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HomeMy WebLinkAbout0015 WASHINGTON BURSLEY WAY s 610-OWIce'Po ,' . I , � I � � 11 � t L I ti K : u �' a - - _ R - 0 s- a y . „ , . ,. , . , ,, . , ,, h ",� 6 4 , - rr. , e ,.;.,v 1.,. , . P�,e . ", , ..-, ., . . ,n. ", a, a ,er- , N, ^ r ' v ,. , ,� „ - 'o 11 „ .,, ,. .: ... ,' a :, < ,: ,. , 'a y .fa Y k - ' ,.,." k , ,. Y �� < y p. --..; .y �„ y I` a '' ; ,n. , , " ,td:• w c I w > t �' a w yam;;` �.p",' .jr `w I'- 4 �. -A., .,' h y,y & Y 3"`" 'a' ,i:.' " aka a' 1. .y, w s 1 ,, y o- .x.. .yr. o } .,� .,r t , w:r` & ,4 se :.a '� . - [, r , v 1. .. x .. # s °� P �T M4 _ J Y�• A - r: r ..f. y r u,. • .. •.> . - ': 4y F? s P r m 1� ' ' ,`` d . ¢ r a �,a; r� w�� , •,, �• . . ;Y .::., '. ' ;�a,. ;„" ui: 4�. :- -+le In 'y':pa: ..�. ,* -.a.$ o " . . ,�, :;.: "°a ti' :., 6 .'=`1,; .11. '..,, v` ,,., r,.., 'y "�'q.r "e,r."�, ��.1-9 �. ^w. , 0 w. rN'.vt - t .'ai. N a ., '., �, : yr, �.. .� �., _ . +:... ..,.� w ��yj d F,, , .r rx.... 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'�" ,, 6 . 4..,-, v a„w � Y� ,t«- - .yyfi � ..k-. - fir, .e' �., L* ..,tt,�i 1. �` " r= etc 1 "'-" av ''. A.:• y,° f`-fir .. .. r . r _ . - a 4 , A F k r . , r t, r y. r s . s „ r ^ r , r _ a l < nq. " h _ a, p : ti.. u ry r - a » m , a 4 , < +1 x _ a 9' r q ➢ - u tc. rx w 1� F , p �131b T THE r Town of Barnstable *Permit# of � Expires 6 months from issue date * Regulatory Services Fee a, * BARNSTABLE, 9 MASS. �" Richard V.Scali,Director �p 63-9" Building Division MAR 3 p 2016 Tom Perry,CBO,Building Commissioner ``nnff nn'' (� -TABLE 200 Main Street,Hyannis,MA 02601 T®UV„� `'� www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY 1Not Valid without Red X-Press Imprint Map/parcel Number /n 2 1 6 Property Address esidential Value of Work$ a Ste. ° Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1-7+D m A S /N J 1�- J-A tz, 1- 1 1L 3 FL v�t✓ 5� ( c� n.�c o�t� N � 1 . C7 3 3 a_� 'P R U L J. CA Z�A U LT -i- Sc.7N--S —Telephone Number b�� H�-u Contractor's Name5 Home Improvement Contractor License#(if applicable) 02 rT(q Email: 8 41 C e (d C_Cz Z2 c :.i f. [Nry, Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner �ve Worker's Compensation Insurance Insurance Company Name L+- 0 1 DJ C_o 1e—P Workman's Comp.Policy# W c— 5- - 1 3 , 3 4 to - -6 C�2 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to �/AS. WJA ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 Ago o® CERTIFICATE OF LIABILITY INSURANCE DATEYYYY) 8/11/2011/2015 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. 4, 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 DOWLING & O'NEIL INSURANCE AGENCY INC NAME CT 973 IYANNOUGH RD PHONE FAX PO BOX 1990 arc No Ext• AIC No): HYANNIS, MA 02601 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: LM Insurance Corporation 33660 INSURED .INSURER B: PAUL J CAZEAULT& SONS INC 1031 MAIN ST INSURER C: OSTERVILLE MA 02655 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 25918664 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 ADDL SUBR POLICY EFF POLICY EXP - LIMITS LTR POLICY NUMBER MMIDD MMIDDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F OCCUR DAMAGE TO PREMISESS(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO ❑ POLICY❑ LOC PRODUCTS-COMP/OP AGG $ PRO- OTHER: $ AUTOMOBILE LIABILITY _ COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS per accident $ i UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-386670-025 - 8/10/2015 8/10/2016 �/ ISTATUTE OTH AND EMPLOYERS'LIABILITY ER ANY PROPRIEfOR/PARTNER/EXECUTIVE YIN N • -E.L.EACH ACCIDENT $ 1000000 OFFICERIMEMBER EXCLUDED? .