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' :s , .u. t. a, a-�:i>r t u-' a �r .`E .:..: _.. ., .5,,..... r. ,.. .v. .,.. .,f, ..:.}_. .: r. ,. .Y Js;:,.. ,..Y ,7f r G ., ,1 r�:, r. :f'. :,. r. < .[. :r ,.:. l... , a :,',: ... tt ., . :pp6, P X / ,!s :,.,1t x„ ., a ,r., .a,, -.:s -...d r s ,_e d` ,dA f �.__._.,..",O` ,A..+._.1e..-tE,,.;__,_s s. .7s-,.._,a,,., ..,a,,.j,' .. .. t-...-...., _.r. .s.... _...._..._- __:-_ .'..,.r-„ ..5 ., .... a„ %e.. x _ _ _. ,-___ —___-__— t 'b'r• - (a , f �€tsw1' f a.Y.'r. w,.11'.`,t x,a�. a:..#+ At--WI t o% F TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel A Application # �ql Health Division ®y Date Issued �-3—�7 Conservation Division Application Fee Planning Dept. �� Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyanni!�•, Project Street Address 2 14 `T_6fZA/ L/ /V 2l C& l5jw vil_La Village Owner `��%+��� �/���'� ��� Address Telephone Permit Request Rettig) &_,I11 I 11<111_cia� 2z`ri z° a�ll d 7 's� d _ ice eo o`11 a c f as it/,a �21i n �G/�r�► f L yerLS "dfh ,elm o ve Net✓ ih sue% -/7 v„ Z Irv � C1//fi f] n nx4 c7/ . Square feet: 1 st floor: existing Qaproposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatioe,?O/9D 0 Construction Type Lot Size 1°S �4 C a Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family )d Two Family ❑ Multi-Family(# units) Age of Existing Structure 447 i Historic House: ❑Yes XNo On Old King's Highway: ❑Yes ❑ No Basement Type: )d Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: J existing _new Total Room Count (not including baths):.existing 7 new First Floor Room Count Heat Type and Fuel: DdGas ❑ 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:'5fexisting ❑ new size _ Other: _5-A/tAq,e $60-<<6-7L Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION - -- --- -- =( J)ER OR =-- n 'Name ��i2i� Telephone Number }Address 214 7-6/L iv LAA/ License # (1N vi L"t' G6. Home Improvement Contractor# Email J "rC.4 i4A/Z4 IS � Y��lade Cc)M Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE w ✓ ' �� DATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE iLECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. , , l /� N - 12' Bath 2nd.Floor Bedroom. Bedroom SmShed No Value . given 42' i ' - 22' ry 20 Bath ,. Patio /A Kitchen Bedroom Storage Pa o No.Valu 14 given _ Den Fpl Living Room 'Bedroom 14' ' i s' :etch by Apex Sketch.v5 StandardTM nents: Y :'YC AREA CALCULATIONS SUMMARY a r LIVING AREA BREAKDOWN Code Descnptton g :' ,Net S¢e Net Totals L , Breakdown Subtotals GI;Al First Floor: " r 1289 50:: 1289:50; First,Floor' "^ GT.n9 ' Second_ Floor 704.00. 704.,00 -60 12. 0 x 56 i0 6-7. t 05 x 42 0. 21 :00 . 2 0 x 20 `0 40 :00 xi' 42 0 504 :00 i 1:s5 3_ ( x 22 0 3 00 l`5 x 13 0 19 50 :Second Floor 16.0 x 42:0, 6Z2 00 ` 4:0 x,t 8 >0 32 00 t, } ' a t A ' 4' h 4 at F p F u 1. r, ,i-(W,+t,L, Tv X-C-440vet�) A/a OA�A�v-6�- 77) FL-vv4 lt4,,,l r 12' Bath 2nd Floor Bedroom - Bedroom 0o SmShed No.Value given .. .. 42' I' 1 22 20' eatti Patio 1 DIA Kitchen Bedroom Storage No Valu gtven 4 Den ' FPI' Living Room Bedroom 14' - 22 :etch by Apex Sketch v5 Standard'"" - ... vents: - ., � ,.. .y.- ,,.-�' s"..' ; G^St .?';.:: of,'-*.,Y,,;':•+p^+,4 ,.#; )nrn. -...E mY ..{,�"" a :„ w { s wr-cwn; xg � ti AREA CALCULATIONS SUMMARYr, LIVING AREA BREAKDOWN a� Code Description Net Slze ;; Net Totals Breakdown Subtotals n.:. GT•ni First. Floor 1289 50. 1289.50 First'-,Floor GUU Second Floor 704 00: 704:00 12:0 x 56 ;0 672..00 7 0:5 '3i 42.0 21:00' 2. x 20 40 00. h 12:0 x ,42 :0 504 `00 1.5 x 22 0 33 00 k ' 1.:5 x 13 0 19 50 Second Floor x " 16.0 x �42 :0 672 00` � 4.'.0 x 8 �,0 32 � a M 3 .lei { `� • , 474 o. 12' Bath 2nd Floor Bedroom Bedroom SmShed No Value given - 42' _ 22' 20' Bath Patio D/A Kitchen Bedroom Storage. No Valu given 1a' - m Den Fpi Living Room Bedroom 14 7 N - IT '.etch by Apex Sketch v5 Standard TM' - - - l' -. '. - ...•...� . vents: i z AREA CALCULATIONS SUMMARY �;�� LIVING AR AKBREAKD N Code Description "�,` Net Stie .£ ' Net Totals E Breakdown Subtotalspw GI�Al First: Floor 1289 50r 128,9.50 First=Floor. Second Floor = s 704 00 704.00 T2..0 x 560 672 .0.0` GT:A7 , 42 ,0 21 -00 2:0 x ` 20 : S ,x 0 504 ;00 t 1,.5 x 22=0 33 _.00 x: 13 ;0 1950 a ,Second Floor 16:0 x 42 0 2 672 00 4 0 x 8.0 t ?lie Commoniveafth fl,-Massachuset s Department ment ct,f r4dustrial Acciderdr ©,ffike offm tigations `- r 600 Washington Street Boston,4,0211 ktarvtv grt nzassvfiiia Workers' Campensation Insurance Affidavit:B:ml'dersiContracturs/EIecfr c ans/P'lumbers Applicant Information Please Print Lewbly' Name�3usme�Organizatio : �J�f�1i�5 ��j S Ad&ess: �y ` i✓. L A/�-t✓ , , cIty/ ta,& /V J �.1//Lf �i�. �?' F� Z1oI1@ Are you an employer?Check the appropriate box: ' Type of project(required), 1.❑ I am a employer with 4. I am a general contractor and I 6.,[:]New constn xt on employees(full ar dfor part-time).* have hired.the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.- 7. ❑Remodeling ship and bane no employees. '.These sub-contractors have g ❑Dertolition woddn; for sae in any capacity: employees and ba<<e woriers' g. ❑Building addition ' [No workers'camp.insurance comrp.insurancie.$ r d_ - : 5. ❑ �We are a corporafion az,rl its 10:❑Electrical repairs or additions �e j 3 3_❑ I am a homeoumer doing all work ofce3s have a ercised their 11.❑Plumbiag repairs or additions myself [No worrkers'camp- tight of exemption per MGL 12.❑Roofrepairs ' insurance require&]S c.152, §1(41 and we have no ; employees.(No wodzers' 13.❑Other camp-insurance required-) `Anyanfica ff-t checks box 9l®stelso fill outtlLesectioubelawshv gthrawoderecompensationpaliryinformatiaa f'Homeowners who submit this af5da[u indicating they am doing all wan$aaxd dies hie outside contractors mast submit anew affidavit iz dieating suclL -�� IC'bntractors tb�a2 ehecY-this-boa�an�ed sn.addiiiansl-skeet—shaumg-the-nau�e of the=sub-c�trse�aad-state trlsether.ar-nntthose- layeIfthesubtantiactfleshaveesaplop�zs,.tfieymoutpmvidetlreirwarkess'tom policynumber .1 am an elnpLgvr that,is pm ding markers'congmwalivn insurance for uzy elvlaye s $eto�v is the pvLicy grud jop rite' information, s litsumace.Company Name: Policy,or Self-in:s:.Lic.#: x. Expirat ou Date: Job Site Address: City/StateI25p: Attach a copy of the workers'compensation policy declaration page(showing-the policy number and expiration date). Failure to serum coverage.as required.under Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up#a$1,50G SOD andfor one-year imprisann-twt-as well as cavil penalties' form of the for of i STOP WORK ORDER and a fame. ofup to$25i0-0�0 a day against the violator. Be advised that:a copy of this statement maybe forwarded to the Office of Invest gatioms of the DIA for insurance coverage wrerificatiaa I ifo.Here c ��uitdcr thap this iuldtnahies of orjur}'thatflie in,fbrntationprovirt�rFatiaf�s s€bus and correct ��/ Bate: one f)aria,use only. Do not w ite in this area,to be completed by city oriown a frciaL' City or Towns Pe'rmritfLicense* Issuing�lnthority(circle one): 1.Board of Health 2.Building Department 3.Cityl Town Cleric d.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Ph-one#: Information and. Instructioans ` Massachuseffs Geheaal Laws chapter I52 requires all employers fn provide workers'compensation for their employees. . p tn this stye,an ernplayee is defined as."_.every person in the service of another under aay conhact of h r,, express or implied,oral or R'zrtten-" An vnpjoyer is defined as"air individual,partnership,association,corporation or other legal entity,or any ttvo or more of the foregoing engaged is a Joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or otherlegal entity,employing employees. However the owner of a dwelling house having not more than three apadments and who resides therein,or the occupant ofthe - dwelling house of another who employs persons to do maintenance,construction or repair worm 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 auy applicant who has not produced acceptable evidence of compliance with the insurance.covexage required." Additionally,MGL chaptEr 152,§25C(7)states"Neither the commonwealth nor ray of its political subdivisions shall enter rota any contract for the performance ofpublie work until acceptable evidence of compliance wish the iasuran ce._ requimments of this cEiapter have Been presented to the contracting authozity." Applicants Please El 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 numbers)along with their cerii icate(s)of ncrrrance. LunitedLiability Companies(LLC)or Limited LiabilityPaxtnerships(LLP)within employees other than the. members or partners,are not requited to carry workers' compensation insurance- If an LLC or LLP does have employees,a policy is required. Be advised that thus affidavit maybe submitd to the Dep&iment of Industrial Accidents for confirmation of insmaac-,coverage. Also be sure to sign and date the affidavit The affidavit should be retzmmed to the city or town that the application for the permit or license is being requested,not the Department of Tnri-u frial A ccidenfs. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy,please call the Department at the number lisft�d below. Self-insured companies should enter their self-intern ce license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legbly. 