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0097 THOREAU DRIVE
?� LA- m a Application number.... .....�.............. ... S o� yy tt �� Date Issued......1,.��..... -1,, ° BAR2Y5TABL& e '3 r (fin !t' �... ..... t639..�a�0 OCT �,�:I Building Inspectors Initials.... :9 g P &Ih ............... ��AlN `y1F- 1� Map/Parcel.......L ....�z.s................... ........ � R TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 97 ZZ re, ✓ �r;�/� �P���"✓,'l�tG NUMBER STREET VILLAGE Owner's Name: _S� La S Phone Number v P - 2, 2 5 Email Address: Ada,,; con- Cell Phone Number r Project cost S 4/.7DO — Check one Residential � Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: 5ep -f(Q�� C��,,-{c -�- Date: TYPE OF WOE l-D Siding E�J Windows (no header change)#�_❑ Insulation/Weatherization Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to W 4 She-/r?a a�e yl?- ! CONTRACTOR'S INFORMATION Contractor's name ; u de. ccrS IaI4 [If,n cow S V Home Improvement Contractors Registration(if applicable)# !7 3 2-q.5 (attach copy) Construction Supervisor's License# 09 S`7 07 (attach copy) Email of Contractor QStjee+ ; J• C (n Phone number 1101" z 2- R - 9�00_ ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS/tU A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. ..`•. APPLICATIONNUMBER.......:.................................................... *For Teats Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. XW®®D/C®AL/PLLLLT STOVES x Manufacturer# Model/I.D. Fuel Type . Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand any 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 documentation required by 780 CMR and the']Gown of Barnstable. Signature Date PLICANT'S SIGNATURE Signature' Date All permit applications are subject to a building official's approval prior to issuance. Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal B Andersen of Southern New England Y g Susan Davis Legal Name:Southern New England Windows,LLC 97 Thoreau Drive RI#36079, MA#173245,CT#0634555, Lead Firm#1237 Centerville,MA 02632 WINDOW RE LACEMENT 10 Reservoir Rd I Smithfield,RI 02917 - H:5083609323 Phone:401-349-1384 1 Fax:401-633-6602.1 sales@renewalsne.com Buyer(s)Name: Susan Davis Contract Date: 09/18/19 Buyer(s)Street Address: 97 Thoreau Drive, Centerville, MA 02632 Primary Telephone Number: 5083609323 Secondary Telephone Number: Primary Email: suedaviscapecod@gmail.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document, the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). y Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $4,700 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $2,350 Balance Due: $2,350 Estimated Start: Estimated Completion: Amount Financed: $4,700 6-8 weeks 6-8 weeks Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: 50% paid now by Gs, 50% 'paid by Gs at compl.Taxes paid in Barnstable Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellationi on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.,You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 09/21/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF.THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Renewa of Southern New England Buyer(s) Q . Signature of Sales Person Signature +' . Signature Kevin Desmarais Susan Davis r Print Name of Sales Person Print Name Print Name UPDATED: 09/18/19 Page 2./ 12 Office of Consumer affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improv.ernent Contractor Registration Type: Supplement Card Registration: 173245" SOUTHERN NEW ENGLAND WINDOWS LLC, Expiration: 09/18/2020 10 RESERVOIR ROAD SMITHFIELD, RI 02917 SCA 1 0 20M-05/17 Update Address and Return Card. , Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Reaiste fi6n Expiration Office of Consumer Affairs and Business Regulation 1Z3245 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW'ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 10 RESERVOIR ROAD Q SMITHFIELD,RI 02917 Undersecretary 4O 1 without signature r Commonwealth € f Massachusetts - Division ®t Professional Licensure Beard of Building Regulations and Standards Construcftn' `upervisor CS-09 707 EApires: 09/08/202.0 BRIAN D DENNISON 8 BLACKWELL DRIVE CHARLTON MA =01307 i Corirrdssioner The Cotntnonwealth'of Massachusetts Department of Industrial Accidents I Congress Stree4 Suite 100 Boston,MA 031143017 wow mass gov/dig Workers'Compensation Insurance A6dsvit:Bullders/ContractorstElectricians/Plumbers. TO BE FILED WITH THE PER.Kf M- C AUTHORITY. Applicant Information l 14 Please Print Levibiv Name(Business.Orpnization/lndividual):_ S L4:fh e r r, Neu) tna lc AW /1 13 � Address: U City/State/Zip:SM(-fAeQ ?( OZq g Phone#: Are you as employer'Check the appropriate box: Type of project(required)` 1. lama employer with c mploym(full and/or part-time).