ' Board of Building Regulations and Standards Construction Supervisor License: CS-0250.77 < PETER C MEOMOTIN0 - 29 BOARDLEY RD ► Sandwich MA 02363 n ' 2, Expiration , Commis siJ 04/12/2016 • �ie tPo�rwnaaiawea�G/z'a ❑lation i ffice of Consumer Affairs&Business Reg EMENT CONTRACTOR ME IMPROV Type.S. ., egistration _§99-lk Supplement i{ Expiration _611912016 RATION COMPANY SUNRISE RES70 I PETER MEOMARTINO p p`.BOX 802 {Ff MA 02537 Undersecretary a C SAMDVVICH, _ , Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-0251077�) PETER C MEOMOTINO' 29 BOARDLEY RD Sandwich MA 02363 I '` Expiration Commissioner 04/12/2016 istration valid for individul use only License or reg date. If found return to: �! before the'expirAt op Business Regulation Office of Consumer Affa►rs and:'. ' 10 park Plaza-.Suite 5170 aid Boston,MA 02116 Not valid, out signature t qq oTME Teti Town of Barnstable o� Regulatory Services Hess.IE$ Richard V.Scali,Interim Director i639. �� Building Division Tom Perry,Building Commissioner 200 Maim Street;Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete.and Sign This Section If Using A Builder I as Owner of the subject property heteby authorize_ KN glse 'RssT'cpgA-r"t o AJ to act on my behalf, in all tnattets relative to work authorized by this building permit 1 °!/ S�, iM M N it Efe7VTL"�V i'—C= (Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled otutil&ed before fence is installed and all final inspections are performed and accepted- ---�" / Signature Ownet Signature of Applicant --jP410<AY*-UO' 42�14 Vert:--- Print Name Print Name -n e.v Date Town of Barnstable Regulatory Services _ - oFt Toiy� Richard V.Scali,Interim Director Building.Division - * mxivsrasc> Tom Perry,Building Commissioner MASS. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6250 HOMEOWNER LICENSE EXEMPTION Please Print DATE. JOB.LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or Iess 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 with said procedures and requirements. Signature of Homeowner Appioval 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 Iack of awareness-often results in serious problems,.part-icularly when the homeowner hires unlicensed persons. In this case; n 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. n.�nrocrr tc�rnv�.fcts..l.i;..e nvnnif G "'A' :WRFSC zinc - SUNRISE RESTORATION COMPANY, Inc. PO Box 802 480 Rte 6A East Sandwich, MA 02537 Home Improvement Contractor#: 160037 CONSTRUCTION AGREEMENT This agreement made this 20 day of September , 2014 by and between Sunrise Restoration Company, Inc.of 480 Rte. 6A PO Box 802, East Sandwich,MA 02537 hereinafter called the Contractor and Bob Melley of 191 South Main St. Centerville, MA hereinafter called the Owner. Witnesseth,that the Contractor and the Owner for the considerations named agree as follows: Article 1. Scope of Work The Contractor shall perform all of the work as agreed between the Contractor and the Insurance Adjuster,to repair the water damage that occurred on September 9,2014 herein called the Scope.The Scope shall include all work to be performed at 191 South Main St. Centerville MA that is agreed upon between the Owner and the Owner's Insurance Company. Article 2. Time of Completion Work shall be substantially completed by: 120 days from receipt of the building permit and receipt of the 1s`bank advance from the homeowner's mortgage holder. Building code upgrade requirements, release of funds by the insurance company may increase the estimated time to complete the work. , Article 3. Contract Price Total price to complete the Scope is: The amount agreed to with the Insurance Company. This does not include any agreed upon change orders or upgrades to the Scope. Article 4. Payments Payments to the Contractor shall be made when funds from the insurance company are released to the Owner. Article 5. It is understood between the parties that all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to;, -Registration Division, Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel: (617)727-3200 ext.26239 Article 6. General Provisions 1. All work shall be completed in a workmanlike manner and in compliance with all building codes and other applicable laws. 2. To the extent required by law,all work shall be performed by individuals duly licensed and authorized by law to perform said work. 3. All change orders shall be in writing and signed both by Contractor and the Owner. Change orders shall be due and payable at the time of the change unless the . Owner and Contractor reach a different mutually acceptable agreement and,put said agreement in writing. 4. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees of subcontractors. 5. Contractor agrees to remove all debris from site and leave the premises in.broom clean condition. 6. Contractor shall prepare detailed estimates for any items that were not accounted for in the Scope and covered by the insurance claim. These estimates shall be submitted to the insurance company in the form of a Supplemental Claim. Contractor agrees to complete the work included in the supplemental claim including all code upgrade work.,Upon the owner's receipt of funds regarding a supplemental claim(s),these funds shall be due and payable to the Contractor. 7. If funds released to Owner are held in escrow by Owner's mortgage company to be released as work is completed throughout the project, Contractor shall be responsible for scheduling the mortgage company's required inspections and release of these funds. Per Massachusetts Law, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Agreed to this day of , 2014. - By on ctor or AuthorizeTRepresentative By Owner or Authorized Represent e ; bl Nff ' - . - . . - � . .> .... µ,.., .ter -t-iiN��'� �:« w`"#'+f.`cyw...r_ .. - �.,+ s.-P`. ...•.�s.1J.a7jx.- TOWN OF BARNSTABLE - Permit No. _______________ { = Building Inspector cash wa .aya OCCUPANCY PERMIT Bond ---------_ f Issued to Larry Nickulas Address, 3 Lot 3, 191 South Main Street, Centerville Wiring Inspector / � Inspection date 4� �"j 41' v - Plumbing Inspector Inspection date xt3 -CPT low Y\ Gas Inspector p ,�? Inspection date C' En meering Department sf/9 � ®� Inspection date / f Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSET S STATE BUILDING CODE. .../.1....:�'... ............... 19. . . -' Building Inspector �Q� �� - �'- - Assessor's map and lot rummer ..... . .......... ......... ...... ........ /_ THE number � . �� � .L SEPTIC SYSTEM MUST B Qyk Sewage Permit number INSTALLED IN COMPL IAN DL,/� � • I7 �., �TS BJHBSTAE. • House number ............. r ......................:.........................::........ WITH TITLE 5 'o, 1639 ' - ENVIRONMENTAL CODE AN '°'F0 MAI TOWN OF BARNS ffn BUILDING INSPECTOR , APPLICATION FOR PERMIT TO ........ ............. � ... ................. .......................... TYPE OF CONSTRUCTION .................... ........' ........................................ :......................... ( ..............! ',o...........19.... 1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........ ®...�......... ...............�+�..I..........`ft................ `-- ........... . ......................... 17 Proposed Use ................ .........,.. .. ................................................................................................. Zoning District ..........�.�.`............................. . .......................Fire District ....... . .......4........... .....jig.:................................ Name of Owner /�►...Address ......�..�. �......:. . �vv/ Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .........................Q.......................................................... Numberof Rooms .......................:.. .......................................Foundation .................4 ......................................................... Exierior ...................lN ...4 ...............:.......,... ........ ......Roofing ................. .�.. Floors ...................... ........ ...................................................Interior ................ / �. Heating Plumbing ..:`..:.:............ ... . ..... .... .... . .... Fireplace .I.....................................................Approximate. Cost ..........1..® .V..' .................................. � �- Definitive Plan Approved by Planning Board ✓--------------_-----------19________ . Area ✓....<.......... .................. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH f . x _J O (� OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ............. .............. ... ... . ..................... .. Construction Supervisor's License ................................-. N I C.KljLAS, LARRY 28309 112 Story No ................. Permit for .................................... Single Family Dwelling ................................................................................. Lot 3, 191 South Main Street Location ................................................................ Centerville ... ................................................................................ _ . -Larry Nickulas Owner ............................................... ............ Frame ype of Construction .......................................... .......... ............................................... • Plot ............................ Lot ................................ P ermit Granted .....Aj4gusp..9........ ....!19 85 , Dote.of Inspection ..................................Z19 SrT -,Date Completed A 9pr WWI M > Cr 16- M 0 P M M 0 Cr M MYCOCK, KILROY, GREEN & MCLAUGHLIN, P.C. ATTORNEYS AT LAW 171 MAIN STREET HYANNIS, MIASSACHUSETTS 02601 OF ('OUN`-I I BERNARD T. KILROY EDWIN S. M+'11O" ALAN A. GREEN APEA CODE 617 CHARLES S. MCLAUGHLIN. JR. 771-5070 A OURE�+ti All. n'1 Ail MICHAEL D. FORD P.O. Box 960 JAMES M FALLA HYANNIS MA« 02601 'August 7 , 1985 MARK D. CARCHIDI , . RF:FEH'TO P'I I M Mr . Joseph DaLuz , Building Inspector Town Hall Hyannis , Massachusetts 02601 RE: Lots 2 & 31 off South Main Street , Centerville , Larry Nickulas Dear Mr . DaLuz: Said lots 2 and 3 located at 171 South Main . Street , Centerville were created in accordance with a plan entitled "Plan of Land in Centerville-Barnstable , Mass . , as surveyed for Alma M. Chamberlain scale 1 in . = 40 ft . , April 1 , 1948 Bea rse & Kellogg - Civil Engineers , Centerville" which is recorded in Plan Book 89 Pgae 75 . As shown on said plan Lot 2 has 16 ,019 square feet and Lot 3 has 16 ,090 square feet . (/ After . zoning was adopted in this area of town , the property was zoned RC and continued .to have a square footage requirement of 15 ,000 square feet until February 28 , 1985 when the minimum lot size became 43 , 560 square feet . However , prior to the zoning change on February 28 , 1985 , the Nickulas ' predecessors in title , Robert A. Thompson and Margaret S . Thompson, checkerboarded the lots by conveying, title to Lot 2 to Robert. A. Thompson under a deed dated February 212 1985 and recorded ' Barnstable Registry of Deeds in. Book 4427 Pgae 9 and conveying ' title to Lot 3 to Margaret G . Thompson under a deed dated February 21 , 1985 and recorded with said Deeds in Book 4427 Page 10 . Title to Lots 2 and 3 is presently held as follows : Lot 2 ( together with a certain way shown on said plan) is held in the name of Larry Nickulas and Cindy Nickulas , Husband and Wife , under a deed from Robert A . Thompson dated March 25 , 198_1) and recorded with said Deeds in Book 4488 Page 281 . Lot 3 is held in the name of Larry Nickulas , Trustee of South Main Street Nominee Trust under a Declaration of Trust recorded with said Deeds in Book 4488 Page 277 under a deed from Margaret G . Thompson dated March 25 , .1985 and recorded in Book 4488 Page 282 . G Mr . Joseph DaLuz , Building Inspector -2- August7 , 1985 By virtue of the aforementioned conveyances , the lots were in separate ownership at the time of the zoning change in February 28 , 1985 and continue to be. held in separ.)to ownership. . • Said lots , therefor , have the benefilt- of the grandfather clause (Section G ) and are buildable lots under the Barnstable: Zoning Bylaw . Very truly- yout'§, Michael D. Ford MDF: jmf 0576j goo'w�OTK x 4. /S.SfGsF h} f2y, ale,r€teA+�//arcs =✓ �� P� _. Vi o CERTIFIED PLOT PLAN ROBERT c B. 1 ' �'GNTE (IL IN G SCALE DATES t3151,9s \ N@ CLIENT All I CERTIFY THAT THE �p�NQgT/dN SHOWN ON THIS PLAN 19 LOCATED QISTERED REGISTERED 85'v�' h 405 NO. ___..._,_z ON THE GROUND AS INDICATED An q CIVIL LAND fi = CONFORMS TO THE ZONING LAWS k ENGINEER JURVEYORS DR.