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 peuniVlicense number which will be used as a reference number. In addition,an.applicant that must submit multiple peffiitllicense applications m any given year,need only submit one affidavit mdira± g carrent policy information(if necessary)and under"Job Site Ad 1dress"the applicant should write"all locations in (cam'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 fuixue permits or licenses. A new affidavit must be fiIled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (ie. 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 tick you i a advance for your cc)operafion and should you have any questions, please do not hesitate to.give us a call The Department's address,telephone and fax number. 'fie C�aum�aawmjfir of hiassachus-tfts ` • ��-��,Ilegarimenfi cif�-dia.�A�i3�nts't `'���'} • - � . �Q4 l�ashingtQu S#z�t -� Bastoi�MA G2111 T(,-L 4 617'27-4900 QXt 4€06 or 1­9 SAAM Fax f l7`27 7M Revised 4-24-07 .masagovfdia (Wt 7-D tZ 0 V rh 6-7 _ 12 - - Bath 2nd Floor Bedroom Bedroom SmShed No Value given 42' r o • I. i LathPatio �A KitchenBedroom J rageVal. 14ven Den Fpl. Livirig Room Bedroom .. 14, 7 :etch by Apex Sketch v5 StandardT'^ - - - -• - _ vents: AREA CALCULATIONS SUMMARY T� , _ LIVI'NG ,AREA BREAKDOWN Code Description ; '_ } ;.Net Stze Net Totals.`4, Breakdown Subtotals _ GLAl First Floor 1289 .50, 128.9.50 First Floor GLA2 Second Floor 704 00: 704:00 12: 0 x_: 56 .0 672 .00 3 . 20:0 40:00.: w 12; 0 �x 42:0 504 00: 1"5 x 22 0 33..00: L 13c0 1950 Second Floor s: r 16. 672 00 4: f • ,i 1:E+ �, - ,:5 :. a a i y / �;� L r :• � � /. //fir �L(W,4 7-0 REW AD�O VC26) 70 12' Bath 2nd Floor Bedroom Bedroom SmShed No Value given i zr 20 Bath . Patio D)A Kitchen - Bedroom Storage No Valu 14+ �! NJ. ,. � �Jv�b��o Den Fpl Living Room 1!®Z Bedroom fVA40.0 22 AA'' y :etch by Apex Sketch v5 Standard'*' vents: AREA CALCULATIONS SUMMARY " r LIVING AREA BREAKDOWN Code Description ,Net Size. Net Totals`f� a Breakdown Subtotals :; ,GT•Al First Floor 1289 5D 128..9.50 ' First' Floor GT;A9 Second Floor ` 704 00 70:4:00 12 0 x 56:0 672 .:00 0 �2 0 x 20:'0 40:00 c 12''' 0 x x42:.0 504 00. 1'5 x 22:`0 33.500 # 15 x 130 1950 Second Floor " + p 16 0 x : 42 *0 y 672 00 3 4" 0 „x 8 0 32 00 t x t - ur i • ..1 : - I:' h } AT. ` 1 S { / A15T ©F CYOw'7,)2AC-1D -S P6 Q'X"� � teo -- J rill U P. r V�f C- SA. I Alb w . (]'6�y. s` )y® 7 /) } - " t �. y 'C y � u E •• . . � - - � j i 1 � k % S a . __ _ _ _ J , f , ,4 �j� - t � � ' ,. �# A � . - � Y A �. �* - 't .. - i �, _, ' ! � .A� „ .. _ __ • _ ' s w ' st y - ' � }. kf -Ice S©L& �/10 v,0� ) - ' � k z • .. -_ - .. j �� y - ,. � ` ` ._ _ _ 1 w � � . • ? � .y �' • � ' i � , - r� � � .,a � �. � � £ r - ., - - IAPPfoaa cry► �CERTIFLCATEC?F UA�tLtTY1NSl��' N A ^� D PATE(MM1DpNM) �: I�ANC - 412812017 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THECERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OE NEGATIVELY AMEND,**.'EXTEND OR ALTER ITHE COVERAGE AFFORDED 8Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE .A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER;AND THE CERTIFICATE:HOLDER. If IMPORTANT: UBROGATION IS WAIVED, subject to the terms and condder is an ADDITIONAL itions of he the policy,certain pol l must have es m ADDITIONAL INSURED amen provisions or St Cement endorson _ i � � policy, ley may�requl�sap��endot`sement� A ettat+arrtsnt one this certificate does not conferri hts to the certificate holder in lieu of such endorsements. License#`1760862 p Cp�iTACT PRcoucER nt NAME . »C _ FAX - HUB International New England PHONE 50$ 945-9136 265 Orleans Road (a_,No,Ext) �508)945=�446 _R (JVC'No):( North Chatham,M1AA 02650_ d- 44 _ - • a- A i •INSURERiS}AFFORDING-COVERAGE p NAIC# r t;IN5--JRER A.Berkshire Hathaway Specialty Insurance Coin an INSURED • INSJRERS - c e r _mt - a Happy Floors Inc. INsJRER C. _ 182 Old Townhouse Road,Unit E =INSURER 0. s „w West Yarmouth,MA702675 �- _�-- � T' .� f �INSURER E: < n ` _ . .. ., 1_4- �. INSURER COVERAGES CERTIFICATE NUMBER-. it ON NU BER: } THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE�BEEN ISSUED TO TNN-ESURED NAMEDABOV'E=FOR THE POLICY PERIOD NDICAtED. F.CIOTNi`HSTANDING ANY*i2EQUiREMENT, TERM Oil CONDITION OF A,NY CONTRACT OR OTHER 600MEW WfTHi RESPECT TdWHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,,THE INSURANCE AFFORDEC BY THE POLICIES DESCRIBED HEREINJS SUBJECT TO ALL THE TERMS, F_XCLUSIONSAND CONDITIONS�OF SUCKPO_LICIES.`LIMITS SHOWN MAY HAVE BEEN REDUCED BY,PAID CLAIMS; INSR ADD L!SUBR _ POLICY EFF `POLICY EXP TYPE OF-NSURANCE I POLICY NUMBER IMMfDI2=11LIMITS t�.COMMEkCIAL G';NERAL LIABIUTY_ a 41 4u 7 A EAC I OCC UP tENCE' .. CLAIMS-MADE OCCUR ° DAMAGE T O RENTED �r: s„� #� -- , -.�••:_ "'-3 -`- ;¢�. ` :- -::- .�. .� P IJlrnr ono peCSdtAi $„ ,..`", - PRE3AIS ... PERSONAL BADV INJURY $ GEN'L AGGR foA'E"LIMIT APPLIES PER. ` ' GENERAL A_GGREGAIE POLICY LOC PRODUCTS COMPIOP AGG $_ OTHER. g AUTOMOBILE LIABILIltl�TY � a4JEa cci00nCNED 0`NG E LIMIT $ ANY AUTO , 84DILYINIURYLPerp�rson)_A$ _ O'M1NED I SCHEDULED y .IAU D�S ONLY� AUTD& p ;.� � to pBRCF Ext f1 UR MAGEscpide�I� AUTOS ONLY AUTOS ONNY ' {PeraccidEni $ ° UMBRELLA LIAR OCCUR EACH OCCURREN CE E_ O f 'EXCESS LWS C IMS-M�ADE� 4i A�CrR {P •- $� �� DE7 i' I RETENTION$ $ A VQORKERS CdOMPENSATION x { GpR 0 AND EMPLOYERS'E UTY Xk. YIN HAWC8959T5 0412512017,Od/25k2018 1,000,000 ANY PROPRIFTTOWPARTNERIEXECUTIVE E.L.EACH ACCIDENT FaFn NE`CLUDD N NIA Mor r$: _ 1,000,000 , # a E U DISEASE-EA EMP4 OYE S bMescnbe under= 1000,000 DPT ON OF OPERATIONS below E L DISEASE-POLICY LIMIT $ - _ „t -' DESCRIPTION OF OPER 7;10NS I LOCATIONS I VEHICLES (ACORD 101,Addidonal Remarks Schedule.ray be attached if more space a rsquiredt 4- CERTIFICATE HDER CANCELLATION OL `{' # SHOULD ANY OF THE AB+]VE DESIttDEA Ptf1CI `BC Ci4filOELLI*D BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 6E DELIVERED IN ACCORDANCE WITH,THPOLICY PR VISIONS. l-l- "f"erI 4 ( aUTHORIZEDREPRE$ENTA•'IY� L /y ACORd 2s 201$ 3) _ - u - ©1ssE`•2o s Aco D" r1, 1 rigi is reServed. Tha AC©RD Mama and logo acxegis#ered marks of P,GIRD ACK312G' CERTIFICATE OF LIABILITY INSURANCE 05/01/201DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Paychex Insurance Agency.lnc PAYCHEX INSURANCE AGENCY,INC. 150 SAWGRASS DRIVE PHONE EXT), 877-266-6850, FAx . 585-389-7426 ROCHESTER,NY 14620 E-MAILADD ESS. Certs@paychex.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 BALANCED HVAC INC. INSURER B: 15 JAN SEBASTIAN DRIVE,S SANDWICH,MA 02563 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS TR INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS-MADE�OCCUR PRFMI',;F'.;(Fa occurrence)MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY =PROJECT=LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED SCHEDULED BODILY INJURY(Per AUTOS AUTOS (Per person) HIREDAUTOS NONOSWNED BODILY INJURY $ T (Per accident) PROPERTY DAMAGE $ (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND X WC STATU- OTH- EMPLOYERS'LIABILITY BAWC842777 03/01/2017 03/01/2018 E.L.EACH ACCIDENT $ 100,000.00 ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100,000.00 � (Mandatory in NH) N/A E.L.DISEASE-POLICY LIMIT $ 500,000.00 If yes,describe under DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION JT Harris SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 214 Tern Lane DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY Centerville,MA PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Barnstable Regulatory Services pU Richard V.Scali, Director Building Division sARxarAMIX Paul Roma,Building Commissioner MAR& 1659. `m$ 200 Main street, Hyannis,MA 02601 prED MA'i www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 5/2-// Please Print DATE: . : JOB LOCATION: / �6 Z fir / �/� G� number L, street village �xoMEowNER": J•�.v►Es'' �r�'�fGl s _ �7��- z�'z-G�/y name Q 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 Persons)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 ,,_'"re " ements. a, Si a ofHomeowner /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. rf k �ZNE Town of Barnstable Regulatory Services ; BAMMBLE, Richard V.Sca 1,Director Building Division Paul Roma,Building Commissioner 200 Main Street;Hyannis,MA 02601. www.town.barnstable.ma•ns Office: 508-862-4038 Fax: 508-790-6230 Property.Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby,authorize to act on ray behalf, in all matters relative to work authorized by, s u this bildi ermit a lication fon g p pp r: (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. Signature of Owner Signature of Applicant Print Name Print Name Date Q.F0RMS:0T;NMPERMLSSI0NP00IS x (05 WA <r_ A- 01n14-4, ®� JOB SUMMARY REPORT Lv L A-t" i N �o R James Harris- 214 tern lane centervilleAte L Memtie�Name��'� ;" ,� _.r..3 .'�=''�k '��•i:Resplts n't Current Solution �. 3�-""-`� ,'�` '�,t,.