❑N N 1 A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION PAUL CAZEAUL.T. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1031 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. OSTERVILLE MA 02655 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 25918664 I 1-3e6670 115-16 NC I shankar.gadale0libertymutual.com ),8/11/2015 4:45:09 AM (PDT) I Page 1 of 1 I Office of Consumer Affairs and Business Regulation . 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 103714 Type: Supplement Card Expiration: 7/9/2016 PAUL J. CAZEAULT & SONS, INC.. ::: `.:..;.:....' ;.::::.• _-_ RUSSELL CAZEAULT ---_-�-- 1031 MAIN ST -- OSTERVILLE, MA 02658 Update Address and return card.Mark reason for change. sCA 1 20M-05111 Address Renewal Employment Lost Card a �2%/zn.�cn�rrenrru!ra/l/c/i^�l>rc,;:ruc�a�.efl':i Off-ice of Consumer Affairs&Business Regulation License or registration valid for iudividul use only z r_nr before the expiration date. If found return to: IMPROVEMENT CONTRAGTOR p _ Office of Consumer Affairs and Business Regulation r Registration;:. 1,037'1.4, Type; 10 Park Plaza-S'ui#e 5170 - Expirati6gs::.7j9j20.16;•• Supplement'ward Boston,MA 02116 PAUL J.CAZEAULT&`SONS'INC: RUSSELL CAZEAULT•:::::::• 1031 MAIN ST OSTERVILLE,MA 02658 Undersecretary Not valid with( nature 1 Nlassac:husetts -Departm:ent of Public Safety Board of Building Regulations and Standards I Construction Super)isor I License: CS-108157 RUSSELL CAZEAULT.; 2071 MAIN STREET == r Brewster MA 024631 - °✓��,, � .. '� Expiration Cavm;ssioner 1 1123/2 0 1 8 i a,. Property Owner Must Complete & Sign This Form If Using a Roofer 1 Builder. f i E I (pint) °71466m� ; F-S P b r , as Owner / Agent of the subject property hereby authorizes Paul J. Cazeault & Sons Roofing Inc. to act on my behalf, in all matters relative to work authorized by this building permit application for: Address of Job ( (a Pi-5ttik 6-7771V 13 L, � 5Lr-y 6Q G�i e (-� 4 s 5 Signature of Owner Mailing Address of Owner FL vM J- S-7 ��ti c o� Telephone # f'P v ' — I c 5 C 3 Date l Please return this form to Paul J. Cazeault Roofing along with your signed contract. It is needed for us to obtain the building permit required by your town to complete your roofing project fax#508-420-4555 office@cazeault.com f . " The Commonwealth of Massachusetts - .� Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 wfvx.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information , Please Print Leeibl Name y U T - `I� GA 7 U �� T -So�`%� Address: 02 'A,A //v -S % t 4= '> Ci /State/Zi S`�` 2-�/I1C � .. MA ®�S� V�—i-11Zfl —1��� tY p Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1,7 I am a employer with employees(full and/or part-time).* 7. New construction 2.F� I am a sole proprietor or partnership and have no employees working for me in $• Remodeling any capacity.[No workers'comp.insurance required.] ❑3.❑ [am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 0 4.