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0489 SOUTH MAIN STREET
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"��ea. -. •.-t.--� h -„ � ....a':3';:"G` s; +3+�'l'.� -�ri �cP`tJ �.+14-�.a ati5s�` '�3 �.}:T�TiSin"�,C_�•4x'�...S""%i.�'sln;�''e.:j;, ti. �s....... - �.s�c "� � a •u' •� :::a'.+:,--.`-•�.�<,-'Sa`:.�--�4=ate_.'--•.'k'.��T �•r "`''st-S s:.- �.r �'•yz,�' , �, i�.G_.. ::+-r r3��e.:y -�,..�e1�i�-�'rSe3 f Assessor's rnco-and lot'number ...20616.3 .............. PTIC SYS a EM MUST BE 7� �L INSTALL _ � o Sewage Pet number .............................................,............. '� IN COadlro�IAIVCE WITH ARTICLE II STATE THE TOWN OF BARNS N AND TOWN," = - y frO�♦ ii • � 89HH9TODLE; i oaY��•� BUILDING INSPECTOR -, APPLICATION FOR PERMIT TO .....Cons.truct....a...Re.sid. . . .ence. ............................................................... ........ .. ..... .. . .. ....... .. TYPEOF CONSTRUCTION ............. ood. Frame............................................................................................. December 26,�......19_78. TO THE INSPECTOR O� BUILDINGS: � �` ` The undersigned hereby �applies for a permit according to the following information: Location .... .South....(�A0.t....... .........Centerville, MA.................................................................................. Proposed Use Si n le Famil Dwellin ` ............ g1.!. .................X........ ............. ........................................................................................................ Zoning District .......RD.-1 ............ .........................Fire District ....O.sterville-Centerville Name of Owner .....Cha.rl...e...s....W......R.ichard.s.on ,,,,Address .82Birchwod....Dr.. ... ...MA .. . .. .. .. o John B. Lebel Construc- Name of Builder ...ti.R?1..G9...r ..............................Address ............................................ Name of Architect Lebe.l.:. Address .Ost.erv„...11e ...Jq�A......................................: Number of Rooms Six ......................................................Foundation .,.Concrete ..................................................................... Exierior W.C. Shingles......................................Roofing .......AsVya.lt...shingles.................................. .... Floors .......0.ak-Caret....................................................Interior .......S1ie.....etroc.........k ....................................................... Heating ..Forced„Hot Water bry...Q 1.................Plumbing .....2...Bath aomz.................... Fireplace ................ One..................... ...........................................Approximate Cost .... 5�.r.90�...OQ..................................... 1st F1 . 1 , 368 SF. Definitive Plan Approved by Planning Board ________________________________19--------. Area 2nd:...F1...........400..SF r Diagram of Lot and Building with Dimensions See attached site Fee .......... .. plan SUBJECT TO APPROVAL OF BOARD OF HEALTH Q C.itc ' ,gip 10 � Iy I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .,�, ��.. ..... ...................................... Richardson, C. VJ. A=286-63 ' ' . ° .. N .' Permit ��iId -mim��� -����—' -- — . �^~---- � . ^ f�u�� ' --..�����..��0��1��.-----_______.. ` . L PCatilr .��..3��t�..C��gt�.Boad______.. . . . C Centerville ^ r 'l---.--.. ----------- _ ` c Owner .—��x'\�^. ________' ' ` '. . ` ~ ' . � Type of Construction ..Wood.Fcao*a.......... � ---- . ............................................................ � �.. — Pk� Lo| ---------� ----------' ' ! Permit Granted --- 2a........lg ?Q ~ ^ . Date of Inspection -- ��1�.�L1.i .��——]g , . 1 Date Completed ' l� | P --------'��--'' ' + ^ . �=~ PERMIT REFUSED r � .......1-!.69t.. ...... �" | . ' . . ........... _..—^�;.`�� . ---------'--'--'------'—'----' ` . � . Approved ---------------' 19 ^ . ------------------~—.-----. `-- ^ - . ^ ---' --------------^—^---'' u `` \ . �t Assessor's map jaiir lot number ...206/.63....................... ? t S t . Sewage Permit number ..... ;........................... ......................... ., g Qyo�INET TOWN OF B AR.NSTABLE 4, O� w Z BABBSTABLE, i o 9.Are�� BUILDING INSPECTOR APPLICATION FOR PERMIT TO .....Construct..,a...Residence............................................................... TYPE OF CONSTRUCTION .............Wo. ....od Frame .... .......................................................................................................... December 26, 19 7$ ........ ...... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location South County Road, Centerville MA Sin le Famil Dwellin ProposedUse ................. ......................Y...................... ........................................................................................................ RD-1 Fire District ....Osterville-Centerville ZoningDistrict ...................................................................... ................................................................ Name of Owner .....Charles W. Richardson Address ..82...Birchwood Dr. , H , M......................................... .................olden.......... ............A........ John B. L..ebe1 Conetruc- Name of Builder ...tion Co..x...InC.!............................Address .O•sterville.:...MA...................::.................:..... Name of Architect Lebe.1.............................. ..................Address .Osterville.t...MA............................................ Number of Rooms SAX Foundation: ....Concrete... ....................................................................... Exterior W.C. Shingles Roofing .......Asphalt Shingles .... ......................... .................................................................. Floors Oak—Carps ..............Interior .......Sh'Wd`ttY'ock............................................................................... Heating Forced Ho.t...Water by..1.i1................Plumbing .....2..Bathrooms::....................:.....................::._ Fireplace ........One..................................................................Approximate Cost ..... .