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HomeMy WebLinkAbout0065 WATERVIEW CIRCLE ��" ' ZA;0 Town of Barnstable 200 Main Street, Hyannis MA 02601 508-862-4038' Application for Building Permit Application No: B-17-3059 Date Recieved: 9/6/2017 Job Location: 65 WATER VIEW CIRCLE,CENTERVILLE Y Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: STEPHEN T DICKINSON State Lic. No: CS-081843 Address: MERRIMAC, MA 01860 Applicant Phone: (508) 676-6820 (Home)Owner's Name: HUSE,MARK J&&MARCIA E Phone: (508)362-5987 , (Home)Owner's Address: 65 WATER VIEW CIRCLE, CENTERVILLE,MA 02632 Work Description: Entry Door CD (.0 0 un Total Value Of Work To Be Performed: $4,500.00 Structure Size: 0.00 0.00 t 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by. filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have . been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Stephen Dickinson 9/6/2017 (508)676-6820 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $4,500.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $35.00 9/6/2017 $35.00 XXXX-XXXX-XXXX- Credit Card 7597 ...................................................................................................................................................................................:........................................................................................................................................ Total Permit Fee Paid: $35.00 o Kam. • f Cape Save Inc: .a OF s? TA c 7-D Huntington Avenue South Yarmouth, WA!01 64 1 10: 06 Tel: 508-398-0398 Fax: 508-398-0399 9/30/14 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits T Dear Mr. Perry, C This affidavit is to certify that all work completed for 65 Water View Cir.,Centerville has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-24 cellulose Kneewall• R-7 FSK All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Application Parcel ® Z A lication # Health Division Date Issued 7131.1 Conservation Division Application Fee " Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address d w vt-evt/ l `� Village CA-1 41 v 1 L 6 e Owner Address S ocni t as a d 'f Telephone 4 a U Permit Request sec.( a IA,4 �-dqpt-1 &-/�J e /-4,,s (i C,,f4,a-I A0 C S w(,,,�k-d1 © . )<-ot ee-�L/Q �l Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation � UUf� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family UZ 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 w CO Number of Bedrooms: existing —new "A 00 Total Room Count (not includingh xi in P 0 ou ( o baths): existing g new First Floor Room CItove: unt Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal ❑ues Flo 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 ❑ No If yes, site plan review# Current Use - Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) / ed66 fag IName W I I�_a M v(��74 Telephone Number / 1� Address r�Glr�1,' V`` `� �T v License # ! 0 J �D Home Improvement Contractor# � �` 3 Worker's Compensation # -ryc 3&rs F6 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE a 0 /� FOR OFFICIAL USE ONLY a APPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE 4 ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO: , f Building Permit Authorization I, Marsha Huse as owner hereby give my permission to Cape Save,y Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at 65 Waterview Circle Centerville, MA 02632 Signed Date 4 The Commonwealth of Massachusetts y Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass-gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Le 'b1;at Y Applicant Information Cape Save,Inc. Name (Business/organization/Individual): 7D Huntington Avenue Address: City/State/Zip: South Yarmouth, MA 02664 Phone#: 508-398-0398 Are you an employer?Check the appropriate box: Type of project(required): l.❑✓ I am a employer with 17 4• ❑ I am a general contractor and I 6 ❑New construction have hired the sub-contractors employees(full and/or part-time). listed on the attached sheet. P. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑ Building addition comp. insurance.' itions repairs or add [No workers comp. insurance 10.