• 7. []New construction 2 am a sole proprietor or partttership and have no employees working forme in $: Remodeling any capaciry.lNoworkers'comp.iasurattce required.] ❑ 3.[J I am a homeowner doingall work myself t 9. ❑Demolition Y ]No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring combraetmrs to conduct all work on my property- I will 10 D Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 l.[]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.[3 I am a general contractor and I have hired the sub-contractors listed an the attached sheet. These sub-Contractors have employees and have workers'comp,irmurance.t 13.QRoof repairs fi. ]We are a corporation and its officers have exercised their right of exemption per MGI.c. 14.('Other (a/,;J &,,1 152,¢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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rCentnictors that check this box must attached an additional sheet showing the name of the sub-cons actors and state whether or not those entities have employees. If the sub-conuactors have employees,they must provide their workers'comp.policy number. I am an employer that is pros nc workers'compensation insurance for my emplayeaL Below is the policy and job site informadon. Insurance Company Name: r O Policy#or Self-ins.Lic.#: W(,A%31S=- Qp?y Expiration Date: Job Site Address: City/StatelZip: C '/le l`'l Attach a copy of the workers'compensation policy declaration page(showing the policy number and expire on 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 penaltids in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ' under the p ' penalties of pei jury that the information provided above is true and correct l Date: Phone OLfieial use only: Do not write in this area,to be completed by city or town qoki al City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACC>R" CERTIFICATE OF LIABILITY INSURANCE DA TE(MM/DD/YYYY) � 12/28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CoBiz Insurance, Inc.-CO PHONE FAX CONTACT 1401 Lawrence St., Ste. 1200 t• 303-988-0446 Arc No:303-988-0804 Denver CO 80202 Aoo MSS: COMail@cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURERB:Firemens Insurance Company of WA,D.C. 21784 dba Renewal by Andersen of Southem New England Southem New England Windows, INSURER C:Homeland Insurance Corn an of New York 34452 i em 10 Reservior Rd INSURERD: Smithfield RI 02917 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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 I ADDL SU R . POLICY EF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER (MMfDDIYYYY1 1MM1DONYYYiLIMITS A I X COMMERCIAL GENERAL LIABILITY CPA3158728 1l1/2019 i/1/202D EACH OCCURRENCE F$30O.000 0 CLAIMS-MADE a OCCUR DAMAGETO PREMISES a occurrence MED EXP(Any one prson)PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,0W,000 X POLICY JECT El LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1I1/2019 1/112020 COMBINED SINGLE LIMIT, a accident $1000 0 0 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED (Per accident) $ AUTOS BODILY INJURY X HIRED AUTOS N.AUTOS NON-OWNED PROPERTY DAMAGE AUTOS er accident $ $ A X UMBRELLA LIAR X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $15,D00,000 DED I X I RETENTION$n $ B WORKERS COMPENSATION WCA315872924 111/2019 1/1/2020 X AND EMPLOYERS'LIABILITY Y/N ST TOTE JOERTHOFFICER/MEMBANY �ERPEXCLTUDEECUTIVE N/AE.L.EACH ACCIDENT00.000 (Mandatory in NH) E.L.DISEASE-EA EMP00,000 Ifyes,describe underDESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYo0,mo C Pollution Liability 793DO73340000 1/112019 1l1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate Retroactive Date 08120/2013 Deductible $2,000,000 $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD BY . ...DATE SUBJECT.._... ........................ — SHEET NO., OF CHKD..BWw rt PATE- .................. .. . ... JOB NO..._ e /p OLJ o 79 � s is �- f ,Cn/IJ. PICO �' �\ Ate' -- C F!f:'t'F i 1 E D PL O- 'JC A; f D P`i ' c ',T P.V y. A (- ;s AX r:t' tv / C . i - x2 Asssc?�'sap and .lot number .. .�7.�..:....... ........... �' 6 SEPT SYS"T t r y` l r IC MST. B IRSTALLE. =I F _ V'd'ITFI „! Cd' L(AN.0 Sewage P„'ermit`'number .....................:...... :/ �+qq A xT=•L II ST, T e i.`.j I •f.: SANITAp- .CQL a m - t E lr� _ Ark TOWN Q�FTHETp � 4? TOWI `. OFJr BARNS'I a j o. Z B1fBB�9T0IILE • G7 � � 3 .;,h �� t �jU I;L D IyN G IN S P Air-A C T O R 'EOMPY �. E� 1. 1 , Q LFOR'-'PERMITt S16, z ................................................................... ............... APPLICATION TO .......... .... TYPE OF CONSTRUCTION :" . .. ,� .............. .. .......... ..... ........................ •............... T7t• 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the fo ing. information: Location ..... ... � ... ..mac..................` ......................................................... ProposedUse ........................................................................:...........................:..............:.............................................. ...... ZoningDistrict ............. .. ..... ............. ... .............................Fire District .......:................................ .:.................................. Name of Owner ..Address r. Nameof Builder ............C........................................................Address .................................................................................... Nameof Architect ..................................................................Address ....................................................................... Number of Room ...........� ............................................... .: ................................. Exierior ....... ... .................... ..... ...........................................Roofing ............... . . . .... ......... ....:...................................... Floors .........1 ....................:................................:..Interior ...... ... ......... ..... Heating ....... -............ .....................................................Plumbing ....... ..... ............... Fireplace ...... Approximate Cost ...........:..j ..... .......�1` Definitive Plan Approved by Planning Board ___________'____________________19________. Area . .. .......®S`....`......... IJAJ 1510 Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH i f I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regard' g the above construction. Name .. �. . .�. .. .. .........:. ........ Small, Alan E. ..... one story, _ - Perm it-for;• T L single' Uhily -dwelling i ;........ ........ ....... ... ... ................................... Loccitiori� Thoreau Drive............................. w CetLterville Owner' ...........Alan E. Small............................ r _ Type of Construction ...........................................frame . . ' rPlot .... Lot ................................ c November 18 "' 7 5 Permit Granted ................. ,,Date of Inspection .. ..................... I Date Completed ry �67 6 Cy'~ T `PERMIT REFUSED .......................... ........ is ................... 19 `. ........................... ........ ... ... .._........... ..... ...... ... ....................... 1 * ` /^ ^ r• `5 �'. ............... !sT F. ...... ............. ........... .... ... ....... .. .................................. ......... Approved ............................................ 19r ........... ............................................................... Assessor's map'and lot 'number .., ...`� Zr Sewage-:Permit number ....:........ <` y TOWN OF BARNSTABLE F 111 E T Z 8JE39TAZLE. i "6 i am _ BULLDING INSPECTOR' 'FPY�` t�� APPLICATIONFOR PERMIT TO. ............................................................................................................................. //J C.—vs'z-'�... TYPE OF CONSTRUCTION .................... ............................................................................................................... ..� �?'•,•.....19... TO THE INSPECTOR OF BUILDINGS: The undersigned 'hereby�applies for a permit according to the following information: Location ... /. �T�....Z........... ... ,if...!....................... ............................................ ,-u ...... . ProposedUse ............................................................................................................................................................................. Zoning District ................:.......................... ...........................Fire District ................................................................................ Nameof Owner .. .......................... ............Address ...... ....,: : - .............................................. Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address ..........................................�.......................................... Number of Rooms ..........Foundation ...� '.........!... ...Roofin ...................................... Exterior .... .....:....... ^?,..............................,.............. g .......1.(... ......,_..... Floors .........................................................Interior .........:...,. .... d1�................................ Heating ...........................Plumbing Fireplace .........:.....%. P7.- ....................................Approximate Cost .......................... i , Definitive Plan Approved by Planning Bo rd ________________________________19________. Area '.... ...:.