`10�000.00................. .. ist Fl. "S�. Definitive Plan Approved by Planning Board ---------------------_----------19________ . Area 2nd. F1. 400 SF Diagram of Lot and Building with Dimensions See attached site Fee plan SUBJECT TO APPROVAL OF BOARD OF HEALTH I �J r f 1 1 ' I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. tName ... .....:.....`....... ......................................................... Richardson , C. W. ----- Location _ ..RoaU_______.. - � ' - �-----' ------------ C �� - Owner --':—..,—B..�����g���----___—. ' ' . � ^ .',- of Construction_ --- ~ ` ' . . � nc* ' - _ - - � re,n'n G,onu*z ` � ~~'^ of Inspection^ —' ' ' . � � ' � PERMIT REFUSE/ - ' � . V ' -----. � / -'� \ _....—..�...--.....--- ------------.. '`-------'---' --^^--~'—^----- � ^ � � '------'..—'--'—\�----^^—^'—'---^^ Approved ................................................ lQ _ � ' ---------------^—^'^—^^—'----' - � -----------------------'—^'^' � - � � -Coiamonwealth of-Massachusetts.. Sheet Metal Permit - Map Parcel 0(o3 lute. :r q , ►i ;� y4►T pernut:# _ . Estimated Job.Cost: $ l�T OCR�,JAN'2 4 2017 Permit Fee:� �5 �b -- -- ._ .--- --------- ---- ���1 �,.� � -�PL -ltevieyvecl_�•.r�-.- No ply Submitted YES rro � ;, Business License# -licant.Lieease# Business I&onn,-doII: Propmty Owner/Job„Looafion.Infor ion: Name: C-A RARI to An J��1 1 � C.' NO= y kt)�I-f �c 0 �mwVb --� _ } d 5`neet 3spiue, •stwt LI H So Lk' VY\/IA� r City/TowrL V4-\\MN LAB,; .vy\A . cityqown ►' :- - - Telephone: L509 30 3 .72,7- Telephone: Photo I.D.required/Copy of Photo.LD.,attaclied: • Y NO ; S 1/M4-Unrest icted.li J-2 IYi-2-restri:cted•'to dwellings-3:stories or less and commercial up-to 10;000 sq.f� 12-stories or less. , Iviulti Condo/Townhouses• Other Residential: 1-2:fmmily fami�y' .Commercial: Office Retail Industrial --Educational Fire Dept Approval- Insdtational_ Other Square Footage:•under 10,000.•sq.ft)4 over 1.0,000 sq.fL Dumber of Stories: i Sheet metal work-to be completed: New Work: ^ Renovation: HVAC� Metal Watershed Roofing. Kitchen Exhaust gystem motel-Chimney/Vents .Air Balancing Provide detailed description of work•to be dome: Ln 'rA 1t AT ozoao f3 4 U q G"i6 CC3�' 9 nfiv r� 1 / z `- �� INSURANCE COVERAGE 1` 1 have a current iiabiiitv.insurance policy or Its.equivalent which meets.the requirements of PLG:L Ch.112 Yes[ No El If you have checked Ysm'Indic ate the type-of cdverage.by checkng the appropriate box.below: A Hatiiifty, insurance policy'. Other type of indemnity ❑ Bond ❑ OWNERS INSUf.ANC1 1 ArVEk--I am:awame ttid the ilcensee d2es.•nof have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and tfrat rrrysigraitum on'this-permh application• •S�is requiremah Check One Oniy 'C Owner Agent ❑ ± Signature of Owner or•Owge -a Agent By checking this-box❑,I hereby certify that all of the detalts and infomration•1 have submitEed(or entered r•egarrrmg this appllcaticn are true•and accurate to the best of'my knowiedge mid•bigall sheet nistal work acid instaliatiam.performed under the permit issued'forthis.appricatidn will be ` in compliance with all per0nent provision of the Massachuseis'Bunding Code and Chapter 112 of the General Laws. Duct inspection requiered prior to-insulafiori Instaliabon:YES - . NO ' • Prospectians . Date Comments Final Ias�tiectiom Date Comments Type of-Ucense: 3Y ❑ Master . •`r.,� ❑ - Master-Restricted 'ity/Town ❑Joumeypersotr. Signature of Licensee �ecmit# f ❑Joumeypsrsor Restricted Ucense•Nuiritor. 7P _ =ee$ ❑ Coed*-at wwX .,Mss.cirivk#ol nspectorSignature of Permit Approvar r Office 9dBm wee# Began,MA d -- - ----- '4�ar�ers'�P�,�4�i j„�n-a�tr�,�.ffrriaQit B�*`f�P�sf�a�aesfE'f�nabers r Are YUM ag=OTL°yC•?Cfxeck.ffil-MF.FE priafr'btu Type of Fmiect(r'eqaire4- - k❑ I am a empfagec wift 4- ❑New =VSayees{fall aworp mt-t=r-)* ha bis tyre 7�I am a sole prop�or arparEner listed on the shad sheet �-��D shy and have na employees .I dos have 8- El Demolif u. =u pinyaes and have worms' g f =aim any cap may g_ fiMls addifion wrap-;t,s a,m,1 L&swos� �-iastmce 10 �terh; ieP� r�lf or additions, 1 5-❑ Tie;am a Capa fimand ifs � 3_❑ I am:a hammer douse all vgari,_ of =-s h&ve e=cm d fps ID rxmbirg sepaus or adffific �.. Myself 190 w�'� -157, esea�g 2dwerbftw MO$nofrepaiss zegnirerlj l -,§IC4},audvrekaseu 13-0 Ott er fL,j,R,ktSistax=urtsttsrb ,lamafTffi sImetsbtr�gti�n>ameaf�e �asme�u rasve �Ivyses_ If:`tiKe hase�plv�s,faeg�st gmvide its��s'�RPo-b��� - atn arr srr�p that�spres4 g Marl era'courpsrisatiatt izratFaac for tir��caciptapi<ssv SeIata is diepaMT aad job sates infinmatiarc Rmrn Compmyl`I"- P cc Self=im`Ii� Jolt sifie- Cifyls afzdlp: Attach a capg cif.6e nMrkers'tIDmpcn=6m Policy dwh=tim page Ow il<ng fie pflfiEy r€mo es e�Oratto�date,. Fatilum to set-urm co ague as=gdtrre&=&r Sew 25A o€MM r- M cm lead to the iposi i=of cirni"i pies of a fTP1 Y Dp to$LSDD DD a�ndlor one`•geari ffi�aS civilPe fits is t form of$STOP Wt}RI OIZI]�$nd a fSflB afap to$250-00 a day agate fhe violainc Br-advised tnt a cog tsf t its dat=mtmmybe faded fa the Oftitii of Imresfigx&m o€fEw DIA fbt irmn==coup verif rdiosL fed har-eby certify W=Zff ticspains Andpsaa7ftm ufperftrrp fltetMs and carmct Lph3m ik F3jizal=&an . Ikr nat trrife fn 6ds area,to bit cmwT&ted by city ar to=qffic C tF orTawM PrrcnitfLi_erne Fssrdng Auffiarity(drde one)-- L Enard 4f$ea7ffi 2.BaUffing TLTzrtmc t I CkbpToLKu Ctxk 4EIerftic-al Inspector S.Pbaahkg Emsprctor CaErbtct gersffu: Phi i Lnform anon an.d lhkruc-ions Massarhusetf s General Laws chapter 152 requires all eznployers to provide workers'compensation for their employees. this sue, an ezVLoyee is defined as"._every person is the service of another under any contract of hire, express or implied, oral or writt=-" An eTrrplvyer is defined as"�individual,partizership,association,corporation or other I or_ legal entity, any two or more of the foregoing engaged in a joint mt=p ise,and including the Iegal rep¢eise¢tatives of a deceased employer,or t1he receiver or trclstee of an individual,partneishrp,association or other legal entity,employing employees- However the owner of a dwelling house having not more than three apartrneat 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 apputi-a thereto shallnot because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states