❑[am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.❑ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. �_aOther)6 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins, Lic,#:_ Vl_� 3� S ` 3 G 67 Z�xpuation Date: Job Site Address: /5- tA! h,/"6rr"a/J 73L Vr-5 L1✓7 Vi 4Y City/S tate/Zip: L��12UtL� 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 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. [do hereby certify under the psains and penalties of perjury that the information provided above is true and correct Signature: Date: /-6 Phone#: ( Z0 r Official use only, Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: f �IIK*E� Town of Barnstable °* Regulatory Services 1AMSfABU MAS& Richard V. Scali,Director 1 9. Building Division Thomas Perry, CBO •Building Commissioner S�� 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 December 18, 2015 Attorney Adam H. Becker Keches Law Group 2 Granite Avenue, Suite 400 s Milton, MA 02186 Re: Massachusetts Public Records Request for the following address: 15 Washington Bursley Way, Centerville Dear Attorney Becker: For copies of documents pertaining to the above.addresses please pay the following: 9 copies at .20 a page 1.80 h Postage .80 Total k $2.60 = Please make check payable to the Town of Barnstable Sincerely, Debi Barrows.. Administrative'Assistant i r /17/2015 THU 13t54 FAX 617 698 0672 U001/001 KECHES I LAW I GROUP A PROFESSIONAL CORPORATION 2 Granite Avenue,Suite 400 Aliy ? Milton,MA 02186 "` ra'n, 1 �' 915 508-822-2000 V�/N OFA c 617-690-0672 Fax 1VS�,Q w ww.kecheslaw.com 'SZE December 17, 2015 George N.Keches Joseph F,Agnelli,Jr, Brian C.Cloherry Town of Barnstable an C. ttaE.Dever Ch Charlolla E.Gllnka Building Division Seth 1.Elln 200 Main Street ClaudlneA-Cloutler• Hyannis, MA 02601 Sean C.Flaherty - JudithB.Cray" Re: My Client: Ms. Launi Griffith , William A.Hanlon Date of Incident: January 12, 2015 Jason R.Markle Brian R.Sullivan Loren E.Laskoski• Dear Sir/Madam:. Marla M.Scott Erica L.verclra Please provide me with a copy of the entire Building Department file regarding Ronald F.,Belluso 15 Washington Bursley Way, Centerville, MA 02632. Please send me an Suzanne CM McDonough",'Invoice with the requested documents which I will pay upon receipt. Boa's N.Levin , Iderstioe Lauren van kernhaiaer Kathryn I•Wickon Thank you for your anticipatedcooperation. Aileen C.Bartlett• Patrick F,Keady Very truly yours, Stavun C,Zoni" Thomas P.Delmar John C.Molloy Adam H.Decker Adam H. Becker Jamie R.Spitler..... r Christopher M.Hendricks AHB/kag OF COVNSEG Ann Marie Maguire Hod.Armand FernandeR,Jr.(Ret.) t ' AoMlrno w MA A%m RI • _ ,, - "A,.ne,Iw MA Atm CT ' —AIb.M M)IN MA,RI a9D CT - --A"irco IN MA roJD NH ♦ „F ••'••ADMIrrEp IN MA Ara)FL Boston r launton Fall River New Bedford l Worcester . 617-426.79110 508.822.2000 `• 500.676-7900 508-994.7900 508-798.7900 CAPE COD INSULATION SIIIR GLASS $1-IL51 SPRA{{OAAI SYSpLNPtP WIS Yyi1LNf INSYMIIOH CSILYVOS _ 1-800-696-6611 "Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, KA 02601 Date: Y113 Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. perfonned & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building pen-nit application. All work has been inspected by a certified BuildingPerformance Institute (BPI) inspector. All work preformed meets or exeeeds Federal & State Requirements. f ' Property Owner Property{ Address Village Ma,:S�A k,-711/2---- Insulation Installed: Fiberglass Cellulose R-Value Restricted U16 tricted T ,._,. F CD GO Ceilings ( ) (� ) ( .