• �;;.,,,,�,�.Comments.r�� Floor:Drop Beam Passed 2 Piece(s)1 3/4"x 9 1/2"2.0E Microllam@ LVL Forte Software Operator .lob Notes 5/2/2017 12:01:28 PM Forte v5.1,Design Engine:V6.5.1.1. Brian Flagg Mid-Cape Home Centers James Harris-214 tern lane centerville.4te (508)760-4430 bflagg@midcape.net Page 1 of 2 } FOR ® MEMBER REPORT Level,Floor.Drop Beam PASSED ® � E 2 piece(s) 13/4"x 9 1/2" 2.0E Microllam® LVL . Overall Length:9 7 0 + + M1�r Hqy� 4 Fytj'Q YY+I J' J, q � '�' J a1. 1 A i:lrl �" �:'4R d'W7` 'SL ✓G=j, * a4[ '�h ail '1[IIJy 900 0 � � All locations are measured from the outside face of left support(or left cantilever end).AII dimensions are horizontal.;Drawing is Conceptual Design Results Actual @ Location Allowed Result LDF Load:Combination(Pattern)? system:Floor Member Reaction(Ibs) 3161 @ 0 2 0 8881(3.50") Passed(36%) -- 1.0 D+1.0 L(All Spans) Member Type:Drop Beam Shear(Ibs) 2446 @ 1 1 0 6318 Passed(39%) 1.00 1.0 D+1.0 L(All Spans) Building Use:Residential Moment(Ft-Ibs) 7056 @ 4 9 8 11775 Passed(60%) 1.00 1.0 D+1.0 L(All Spans) Building Code:IBC 2015 Live Load Defl.(in) 0.191 @ 4 9 8 0.308 Passed(L/583) 1.0 D+1.0 L(All Spans) Design Methodology:Aso Total Load Defl.(in) 0.242 @ 4 9 8 1 0.463 Passed(L/459) 1.0 D+1.0 L(All Spans) Deflection criteria:LL(L/360)and TL(L/240). Bracing(Lu):All compression edges(top and bottom)must be braced at 9 7 0 o/c unless detailed otherwise.Proper attachment and positioning of lateral bracing is required to achieve member stability. Bearing Loads to Supports(Ibs) Supports Total Available Required Dead Floor Total Accessories a Live ' 1-Column-SPF 3.50" 3.50" 1.50" 669 2492 3161 Blocking 2-Column-SPF 3.50" 3.50" 1.50" 669 2492 3161 Blocking •Blocking Panels are assumed to carry no loads applied directly above them and the full load is applied to the member being designed. Tributary Dead Floor Live Loads Location(Side) Width (0.90) (1.00) Comments 0-Self Weight(PLF) 0 0 0 to 9 7 0 N/A 9.7 1-Uniform(PSF) 0 0 0 to 9 7 0 13 0 0 10.0 40.0 Residential-Living Front Areas Weyerhaeuser Notes SUSTAINABLE FORESTRY INITIATIVE Weyerhaeuser warrants that the sizing of its products will be in accordance with Weyerhaeuser product design criteria and published design values. l Weyerhaeuser expressly disclaims any other warranties related to the software.Refer to current Weyerhaeuser literature for installation details. (www.woodbywy.com)Accessories(Rim Board,Blocking Panels and Squash Blocks)are not designed by this software.Use of this software is not intended to circumvent the need for a design professional as determined by the authority having jurisdiction.The designer of record,builder or framer is responsible to assure that this calculation is compatible with the overall project.Products manufactured at Weyerhaeuser facilities are third-party certified to sustainable forestry standards.Weyerhaeuser Engineered Lumber Products have been evaluated by ICC ES under technical reports ESR-1153 and ESR-1387 and/or tested in accordance with applicable ASTM standards. For current code evaluation reports refer to http://wwv4.woodbywy.com/services/s_CodeReports.aspx. The product application,input design loads,dimensions and support information have been provided by Forte Software Operator Forte Software Operator .lob Notes 5/2/2017 12:01:28 PM Forte v5.1,Design Engine:V6.5.1.1 CEnu., r James'Harris-214 tern lane centerville.4te j 751-wso - = Page 2 of 2 Town of Barnstable BL1ilCling �xnsrsrs Post This Card So That it is Visible From the Street-Approved Plans Must be Retained onJob,and this Card Must be Kept ` a `�' }PostedsUntil Final Inspection Has Been Made "5 r` Permit ,Where a'Cercate of Occupa tifi ncy is Required,such Building shall:Not be Occupied until a.final Inspection has-been made. Permit NO. B-18-72 Applicant Name: CHRISTOPHER W ELLIS Approvals Date Issued: 01/19/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 07/19/2018 Foundation: Residential Map/Lot: 192-029 Zoning District: RD-1 Sheathing: Location: 214 TERN LANE,CENTERVILLE Contractor Name: ,CHRISTOPHER W ELLIS Framing: 1 Owner on Record: HARRIS,JAMES T&CAROL ANN ' Contractor License CS-094024 2 Address: 19 STRATHMORE ROAD Est Project Cost: $39,000.00 Chimney: WELLESLEY,MA 02482-4523 4Permit`Fee: $248.90 Description: Finish off Half of the basement complete with bar and half bath _ Insulation: wet Fee Paid:' $248.90 Project Review Req: .= Date 1/19/2018 Final: E u v'a 3 d1i .k'R 1j l� ' � ,� ,� �* x .,. ;�< QI'V>^\ Y'-{V•-`"^`I'"'w,�// Plumbing/Gas Rough Plumbing: Building Official x Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced with in'siz'months'after issuance. All work authorized by this permit shall conform to the approved application'and theiapproved construction documents forwhich this permit has been granted. Rough Gas: i-N All construction,alterations and changes of use of any building and structures.shal.be in compliance with the local zoning by-laws and codes. 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 Final Gas: 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. Minimum of Five Call Inspections Required for All Construction Work: ` - Service: 1.Foundation or Footing 2.Sheathing Inspection x Rough: �. anw-" � 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 r .. Applic2don Number.. . + o+ BAPXSZAB= • Permit Fee.......................................other Fee........................ MASBr 3UILDINGDEPT Total Fee Paid..................................................................... TOWN OF BARNSLUIX .... ........:. 1t.. .�,�...... 8 2118 Pe�Approvalby.. . .on.... BUILDING P�, 2 APPLICATION F BARNSrAeLE map.......... ..........Paget... . Section 1 — Owners Information and Project Location. Project Address Z111 4,,J Village Vie= zv-c,t-f Owners Name JA;,,cs Owners Legal Address Stng- City ., .,.� State ,4 = zip Owners Cell# 7r-I- Z92 - o6/ei E-mail Section 2—Structural Use Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Section 3—Type of Permit ❑ New Construction ❑ - Move/Relocate ❑ Accessory Structure. ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar dE�Renovation ❑ Pool ❑ Insulation C � , Other-Specify Section 4—Detail Cost of Proposed Construction 9/e Square Footage of Project Age of Structure Dig Safe Number #Of Bedrooms Existing �� Total#Of Bedrooms(proposed) 110 MPH Wind zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Last updated:ll/7/2017 Il. Section 5 -Work Description 1 �TritJ��1.0 Ofrl'� hWLI� Q� /11(� /,y[.��+�+GN� � �bt�t�1`C �4Jt.`ir)1 �I✓{'T `.�/Q7'! 1 i , r � l i Section 6—Project Specifics i ❑ Wiring ❑ OR Tank Storage . ❑ Smoke Detectors . ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑.Heating System ❑ Masonry Chimney ❑Add/relocate bedroom f, Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: If I am using a crane C Ye No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Z Proposed Use Lot Area Sq.Ft Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) / Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard. Required Proposed i Has this property had relief from the Zoning Board in the past? ❑ Yes No rsrupdetc&11nrz017 CHRIELL-01 DKENNEYFIELD ACOR©° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)0 9/1 812 0 1 7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: 128 Den Street A/C,, o,Ext):(508)824-8666 AAiCC,No):(508)880-0142 128 Dean Street E�A Taunton,MA 02780 EDDRAILEss:info fbinsure.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Selective Ins Co of SC 19259 INSURED INSURER B:Associated Employers Ins.Co. 11104 Christopher Ellis dba Frame 2 Finish Customer Builders INSURER C: 25 George St INSURER D: Plymouth,MA 02360 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADSDL SUBR WVDPOLICY NUMBER POLICY EFF POLICY EXP - LIMITS . A X COMMERCIAL GENERAL LIABILITY MMIpprfyyyl EACH OCCURRENCE I$ 1,000,000 CLAIMS-MADE OCCUR 52187164 07/16/2017 07/1612018 DAMAGE TO RENTED 500,000 PREMISE Ea.. r.nce $ MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ 3,000,000 X POLICY[K jE O- LOC PRODUCTS-COMP/OP AGG I$ 3,000,000 OTHER: I$ AUTOMOBILE LIABILITY _(Ea SINGLE LIMIT _(Ea accident) $ ANY AUTO BODILY INJURY(Per person $ OWNED SCHEDULED AUTOS ONLY AUTOS p BODILY INJURY(Per accident) $ AUTOS ONLY AUUTOS ONLY (PeoacEciRdenDAMAGE $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE Is EXCESS LIAB CLAIMS-MADE AGGREGATE Is DED RETENTION$ B WORKERS COMPENSATION X STATUTE OERH AND EMPLOYERS'LIABILITY WCC5005012305 07124/2017 07/24/2018 100,000 ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' N/A 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,descr be under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Christopher Ellis,sole proprietor,excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Wareham , THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Memorial Town Hall 54 Marion Road Wareham,MA 02571 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): /*AA-c., Z C,uS7f,--- Address: iU- 614Az, 5V City/State/Zip: /°/-YA4ud. A,,4 072e,0 Phone#: 5'z2�- 9F9 r-/z.G AR 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' � 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ 10. Electrical We are a corporation and its ❑ repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required]t c. 152, §1(4),and we have no employees.