°:...`.........+.............. Diagram of Lot and Building with Dime sions Fee ....... .�.................;, 1..... SUBJECT TO APPROVAL OF BOARD OF HEALTH - - 170.0 VV t � 7-C)AO I hereby agree to conform to all the Rules 9nd Regulations of the Town of Barnstable regarding the above construction. Name ...... .....,.;...:.........:....... .. .... Small, Alan E. A=191~225 . 18057 *' one or No ................. Permit for ---. - single 141a1ly dwellin . . -------`-----------''4�----- . ~ kT6oreau Drive ` Location ................................................. .............. Centerville � --------.---.-------------- , � Alan E. I80Q0[ Small ' Owner ..................................................' . -----.. � � framua- ' Type of [onstruction ---- ^ ' . ,". "^. m ' Permit. Granted � ' ~~'~ of ^'"pe^ "°' ' Date o��e6 ' � ' � . . � � FERIALT REFUSED 19 ...— -----.. . ' ' . . . . ^--`^~ ---'^^`' . -----'� —^---'' ...................................................... ) v Approved .................. ..�---. l . � ` ^ � ---------------.--.----.--.,�.. . ' ---------------------.---.—. . ' y ^ � i 0 of C"E* SAVE,,--a'.." DIVIllryij Weatheriez ation .e 508-398-0398 December 14,2011 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 R. RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#201101654, Status A, Parcel 191225 at,97 Thoreau Drive,Centerville, Permit type: RADD, and issued on 4/11/2011 has been inspected by a certified Building Performance Institute (BPI) Inspector. R-10 Cellulose insulation was added to the attic. Walls were dense packed with R-13 cellulose insulation. R-19 Fiberglass batts were added to the basement sill.All work performed meets or exceeds Federal and State Requirements. Sincerely, William McClus.key bh 113�1 Z OV Town of Barnstable 1d1I1 g , . "'; S ?ha �a rs.V�s�ble-:Fr..om,lheStreet.'.�A roued:Plans Must=be Retained on J;ob and°ahis Card�Must,be.Ke' fi Post arn�: Posted UntillFinal�tns ectlon Iias;Been;Mad�e: ;, ,� �., = P� �,�'�� � � 16 9 z r, 5 P `.5 v+' ,q; ;. s ,£1 5 ;- o ` 8r;3 """ „i � `'�' ' � " � "" � � ;be'Occu ied�in#rl a�;Fina)lns`' echo"nrlias.been<ma` Permit ram+ �W e�e�a.Cert�ficate of Qccupancy�,is Required,such Bu�ltlmgshall No# p p de �a'r.... ., .. ,...,, ?Y...;,."..�,�k.. ...._ar,.� .�...,.,,aa...�. ,, ... ,�. �:.. ,%jai a. s;�S,.�„:,�c�?4,..r ;�.;6:�.... ..<., � ..�...,..,�i'�a:,, _.,as. .�,:�,!k.>�,.. 2>,�.� * .. '� . aw Permit No. B-18-2828 Applicant Name: Nathan Tissot Approvals . Date Issued: 09/14/2018 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 03/14/2019 Foundation: Location: 97 THOREAU DRIVE,CENTERVILLE Map/Lot 191-225 Zoning District: RC Sheathing: Owner on Record: DAVIS,SUSAN P A TRH y ISontr�a�E�to`r Name _.TESLA ENERGY OPERATIONS INC. Framing: 1 DBA Tesla Energy Address: PO BOX 142 �> 2 "`Ctinttactor�,License ��168572 MARSTONS MILLS, MA 02648 Chimney: jw Description: Install solar electric panels on roof of existinghouse with any Est Protect Cost: $8,000.00 upgrades,when applicable,specified by Design T`be Perm�t�Fee: $90.80 Insulation: interconnected with home electrical system. 933-0263952 5.2KW 16 �Fee�Pa ': $90.80 Final: K 1 Lf, Panels x' 16 Date 9/14/2018 Project Review Req: r Plumbing/Gas �x s kr Rough Plumbing: . , y � s •qu .: Building Official . Final Plumbing: s K f Rough Gas: Final Gas: This permit shall be deemed abandoned and invalid unless the work authoriiedby this permit is commenced within six rnon2hs after,issuance. All work authorized by this permit shall conform to the approved appl atjon and e approved construction documents for which this permit has been granted. Electrical All construction,alterations and changes of use of any building and structures;shall1b n compliance with the local zoning by raves a, codes. This permit shall be displayed in a location clearly visible from access street or road and shall be mamtamg pp",,or public nsPection for the entire duration of the Service: work until the completion of the same. 1A Rough: a .. 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: Final: 1.Foundation or Footing Low Voltage Rough: 2.Sheathing Inspection g g 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 Low Voltage Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Health 7.Final Inspection before Occupancy Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Fire Department 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). ow�� E►Y►.�'L s Err - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ' g Parcel '�` J Application # Health Division ' 'Date Issued AA�l l Conservation Division Application Fee kjo Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board /�j�lj� Historic - OKH _ Preservation / Hyannis Project Street Address T h C> Y'e0.A r'i Ve Village Cev4er V1lie Owner Address s-n m e- Telephone 50 2 - —7 Permit Request hic 1 • i 1 w GL !