��) ( ) (x) A. Slopes M Floors ( ., j ( ) ( ) ( ) (' ) aZj , Walls 4,v .SCd t(nq V Sincerely EIe y E C" sidy J , President Cape Cod nsulatron, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ( O Application #-�v/ OJ7� Health Division Date Issued 11. r 1 ( -3 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address I Cj tL5(�l►� TUB �uv5� Village agk*y1/1,e I Mac 026 ;5-Z- Owner �6✓'Ao_ ,P.f'-� Address Telephone r)Ufa- 6 Z ' _21� 3 (o Permit Request l W&a A-eY� haw' 1 Z wW 14OW' all, 5e& ��OZv � � 1 � a,4 15�0 Op�P/f � lG {GDD� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ��Oro D�6 Construction Type 44�/O_� 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 Qaths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor RocF Pount ?G'42 o Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: Yes;3-No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ raw tile Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: , � n Zoning Board of Appeals AA thorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 3 No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION _;__�(BUILDER,OR HOMEOWNER) Name4;W �/ ,e,4 Telephone Number ;;� /2- Address A ,& ,44g P�VA/*,10 Z/ ense #�/c;Pe Xg: r Home Improvement Contractor# f5G ✓�L Worker's Compensation #4&eAu,!U,5Me,/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY Pr APPLICATION# DATE ISSUED { MAP/PARCEL NO. s f ADDRESS VILLAGE OWNER r_ DATE OF INSPECTION: FOUNDATION FRAME 4 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ? GAS: ROUGH FINAL t i FINAL BUILDING oti DATE CLOSED OUT ASSOCIATION PLAN NO. ►— - .� ..... _ "y f Nlassachusetts.- Department of Public S:1fet%- Boar•('of Bull-ding Re-ulations and Standards_ i Construction Supervisor License s�' - Licen :: CS 100988 su HENRY CASSIDY 8 SHED ROW ; WEST IARMOUTH., MA 02673 Expiration: 11/11/2013 ('munissimer Tr#: 7620 =- Office of Consumer Affairs and Business Regulation , = a -- - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contraktor Registration Registration: 153567 Type: Private Corporation Expiration. 12/15/2'b14 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 ------ ------- - -- Update Address and return card.Marls reason for change. 4 [],Address Renewal.n Employment L_I Lost Card KA 1 Co 20M-05ltJ ??..,, �l'��c �otrcrienrecaer7l/�n'���llr9JncicuJe�_ � � ' dk_\ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - Office of Consumer Affairs and Business Regulation 158567 Type: 10 Park Plaza-.Suite 5170 k'f�__J'egistration: piration: 12/1572014 '.Private Corporation Boston,MA 02116 t CAPE COD INSULATION,'IN6:. , HENRY CASSIDY t . r 18 REARDON CIRCLE _ S0.YARMOUTH, MA 02664 Undersecretary of Val witho t nat re N u, J U U'J 1`. ram` Cllent17:4597 GCINSUL r• , A CORC .