[No workers' 13Other/Y �ert� comp.insurance required] *Arty 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 vyhetber 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 isproviding workers'compensation insurance for my employees. Below is the policy andjob site information. ,,// Insurance Company Name: �ISSoc�.atsn _-A.S Cb Policy#or Self-ins.Lic.#:b CC,SZ y S-vl Z.3 0 3— Expiration Date: Job Site Address: Z/Lt 70A)-eu City/State/Zip: LTL-..G.... 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 and epains andpenalties of perjury that the information provided above is true and correct. Si mature: Date: / D Phone#: bI' ZC ' 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.EIectrical 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 eo of the foregoing engaged in a joint enterprise,and including the legal representatives vcs�f a �PtYer,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 do maintenance constriction or repair work on such dwelling house dwelling house of another who employs persons to „ such employment be deemed to be an employer. shall not because of su ds or building a urtenant thereto . or on the groan g pp. . 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 e b resented to the contracting authority." requirements of this chapter h av been p 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 permitllicense 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 hke 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 Massadhusetts Department of Iudustcial AeKA'dents Office of Investigations 600 Washington Strtet Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1477-MASSAM Fax#617-727-7749 Revised 4-24-07 www.r =,gov/dia i 1 1. j, Commonwealth of Massachusetts t;�' Division of Professional Licensure u/ Board of Building Regulations and Standards Consir ctN),Abp�rvisor . CS-094024 I{ 4�ires: 11I27/2019 f f CHRISTOPHE=R WXELLI :` y 25 GEORGE PLYMOUTH MA.02360�, 40 Aj Commissioner v" �lze�poanineo�recaea�i C�aa�ccaeCta . Office of Consumer Affairs&Business Regulation F HOME IMPROVEMENT CONTRACTOR i Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: F3eaistration Expiration Office of Consumer Affairs and Business Regulation 8941i8 06/20/2019 10 Park Plaza-Suite 5170 TME217INIS�iCl7T0�M7B-ILDERS,INC. Boston;MA 02116 CHRISTOPHER E"LFS C — 25 GEORGE ST PLYMOUTH,MA 02360--" Undersecretary Not valid without signature I l l Sh✓��� I l ) �rsrr.N G Luy r J . go FINISH C& Ro.ft 1174 Sagaincra Beach,MA 02M Engagement for Services DATE:November 1,2017 Homeowner: JT Harris . Address: 214 Tern way Centerville,MA We are pleased to provide you with this outline and agreement for services as described below. The Summary Description of Services highlights the major elements of the project and the services we will provide for each phase: Summary Description of Services: Part 1 Built-ins We will come up with a design for a built-in in the living room for the television that will go with the fireplace. It will most likely be a comer unit that we will build and install. In the back office room we will build another built-in that will go next to the chimney. This one will be for storage of plates and things. 1. T.V. comer unit $1,800.00 2. China cabinet $1,100.00 3. Painting of the units $ 900.00 4. O+P $ 570.00 TOTAL $4,370.00 Part 2 Finish one side of basement We will come in and frame out the right side of the basement as we talked about in our meeting. It will include the closets across the back wall of the basement,doors framed in for the access into the crawl space and a door framed in for entrance into the unfinished area. We will strap the ceiling for a blue board and plaster finish and not a drop ceiling. Once we are framed up we will get the electricians in to wire everything up. This will include recessed lights, outlets to code and switching where you want. After this is finished we will get it all inspected and then insulate and inspected again before we blue board and plaster. The plaster will be smooth walls and a textured ceiling. We can then prime all the walls and ceilings then lay down the floors and do the finish work. Last we will have the painters back to give eve two P � Ding finish coats. 1. Framing $2,650.00 2. Electrical $ 3,200.00 3. Insluation $ 1,125.00 4. Blue board and plaster $ 1,800.00 5. Flooring(LVT floating floor)product only $3,150.00(allowance) 6. Flooring install $ 1,700.00 7. Finish work(doors, stairs and rails,base board) $3,800.00 8. Paint(prime and two finish coats) $2,650.00 9. O+P $ 3,010.00 TOTAL: $23,085.00 Payment Schedule TBD when scope is selected *This Agreement will expire 30 days after the date at the top of page one of this contract,if not accepted in writing and returned within that time. Standard Exclusions:Unless specifically included in the"Description of Services" section above,this Agreement does not include labor or materials for the following work: Custom milling of any wood for use in project. Moving Owner's property around the site. Labor or materials required to repair or replace any Owner-supplied materials;correction of existing out- of-plumb or out-of-level conditions in existing structure. Correction of concealed substandard framing.Rerouting/removal of vents,pipes,ducts, structural members,wiring or conduits, steel mesh which may be discovered in the removal of walls or the cutting of openings in walls. Removal and replacement of existing rot or insect infestation.Failure of surrounding part of rexisting structure, despite good faith efforts to minimise damage, such as plaster or drywall cracking and popped nails in adjacent rooms or blockage of pipes or plumbing fixtures caused by loosened rust within pipes.Exact matching of existing finishes or painting or finishing unless specified above. Charges for additional work; concealed conditions,deviations from scope of work,and changes in the work 1. Concealed conditions: This Agreement is based solely on the observations made with the project in its condition at the time the work of this Agreement was bid.If additional concealed conditions are discovered once work has commenced or after this Agreement is executed which were not visible at the time this Agreement was bid,we will point out these concealed conditions to you,and these concealed conditions will be treated as additional work under this Agreement. We may execute a change order for this additional work.We are released,held harmless, and indemnified by you from all pre-existing mold,fungus,mildew,and organic pathogen problems and are not responsible for costs or damages associated with correcting,containing,testing,or remediating the same. AND LIMITS THE DURATION OF IMPLIED WARRANTIES TO THE FULLEST EXTENT PERMISSIBLE UNDER STATE AND FEDERAL LAW. THIS LIMITED WARRANTY MAY NOT BE VERBALLY MODIFIED BY ANY PERSON.THIS LIMITED WARRANTY IS GOVERNED BY THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS. Work stoppage and termination of contract for default We shall have the right to stop all work on the project and keep the job idle if payments are not made to us strictly in accordance with the Payment Schedule in this Agreement, or if you repeatedly fail or refuse to furnish us with access to the job site and/or product selections or information necessary for the advancement of our work. Simultaneous with stopping work on the project,we will give you written notice of the nature of the material breach of this Agreement and will give you a 14-day period in which to cure this breach of contract.You will follow this same notice procedure with us if you allege that we are in material breach of this Agreement. If work is stopped due to any of the above reasons(or for any other material breach of contract by you) for a period of 14 days, and the you have failed to take significant steps to cure the default,then we may,without prejudicing any other remedies we may have,give written notice of termination of the Agreement to you and demand payment for all completed work and materials ordered through the date of work stoppage,and any other reasonable loss sustained by us. Thereafter,we are relieved from all other contractual duties, including all punch list and warranty work. Force Majeure Not withstanding the above provisions,neither party shall be deemed in breach of this contract for delays caused by Acts of God or other actions and events beyond their individual control. SeverabiIity If any court determines that any provision of this contract is invalid or unenforceable, any invalidity or unenforceability will affect only that provision and will not make any other provision of this agreement invalid or unenforceable and such provision shall be modified, amended or limited only to the extent necessary to render it valid and enforceable. Dispute resolution and attorney's fees: Any controversy or claim arising out of or related to this Agreement involving an amount less than$5,000(or the maximum limit of the Small Claims court)must be heard in the Small Claims Division of the Boston Municipal Court. Any dispute over the dollar limit of the Small Claims Court arising out of this Agreement shall be submitted to an experienced private construction arbitrator that shall be mutually selected by the parties to conduct a binding arbitration in accordance with