� L' E'�7 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed- Total:ne Zoning District Flood Plain Groundwater Overlay OD Project Valuatior 6' 1060 Construction Type -5 f� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ® Two Family ❑ Multi-Family(# units) Age of Existing Structure 7 5 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: N Full ❑ Crawl ❑Walkout ' ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing 0.1 new Half: existing new - Number of Bedrooms: 3 existing-new Total Room Count (not including baths): existing t' new First Floor Room Count Heat Type and Fuel: A Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes W 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: IQ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION ` r (BUILDER OR HOMEOWNER) Name &4e Telephone Number 50 328 -0 3 g 0 Address C t On I nG-hor &VP License # Ic 0 d\:' T 6 nn e f 5 004 YcLrrry Q�k !r, A O� b C L! Home Improvement Contractor# 103 q�4 Worker's Compensation # g 9 30 95 I ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Y�krrujll-L SIGNATURE DATE 1 { -` FOR OFFICIAL USE ONLY APPLICATION# c , i DATE ISSUED { MAP/PARCELNO. t ADDRESS VILLAGE E - 1: OWNER '.4 1 i DATE OF INSPECTION: FOUNDATION F s FRAME w` 4 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 3 PLUMBING: ROUGH FINAL } GAS: ROUGH FINAL FINAL BUILDING .f ` DATE CLOSED OUT x. ASSOCIATION PLAN NO. tia ' t .. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance.Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): m l ca Ae® A� %S i( Dlalk Q Address; - -C, (A iA r1611 ni G_M t,3 Aar- City/State/Zip:�_YA4ZAo%.kT14- A 62 Phone##: `� Are you an employer? Check the appropriate box: Type of project(required): 1.91 I ain a employer with Q, 4. ❑ I am a general contractor and I employees(full and/or part-time}. -have hired the sub-contractors . 6. ❑New construction 2.El I atn a sole proprietor or partner- ship listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have and have no employees 8. [:].Demolition working,for me in any capacity. employees and have workers' comp.insurance.- 9. ❑ Building addition [No workers cotiip. insurance p• required.] 5: ❑ .We are a corporation and its 10.❑ Electrical repairs or.additions 3.❑ 1 am a homeowner doing all work officers.have exercised their I I.❑ Plumbing repairs or additions. myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152,§1(4);and we have no . employees. [No workers' 13.� Other nsu a+l oft comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they axe doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the.policy and job site information. //.�� Insurance Company Name:. �.( T f 1> (�J kr1 9&j C—L Policy#or Self-ins,Lic,#: . C, 13- Expiration Date: ( 9 ors ' �, �y� Job Site Address: Y Ili City/State/Zip: . it"�t'lh(� 9 V 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 Section 25A of MGL c. 152 can lead to the.imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form.of a STOP WORK ORDER and a fine" of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the paines #d penalties o perjury.that tine information provided above-is true andcorrect Si afire: f °°'� a Date: Phone.#: Official use.only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health. 2.Building Department 3.Cih'/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ''AC®RH CERTIFICATE OF LIABILITY INSURANCE °A'E`MM'°D"``"r' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE, DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE.POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the Policy(ies)must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER D T CT Shannon S 1 NAME: perrazz Risk Strategies Company i PHONE (781)986-4400 FA/Ac No:(781)963-e420- - 15 Pacella Park Drive AEs.ssperrazza@risk-strategies.com Suite 240 PRODUCER A0018476 T Randolph MA 02368 INSURERS AFFORDING COVERAGE i NAIC# INSURED �LNSURERA:SeneCa Specialty Insurance Co ' — INSURER B.—Keating B.-Keating Group Ins Services _ .Michael McCluskey, DBA: Cape Save INSURERC:Chartis Insurance 7 C Huntington Ave INSURER D: T INSURER E:South Yarmouth Yarmouth MA 0264.4 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1011132675 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 MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED�BY PAID CLAIMS. ILA'.