- CERTIFICATE OF L-_JABILITY INSURANCE l1 A'I'l(Polhllllll)Y15'y( TIFK TH18 CF JATE AT�- IS ISSUEq AS A MATTER OF INFORMA`Iluty i)IvLY ANU CONFER3 NO RFGHT3 UPON THG GEF:TIFIGATE HOLDER,02120-12 CERTIFICATE UQtS NUl'AHFIRMAI'IVEt Y UR NEGATIVFLY AMi::rin,EXTEND OR ALTER THE COVCfRAelm AFFORDED UY THE POLICIES F.ikL.OW,'I HIS CL'Rl'1FICATC OF INSURANCE DOES NOT CONS 1 Li U IF A GQNTRACT LiE]WEFN"I,Iir t$�UING IN:SURI R(S),AU'rtIQRILLLI .IPR REE3VNIFATIVF_ OR PRODUCER, AND THE CFRTIFICATtIUL IL)c:R, ANT:If tho i ertlflr atu tlulLlui iC an AlaDll'IDNAL INSUI�I a the 1)Dlicy(les)rouxt beendo�yefl.II`SUF)ROGATION I�WAIVED,xutya,.l ro _--.. Ittc Iclnlu unLl caunlIii, of the Policy,cnrt'Alit 11011clea nt4y Iv.,,I,u n aridoranDl1lnl.A atu(anlerll Uh(his clarUllL ulcr U4ea nul(;ulll'vr Ii0111a hl IIIc f,LI IIIIcelv_114I1h+f --- I14U taf Sl1Vrl pll(IU(9t;1114111(�), RuLlcr:; 6. Gr;ly lug. -Su. ❑nrinls NAME: MYI Liret YounLl -RILItV 134 509 76O502 :...a.11^ .I )_ i ......_......... - . -._..._. ;iu,.11ll l.hlnnlz MA l).,U_G I"1 GU'i _ autf:1)if /91iD rvtun�rlu)AFFORIANUCaytillAfiC ._...--- . wsl,aeaA; eer 0s5 insur�ulcu - IU333 Crape Cod Imiulat(nn (no Nsu1EeB:tvanSton Inew'ancLi CtL111"lly — _... - - - d'i!,Yarnlrluth huacl INsuReac:Atlantic Chcu'ter InsDrt+rlca WAIRI-R2:GQH1111-rt In6urat1ce C�onl11 I1yullni�, IVIA O;:uU'I � � • _._._..,_ N`1_y-,..__-___- .... 3475'1 r )vlltat;l5 ('1 IR IFICAILNUMBER: — II,I„ )s lu l t Rl u'y' I I IA't' CHI,- 11 1- —— _ __ REVISION NLHVIUL R Ol IOIr.:; Or wtihRHNGE 11AVE BEEN ISSUED TO I HE INSURED NAM1=D ABOVE I-OR 11L POLICYI' 00hIOU wUI�:LIEU NO)WIII ISIANDING t(NY' tihOUIRCNIFNT ltRM OR CON1-1110111OF ANY CONTRACTOR OTHER 00 Uh1ENT WITH FtGSPLCI' 'f0 WIIICII Iluti F:rtIIFIL;AIL'. MAY tSl_ ISSUE:I) OR MAY PERTAIN. THE INSUR'iN(:L. A'-,ORDEO BY THE POLICIES DESCRIBED HEREIN IS SULI,IEGF `1-0 ALL I'l-IF I'VkNIS; i hCt.t151UN5 ANO CONDI11ON5 OF SUCH POLICIES. LIMITS SNpinml Ai,-.Y 11AV9 BEEN REDUCED k11' PAID CLAIMS. TD AOUL SUBR - - -- IYNrOPINyUNANGk POLICY EFF �FIO rul.l. r+�v��rl IMnIIDDlYYy'YI L41LHAL.UmilulYBPa26308 -AIU112U 12 EACH OCCt.IftttL_NCE G'1,t1U_U Ul1U tY t;(1Mh1LR(_IAL GL-NrHAL LIAEIILIIY - NI4�AIt�S .1�EN I� IAI)3-S .,,, L9'IUIJ000 CLAIMti-MAUf_ (( Xll OCCUR L_...__.I IVIE4 t hr'LAiIY mw uuroun) S 5,000 t'KRdQPIAI,a ADV INJURY �'I 000 000 .. _.._....._._ .__-__ LIENf_RALA(II,1dI,llAhk_., 0.001.,UUU � NL Al4U)-i-Unilk LIM11 APf'LIGtI prH, ..... ____ pRp- PNUOLICTS-coml v AUG s 2 000 ODU-_-.-_- _L__L I'LR IL- 1 1__1—LU4 - -- -.. y. 1) AIJTON101,1L.k LiAhlLll'Y "-._-_--... ______ -' CC) II1311JE-_OSINGLG LJMII' _ — 12MMaCKvly;1, a1U112U12 Ua101I2U1; 24ux,I,�,u-_______ I UUu.UUu__-- -- BODILY INJURY P., _- ALI.UWNtt) ' scrlf�l)uLEu Al,�l-O.`i BOOILh'INJURY IP I x r,IHLO AU tU5 x NQN-OYVNEU � ' AUl'O3 PRQPEfth'- I'1 X UMtlItLLLA _-____ .__._.._......_....__....._._._.. - gcc:ur¢ XONJ4535I' 410'1120'12 041011`201' EAcri ocr_urarkNCla r1 000 00U exCE�(,UAU CLAIMS-NIAOk ---T.__---- ACQWe CATS k1LUVULUl1U ___ _ . taro X ncilr.lvuor) IU(jUl1 - C WuitntI0I onirtnnAlwN — — Alit) t)vtN I_)Awlrry WCAOU5259U_ 613U11U1'? 11613U1'lUl` X wGSlJuli II IIOiil Y/N 1YiJcutl.,5.1 _,Itli V N �laourvs— G,L,C�CiIHCCIOI;NI 1 OUh000 UF),ILE)I roI�M �2�YG7_f�ncl�4 II NIA _ _ _ �__� (hluntlolop u,NHI `—N� � - — II rvo,auccnliu undo, - E.L.DISF-ASC..6A Chili M'GL $( QUO UOU _... I)I[SCNIPfIONOF OPI:hATIONS Deluca C.L.DI:;LASG-PO"'f,L. 9i'I aQ�UUU I IIC•l�adl'IIt1N UP IJPCkA1101,15 I LOCATIONS 1 VEMCL6S(Attach ACORU IUI,Addh Ln,.;�,o,,,,s,:c 4phpawy,II IAGN Bpq�U IB fdgtllidU) Workers Comp InPorrnutiort IID I(I(lu(I Officers pr Prppr1atol'5 i;tlrtlrlt:ate tluldnr iw inL uded H--i tin Hdditional instl(nd urlil,ll i;ullurtl LIBUiGfy wtlEln rOtlUllQd'tay Wfltt4�l1 contract Or agreeniel)t, iila"IFICArf IiOLI)L=FL CANCELLATION Crtpu God hwulatiolt,InC SHOULD ANY OFTHFAElOVt,:OE-3 GRifil'U POIL ICIIi4i DEGANGlI1,L);il Uhl ONL•. THE EXPIRATION DATE THEREOF, NO'rlcE WILL 19E UELIVLkkU IN ACCORDANCE'WITH THE POLICY PROVIWON3. ._........