tigt revery state or Iocal licensing agency,shall withhold the issuance or renewal of a licence or permit to operate a business or to construct buildkp in the commonwealth for arty applicant who has not produced acceptable evidence of compliance with thenssuraucu 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 ofpublic 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 wormers'compensation affidavit completely,by chexJdag the boxes that apply to your situation and,if necessary,supply sub-Contractors)na;ne(s),addresses)and phone mr- .er(s)along with their cmtncate(s)of insuramm Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)withno employees other than the, members or partners,are not required to carry workers' compensation fi nmaw If as LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be mibmit teed to the Department of lndus#rial Accid m ents for conformation of insurance Coverage. Also be sure to sign and date the affidavit The affidavit should be returned to$te city or town that the application forthe permit or license is being rmq;rested,not the Department of lndastrial Accidents_ Should you have any questions regarding the law or i you are required is obtain a workers' compensafion policy,please call the Depai tment at the ummber listed below Self-insured companies should enter their sr-If-insurance license number on the appropriate line_ City or TowIr 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 ofInvestigaiionshas to contact you regarding the applicant Please be sure to fill in the pennitllicense mnnber which will be used as a reference number. In addition,an applicant that must submit multiple pennit/Ecense spplitaiions in any given year,need only submit one affidavit indicating cinrunt 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 maybe provided to the applicant as proof that.a valid affidavit is on file for future permits or licenses_ A new affidavit must be filed out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture CLe.a dog license or peanit to bran leaves dc.)said person is NOT requited to complete this affidavit The Office.of Tnvestigations would like t o thank you in advance for your cooperation and should you hav a any questions, please do not hesitate to give us a call The Department's address,telephone and fax ntraber= • �`he�ozgmaz<w�at�of I�assach� . Depa�neLt cf s _&QCjdents BastGzts Ili G21 11 TeJ-9 617 7-4 Qxt 4-€6 of I-V-7-MA I S. Revised 4-2447 Fax A 617-727-7-749 q Town of Barnstable Regulatory Services , KAM• s�sreau' * Richard V.Scali,Director i679. Building Division. Paul Roma,Building Commissioner MA..0260.1- _ . -- - -- -•-- -..----- --- --:- www.town.barnstable.ma.us • r - Office: 508-862-4038 — -- Fax: 508-790-6230 Property Owner Must Complete and Sign This Section E , If Using A Builder I '/�i�►��l7 C 6,� 64(d t`as et o Own f the subject property, hereby authorize _C6(`rl!!M lk0 '" to act on my behalf, in all matters`relative to work authorized by this building permit application for: (Address of Job) **Pool 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. S e-af�tivnet�� Signature of Applicant Print Name Print Name k Z' Date f Q:F0RMS:0WNERPERMISSI0NM0IS A MIL r 4� ���;��. ► PDRIVER'S " x� LICENSE y 5 20 3'ill END o�xuMBEa "�r'm w' " NONE [►A f ,q68, • �{ 0, 12048 0&02.4 950- , NONE . „icT.F 03 PA ,,.q A161 n !' ' a - ��ipu i I :VETS AVE / FALMOUTN MA,02540 3352 e 5,go03.�20vw77 �o�.�szoo� . .:. , f �� COfV MONWEALTH OF MAtSACHUSETTS e e e e e BOARD OF SHEET METRE WORKERS ..3 ISSUES THE FOLLOWING LICENSE AS A ', " MAST:ER UNRESTRICTED� ! y rr ti 3� .. PAUL A CARRIGAN A + i P BOX 2084 `'TEAT"ET: MA-02536 2084 ion 3288 04/2812018�``M R, :r 33887 ^ ..:. 9.MUM i e , . PERMIT Town ®f Barnstable *Permit# ( '1U � ` 4 Lvpires G nor the from'sue dale A � 2007 Regulatory Services Fee r Mass ARNSTABLE Thomas F.Geiler,Director Building ]Division �;II►I� �' Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL, ':)NLY Not Valid without Red X-Press hrtprint Map/parcel Numbers I I li Property Address o \ n-) y Residential Value of Work, Minimum.fee of$25.00 for work undo. .;t?00.00 Owner's Name&Address_ C 4 rat pn\, CNTA'So n v ry 5--�• -- I Z a ccas�f C' I\A CC( Contractor's Name ?" ZzeA.)& •— Telephone Nuntber Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Bworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ 1 am the Homeowner I have Worker's Compensation Insurance Insurance Company Name 1 !TA (Lk cc, Workman's Comp.Policy# U Q2ZaA:53\0A U Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Q'Re-roof(stripping old shingles) All construction debris will be taken to t -- � ❑Re-ropf.(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ' "Where required: Issuance of this permit does not exempt compliance with other town do artmen p1 P ��� Ceitscro�rl °"` ***Note: Property Owner must sign,Property Owner Letter of Permission. Home Improvement Contractors icense is required. SIGNATURE: Q:F6rms:expmtrg 3fSi!' >1a x Revisc071405 I Board of Building Regulati ns and Standards One Ashburton Place - Room 13.01 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 103714 Type: Private Corporation Expiration: 7/9/2008 PAUL J. CAZEAULT & SONS, INC.."'..! Paul Cazeault 1031 MAIN ST OSTERVILLE, MA 02658 Update Address and return card. Mark reason for change. DPS-CAI Co 50M-05/06-PC8490 n Address Renewal I j Employment Lost C:ird ,per �� G�,�,��� 0�✓1�,�/ • Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: .103714 Board of Building Regulations and Standards Ex iration:. One Ashburton Place Km 1301 R 7/9/2008 j Type: Private Corporation Boston,Ma.02108 PAUL J.CAZEAULT&.SONS,:INC Paul Cazeault 'rZ 1031 MAIN ST OSTERVILLE, MA 02658`' Deputy Administrator Not valid without signature Board of Building egulations One Ashburton Pace, Rm 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 10/20/1959 Number: CS 026325 Expires: 10/20/2007. Restricted To: 00 PAUL J CAZEAULT 103I.MAIN ST OSTERVILLE, MA 02655 Tr.no: 7696.0 Keep top for receipt and change of address notification. PS-CA1 Cr 50M-04/05-PC8698 , ✓1. V)OOItIl207i[lMgti({p p�✓UfRddCLGtClJe 6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR y Number CS, 026325 .... . j B(rthdate;°,;10/2,0/1959 n E9ires:,.'10/20/2007 Tr.no: 7696.0 Restricted 00 PAULJ CAZEAULT , ` • 1031 MAIN ST �I4A PRODUCER s ,...