• TYPE OF INSURANCE jADDL WVD1 POLICY NUMBER MMUC09% i MMIOO/YYYY LIMITS GENERAL LIABILITY + EACH OCCURRENCE $ 1,000,000 RCOMMERCIAL GENERAL LIABILITY ! DAMAGE"j RENTED 7 PREMISES fEa occurrencsh $ 50,000 A CLAIMS MADE X OCCUR AG1002608 10/16/2010'10/16/2011, I MED EXP(Any one Person) $ 10,000 PER &ARV INJURY ;$ 1,000,000GENERAL AGGREGATE j$ 1,000,000 y—GE—N L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,000 000 X POLICY 1 ' PRO- LOC j f $ --__ -- i AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO 6208200 11/6/2010 11/6/2011 (Ea accident) $ 1,000,000 I BODILY INJURY(Per person) 'S —;ALL OWNED AUTOS I ! BODILY INJURY(Per accident)1$ 1 X {SCHEDULED AUTOS _ _------ PROPERTY DAMAGE X HIRED AUTOS i leer accident) `$ X NON-OWNED AUTOS i X `UMBRELLA UAB OCCUR i EACH OCCURRENCE $ 1,OOO,000 ^`EXCESS UAB __ CLAIMS MAOEI ++ — I AGGREGATE $ 1,000,000 DEDUCTIBLE B RETENTION $ ; j023578601 �0/16/2010 10/16/2011': Iis C i WORKERSCOMPENSATION chael McCluskey 1NCSTATU- OTH-i AND EMPLOYERS LIABILITY YIN' i 1 X '.TORY LIMITS: I ER ANY PROPRIETORIPARTNERIEXECUTIVE 1is excluded from coverage E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? a j NIA 500 '000 {(Mandatory in NH) 19930951 10/21/2010 10/21/2011 If yas,describe under ,E.L.DISEASE-EA EMPLOYEE'$ 500 L 000 DESCRIPTION OF OPERATIONS below i i E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is recµ fired) Issued as evidence of insurance. Contractors-Executive Supervisors or Executive Superintendents. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Ruth 460 West Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601-3698 Michael Christian/SMS ACORD 26(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2oosw) The ACORD name and logo are registered marks of ACORD 460 West Main Street HOUSING Hyannis; Nir 02601-3698 ASSISTANCE ENERGY & HOME REPAIR T (508} 790-7106 r (508) 790- CORPORATION 2425 HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THISFORM IF YOU ARE r THEAPPLICANT HOMEOWNER. ! s hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation ( herein after referred as "Agency") on the property located at: Theweatherization work donewill be based on programmatic priorities and availability of funding and it may indudeall or someof thefollowing measures: Weather-stripping& caulking of windowsand doors, insulation of attics, sidewalls& basements, attic and other ventilation measuresand possibly replacement of badly deteriorated windows, In consideration of theweatherization work to bedoneat my home I agreeto thefollowing: 1. I givepermisson to the"Agency" itsagents and employeesto travel onto or acrosssaid property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect thefuel or utility bill for the weatherized unit on an ongoing basisfor no morethan five(5) yearsafter theweatherization work iscompleted. I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (Signature) Date: 3 4 Agent: (signature) Date[ HAC approved Weathe-ization Company : All Cape Energy, Caliber Building&Remodeling, Cape Cod Insulati , Cape Save, Creswell Construction, Frontier Energy Solutions, Lohr&Sons, Peter Smith, Resolution Energy, Rock Solid Construction ... _:. .. ... .. ...: .: .;...:: F..: . .. ::.':: .�... � I .......I .:, � .��A� .. 11 .1. 111, i�," I 7iFlir�""I",,%,;:�:]: ,::.: ,:.:::,� 7-:-:.�::-.- , I ,.1".-I .1 "I 1,)Mo�� .,.I , " , - — : 1� f �51; � �, I �:"R - �,::::.:::::::,: :::::::1 :�::. ,.: , .. , . ,� "ll-,'* "Ill , N I : ::... ,, : :::::.::�...:� :: . I .I —I -� "� ;171 F 1 {�� 1 . . ... . — : , "",,-,� " —.—...:.... �, � - I ''.I � —I I , :::: �::: ''... .,......-P :....--;�I&,—�.. I �::::::::::, 'I., ''..''...— ...— .I-- � :4b , .,�, . ::.,�,Ii : , . �''�...:::!::::: -::: �:::::,:.:� ::.,::::� - -. ....... , " ': �� 1 . ::- I - --- -: ....b.1,..- ,� -11 6"� , 6, , 11 , ''1f=::::: , - :,::::: - : � � '. �� .� , .. ::: ':: :: ..;� ...: .. .. i ... .: ... .. :' : ... .:i .:: , -:: .... .... ...... ...... .... .:: :... ... -. ... ... ........ ':::::. ...... ..... .... ... ......... .. ...::.! ..:.:.. :.:... .. ..... . .... .'�:.. ... _ .-.. .... ... .. ... . .. . .. .. ::: :i.. tagust!2 , W om May Coy cer . ... i 1 c tc s ey �s a �L plp ee of Cape Save a s ac t arNxe r� agate contracts and it i1. e1. its for co r m I - I I—M I'll �.. 11.1.�:��, -i���::"e) '.:::::.::l:::,.'- —::�!:�:: I .... . --:�:::: 1. — ..... � r. chael icC�usk . : gape Saue ..Owner _ : 9-593-599 cell' . . :' 7C;H6htt`r tors Av n , S.o t Ya mo Q2 i . . : .. .... .::: 9. .:: ~ �,t3;, 4..�''�'�#'�i�i �/J�•��;FiD�����''�'�c'�,�'"i �i "-� C.. af .%:in: .��'�a'' _` �+ Office of Consumer Affais and Business Regulation `A `r l0 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164432 Type: Supplement Card CAPE SAVE Expiration: 10l6l2011 WILLIAM MUCCLUSLEY --___........:_. _.__�_......