the arbitration laws of the state of Massachusetts. The arbitrator shall be either a licensed attorney or retired judge who is familiar with construction law.If the parties can not mutually agree on an arbitrator within 30 days of written demand for arbitration,then either of the parties shall submit the dispute to binding arbitration before the American Arbitration Association in accordance with the Construction Industry Rules of the American Arbitration Association then in effect. Judgment upon the award may be entered in any Court having jurisdiction thereof. If we prevail in any legal proceeding related to this Agreement we shall be entitled to payment of reasonable attorney's fees,costs,and post judgment interest at the legal 2.Deviation from description of services:Any alteration or deviation from the Description of Services referred to in this Agreement involving extra costs of materials or labor(including any overage on ALLOWANCE work and any changes in the Description of Work required by you, your design professional, agent,or governmental plan checkers or field building inspectors)will be treated as additional work under this Agreement resulting in an additional charge to you as set forth herein. We may execute a change order for this additional work.Payment additional work is due upon completion of either all or part of the additional work and submittal of invoice by us. WARRANTY Thank you for choosing Frame 2 Finish Custom Builders,Inc.to perform this work for you.Your satisfaction with our work is a high priority for us.However,not all possible complaints are covered by our warranty.We provide a limited warranty against material defects on all our supplied labor and materials used in this project for a period of one year following substantial completion of all work. This warranty covers normal usage only. You must contact us at the address on page one of this Agreement in writing for warranty service immediately upon discovering an item in need of warranty service. If the matter is urgent,you must also call us and send written notice of the need for warranty service. Failure to notify us of the need for warranty service within ten days of discovery of a warranty item may void this warranty. Additionally,hiring of others or direct actions by you or your separate contractors to repair a warranty item are not covered by this warranty and will not be reimbursed. No warranty is provided on any materials furnished by you for installation.No warranty is provided on any existing materials that are moved and/or reinstalled by us within the dwelling or the property(including any warranty that existing/used materials will not be damaged during the removal and reinstallation process). One year after substantial completion of the project,your sole remedy(for materials and labor)on all materials that are covered by a manufacturer's warranty is strictly with the manufacturer,not with us. Repair of the following items and related damages of every kind are specifically excluded from our warranty:problems caused by lack of maintenance;problems caused by abuse, misuse,vandalism,modification,or alteration;and ordinary wear and tear.Damages resulting from mold, fungus, and other organic pathogens are excluded from this warranty unless caused by our sole and active negligence as a direct result of a construction defect which caused sudden and significant amounts of water infiltration into a part of the structure.Deviations that arise such as the minor cracking of concrete, stucco, and plaster;minor stress fractures in drywall due to the curing of lumber;warping and deflection of wood; shrinking/cracking of grouts and caulking; fading of paints and finishes exposed to sunlight are all typical(not material)defects in construction, and are strictly excluded from this warranty. THE EXPRESS WARRANTIES CONTAINED HEREIN ARE IN LIEU OF ALL OTHER WARRANTIES,EXPRESS OR IMPLIED,INCLUDING ANY WARRANTIES OF MERCHANTABILITY,HABITABILITY, OR FITNESS FOR A PARTICULAR USE OR PURPOSE.THIS LIMITED WARRANTY EXCLUDES CONSEQUENTIAL,INCIDENTAL,AND SPECIAL DAMAGES rate. We appreciate the opportunity to present this proposal and look forward to working with you on this in the near future. This Engagement for Services will remain effective for 14 days from the date above and we are happy to address any questions or concerns you may have regarding the project. Best regards, Frame 2 Finish Custom Builders,Inc. I have read and understood, and I agree to,all the terms and conditions contained in the Agreement above. DATE Frame 2 Finish Custom Builders,Inc. DATE O er Section 9-Construction Supervisor Name C6rA?y- r_C is Telephone Number Sae'W? r-1Z6 Address zs G"ca,-z�6 r- s� City /fG✓s�, � State -4� Zip Oz-1-1161,0 k S License Number O9yOZ y License Type Expiration Date Contractors Email t5c,"e kr CoA Cell#_ S-vr- P t I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State B ding Code. I understand the construction inspection procedm es,specific inspections and documentation required by 7 and the Town of Barnstable.Attach a copy of your license. Signature Date IV,? 9 Section 10-Home Improvement Contractor Name F:c,�s Telephone Number SOS 9 Address ZSJ r,6oftz-c S7 City ,,,r-)0�,VUr& State Af.,4 Zip_ OL36 p Registration Number Expiration Date�✓zo�9 I understand my responsibilities under the tales and regulations far Home Improvement Cotaatois in accordance with 780 CMR the Massachusetts St8±0 Building Code. I understand the conslxv on inspection procedures,specific inspections and doc rnentation b 80 CMR and the Town of Barnstable.Attach a copy of your H.LC... Signature Date e. Section 11 -Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and r docurnentatim required by 780 CMR and the Town of Barnstable. Signature Date a PLICANT SIGNATURE Signature Date i Print Name Cc-Is Telephone Number Say 9�9 E-mail permit to: 1*t, 4A,<, z r Last updated.1012017 Section 12—Department Sign-Offs Health Department © Zoning Board(if required) Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please-take your plans directly to the fire deparhnent for approval Section 13—Owner's Authorization 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 i i 1 Last updatcd:11/ /2017 _Town of Barnstable p Building .nwvsrwet4 Post This Card So That it is Visible From the Street proved Plans Must be Retained on Job and this Card Must be�Kep Posted Until Final Inspection Has Been'Made 1659 . Y q . ppy�m FaMxs° Where a Certificate of Occupanc is Re uired,such Building shall Not be Occupied until a Final,Inspection has been made Permit jjjlt Permit No. B-18-190 Applicant Name: HENRY E CASSIDY Approvals Date Issued: 01/24/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 07/24/2018 Foundation: Location: 214 TERN LANE,CENTERVILLE Map/Lot: 192-029 Zoning District: RD-1 Sheathing: Owner on Record: HARRIS,JAMES T&CAROL ANN _".` Contractor Nam :'_CAPE COD INSULATION, INC Framing: 1 Name' '_CAPE } Contractor License 453567 Address: 19 STRATHMORE ROAD � � �� �` `��� � 2 WELLESLEY,MA 02482-4523 i Est Project Cost: $2,000.00 Chimney: Description: 10 MIL Poly On Crawl Floor,Closed Cell Foam on Interior Crawl Permit:Fee: $85.00 Walls. _ �' r Insulation: Fee Paid`. $85.00 Project Review Req`. rt Date 1/24/2018 Final: 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'montlis efterissuance. All work authorized by this permit shall conform to the approved application~and th_eapproved 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. 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 Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures,by the Buildingand Fire Officials are provided on this.permit. Minimum of Five Call Inspections Required for All Construction Work: " Service: 1.Foundation or Footing 4 ' -2.Sheathing Inspection Rough: � _ - � � - 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 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). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION <. Map Parcel 009 Application # Q Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address 7e_ kw i�ao6. Village . E� cat/��_ a Owner 1/�-1MP Aq ef-I C Address Telephone ��� 06 /L Permit Request _n-y1Y7JAJ1 Square feet: 1 st fl or:; existing proposed 2nd floor: existing proposed Total new Zoning District —J Flood Plain Groundwater Overlay Project Valuation�jOM, —Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Base r6ished Area (sq.ft) Number of Baths: Full: existing new j3kJ1J Half: existing new Number of Bedrooms: existing _new JW �Z TMW Total Room Count (not including baths): existing AFirst Floor Room Count T� 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 JO No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name V,ew, Telephone Number6 Address License # A/')q F CJ U0 SO� � Home Improvement Contractor# Email 42d orker's Compensation # �� ' ALL CONSTRUCTION BRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION # a DATE ISSUED MAP/ PARCEL NO. 7 - i ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL P PLUMBING: ROUGH FINAL -GAS: ROUGH FINAL p 'FINAL BUILDING a , DATE CLOSED OUT f _ r ASSOCIATION PLAN NO. DocuSign Envelope ID:OB5EE2FC-0899-4545-AED6-582DOC4B44DD of THE Toy Town of Barnstable Regulatory Services atuvsTAB[E, Richard V: Scali,Director MASS. q, 69.