>.x+i .........e s DATE(MMLDD�YY ;. ....>....� ........a ...:-::.:,..� .:.,.a , '. I THiS GERTIHCATE IS iSSUEp AS A;AATTER OF IN�uc�cacc DOWLING & O'NEIL 5 AGC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE: :222 hE$T tIAIN .STi. :T. HOLDER. THIS CERTIFICATE DOES NOT AMEND t'1?O::BOX19 9 0 ALTER THE COVERAGE AFFORDED BY THE PO EXTEND'-'OR IE`�BELf1Yi(_. HYANNIS MA 02C01 COMPANIES AFFORDING COVERAGE f 22LCR ` GCiMFAvr, A TRAWr.;I1S PROPE;R.TY C,A$UALT'i COP91?AN'! n AMkaLICA + P.: COMPANY MAUL J CAZEAUL' 6 SONS .INC. 1031:MA.IN STIiY.'. 057ERV.ILLE MA• 2655 COMPANY C COMPANY COVEAG""ES z"s.^:. Q' :;,;< nW.•Yi.v'a`.; " "*L:' ..:i;.• 11;i%f:L.: ::;:: ,00 mi•o' Ci:: D sTH1518`TII.CERTf" ...:w t" :. .. •., i:`sa-: FY THA': "1PE POLICIES-'OF INSURANCE LISTED'BED,-. ',y `:' :.ao¢ : ,.,, :;': £;`,^,.. ,v.y sk t 1 r INDICATED;NOTYJITH TA; DING ANY REQUIREMENT,TERM OR CON 'MON OFBANY CONTRACEEN ISSUED T OTHER DOCUMENT WITH RESPECT T WHICHaTHIS URED NAMED'AF30VE FOR THE 1'pltCV ProQ. .CERTIFK:ATE.MAY BE ISSJED OR MAY PERTAIN,THE INSURANCE r .JRDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AS.i_THE TERMS, !'EXCLUSIONS AND CONDI i 7N3 OP-SUCH POGCIES.LIMITS SHONT)M s r; r i-. '.a` S:::..•. ....,_ - \VEBEENREOUC6DBYPAIDCL'AIMS.' s. CO LTR' TYPE OF INSURAtA'.. POLICY NUMGLR POLICY EFFECTIVE POLICY EXPIRATION' £ DATE(rSd10D\Y Y) DATE(MU\OD\YY). LIMITS OENERALLIABILITY .- �, + CUMMtH(3fAL GtNEF:'.:.LIAk)ILIIY GENERAL AGGREGATE f - %t CLAIMS MADE NHUUU(iy t Sjhep/Ur . f , '1 [- ]OCCUR. ._. t (3WNWS A CIJNTRAt,:jms PRO1•• PERSONAL&ADV.IN.IIPRY f FAGPIOGCURRGNGC j ' + RRE DAMAGE(Any one tire) f >;; AUTOMOBILE LIABWTY MED..EXPENSE.(Any ono pe rn) S. ANY.AUTO COMUINCDSINi,I@ 1 , ALL OWNED AUTOS LIMIT j SCHEDULED AUTOS BODIEY INJURY - (PM Person) j HIRED AUTOS ` ° f NON-OWNCO AUTOS BODILY INJURY (Pe(Accident) f . GARAGE LIABILITY' PROPERTY DAMACC. j w + i ANY AUTO-' AUTO'ONLY- EA ACCIDENT' f GTNERTiiANAUTitiINLY: EACH ACCIDENT, ... . EXCESS LIABILITY AGGIILGAlL UM,ORELL A FORM EACH O(1CURRENCE f OTHERTHANUMBRUL-A FORM AGGREGATE j WORKER'S COMPENSATIr,v AND. I A EMPLAYER:SUABILITY..' (UB-0095B69—A-06) 08-10-06 OB— -STATUTORY PROPRIETOR/ 10-07 t '.PARTNERS/EXECUTIVE `. INCL EACH ACCIDENT f. OFFICERS ARE: EXCL DISEASE-POLICY LIMI"i l? S +yS. =' DISEASF-EACH EMPLOYEE g t Mir t. L ►T {' , tz ` REPLACC tJY PRIOR CL'RTII ICATC I„SUED TO '1tIC" CEP.TIFIC c: :• ;rt.. iiTE H GCTI11 0 o a. •w cr F�QI f i' }i.wy.. „'s•:• "'j:':N.r...,,�. t s OLOGT. AC F G VTORI:LR. COMP COVERAGL. 3.,. "'�—����.-- •n':M ....M'v tnY wiil�uv. v.33 ..=.:::iii.�::: �fi"v + -' .�. _ `- ..w %.;....•:.,, -.,-,.ao^:.:v •C•.&i..ti:`nL'L'.0:S�::J,.i�M:iS Y. ;•�:..i:;:;:..a:�.s SHOULD W OF THEABOVE DESCWBED POLICIES BE CANCELLED THE , �r PdUI.J Ca'.:eaUlt 8.SODS. EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1 + ROOfIClgri iC. 10 DF\Y°i WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE + LEFT BUTFAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OOUGATION OR 1031 Mai:- Street LIAIUUTY =FANY,BINDUPuN7HECOYpJiyy,RTSA ►1TSORRGDRES j�jll r t Ostervilic, MA 02655 AUTHORi:;.,D REPRESENTATIVE A b„ ;. ..• i 0kti:CgHpoli�TlUP(1893'; r Client#: 19989 2CAZEAULTPA ACORD.M CERTIFICATE OF LIABILITY INSURANCE 0DATE W) 5/19106D k, PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling 8r O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 222 West Main St PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Western World Paul J.Cazeault&Sons Roofing,Inc. INSURER B: 1031 Main Street Osterville,MA 02655 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE(MMIDDIM LIMITS A GENERAL LIABILITY NPP1012091 04/30/06 04130/07 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAPREMIEES EN of nce $50 0OO CLAIMS MADE a OCCUR MED EXP(Any one person) $2 500 X BI/PD Ded:1,000 PERSONAL&ADV INJURY $1 00Q 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $1 00O 000 POLICY JEa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS ' BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ , NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ ' AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY TORY LIMITS i ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERlMEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate of insurance will be issued directly by the insurance carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Informational purposes only DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SP SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R PRESENTATIVE C. ACORD 25(2001/08)1 of 2 #42866 LS1 O ACORD CORPORATION 1988 I , ��- Town of.Barnsta le Regulatory Services •avrss, $ 'Thomas F.Geiter,Director Building Division Tom]Perry, Building Commissaaner 200.Main Street, Hyamis,MA 02601 M www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Ommer Must Complete aid Sign This Section If Using A,Build= x I, ct ila� %.c, ,as Owoes of the sub .ct asopetty ' hezeby.authorize 2�cis .0 a--I I-n C-. to f--':.;zi inp behaH, 7 in all tnaflets relative to work authorized by this building permit application fcx: ��°I � • Mtn �- o,n�2r'1��11Q..:. (Address of job) Signature CLOW= Date Pikt Nam YOU WISH TO OPEN A BUSINESS? . For Your Information: "'Business certificates (cost$40.00.for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: 5/I Fill in please: C/;• i� 2/Ud �J'cYJ •.;;tW,1u34' . APPLICANT'S YOUR NAME/S: BUSINES YOUR HOME ADDRESS: � /7�fil�/✓!�� m � ?— .I��= TELEPHONE # Home Telephone Numbed 5SN or EIN S—Z C/U fEMAI NAME OF CORPORATION: 'J NAME OF-NEW BUSINESS TYPE OF BUSINESS T C�s'�/� / 1S THIS A HOME OCCUPATION? YES NO O �Z ADDRESS OF BUSINESS,- d) /� i - i�l�l MAP/PARCEL NUMBERr x(.(/� '— 0(a� (Assessing) ere are several thins you must do in order to be in with the rules and regulations of the Town of e starting anew business there g y . When g . Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST .GO TO 200 Main St. — (corner of Yarmouth ' Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO !al SSIO ER'S OFFICE MUST COMPLY WITH HOME OCCUPATION This individ i of per it requirements that pertain to this type of business. RULES.AND REGULATIONS. FAILURE TO rvOAut iz d Signature"* COMPLY MAY RESULT IN FINES. COMMENT • n t , 2. BOARD OF ALTH MUST COMPLY WITH ALL This individual has been i �ofermit requirements that pertain to this type of business. HAZARDOUS MATERIALS REGULATIONS Autho i e rejl* , COMMENTS: 3. CONSUMER AFFAIRS [LI NSING AUTHORI ) This individual has en informed of the li a ing re it ments that pertain to this type of business. o ized Signetur COMMENTS: 1 own of isarnstable OpTHE r� Regulatory Services �y` o Richard V. Scali;Director uatv , Building Division . 19 `0� Tom Perry,Building Commissioner 'rEn►rat a 200 Main Street,Hyannis,MA 02601 ' www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 ' Approved• 2 19 Fee: S Permit#: . HOME OCCUPATION REGISTRATION Date: Name: `Ci S Phone#: Address: 0 S rn�NYI � C n��'ll�. al a�v g e: .Name of Business: JT Met, rn - . 0i Type of Business: � (/! \ Map/Lot'-���S��S oL IN=- It is the intent of this s don to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor,no visual.alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit;located within r that dwelling unit • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. ! No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, l odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of ` normal household quantities. • Any need for parking generated by such'use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lofcontaining the Customary Home Occupation. •, No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit I,the undersigned have read and agree t with the above restrictions for my home occupation I am registering. Applicant: G �J�vl� Date: L Home= 0 v.103113 BALCONY r CATHEDRAL BEDROOM ►_— z} OPEN TO >70±SF Q LIVING RM °0 HALL BEDROOM -- >70f SF sp ATTIC STORAGE • . . y� cam—,._ Co. r { SECOND FLOOR A DECK• n �� ENTRY DINING KITCHEN LIVING ROOM 71t ROOM LNDY. HALL ENTRY 2 BEDROOM Q m DEN >70t _ f ENTRY BEDROOM >70f SF I' �w FIRST FLOOR ' FLOOR PLAN t 489 SOUTH MAIN STREET, CENTERVILLE, MA Basement a. ... 40.. _ . . „».....�TO WIN ,M I IR i Finsihed Side ' �CT- 4AAjlj{ 1 SIGH ; _ ....... . f i. j. 3 � 1 0 KE DET K TORS REVIEWED j l BARNSTABLE BU LDING DEPT. DATE =fr j Utility Room FIRE DEPARTMENT DATE BOTH SIGNATURESARE REQUIRED FOR PERMITING si 1 st Floor _ 40, Kitchen Living Room _ ...... i l 0 . ,. . Bath Bed 2 _ Closet .:= _ Bed 1 4 Q 2st-Floor a- --- - 40 Closet Bed 3 Vaulted Ceiling _ r f ,NO CO _ 1 � 1 E f Gv s Bath " ... '56 Bed 4 MIN F3 Closet I� Attic space ° r�, (g�i � � '�- � � 0012 � �k,K 4V1. �(`no� eln c�� ^'1 ' `�'` ��� ��� �� �ti 8m a�-S y�e a� + D P '�`- ��� ��e �� � vu �e�� a �'� ��oti�S YOU WISH TO O For Your Information: Business certificates (cost$40.00 for 4 years). must do by M.G.L.-it does not give you permission to operate.) You must Take the completed form to the Town Clei k's Office, 1 st FI., 367 Main required by law. DATE: A'Raj ��,� ,:�� -. �• APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADORE _ . TELEPHONE # Home Telephone Nu NAME OF CORPORATION:` NAME OF NEW BUSINESS IS THISA HOME;OCGUPATION? ADDRESS OF BUSINESS When starting a new business there are several things you must do in or Barnstable. This form is intended to assist ou in obtaining the informatio Rd. &Main Street) to make sure you hav the appropriate permits and i TOWN OF BARNSTABLE BUILDING.PERMIT APPLICATION O� 3 � Map C� � Parcel QU+, Application # 4 3 V .DING C) P r Health Division Date Issued'/0 _06 Conservation Division OCT24 Application Fee Planning Dept. T6WN OF BARNSTAg� Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address a MGLI A Village CtAAJRWVI ((e_ Owner 2UA-H L'u, Address kAnIS Telephone Permit Request -6n is cTx40 bsep�- -. A�4 i t�!j 4A14/i on /S�-flvu r TAM Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation JI c3cry Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family NI/ Two Family ❑ Multi-Family (# units) Age of Existing Structure d ` 31 rs Historic House: ❑Yes 4No On Old King's Highway: ❑Yes Z_ No Basement Type: ❑ Full ❑ Crawl 8 Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing IQ new Half: existing new Number of Bedrooms: existing _�[new Total Room Count (not including baths): existing new- First Floor Room Count Heat Type and Fuel: ®'Gas ❑Oil ❑ Electric ❑ Other Central Air: Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 2 No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name belhAi'15 4A Telephone Number "S-7 7- 7 Address 16 L4_0�4 License # C5 - 093 4qS 4A-1 AAA 0,60 I Home Improvement Contractor# �� I Email Iua t16L rC41:1 w eog P Cd 41 Worker's Compensation # y-Z-L7 a 9 1 '6 31 U 5 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO PC;Lj PV i(G-� Ltx s �-_ J h SIGNATU DATE )0 l I J l 4 r , a: FOR OFFICIAL USE ONLY 'APPLICATION # ` DATE ISSUED MAP/ PARCEL NO. ,i ;S s �.t ADDRESS A VILLAGE OWNER ffr, DATE OF INSPECTION: ' FOUNDATION kr FRAME I j INSULATION rk , FIREPLACE ELECTRICAL: ROUGH FINAL :l F PLUMBING: ROUGH FINAL ` GAS: ROUGH FINAL FINAL BUILDING r 4 t DATE CLOSED OUT `7 ASSOCIATION PLAN NO. Town of Barnstable" ' ,Y Regulatory Services Richard V.Scab,Director. 1659. .� ► Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230, A Property Owner Must Complete and Sign This Section If Using A Builder I, (u ((., as Owner of the subject property hereby authorize No 1 i S 4 d' to act on my behA in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool 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. ; r, brillus Print Name Print Name /O/17 /M! Date Q:FORMS:OWNEUERMISSIONPOOLS i I Town of Barnstable Regulatory Services dF Richard V.Scal4 Director a Building Division BARNSTALEM Paul Roma,Building Commissioner NAM 3 `�� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ` Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILINGADDRESS: cityhown 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 with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the-provisions of this section(Section 109.1.1-Licensing of construction Supervisors);_ provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Massachusetts Department of Public Safety Board of Building Regulations and Standards License: OS-093445 Construction Supervisor DENNIS