_..... .. _ - 8201 S. HOURD CT CHAPEL HILL, NC 27516 Update Address and return card.Mark reason for change. Address Renewal Employment i... Lost Cant Office of Consumer Affairs&Business Regulation License or registration valid for individul use only . � before the expiration date. If found return to. Al` HOME IMPROVEMENT CONTRACTOR z-f Office of Consumer Affairs and Business Regulation Registration: 164432 Type: 10 Park.Plaza-Suite 5170 Expiration:.10l612011 Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM MUCCLUSLEY �� 7G HUNTING AVE. S.YARMOUTH,MA 02664 Undersecretary Not valid wit oa signa '�1;a«tt�ittiei'la.v - l)�•{t;it•tttarna it13'ttiili4`.tii:t`* f3��;tt tl =►t l3tttititn•� its.ttalft+i,rt. .ttttl �t'.attel:ir-ti; c2rrse: CS SL 102776 RHst+sited iu: IC s+ WILLIAM MC CLUSKY 37 NAUSET ROAD . WEST YARMOUTH, MA 02673 �•�--_� '�y—` i r.pt aticrrt. 6/28//�2p013 i ,}i1f11F i'•iFi' ' - gf^. 102776 t, X-PRESS PERMIT Town of Barnstable *Permit# C �l Expires 6 months from issue Regulatory S JUN 0 9 2006 g y Services Fee Thomas F.Geiler,Director TOWN OF BARNSTABLE Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint . Map/parcel Number Property Address _ 7" i ��oI (_� I _ r esidential Value of Work �r o ( �'�n�Minimum fee of$25.00 for work under$6000.00 Amer's Name&Address Contractor's Name_ Tavvtsq� (®"L"Telephone Number se)Es���'f Home Improvement Contractor License#(if applicable)__ , 10 I Construction Supervisor's License#(if applicable) W 's Compensation Insurance eck one• m a sole proprietor El I am Homeowner ve Worker's Compensation Insurance Insurance Company Name V Z/1 t4A 1_" Workman's Comp.Policy# bu 60 U WAM—A-�)S Copy of Insurance Compliance Certificate must be on file. Permit R=e-roof box) stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. ome ement Contractors License.is required. SIGNATURE: Q:Forms:expmtrg Ly Revise071405 , David Sawyer Construction 318 Meiggs Backus Road Sandwich, MA 02563 (505)-539-1992 Proposal Submitted To: Work Place: Date v. d - �~V=�La Strip, Remove, and Haul Away all old roof and or sidewall shingles. SUPPLYMNSTALL: COLOR: Y '- .�/o n o Q-1 !41' GaV w h Ic, ►�h C(,f�i/1 a Lt.�Ldjz4 ( Paper � . Vey14— p7 Ot (ru� W'CLEAN&REMOVE ALL DEBRIS FROM WORK PLACE AFTER JOB IS COMPLETED. ALL DEBRIS TO LANDFILL. TOTAL MESTMENT FOR MATERML&LABOR$ All material is guaranteed to be as specified,and the above work to be performed in accordance with the specifications submitted for the abo work and completed in a substantial workmanlike manner. Payments to be made as follows- i1p . -A,lI a Any alteration or deviation from the ork specifications involving 6xtra costs will be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control.Please remove and/or secure any fragile household items_ Not responsible for broken or damage household items. 10YEAR LABOR WARRANTY/PLUS MANUFACTURES SHINGLE WARRANTY. This posit ma be withdrawn by us if not accepted within 30 days. Respectfully submitted e 44" ACCEPTANCE OF PROPOSAL The above Prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payments will be made as outlined above. 6 Date* l8 o G> Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia• 'Workers' Compensation Insurance.Affidavit:Builders/Contractors/Electricians/Plulrnbers Applicant Information Please Print LeldbIy Name(Business/organizaticnllndividuq — -DI O'd I- Address: �—)/ a City/State/2ip: • Phone#: (��'�J Are you an employer? Check the-appropriate box, Type of projecf(requlred): 1,❑ I am a employer-ith 4. ❑I am a general contractor and I 6, ❑New construction loyees (fall and/or part-time).* have hired the sub-contractors 2.Ki mn a sole proprietor or pm:tner- listed on the attached sheet 3 7. ❑ Remodeling ship and have no employees These sub-contractors have ss ❑ Demolition working.for me is any caps,city.. workers' comp.insurance. 9. ❑ Ehiilding addition [No workers' Comp.insurance 5. ❑We are a corpgration and its - 10.❑ Electricalrepai s or additions required.] officers have exercised then 3.❑ I am a hom iwmer doipg all work night of exemption per MGL I L❑ Pimnbing repairs or additions nwnlf:[No workers' comp, e. 152,§10),and we have no 12.❑Roof repairs tommee required.]t , employees.[No workers' comp.insurance required.] 15.0 Other Any applicant that checim box#1 must also fill out the section below showing Their workers'compensation policyinfartae#on: Emneownas who submit this affidavit indicating they are doing all work aadthen Nre outride coataotors mast submit anew affidavit indicating,U=b. ontrachm that check this boa mast attacked an additional aheet showing The acme of the sub-contractors and their workers'eomp.polcy information. am an employer that is providing workers'compensation Insurance form y employees. Below is thepolic and job site inf brmat{on. . . : '•j. m cyutt CompaayName poli ;;`or S' .Luc. Iarae: Job Site Address: City/Stateaip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure to seeorc•eoverage as required undet Section 25A of MGL c. 152 u:an lead to.the imposition of cr�mal penalties of a finenp to$1,50Q.00 and/or one-year imprisomment,as well as civil penalties is the-fa ma oi'.a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penal#es of pedury that the information provided above is true and correct, r tire: - Date: Phone M iai u�f . �o t e his Ma,to ik ca d c ,or MM_s,Jcid , City or Town: Perm%U tens e# I Issuinga Authority(drcle orle), 1.Board of Health 2.Building Department I City/—I own Clerk 4.Electrical Inspector- 5.Plumbing Inspector- � 16.father i Coleact Person: Phone#: Department oflndustriat Accidents 3. Office of Investigations 600 Washington Street Boostton, MA 01111 • � �/!