®Y� OF ®ARNSTAaLE, MA83 Y \ ' x 712' MAIN 'STRE.E.T CH.®Ys � - \ 9 HYA!<41S, MASS. SHEETaOF � � � DATE REG. LAND SURVEYOR. 0.........1� ........ . .......... sessor's map and lot �10 O*THE Sewage . ... (9 . ...................Sewage Permit number .......................G... EARISTIBLE, Hobsenumber ......................................................................... MA81 OO 1639* CFO MAY Or• TOWN OF BARNSTABLE BUILDING INSPECTOR 'APPLICATION FOR PERMIT TO ......... .... ...... ......... . ... ......................... .......................... TYPE OF CONSTRUCTION ..................... ....................... t............................... z TO THE INSPECTOR OF BUILDINGS: ............../� ............19....The undersigned hereby applies for a permit according to the following information: Location ......... ................ .................. ............................................ 1.41.t............................................ Proposed Use ............... ZoningDistrict ........../I............................... .......................Fire District ....... .. ......A.......... .................................. Name of Owner ......... avl..... ,--x ,:c................. .... .....................Address ......&.....0.�... ... ...... . .......... K Name of Builder ....................................................................Address ............................ ................ ........................................ Nameof Architect ..................................................................Address ............................... ...................................................... Number of Rooms ...................... Foundation ..................i ... ........................................................... ...Roofing ................. ............................... ................................... Exterior ................. )1d ..... Floors ...4 ... Interior ................ ................... ................................................. ............ ..... ..................... Heating ..................... ..................................Plumbing ....................... ......................................................... Fireplace .......................... .....................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board --------------------------------19--------- Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ............... ................... ..... ...................... Construction Supervisor's License ........ ..... .. .................. ^ 1/08-08 Centerville Frame /ypum Construction —.'�����--------.. --------------------------. . ' Plot ............................ Lot ----------' August 9, 85 Permit Granted -------------.lP Date of Inspection .�—'---------l4 , Dote 'Como��e6 .----------.' lg � � � y . | ' \ / \/ � - ~ ' / ^ �0| r 1 P / TOWN OF BARNSTABLE ��� Bulldilng 201408843 * MUMSTABLE, Issue Date: 01/12/15 Permit MASS. pr16 339. a�� Applicant: SUNRISE RESTORATION COMPANY Permit Number: B 20150053 Proposed Use: SINGLE FAMILY HOME Expiration Date: 07/12/15 Location 191 SOUTH MAIN STREET Zoning District RC Permit Type: RESIDENTIAL ADDITION/ALTERATIO. Map Parcel 208081003, Permit Fee$ 35.00 Contractor SUNRISE RESTORATION COMPANY Village CENTERVILLE App Fee$ 50.00 License Num 160037 Est Construction Cost$ 100 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND REMOVE NON BEARING WALL ON 1ST FLOOR TO ENLARGE LIVING RMIIS CARD MUST BE KEPT POSTED UNTIL FINAL DELETING EXISTING BEDRM 1ST FLOOR&REMODEL BATHRM D T OI0WCTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: MELLEY,ROBERT E&ANN MARIE BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 