KERKADO 16 KINGS ROAD HYANNIS MA 02601 Expiration: Commissioner 02/26/2018 Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:WWWW.MASS.GOV/DPS CNI, IG/v&oacluaiea ,. office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR 5 - gistration: 177919 Type: xpiration 2124 LLC BAYRIDGE REALTY LLB DENNIS KERKADO 16 KINGS WAY HYANNIS,MA 02601 Undersecretary License or registration valid for individul use only before the expiration dateAf found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature I Cvrfe�+ 3G sew, 14 Ile- T �ihr�nis;�•� (boev'� !S x 40.. �- r - F F I _ Flow- E i 1 l i i r` f i i CERTIFICATE OF LIAMLITY INSURANCE j 03-17-2016 THIS CERTIFlCAiE 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 REPRESE VTATIVE OR PRODUCER,c AN must be endorsedTHE TEif SUBROGATION IS WAIVED, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, p y( ) suhect to die terms and conditions of the policy,ce-tain policies may require an endorsement. A statement on this certif sate does ot confer rights to the certificate holder in lieu of sL ch endorsement(s). CON, cT i,1x PHONE I 1 &GRAY INS 'A'C.No Exti I ^, E-MAIL. — --_-- 02660 f3Ess--_ ------ — -- SOLTH D_NNIS.Mr NAn...,—' , - - I INSURERS)AFI`OROING COVt RAGE . T- - MSUREP A:.40.SERICAN=IJRIG".INSURANCE CO-MIP/UvY ,I EA1"iDGF.PEAALTY LLC NSURER C: —.—.--.. --- IF,KINGS WAY INSURER D HYANN'IS,MA 02601 ----- -- i NSURER E: INSURER F: CO:_EI CERTIFICATE NUfiIBER: __—__ — REVISION NUMBER:— S IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NA IED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, PERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, T HE REIN IS SUBJECT TO ALL THE TER INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN IAAY HAVE BEEN REDUCED BY PAID CLAIMS. ___ ----- --_T-.__-- ----._ POLICY EFF POLICY EXP I - .�cR ADDLI SUBR POLICY NUMBER MMfDDlYYYY MMIDDlYYYY __-.. .-__ LIMITS TYPE OF INSURANCE INSR'WVD �_ ) - --,-'- -._ --_ —r j EACH OCCUF,F1.FNCF GENERAL LIABILITY - - I �UAMAGE TO RENTED 5 i i _ C0:1,11,4ERCIAL GENERAL LIABILITY I PREMISES(EP ',C!_AIMSMADE OCCUR % I MFD EXP(Any or:u person) $ _ PERSONAL 3 ADV iNJUR}' __—_- --- _ GENERAI_AGGREGAIE I� � _ - —_ PRGDUC75 ONjp')PPGG !S •� R . 4TE LIMIT APPLIES PER: PRO I 1 I _,C . LIABILITY i-LE-L i I60LI YINJURY er Pei Sci) 4 ,__.._. ALL O/✓NED -SCHEDULED I I PODII Y INJURY( er d.,nry f ,AUTOS AUTOS I,I i P,j20PERTY DAMAGE is ' . NON OWNED I er aceie'enti —I hI1RFD AUTOS AU fOS I S EACH OCCURRENCE Ul:,BRELLA.LIAR - 7 A DED RETENTION i X W C o IATU-j—i OT 1 ORKERS COIdP—EN S AT[0N nRv Llydl15 AND EMPLOYERS LIABILITY I �—L-�-- —I Y'tJ l 100,000 r I(t PhIrTOP PARTNCPt/tXECU'I IV'E— N 1 A I F L.EAC ACCi iF1' o. rEl 19 r eLr Exc.ulDr_'D% jJ E ZZUB 03-09-2016 03-09-2017 L DISEASE-EA FMT Lo FF I S i 00 000 a o r n-i I 9F537099 i _-- -- - --! POuc LIMIT j S50G,000 -- DESCRIPTION OF OPERATIONS i !DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(Attach F,CORD 101,Additional Remarks Schedule,if more space is required) i • _CF_RTlFICA T E HOLDER CANCELLATION__.— --- - --- ._....--- ------- ' � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE (CANCELLED BEFORE THE EXPIRATION DATE THEREOF,( NOTICE WILL BE DELIVERED IN ACCOKDANGE YVtTti THE POLICY PROVISIONS. __--_.---.- --i AUTHORIZED REPRESENTATIVE - -- —-- -- -"--- -- ©1988-2010 ACORD CORPORATION.Al!rights reserved. .CORD:5(20101051 The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street Boston,MA 02111 5. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bayridge Realty LLC/Dennis Kerkado Address: 16 Kings Way City/State/Zip:Hyannis, MA 02601 Phone #: 508-577-7258 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees have hired the sub-contractors o ees full and/or part-time).*P Y ( P ) 2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition No workers' comp. in 5. ❑ We are a corporation and its [ insurance rP 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]f 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. f 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:American Zurich Insurance Company Policy#or Self-ins.Lie.#: 6ZZUB9F537099 Expiration Date: 03/09/2017 Job Site Address: 489 South Main St city/state/Zip:Centerville, MA 02632 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t pen,Urfi?rV1pe,,rjuty that the information provided above is true and correct. Signature: Date: 10/17/2016 Phone#: - -7258 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: i (e X .G we�V,0 a j r i I �r Town of BarnstableBuilding ' tT a� i> anixNst I Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept Posted Until Final Inspection Has Been Made. x6g9• ♦� at�at° Where a Certificate of Occupancy is Required,such-Building shall"Not be Occupied until a Final Inspection has been made. ermit Permit NO. B-16-3060 Applicant Name: BAYRIDGE REALTY LLC. Approvals Date Issued: 10/26/2016 ;, Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04/26/2017 Foundation: Residential Map/Lot: 206-063 Zoning District: RD-1 Sheathing: Location: 489 SOUTH MAIN STREET,CENTERVILLE Contractor Name: BAYRIDGE REALTY LLC. Framing: 1 Owner on Record: RICHARDSON,MARGARET M ESTATE OF Contractor License: 177919 2 Address: 16 KINGS WAY Est. Project Cost: $20,000.00 Chimney: HYANNIS,MA 02601 Permit Fee: $152.00 Description: Finish 15x40 family room in the basement.Add 1 full bath on first floor Insulation: Fee Paid: $152.00 Project Review Req: Finish 15x40 family room in the basement.Add 1 full bath on first Date: 10/26/2016 Final: floor Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless.the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service:. Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3:All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 6/28/2017 Permit Form Ap tl� "J �` sty'. b - it i x M t a` it r rtya:,r€ ,# ,F`,. s2.60a 5�1 ..t 62 tta a „ i m i dkerkado@gmail.com(Contractor) Z Balance Due: $0.00 -PERMIT INFORMATION Occupancy Type Building Type Date Submitted Date Issued Permit For Residential Single Family 10/17/2016 10/26/2016 Building-Alteration INTERIOR Work Only-Residential Project Cost Permit Fee Additional Fee Total Fee Total Paid 20000.00 $102.00 $50.00 $152.00 $152.00 Work Description Finish 15x40 family room in the basement.Add 1 full bath on first floor OWNER APPLICANT RICHARDSON,MARGARET M ESTATE OF BAYRIDGE REALTY LLC. 16 KINGS WAY 16 KINGS WAY HYANNIS MA 02601 HYANNIS MA 02601 ............................................... ............ CONTRACTOR I - 'I. 177 19 02/24/2018 BAYR DGE REALTY LLC. 16 KINGS WAY HYANNIS (508)577 7258 dkerkado@gmail.com 9 Attach Documents 1 Photos Mr m APPLICATION REVIEW STATUS Building -Admin Department Ap,,ryrewed D c 2 1g No(Ionimscnts Avaiiable .................................. ....................... .................... ........ _ .................. ...... ...... ... ..... Health-Inspector Department API:€rtweci Oct 24,2P!6 �;orE€runts Oct 17,2016 need a 4 BR deed restriction recorded-a full set of house plans and septic permit approval(not done yet) Oct 24,2016 Septic permit 2016-379 4 Br and a 4 BR deed restriction. Oct 24,2016 2016-379 septic permit 2016-379.4 BR deed restriction on file https://portal.viewperm it.com/Secured/Perm itview.aspx?enc=+i G90KJTlw7ouCVW Z041z30+OgYHzO4Vj9vFBfNf8gE5HcOl Zo+iVJ2ijigAH/PY 1/2 TOWN OF BARNSTABLE permit No. ____ __21141 ___ Building Inspector 5 8 0.0 0 b l d r �ae�rrn��!: cash $___-�.�� ��O ■6 9 P OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Charles W. Richardson Address Holden, MA 489 South County Road Centerville Wiring Inspector Inspection date Plumbing Ease Inspection date Gas Inspectov Inspection date �7 Engineering Department, Inspection date.0 THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOTE BE OCCUPIED UNTIL- SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ........................_.«....„_................1 19 .......................................... ................. Building Inspector J TOWN OF BARNSTABLE 21141 Permit No. --------- DAW3TAM : Building Inspector Cash $5 8 0.0 0---- b l d r o times —--- -- � OCCUPANCY PERMIT Bond ---___-- "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Charles W. Richardson Address Holden, MA 489 South County Road Centerville 0 Wiring Inspector Inspection date Plumbing hasp Inspection date Gas Inspectof Inspection date 1/ Engineering Departmen Inspection date 0 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. / ...................................................._, 19__ _ .................................................................................__ Building Inspector J 21141 TOWN OF BARNSTABLE Permit No. 1�. , Building Inspector cash $5 80=00 t b l d r ) �crpY� OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Charles W. Richardson Address Holden, MA 489 South County Road, Centerville Wiring Inspector S' Inspection date ' s`-- Plumbing Inspectors _ Inspection date Gas Inspector Inspection date Engineering Department r 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. ...................................................», 19..........» ........................................ ......................». Building Inspector IME Town of Barnstable *Permit OCR �3�5` '4 Expires 6 months om issue date Regulatory Services Fee '?, 60 _ &UMSTABLE, : Thomas F.Geiler,Director nsasa. ,�, 9 � yI t63q .0� Building Division -PRESS PERMIT Tom Perry,CBO, Building Commissioner . 200 Main Street,Hyannis,MA 02601 APR 16 2008 www.town.bamstable.ma.us T®�� ®F �� Office: 508-862-4038 � WW6230 . EXPRESS PERMIT_APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number V 09 Property Address t� a .c � r:�:t t, �'\���:��--2 cJ - �a E C._/Z_ o 7—�g.r 94esidential' Value of Work Minimum fee of$25.00 for work under$6000.00. Owner's Name&Address �(� C.,k A e- t � ���� !b c,0 6 1'4 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor [9,Tam the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) 5 Re-roof(stripping old shingles) Alfconstruction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) . 5 Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum. •WT *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 is required. r SI� . Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organiration/Individual): �c��S 6y'Y� kddress:a k. ��ko�c. 6 k (--3.) City/State/Zip:���'�f-�y i ( F'�(fi o22ZPhone:#: off ��g ' \3 6 Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time). * have hired the stab-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet- 7. ❑Remodeling • ship and have no employees These sub-contractors have g• ❑Demolition , working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.-insurance comp.insurance.t ,�, r �] 5 ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.L1d'I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself[No workers' comp. right df exemption per MGL 12 �Roof repairs insurance re t c. 152, §1(4),and we have no ' �] employees. [No workers' 13.�ther S r `� comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their warkers'corrnpclnsation policy information. t Homeowners who submit this affidavit indicating they are doing al work and then hire outside contractors must submit anew affidavit indicating such. TContractors Ont check this box must attached an additional sheet showing the name of the sub-contr-actors and state whether or not those entities have employees. If the subcontractors have employees,they must providt 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. 4 Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: -job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to scarce coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimirial 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 statcmerit may be forwarded to the Office of Investizations of the DIA for insurance coverage verification. I do hereby air�and enalties of perjury that the information provided above is true and correct Date: C �p Phone# �6 - ?g - 1 3 cs Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:- Phone#• r r 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 representative's of a deceased employer,or the . receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)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 born 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 UmmonwWth of Massachust:tts Dqw-trnent of Industrial Accidents Office of Investigations '600 Washington Street Boston,MA 02111 Tel. #617-727-490.0 ext 4.06 or 1-977-MASSAFE Fax#617-727-7744 Revised 11-22-06 www.mass.gov/dia tHe Town of Barnstable . .. �oF ram, Regulatory Services r r BARNSfABEZ, « Thomas F.Geiler,Director b Building Division plFD Ml►i A , Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma:us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: i Sh k 1 a) �'L J.