--..... AU LHURIZE0 REMSEN I AT(VE O'IOB -'201U AC014D CQRPQF1Af)0N:All rlyhir w=vvtI.' M l.11<O :1(=U1U/U5) 1 of 1 file ACORD Itallld and 10(10:,n1 rulsLorud marks of ACORD rfsdad�ulma3a�Itt mf�Y ' The Commonwealth of Massachusetts :Print Form = Department of Industrial Accidents 01 `• Office of'Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors%Electricians/Plumbers Applicant Information Please .Print Le ibl Name (Business/Organization/Individual): l iml Address: ZAVAt �lV�it City/State/Zip: Dt, %V A IM�'_ Phone #: r'2'Off- 7 ' - 1 Z ( _ Are you an employer? Check t e appropriate box: Type of project(required): I. I am a employer with 90 4. ❑.1 am a general contractor and I * have hired the sub-contractors 6. ❑ New construction employees (full and/or-part-time). - 2.❑ 1 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. 5. We area corp oration and its 10.❑ Electrical repairs or additions required.] ❑ p 3.ElI 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 rep airs� insurance required.] t c. 152, §1(4), and we have no j e��Q ^I employees. [No workers' 13Y Other W kG{/ h opi comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation. 1 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 Marne of the sub-contactors 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 u the policy and job site information. ��//�� � (/ Insurance Company Name: (iV1�L LAMVfw - IH V a 0 G C/ Policy #or Self-ins. Lic. #: Expiration Date: �' �6)- tt Job Site Address: IJ5 �l/L l/� City/State/Zip:420 6"12 Attach a copy of the workers' comp sation 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 STOP WORK ORDER and a tine 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 cent j filler the pains Znd penalties o er'urr that the in ormcrtion provided above is true and correct. Signature: Date: 1/16113 Phone Official use only. Do not write in this area, t�be completed by city,or town official City or Town: Permit/License# y Issuing Authority (circle one):'. 1. Board of Health 2. Building Department.3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Othem Contact Person: Phone#: '- OaYpfeL'tOSSo„` mass save PCQNI�CiOA .a,.:Jc cwa.�xr nw:.ey H'rrcr. VMCM PERMIT AUTHORIZATION FORM I, owner of the property located at: (Owner's Name, printed) 644 hkl,� 6ukZ5 (Properly Street Address). (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature kTi-b, Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Partic acing Contractor Date Rev.12132011 t WA /DO 5Z �+> e � , v _ ace 19 D. f � fir., 43.r 'f•. �S�'.`+A" �p 7 /coo 6,4G 97 N SEF' TK, Ex P (:� i000 Gct, c�9 G4-,4c�l AA I"c' ' P,T - R CHAFiA u A. MXTER - ��nc o� C,EQTIF1Et7 Pt.bT 4 SuA� 1,OGAT1O" 6(-:.QT'E.O-Vi(.La I G6.9ZTt F Y TNA r THE F-OUWDATIOI-J S0,0,.uw P�-A�•.1 ��F�cR��.lGE Nr--ZQOW CaMPI-VS W ITN T G- AWtD SET13ACV- RE4UIIZeMEWTe, OP T14e �'r �� 'To w U O�= '"�. p,l2 tJ��" ' Pc ,'B le3©G? P B/�XTEtZ t4, w�E I4JG_ REGKrr_aSl> t A W D 15UeVGYOV-S TV-115 Vt-AW IS WOT BASE`S 01-4 AN OSTE2V►L.l. o IInASS. t•!ST'QtJMEtJT SvGZVCz�( �{; TIaE (>FG"�,�C'S 'S�-1o1►Jl.a ) ►•bT 6� usca ro t)CTr--zmi t= LDT LIWeS A!'