191 S MAIN STREET INSPECTION HAS BEEN MADE. CENTERVILLE,MA 02632 Application Entered by: JL Building Permit Issued By: U&a THIS PERMIT CONVEY$;NO RIGHT TO OCCUPY'ANY STREET ALLEY.OR SIDEWALK OR ANY PART THEREOF,EITHER ORARILY 0 P N ,ENCROACHMENTS ON'P:UBLIC PROPERTY,NO SPECIFICALLY PERMITTED UNDER THE BUILDING CODE;'MUST BE P PPROVEDBY THE IORISDICTION. STREET OR ALLEY GRADES A WELL AS-DEPTH AN[)LOCATION OF PUBLIC SEWERSMAY BE,,. OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS sTIIE ISSUANCE OF TIiIS PERMIT,DOES NOT RELEASE rflID'APPtiICANT FROM THE CONDITIONS OI ANY APPLICABLE SUBDNISION .. n fti s RESTRICTIONS MINIMUM OF FIVE CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.SHEATHING INSPECTION 3.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 4.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. } 5.PRIOR TO COVERING STRUCTURAL MEMBERS(FRAME INSPECTION). 6.INSULATION. 7.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED-UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.I42A). S S § P BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 L�.iS Q 3�9 IS 2 2 3 / 1 Heating Inspection Approvals Engineering Dept � C1, Fire 2 Board of Health I TOWN OF BARNSTABLE B,,Lti-Iding , �tHE 201406783 BARNSTABLE, Issue Date: 10/14/14 Permit, MASS. 9� 1639. Applicant: SUNRISE RESTORATION COMPANY RFD MAC A Permit Number: B 20142792 Proposed Use: SINGLE FAMILY HOME Expiration Date: 04/13/15 Location 191 SOUTH MAIN STREET Zoning District RC Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 208081003 Permit Fee$ 204.00 Contractor SUNRISE RESTORATION COMPANY Village CENTERVILLE App Fee$ 50.00 License Num 160037 Est Construction Cost$ 40,000 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND RESTORING FLOOR PLAN ON i ST FLOOR FROM WATER DAMAGE RENJWFcARD MUST BE KEPT POSTED UNTIL FINAL FLOORING&INSULAND REPLACE BASEMENT BUILD OUT FAM R OMQrION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: MELLEY,ROBERT E&ANN MARIE BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 191 S MAIN STREET INSPECTION HAS BEEN MADE. CENTERVILLE,MA 02632 Application Entered by: JL Building Permit Issued By: ' _THIS PE CONVEYS NO RIGHT TO OCCUPY ANY STREET ALLEY OR SIDEWALK OR ANY PART THEREOF EITHER TE} ORARILY OR ENCROACHMENTS ON PUBLIC PROPERTY NQ SPECIFICALLY PERMITTED UNDER.THE BUILDING CODE MUST BE APPROVED BY THE JURISDICTION. STREETLOR ALC ,GRADES AS L AS- AND LOCATION OF PUBLIC SEWERS-MAY BE a OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS-:THE ISSUANCE OF THIS PERMIT TOES NOT RELEASE THE APPLI, FROM THE CONDITIONS OF,'ANY APPLICABLE SUBDIVISION'; RESTRICTIONS ` MINIMUM OF FIVE CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.SHEATHING INSPECTION 3.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 4.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 5.PRIOR TO COVERING STRUCTURAL MEMBERS(FRAME INSPECTION). 6.INSULATION. 7.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF.CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A).. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECT�IIO�N APPROVALS I'L/j 161 41 CSC' 16 2 Ns u g1l 2 2 3 1 Heating Inspection Approvals Engineering Dept Firre 2 Board of Health S t N I vv 17 MELLEV RESIDENCE 191 SOUTH MAIN STREET CENTERVILLE MA I°RIST FLOOR PLAN , LA { i 1-7 -- a Y Zcao t� z'�,� II� -E Gr f rya Ss T*X%j CL I 6 - 191 SOUTH MAIN STREET Li I CI ' . �� 1 N � CENTERVILLE, MA i BASEMENT FLOOR PLAN $ AI/ :l N SMOKE DETECTORS REVIEWED Q' B(�F+V LPL f 'ILDINC,DEPT. GATE FIRE DEPARTMENT DATE . J BOTH SIGNATURE. ,Rc«<"T crj FOR PERMITTING CIO ct 03 « t 03 rn .�•,.,.--._.,.._ ... _. Y 1. y .,. _ .. .. t: T r ' 191 SOUTH MAIN STREET ... . CENTERVILLE- MA • 1 3 - � _ _ • . St .REVISED 1 FLOOR PLAN RE to i -- - MELLEY RESIDENCE 191 SOUTH MAIN STREET CENTERVILLE MA FRIST FLOG IY��YIf' -_ '------- l. � R r P LA ' ; .17 ' rr l ) 1 •�.. , . � i � .• _- ' MELLEY RESIDENCE 191 SOUTH MAIN STREET CENTERVILLE IAA ASEME T FLOOR PLAN 6ql i F IVA Stt � l-t At-4- V TA 191 SOUTH MAIN STREET 1 CENTERVILLE, MA i REVISED BATH PLAN •ii