-kr's- 12,.U 1 number street village Q "HOMEOWNER!':. M'►c hAl— borJ6N ArJ v`69 name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six-units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building pemut. (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 mmi ection procedures and requirements and that he/she will comply with said procedures and re ments. Signs a of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State•Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1,1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. l OFtHE►o Town of Barnstable Regulatory Services M AS"SBIE Thomas F.Geiler,Director 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 J I, t 61 R Q- D�'J�`��� , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date i Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. (1•FhR XAQ-OUWPR PFRRMT.QRT(W- ,► r Town..,of Barnstable *Permit# C) 6 206� Ex pir 6 months from issue date Regulatory Services F • snxxsrAB Thomas F.Geiler,Director � � MASS. , 1639. Building Division 1°rEn nw�" - 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 Property Address ��D ���vi° l ��� a�l!�� ✓�/ Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address I, ' � �-� �`'r a � Telephone Number' Contractor's Name ��� - Home Improvement Contractor License#(if applicable)r � ❑Workman's Compensation Insurance -P S P1ERM1T Check one: ® I am a sole proprietor APR 16 2008 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTA'BL:E Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping-old shingles) All construction debris will be taken to ❑Re-roof(not stripping:. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U=Value (maximurn'.Y-1 *Where required: Issuance of this pennit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission.. Cj A copy of the Home Improvement Contractors License is required- - �E•, C �:.i r 3�c SIGNATURE: QAWPFILES\FORMS\building permit fonns\EXPRESS.doc Revise020108 ' 04/15/2008 14:43 15086529776 PAGE 02 ' FROM t FAX NO, Apr. 15 2008 1 �j:40PM P3 I Town.:of Barnstable Regulatory SerMces . j Thaum F.Wertrmox r Building Divi�on Thomas Perry,G'�O auMing Commisdt ner 200 Main Street, Hymnis,MA 02601 t wwwtowmbarnstatsl mains Office: 508-862-4038 I Faa: SO& 90-6230 Property 4wnei Must Conpletc and Sign This Section If Using A Budder T, ' l ,as.Owner of the subject property ' hereby authorize h-L ,, � to act on my behalf, r it all matters relative to wo&authorized by this binding pemut application far. (Addmss of job) Pf Signature of z Date • Print Nam f Q,11Ai'FfL�tiFp�t34t91buildinp,pertni4fonns1870?RP33,doc , , I:,. . .ti .d 1 ' Ret+�lc0201 p8 1 . 3 ,per The-Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors(Electricians/Plumbers < Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: 19 City/State/Zip: Are you-an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction' . employees(full and/or part-time).* have hired the stab-contractors 2. ] I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• E]Demolition working for me in any capacity. employees and have workers' 9 L]Building addition [No workers' comb-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 11.❑Plumbing repairs or additions myself[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp,insurance required.] *Any applicant that checlm box#1 must also fill out the section below showing their workers'comprnsation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors 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 wbether or not those entities have employees. If the sub-contractors have employees,they must providb 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.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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 incr,rance coverage verification: I do hereby certify under the ains-andpenalties of perjury that the information provided abo a is true and correct. Signature: Y Date: Phone Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board'of Health 2.Building Department 3.City/Town Clerk.4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees: Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." - An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representative's of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants - Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of insurance_. Limited Liability Companies*(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the member 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 awe 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 onr,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 fixture 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 bairn 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 Dgwtnent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 W. #617-727-4900 ext 4.06 m 1-977-NIASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia h.e �p - 4 { �� _ -- -__ . ' ✓1ie�omvn'w�uuecc�l�+o��� �x Board of Building Regulations and standards �� HOME IMPROVEMENT CONTRACTOR Registration 156959 •, I Epira# n ��8/20x/2009 Tr# 258309 fit; Type NiLE A.MORIN REM3ILIN t NILE MORIN 28 CHERRY ST '°"` � HYANNIS,MA 02601 Administrator 3 t� k � " License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,Ma.02108 �4 M f t, Not valid without signature ------------ t .M Y x , r V. i € *M, a w. 4 4 n s �. VFa..t - _ fi 5 • P�4 Fir r Loc° u -, r1 a°c -"'�1/ • ` 5 . . .., It, ... .._ ' j l� _ _______...�'Peu.e - a i�'•tM �•1 �- } z I dd ' �► 4I � , � __._ tom B 14, 4.1 IA P4 'f '\ "•'' �.•',� ' ' f , , \4J1 � try t - � i � iS•G l 1 41 OF T�4 M- TowL4 CIF LAOD Oro Q w / ...._ • - it l - _�.._,.. .._ pE�F L_oT1 -- (4f_ eDO, w L LIB c �c;' �.tC-,t c►ivc: .. ,�.._ ` --________ __.-____ 'DAc�-r Fi,_oVI - ito AAA) � t~PS ►c, 'ram�.� d�lp +C ! , © n. 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