� �� . 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 Property Owner Must Complete and Sign This Section I, JAMES HARRIS as Owner of the subject property hereby authorize cam C A 2-���� ©� to act on my behalf, in all.matters relative to work authorized by this building permit application for: 214 Tern Lane Centerville, MA 02632 (Address of Job) DocuSigned by; �, ,�}✓ 1/2/2018 10:12 AM EST Signature of Owner Date James Harris Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form. C:\Users\decollik\AppData\Local\Microsoft\Windows\lNetCache\Content.Outlook1L7U69LF2\EXPRESS(2),doc 01/25/17. f . . The Commonwealth ofhMassacliusetts Department of Industrial Accidents i I Congress.Street, Suite 100 Boston, MA 02114-2017 www,mass,gov/dla Workers' Compensation Insurance Affidavit; Bullders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, r�Molicant Information Please Print Leeibly Name (Business/Organiza6or4ndlvidual); Cape Cod Insulation Address; 18 Reardon Circle City/State/Zip; South Yermouth,MA 02664 Phone_#; 508,,775-1214 Are you an employer?Check the appropriate boxt I,©l am s employer wJth 48 employees(full and/or part-time) Type of project(required);, 2,01 am a sole proprietor or partnership and have no employees working for me In 7' New construction any capacity,(No workers'comp,insurance required,] 8, [] Remodeling 3,C]I am a homeowner doing nil work myself-(No workers'comp,Insurance required,)i 9, ❑Demolition 4,[]1 am a homeowner and will be hiring contractors to oonduot all work on my property, I wlll. 10 ❑ Building addition ensure that ill contractors either have workers'compensation insurance or are sole proprietors with no employees, 11,❑ Electrical repairs or additions 5,[]I am a general contractor and I have hired the sub-contractors listed on the attached shoot, 12, plumbing repairs or additions These sub-contractors have employees and have workers'comp,Insuruttee,t 13,Q Roof repairs 6.0 We era t acrpor'ation and Its officers have exerolsed thoir right of exemption porMdL o, 14,lY y Other W eatherizatlon 152,11(4 and we have no employees, (No workers'comp,Insurance required,] *Any applicant that cheeks box fEl must also fill out the section b low showing their workers'compensation policy Information. t Homeowners who submit thfii,4davit Indicating they arc doing all work and then hire outside oontraotors must submit a new affidavit Indicating such. tContnotors that cheek this box must attached an additional sheet showing the name of the sub-oontractors and state whether or not those entities have employees, If the sub-eontnctors have employees,they must provide their workers'comp, lley number, 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name, Atlantic Charter 431902' Policy#or Self-{ns,Llo,#;-WCE00 Expiration Date- 06/30/2018 Job Site Address: P /,Ll Ti"r—A) _ �3 `� --- �..._,..City/State/Zip; jY./� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure to secure coverage as required under MOL e, 152, §25A is a criminal violation punishable by a fine up to$1,500,00 and/or one-year imprisonment, as well as alvll penalties In the form of a STOP WORK ORDER and a fine of up to$250,00 a day against-ths violator, A copy of thls statement may be forwarded to the Office of Invest gations of the DIA for insurance coverage verification, l do hereby cer*under the pains and penalties of perjury that the trf'ormaHon provided above is true and correct, Signature; Henry Cassidy �."a 508 775 1214 Offletal use only. Do not write!n this areal a, to be completed by city or town ofjiclal, City or Townt Permit/License# Issuing Authority(circle one): 1, Board of Health 2, Building Department 3, C(tylrown Clerk 4, Electrical Inspector.,5, Plumbing Inspector .6,Other Contact Persont Phone#: r 1 -�1 CAPECOD-27 DOYLE ,d►�oRO° CERTIFICATE OF LIABILITY INSURANCE DA06/30/2017017TE(MM/ Y) - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT'BETWEEN-THE ISSUING 1NSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the,policy(les)must have ADDITIONALINSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER C ACT Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 A/C No Ext; ac No:(877 816-2156 South Dennis,MA 02660 E-MAI •mail ro q ers ra .com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Com an 24198 INSURED INSURER B:Safet Insurance Company 39454 Cape Cod Insulation,Inc. INSURER C:Endurance American Speclalty Insurance Company 41718 18 Reardon Circle South Yarmouth,MA 02664 INSURER :Atlantic Charter Insurance Compariv 44326 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE CLAIMS-MADE ❑X OCCUR CBP8263063 04/01/2017 04/01/2018 DAMAGE TO RENTED' 100,000 c MED EXP An one erson 5,000 i - PERSONAL&ADV INJURY 1,000,000 EN'LAGGRE ATE LIMIT APPLIES PER: GENERALAGGREGATE 2,000,000 X POLICY pte LOC OTHER: 2,000,000 PR DUCTS-COMP/OP AGO ' B AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT 1,000,000 ANY,UTO 6232707 COM 02 04/01/2017 04/01/2018 BODILY INJURY Perperson) AAURTEOS ONLY rx AUTOSSyUVLNEDpAUTOS ONLY A&TOS ONLY ' PROOPERTYU AMAGEaccldenl Per accident $ C UMBRELLA LIAB X :OCCUR EACH OCCURRENCE 2,000,000 X EXCESS LIAB CLAIMS-MADE EXCIO006635002 04/01/2017 04/01/2018 21000,000 AGGREGATE DE RETENTION$ D WORKERS COMPENSATION - x PER OTH• AND EMPLOYERS'LIABILITYTATI _ 11. ANY PROPRIETOR/PARTNER/EXECUTIVE YIN R/O WCE00431902 06/30/2017 'b6/30/2018 pFFICER/MEMBER EXCLUDED? aN NIA E.L.EACH ACCIDENT 1,000,000 (Mandatory n ) If yes,describe under E. .DISEASE-EA EMPLOYEE 11000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Workers Compensation Includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 f201R/n31 r r p Commonwealth of Massachusetts ®/ Division Board o °f Professional Lic_ensure f Building+Regulations Cons and Standards ��rt�Ctl�r{r�.5P�visor CS.100988 y f. ff�pires: 11/11/2019 HENR S Y E CA SHIED IDY+r ; 8 ED ?S ROWS ARMOIjTH� WEST Y � Commissioner Lf" ' R • "utOffice of Consumer Affairs and Buslness 10 Park Plaza - SUIte 5170 Regulation Boston',.Ma �g�a' usetts 02116 Home Improveme� . tractor Re • ��.����=:�,��.,---•,..� glstration Cape Cod insulation I x -1 1, =` ~T" �' .r TYpe: Corporation Inc' ,^ : 1,1 Registrativn: 18 Reardon Circle ,:�•y1� : ;,; Ex Ira 153567 So, Yarmouth MA 02664 nc 12/1a/2018 11 r,i 20M•05111 f^'_ ' -- Update Address and return �j card ark,-M reason for change, a (0007VI7L09L[U6CG�r✓ -------- .._— - ...._--....,_ __._ (�.gdr',�, ��_T'. L����uJouc/tcoeCA. lti3tz :,'�7C-1 � to!Yrz�nt Of11ee of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR l.GrstarH• _....._ i Tyke; Corporation Registration valid for Indlvldual Use before the explratlon date, If foun a only ,•,• '^ ••:;t -• LatLep office of Consumer Aifalrs and urn to; sl so Regulation 12/14/2016 10 Park Plaza• e 8170 Cape Cod Insul4dl `141i ��s, Boston,MA 11 Henry Cassld �. � - 18 Reardon Clrc(' t�t CCQV So.Yarmouth Undersecretary t al hout sl atu 'V10 'z/V ��QyO%THET��yw TOWN OF BARNSTABLE i 339HHSTADLE. S NAM � BUILDING INSPECTOR APPLICATION FOR PERMIT TO / // .. ................................................................... TYPE OF CONSTRUCTION .. L7. ...c����F....��J.e.... ,.1/ ..... . " ................................ ......f.O..l 9.1P. . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....14'C.'..!?.... .r- �"1.�......... .�1 .l .1/i.l./� .�... � .S.S.................................................................. Proposed Use ...4 .....4 .....rzo. fn. ........................................................................................ 'A ZoningDistrict ........................................................................Fire District C......!?l ........................... .................... Name of Owner �1..1. F•;i(•'. 474.0..W. .Address Z 4..Z! e. C,4..../?. Name of Builder A.D!/'I. .S..././...:..., ,,9a.y2.................Address)'` /4 Name of Architect l..l�t T.�1^� /( .C� l�I...................Address ./ vos_s Number of Rooms ....4.V-��...............................................Foundation ............. ?....('.��........................... Exterior .....>1?.l.l?.C�I.TS....................................Roofing` . .....-. .1........s. �.�. /s FloorsW0.0.. ...............................................................Interior /?•��/?/ Heating .770?.aa. ..*(P ..:{'Y.. :14.f...............................Plumbing ........ .... ?, f`................................... Fireplace ....C9l.7.e............................................................... d(� Q��.....Approximate Cost ..........�........�.�:..............�........................... Difinitive Plan Approved by Planning Board --------------------------------19--------• '- r Diagram of Lot and Building with Dimensions I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Allt _0 w. . Sarianowicz, Mitchell J. J0 012283 1 l/ storyt I 0 ................. Permit for .................................... single family dwelling ............................................................................. cation Tern...I.a ne..................Z9-7-e-1........ .............. Centerville ............................................................................... Owner ..........Mithhell J. Sartanowicz ........................................................ ...... .... Type of Construction ......frame......................... ................................................................................. 4-( Plot ...9.Y P 4 ... Lot ... 7....................... Permit Granted ....... ................19 69 Date of Inspection ........19 t Date Completed ........... ..............19 PERMIT REFUSED ii ..................................................I............... 19 ............................................................................... ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... J� .i v Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag:'508-398-0399 2/7/17 Thomas Perry CBO Town of Barnstable x �U�L�I�Ca Building Division - P -r 200 Main St. FE� 7 Hyannis,MA 02601 ' 2017 OF'RAFj1V S7ABLe RE: Insulation Permit 16-3727 Dear Mr. Perry x, This affidavit is to certify that all work completed for 214 Tern Lane, Centerville has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. ; Sincerely, William McCluskey Page 1 of 1 Coyle, Brenda From: James Harris Otcaharris@yahoo.com] Sent: Thursday,April 06, 2017 12:14 PM To: Coyle, Brenda Subject: Fw: 214 Tern Lane, Centerville MA(Elec. Permit E-17423) ---Forwarded Message--- From: James Harris<jtcaharris@yahoo.com> To: "brendacoyle@town.barnstable.ma.us" <brendacoyle@town.barnstable.ma.us> Sent: Thursday, April 6, 2017 12:02 PM Subject:214 Tern Lane, Centerville MA(Elec. Permit E-17423) To:Town Inspector,Bill Amara Please remove electrician Richard Bentley immediately.(elec.,permit E-17423)from Tern Lane Centerville,MA I will hire another.electrician. I will also send a hard copy of this notice to remove electrician via'mail. Please let me know if you require any further information. , �1 a CD Thank you, James Harris 214 Tern Lane F '1 Centerville,MA 02632 781-292-0614rn y W P \7 i •t p � ' 4/6/2017 f � e l.a, J IKE Town of Barnstable *Permit# of y-.�, ? Expires 6 months from issue date �T °* Regulatory Serviees`-- Fee annivsTnsr.E4 : Ai — s ` Richard V.Scali,Director. Building Division 0,k 2vie Tom Perry,CBO,Building Commissioner �y 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 c;2/9 7e r{�1 //I r yI/l e /VA 6 Z 6-'?,p2 (Residential Value of Work$ `1 dry©. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address idl1gt.QS �HA yel C Contractor's Name_4rrvt i nv`s ros-ck-� Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ' -?s 66 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance " Insurance Company Name AM 0u 0­-V d Workman's Comp.Policy# Rd- V(f 7$ It' 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) Re-side Replacement Windows/doors/sliders.U-Value Q- (maximum.32)#of windows #of doors:�7_ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: 6� t9 Ifs C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 r r < rr BAMSTABLE S 16_19. ,� Town of Barnstable A ° Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner < 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the'subject property hereby authorize 14,tPVi kul-S. h/h4-70, to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job). Z�4C_� Si ature of Owner' Date �--7� cam. Print Name t If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc ± Revised 040215 j Vie '` C � : '' tons _and :' Stan..� dS B I i n Reg � � t , B Se Mpg 3566 K *ce C, Con g AREMINAS DIMSA IE E LANE I T PAT } x CoTuff MA 02636 4 � M , . 02/201 i �i�Of Consumer airs usirves�Regt�l ol� . 14 # t ANT-CONTRACTOR Registration valid for individual use OntY i before the expiration ation date. if found return to. !on €�al f ce of Consumer Affairs and Business Regui T .- te 1 ratio x it lon w. 10 Park Plaza - Suite 5170 016 r= Boston, NSA 02116 AMN lip coft� ;.- 2 ram• - ... - -- - - _ UhdersecrOaq Not valid without i n ure a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 turvw.rrrass got/dia Workers' Compensation.Insurance Affidavit: Buildens/Contractors/Etectricians/Ruvabers Applicant Information `l Please Prmt Leo'bly Name(BusiussfOsganizationlladividUai): 1'r tni,Ya S U i'/✓1��0� Address: 1-7 P(,.,+j.,e /Pi City/State/Z:p Cc4c4 1 IIq rt o263 s- Phone F—67S- �?702 0 AreYOU an employer?Check the appropriate ox' Type of project(required): 1.❑ I am a employer with 4. [ I am a.general contractor and I employees(full and/or part-time)." have hired the:sub-contractors 6. [-]New c5onstntcton. 2.[3 I am a sole proprietor or partner- listed an the attached sheet: 7. ❑Remodeling ship and have no employees These sub-contractors have & []Demolition woddng for me in any capacity. employees and have wodcers' 9. ❑Building addition [No workers'comp.Dance comp.insurance. required:] 5. ❑ We are a corporation and its 10T1 Electrical repairs m additions 3.❑ I am a homeowner doing all work ofioers have exercised their 11.❑Plumbing:repaim or additions myself[No worbeW comp: right of exemption per MGL 12.Q Roofrepairs insurance required]1 c. 152,§1(4) and we have no employees.(No workers' 13.❑Other comp_insurance required:] *Anyappli=that C hacks box#1 mo*also fill out ft section belm-showing dwir wwkers°'cougmmtiompolicy infbnnxdm I Hameownus who submit this effRbvir:indicating they me doing all wazit,and then hire oautde contras tors mast sobma,a new affidavit indicating such. lCoattactors that check t Cis box oust attadwd am additional met dowi g the name of the ond.state wbedw ou not those eatities bane employees. If the sub oo=ctm bm mploy %daymm provide their workers'comp.polio number. I am on emptoyer that ispmiding workers'conrper sation inuarance for my enplojwes. Below is the polky and job site information. Insurance Company Name: �fbt0.f Policy#or Self-'ins.Lic.. L(2)p R Expi>•at on Date: /0 ,b/z Job Site Add s: V\ h CitytState/Zip: (.Catl4r kill M Attach a ropy 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$1500.0D and/or one-year imprisonment,as well as Civil penalties in the forth of a.STOP WORK ORDER and a tine of up to$25000 a.day against the violator. Be advised that a copy of ibis.statement may be forwarded to the Office of Imestigations of the DIA for mmumm coverage verification. I do hereby cerhly under thepars and perrolties ofper iry NtatHie information pmvided above i .byre and correct signahue: /�ii�G�-u S J�l, Date: 1�,2 Phone#. 0 ' U.#'rcial use onty.. Do not write in this area,to be completed by city or town of ciat City or Town: PermitlLicense# Issuing.Authoritp(circle one): 1.Board of Health 2.Budding Department 3.City/rown Clerk 4.Electrical.Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: :: .� - 1: I � .� -�.,. .. b . ,, Ae D� DATE(eAM/ _. ...) CERTIFICATE 1.OF LIABILITY INSURANCE .. " 10�26/201s THIS CERTIFICATE is ISSUED A$A MATTER OF;INFORMATION"ONLY AND CON1 .1111 FERS NO RIGHTS UPONTHE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EI- OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOW: THIS CERTIFICATE OF INSURANCEIWES NOT'CONSTITUTE"A CONTRACT.BETWEEN=THE ISSUING:INSURER{S), AUTHORIZED >. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER ,.. . IMPORTANT: If'the certificate holder is an ADDITIONAL INSURED;the.policy(ies)must have ADDITIONAL INSURED provisioiTsbr be endorsed.' ff SUBROGATION IS WAIVED,subject to ttie terms and conditions'of the,:policy,certain policies may require an endorsement:.'A statement'on tiTis certificate does not confer rights to the certificate holder in lieu of such;endo>sement{s) PRODucER. NnME: Victona Stiarapova` ALD insurance Inc 6t3A Brighton Avenue PHONE a No Allston,MA 02139 ED"RE ADDRESS `� .. ;. FFOR13ING COVERAGE` NAIC:r z; INSURERS A .1 iNsuRERp =ATLANTIC CHARTER•INSURANGE COMPANY :; 44326 1wsuRED Belcape'Construct+on lLC iusURExB. AMGUARD INSURANCE.COMPANY � 42390 42 WOODBURYAVE Hyannis;MA02601 iwsuRERc: . y .... ..L. 5 : INSURER E , :-,..,--,,,.��,". : aINSURER F :COVERAGES :' CERTIPICATtkumBER: 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 i ;CERTIFICATE MAYBE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED;By'(HE,POLICIES;,DESCRIBED HEL.REIN IS SUBJECT TO ALL THE`TERMS EXCLUSIONS AND;i O ITIONS OF.SUCH P_OLICIE1, 9SAIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS . , I�jR TYP80F INSURANCE ADD UBR1. POLICY EFF. POLICY EXP POLICY NUMBER M M LIMITS A; COMMERCIAL GENERAc LIABILITY; LWO04009-1 01/14/2016 1/14/2017 ,.�A�H occuRR ICE g 1,000,000 CLAIMS MADE I OCCUR:` I R NT9. 100,000 - .'- PREMISES Ea ocwnence $ .e MED`ExP(Arty oiie person) $ $,000 . . .. ..,'..,:, ... . ­­ 1 9..�..L.4! 11. &:� "_�:�.�'..:::� L,,,,, PERSONAL 8 ADV INJURY :, $ 1,a13C,OOD Gr=OL AGGREGATE LIMIT APPLIES PER:i fL . GENERAL AGGREGATE $ 2,000,000 POLICY a JRCai 'Q LOC:: im PRODUCTS COMPlOP AGG S 2j 1 1.000 000 OTHER. L. S AUTOMOBILE LIAMUTY COMBINED SINGLE LIMIT :'. $ Ea-aoddeM ANY AUTO BODILY INJURY'(Per person)',' $ OWNED SCHEDULED BODILY IN,-,, er aOiI S AUTOS ONLY; AUTOS, ( 1 HIRED NON-0WNED r PROPERTY DAMAGE AUTOS ONLY; AUTOS.ONLY v, Pet accident UMBRELLA.9. 