.41.J SMA�-C, tNL .Assessor's .~' and ..~..~. -_— --'----' -_.~ �� ` ... -��� 66vvoga number ---- .. � Pert' . TOWN������7�� ���� �� � �� ���� r�� � �� �K �� � �� p� � ��� N�, �� �� |`� �� ]� �� ���� �� BUILDING � 00 �� 0 �� INSPECTOR �� �� 1639. ��0000-�0 � ���� � �����~N� �� � �N �� , �� �� � ���� � w� =w � m�~�m ��~~ � �~ �= � am APPLICATION FOR PERMIT TO ....... ------------------.-----..-____-. ~- TYPE OF CONSTRUCTION ---- -.--_--. _-.-.-------.--... -1 ............................... � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for o permit according the following Location ........ ................. ' ^ Proposed Use --,4(� -----..-....- ...................................................................................... Zoning District -. . . . . .... .. . . -.....-....Rne District .. ..................................... | . | Name of Owner ......����:�� --..�---.A66reox .... -�, ................................ Nome of Builder .................................. .---..------'A66res -.---.-..--..-.-..-..-..-.-.------ � . � Nome of Architect ----------.!-----------.A66res ---.. . --------.----.. Number of Room � ----------------�Foun6o�ion -� ----------___.� CO— �_ Emerio, --' -----------'-----Roo�ng - -.--_----_-,_ Floors ----Z' ��3^.,-------------.---.]nterior .............. .... ..................................... ~~ /-� � Heating ---'"°- ---''...-. ------.-.-.-..p|umbin0 -.. .... ....^---^--'-'----' Fireplace ---`.--....-�-�����~ --------.App,oximote Cos ---��..���/-/�___.�� . ' r � Definitive Plan Approved by P|onn|4 nJ lR----. Am»o -��-�}.� .c�------' � - �J�- � Diagram of Lot and Building with Dimensions Fee ...... ' SUBJECT TO APPROVAL OF BOARD OF HEALTH ` � � \ ' \ � \ ^ � = - j~ ' � r ~~l�' | hereby agree to conform to all the Rules and, Regulations of the Town of 8ornxhz6|e regarding the above construction. _ Name ... Small, Alan A=172-186 Y �.934A one story No ................7-'Permit for ........................... .... .. single family dwel1bg ....................................................................... Loc f�, Washington Bursley Way ................................................................ Centerville ............................................................................... Alan Small Owner .................................................................. Type of Construction „ ,,, frame . ....... Plot ....................... Lo #98..................... Permit Granted June 27 ....19 77 Date of Inspection .....................19 Date Completed ......................................19 PERMIT REFUSED ............................ 19 ............................ .................................................. ............ .. .............................................. r/ .I...................... .........................D. . ...................... Approved .............. ........ 19 ............................................................................... Assessor's map and lot number ..M.