►7�.mass.gov/din• • Workers' Compensation Insurance Affidavit: Builders/ContractorsMIectricians/Plwnbers A l cant Information Please Print Le 'bI Name pusaess/organiZatonUdividu4: 12, S_ UjAz,4,_ Address: lrwzax City/stee/Zip - Phone M Are you an empl Check the-appropriate box; Type of project'(regaired): 1,❑ I am a loyer with 4. ❑I am a general contractor and I 6, D New coastmctfon yees (fall and/or part time)* havebaed the sub-contractors 2. am a sole proprietor or,partner- listed on the attached sheet t 7. [--] Remodeling ship sad have no empployees These sub-contractors have 8a ❑ Demolition working for me in any capacity.. workers' comp.insurance, 9. ❑ Bu3l&g addition (No workers' c=p•insurance 5. ❑We are a corporation and its 10,❑ Electriealr airs or additions required.] officers have exercised then 3.❑ I am a homeowner doag all work right of exemption p er MGL I I.❑ Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12,❑Roof repairs insumace=equircd.]t , employees.(No workers' 13.❑ Other comp,fimu mce required.] *Any applicant that checks box#1 mast also fill out the section below showing their workers'compensation policyinf=astim t Hmieownan who submit this affidavit indicating they ate doing e11 work aadffien hire outside ceatmact=mast submit anew aMdavh indicating such. ZContraeton that check thiabox mast attached as additional sheet showing the acme of the enb-ecatracton and their workers'comp,policy bfvsmspoa. ram an employer that is pro-vtding workers'compensation insurance jor.my employee& Below is the policy and i'ob site Informadox Insurance C,ompanyName: ... policy#•or bias.Lie. : Job Site Address: City/5tate/z2p: Attach a copy of the workers' compensation pency declaration page(showing the policy number and eapiratfon date). Failure to secnrg coverage as requu•ed nndei Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,504.40 and/or one-year=prisQmment, as well as civilpenaltim in the-form of.a STOP WORK ORDER and a lime of up to$25 0,00 a day against the violator, Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insUmance coverage verification. I do hereby certify under a pat and penalties of perjury that the information provided above is true and correct. Sr tie: JAF Date; l Phone#; ciai Aga ,sue. Do nWf 9764 In Sim urea,to be e i-b.C#.or tPM officid City or Town, P ermit/License# l ILauing Authority(circle one); 1.Bozrd of Health ?.Building Department 3.City/Town Cleric a,Efectx1cal inspecter 5.Plumbing Iuspe— tar 1 6.ewer Co Persou: ?hone#: ' Board of Building Regul ions and Standards i One Ashburton Place -..Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 134313 Type: DBA Expiration: 10/24/2007 DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. Address Renewal Gi Employment Lost Card 'Al is 5OM-WOS-PC8698 - ✓�ie�o�nmzo�zusealC� 0l'✓1/laa:s¢cfuaella Fj1 Board or Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: t34313 Board of Building Regulations and StandardsOne Ashburton Place Rm 1301 Expiration: 10/24/20o7 Boston,Ma.02108 Type: DBA DAVID SAWYER CONSTRUCTION ' DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH,MA 02563 Administrator Not valid without signature c P � L " STPAUL TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-8014AB8-A-05) RENEWAL OF (6KUB-8014A88-A-04) INSURER: THE TRAVELERS INDEMNITY COMPANY NCCI CO CODE: 11347 1. INSURED: PRODUCER: SAWYER, DAVID R KERRY INS AGCY INC 318 MEIGGS BACKUS ROAD PO BOX 1945 . SANDWICH MA 02563 NORTH EASTHAM MA 02651 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached.- 2. The policy period is from 08-28-05 to 08-28-06 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in o� Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit ,_ Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A o� D. This policy includes these endorsements and schedules: op SEE LISTING OF ENDORSEMENTS. - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating u•— Plans. All required information is subject to verification and change by audit to be made ANNUALLY DATE OF ISSUE. 0 82405 ML ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: KERRY INS AGCY INC 28SHB