6 OCCUR; ^ EACH OCCURRENCE $. EXCESS LIAB CLAIMS-MADE AGGREGATE ` $ DED -:RETENTIONS $ B`' WORKERS COMPENSATION R2WC784369 10/29/2016 ,10/29/2017 PER OTH AND EMPLOYERS LW�UTY, Y/N R2WC649737 10/29/2015 10/29120I araTUrE ER - ANY PROPRIETOR/PARTNER/EXECUTNE E L EACH ACGDFJVT S 1,000 OOO OFFICER/MEMBER EXCLUDED? N l'A (Mandatory in NHL? E L DISEASE EA EMPLOYEE S 1 A 000 tt qes descdbeu�er 1,000 000 DESCRIPTION OF.OPERATIONS below E.L.DISFASE POLICY LIMIT. 5. DESCRIPTION OF OPERATIONS I LOCAT10Ns I VEHICLES(ACORD 101 AddiUonaf;Remarics Schedule,maybe attedied if more space is mu ed) ''.. v .: :.F : b : ;.: - .. . ,`�.'' .. ._�-9,�- . I .-9. . -. .I . . , - . . A .. -. .. .. _ .....: r' CERTIFICATE HOLDER i. k CANCELLATION ' _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE OANCELLED BFfORE THE':EXPttiATTON._ DATE THEREOF; NOTICE WILL`_BE' :,DELIVERED ::IN �a' ACCORDANCE WITH THE POLICY PROdIS10NS': r AUTHORIZED REPRESENTATIVE '' .�"'`._ .. . Id I ..__ .L ' r. ©1988-2015 ACORD C,ORPO.RATION::AIl rights reserved .;ACORD 25{2016/03)r. The ACORD name and logo are registered marks of ACORD a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map l 9 Parcel 0 a 9 3UIL DING OEPT Application # Health Division Date Issued Conservation Division DEC 21 2016 Application Fee Planning Dept. TOWN OF BARNSTABLE Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis -�i�rLfai�t� Project Street Address 11�A Tern Lko,& Village�aAktM IIfi Owner Z'tirwfa rvr;S Address S'p MA, Telephone Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes �d`No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) I , G A 3 Name � Telephone Number � � $ 03 � Address v� j n akf- License# -C 10 �► �Arrn a u<'f,_ J�7 _k A 6 6 Home Improvement Contractor# 1,7 t y cF b Email Worker's Compensation # VC_0gy5 q 0?_00 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ro, SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION E' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING J DATE CLOSED OUT ASSOCIATION PLAN NO. i L. MWlthoMsdcss T " !r �Tlie C O 7Department oflndustrialAccidents "` "'`�A s 1 Congress Street �S.ucte.1:0.0 _ ?� e � i r!,a. f ...' 7,a s • ,r,,ft,i 7, i .., , c b .,..t„ ` -E,j..�� •7 ..{1 !. .µ�•-1 7 P.!fl KT :!.�.' r J'� i•„ .,♦,•F`, " $ ;1_ t�" Boston,:MA 02114-2017 3 ' i'`i'r ?�. row. ,'G.S ^,..y+ , - r ..5 T�5 r '(1.: t.'. ,; ,^..,'Y'i..e 7 ,1 a-F t!''tt T1 •. ".tS ."'y'. a.r7•i, M wivw mass g aia A'orkers"Compeusation.Insdrance`AfSdavitsBuilders/Contractors/El'ectrician's%Plumbers, + TO BE FILED WITH THE PERMITTING AUTHORITY. , t Applicant Information Please Print Legibly ' I NaTl1e(Business/Org Caa Save Incanization/Individual): P, r ` Address:7-D Huntington Avenue ` .. . j City/State/Zip:South Yarmouth, MA 02664 - -. • *Phone.# 508-398-0398 - ! Are you,an employer?Check the.appropriate boz: , ype of project(retluired)'. ' T ,,G n 1. 1 am a employer with 15' ° employees(full and/or pan .. v, + �, 7 Q Ne construction t 2 1.a sole: ro netoror aitnershi and have no em hi ees workin for me m}p, P P, P _ p Y g 8. ❑Remodelizig•� ;c any capacity.[No workers'comp insurance required.] , f 9. E Demolition c, Ir I am a homeowner:doin all work m self.g y [No workers comp..insurance required:]# - _. 10 Q'Building addition i g mP a -ail y Property.•I wi1lJ � ep 4.❑:I am a homeowner and Will be Kirin contractors to.conduct all work on m _ensure that all contractors either have workers'co ensahon:insurance-or are sole 11.❑Electrical r airs or additions ; proprietors with no employees. r 12.❑Plumbing repairs or additions ! 5.17 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. y These sub.-contractors have employees and have Workers'comp,insuiancea 13:❑Roof repairs , + 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[E]Other Insulation. . i 152,§1(4),and we Have no employees..[No workers'comp.insurance required.] ' *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information ` " • ' �' i t Homeowners who submit this affidavit indicating they are doing all.work and then hire outside contractors must submit a new affidavit.indicating.su.such. - *-Contractors that check this box must attached an additional sheet showing the name.of the:sub-contractors and state whether or not those:entities have , employees. If the sub-contractors have employees,they must provide their workers'comp.policy number: ! I am an employer that is providing workers,compensation insurance for my employees. Below is thepolicy and job- site i-1" 9forinad6n. F * • :,,' %, . , _ t I �` Insurance Company Name: Star Insurance Co. Policy#or Self-ins Lic:#: WC085540700 - t = Expiration Date 4/9/201 T Job Site Address:_214 Tern Lane't t City/State/Zip:*- • , ' • • Centerville • • r r Attach a�copy of the workers compensation policy declaration page(showing the policy,number and;expiration date)._ Failure to secure.coverage as required under MGL c. 152,§.25A is a criminal violation punishable by a fine up to$1,500.00 and/or one=year imprisonment,as Well as.civil penalties iii the form of a STOP WORK ORDER and a fine of up to$250.00 a dayAgainst gainst the violator.A copy,of this statement may fotwvarded to the Office of Investigations of the DIA for insurance t },,•, s, _ t coverage Verification. I do hereby certify under,th :pains and penalties of pePjury that the information provided.above:is true and correct Si ature Date: 2/21/16 1 Phone#:508-398-0398 { t O icial use:onl Do not:write:to thin area to be completed by city or town ofyiciat City or Town, ::, .tM ` PermitlLicense# I Issuing Authority(circle"one). „1,BoardofHealth.2 Building.Department,3.City/Town'Clerk 4.Electrical:Inspector 5..P.lumbingI.nspector.• i 6.Other 7 i Contact Person: Phone_#• F Aco CERTIFICATE OF LIABILITY INSURANCE FDATE(MM1DDNYYY) 10/24/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: Colleen Crowley ' Risk Strategies Company PHO No E (781)986-4400 FAC No: (781)963-4420 15 Pacella Park Drive E-MAIL ccrowle @risk-strata ies.com ADDRESS: Y 9 Spite 240 INSURER(8)AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURER A:Liberty Mutual Insurance Co INSURED INSURERB Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc INSURERC:Ohio Casualt /Peerless Insurance 24074 7 D Huntington Ave INsuRERD:Star Insurance Co INSURER E South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER•CL16101422377 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 TYPE OF INSURANCE ADOL SUSR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDO MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE_ A CLAIMS-MADE FxI OCCUR PREMISES Ea occu u nce $ 100,000 a B3681757245490 10/16/2016 10/16/2017 MED EXP(Any one person) $ 15,000 . PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT F—]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED Ea accident SINGLELI T $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED E SCHEDULED AWSA46796600 ll/6/2016 11/6/2017 BODILY INJURY(Per accident) $AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTO NON-OWNED (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2 000 000 C EXCESS LIAS CLAIMS-MADE ,a AGGREGATE $ 2,000 000 DED X RETENTION 10,000 VS057246490 10/16/2016 10/16/2017 $ WORKERS COMPENSATION Officers included for X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIE)(ECUTIVE Coverage E.L EACH ACCIDENT $ 500,000 OFFICERJMEMBER EXCLUDED? N❑ D NIA (Mandatory in NH) WC0855407 4/9/2016 4/9/2017 E.L:DISEASE-EA EMPLOYE $ 500 000 It yes•describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Evidence of Insurance / Insulation Specialists r • i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE' THEREOF, NOTICE WILL BE DELIVERED IN Barnstable County ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact 460 Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02061 Michael Christian/CLC "� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) „ 4 Ty Ice 084 y S �T . h48 Gsdli � 5 At �PA.C}TS' Snag if t d Office.of Consumer Affairs and Business Regulatlor: 10 Park Plaza;.-. Swte 5170 Boston;Massachusetts.02116;,, Horne Irrproveinent;Contractor keglstratlori Regist[ation 171380 Type Corporation Pa „ Expirafion. 3>14/201;8 Tr# 419291 } s, i - 4 i CARE SAVE INC. WILLIAM 'McCLUSKEY M - 7-D HUNTINGTQN AVENUE SOUTMRMOUTH MA'.02664:H= Al Update Address and return card Mark reason for'change. wwM Address. ❑.Renewal 0 Employment Q Lost Card SGA 1 CY 26M-05111 �e�al�arxartrue�cll�a a��f�liu�ucf rweL(s � Office of`Consumer Affairs&Business Regulation License or registration valid for indiyidut.use only _ HOME IMPROVEMENT CONTRACTOR before the expiration date.'If found'returfiAo l Registration j71380 Type: Office of consumer Affairs':and Busmess.Regulation Expiration 3/1�3/2018 Corporatio6 10 Park Plaza-Suite 5170' —y Boston,.MA 02116 CAPE SAVE INC. WILLIAM McCLUSKEY 7-1)HUNTING TONA. `.Ew SOUTH YARMOUTH,MA'o2fi64 Undemcroary Not valid: i signature Massachusetts--'D.eparttneht of-Public Safety Construction Supervisor Specialty Restricted to- Board of Building Reguiations.and Statdards CSSL-IC-Insulation Contractor r c_ auI Iwui`u6n ouiiEuvi56a o nca�n rr License CSSL 102776 WILLIAM J MCU 37 NAUSET ROAfl West Yarmouth 1YIA kjJ7, x Failure to possess a.current edition of the Massachusetts Expiration State Building Code is cause for revocation of this license. Commissioner 0612812017 DIPS Licensing information visit: WWW.MASS.GOV/DPS