-A- a.....:�r It 4 i ;SEPTIC SYSTEM MUST BE . INSTALLED IN COMPLIANCE r y Sewage Permit number ..........................................................` WITH ARTICLE Il STATE SANITARY CODE AND` TOWN �FTHETp TOWN OF -BAR'Nk5 "'9'- R�1L�DING # INSPECTOR ��YPY a�9 � wL• Y (j IN APPLICATION.FOR:.PERMIT TO . ..... .... . TYPE OF CONSTRUCTION ,---,.!............. t� �" ............................. ... ........... ....:...................... .......... - ' .............19 .., TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following informatio L Location ..................................... ..........�..... �....<. �.. ........... ...................... L............. .�.. .J' ProposedUse ...... .......................................................... ............................................................ Zoning District ............... ......... .....................................Fire District 6-4"W Name of Owner ... ... ." °" .............. .Address .......~ ..................................... .Volt Nameof Builder ....................................................:..........:....Address .................................................................................... Nameof Architect ...........:......................................................Address .................................................................................... , Numberof Room .......... ............:.........................:.......:...Foundation ......................... ......................................... Exterior .. :....... ... .......... ......:.......................................Roofing ......... 4rlo. ..:....A . .................. Floors :. ,......................................................lnterior :.......:...��1 .... ...................................... Heating . ...................................Plumbing .....cry...:... ..'e?..................................... Fireplace .... ........................... Approximate Cost .........<....`� ................... .. 17 Definitive Plan Approved by Plannin card _____________________________19________ Area ..../....... ... Diagram of Lot and Building with Dimensions Fee Q' SUBJECT TO APPROVAL OF BOARD OF HEALTH �o 1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Small, AAAn 19340 one story Na,r..... .......Permit for. . ................ ............. :. usingle _`family dwelling...................... - Location.:.' ....Wishington Bursley Wa ..... t - Cenferville a` - .......... ...................................... ......r............ n Owner ............Alan Small ` .... ......... a; ........................ r. . Type of Construction ............frame a •••.•• rI. ' ........................ ..•............................ .... ... .. Lot ......... ` 98 Plot•. :........... `, • T• • �• June 27 Permit Granted` ....19 77 ' / � C Date of Inspection ... ....��..�...119 Date Completed;:..� , �. .... .....19 i z t ' PERMIT REFUSED ; ............... ... ...... }... .. .. 19 ..... ............ ' .............. d •..................................... ............... ` ...... " I ~; ...... � ....................... ......... j .......................`... ........................... .... ..... . Approved ..........................................:..... 19 F