❑ Electricalp required.] 5. ❑ We are a corporation and its I required.] a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions 3• right of exemption per MGL 12.❑Roof repairs myself. [No workers' comp. c. 152, §1(4),and we have no Insulation insurance required.] employees. [No workers' 13.❑✓ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. d an additional sheet showing the name of the sub-contractors and state.whether or not those entities have +Contractors that check this box must attache 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 and job site information. Insurance Company Name: Technology Insurance Company TWC 3353968 Expiration Date. 04/09/2014 Policy#or Self-ins.Lic.#: Job Site Address: wvf f/ /l tk/ ( d��r City/State/Zip. U1 f Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). osition of criminal penalties of Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impa STOP WORK ORDER and a fine fine up to s1,500.00 and/or one-year imprisonment,°as well as civil penalties to the form Of 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 enalties of perju t at the information provided above is true an4 correct. Date - -Signature: Phone#: 508-398-0398 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.Plumbint Inspector 6. Other Phone#: Contact Person: f CERTIFICATE OF LIABILITY INSURANCE 4/9/2013 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 NAME NCT Colleen Crowley Risk Strategies an PHD� (781)986-4400 FAX (782)g63-+I420 g company A! o f . C No: 15 Paeella Park Drive ADMALESS- Suitete 240 INSURERS AFFORDING COVERAGE NAICS Randolph Nam. 02368 INSURERA:Selective Insurance INSURED INsuRERS:Safet Insurance C 3618 Cape Save, Inc INSURER C:Tecbnology Insurance Company 7 D Huntington Ave INSURERD: INSURERE: South Yarmouth NIA 02644 1 INSURERF: COVERAGES CERTIFICATE NUMBER:CL134960509 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 DDLSU TYPE OF INSURANCE ABR POLICY NUMBER MPMOIDDYEFF MPMIDD EXP LIMITS LTR GENERAL LIABILITY - - EACH OCCURRENCE 11 OOO,DAMAGE TO RENTED 000 X COMMERCIAL GENERAL LIABILITY PREMISES fEa occurrence $ 100 COMMERCIAL A CLAIMS-fnADE a OCCUR 9199448001 0/16/2012 O/16/2013 MED E(P(tiny one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COAIPIOP AGG $ 2,000,000 X POLICY JECT LOC $ AUTOMOBILE LIABILITY ., Es accident SINGLELIMIT 1,000,000 BODILY INJURY(Per person) $ B ANY AUTO ALL OWNED SCHEDULED 6208200 1/6/2012 1/6/2013 BODILY INJURY(Peracciderd) $ X AUTOS X NON-O MIED PROPERTY DAMAGE $ HIRED AUTOS AUTOS X I Underinsured motorist BI split $ 100 000 A X UN113RELLA LIAB X OCCUR 199448001 O/16/2012 0/16/2013 EACH OCCURRENCE $ 1,000,000 EXCESS LIAR CLARASMADE AGGREGATE $ 1,000,000 DED RETENTION$ $ C WORKERS COMPENSATION DEficers Excluded from X T RSTATTH- s O R AND EMPLOYERS'LIABILITY ANY PROPRIETORfPAP.TN�R c)(ECUTIVE Y/N overage E.L.EACH ACCIDENT $ 560,000 OFFICEPJMEMBER ECCLUDEO? ® NIA rWC3353968 /9/2013 /9/2014 (Mandatory In NH) E-L.DISEASE-EA EMPLOYEE $ 500 000 ityas,desaibeunder E-L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(A1lach ACORD 101,Addivanat Remarks Schedule.If mere space is required) Issued as evidence of insurance. Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a/ National Grid, Action Inc., Colonial Gas Company and NStar Electric are listed as additional insureds as respects General Liability as .required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact: PO Box 427/SCH ,, AUTHORIZED REPRESENTATIVE 3195 Main, Street Barnstable, MA 02630 chael Christian/CLC =-� ACORD 26(2010/05) OO 1999-2010 ACORD CORPORATION.All rights reserved. INS025(201005).Ol d The ACORD name and logo are registered marks of ACORD T , -1lassachusettS- Department of Public SafctY Board of Buildin-, Re!-yulations and Standards Construction Supervisor Specialty License License: CS SL 102776 Restricted to: IC ' k - WILLIAM MC CLUSKYM 37 NAUSET ROAD WEST YARMOUTH, MA 02673 Expiration: 6/2812013 ( nnmixsim.�• Tr=: 102776 Q . Office of Consumer Affairs and Business Regulation a w `�_ ' 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration - _ Registration: 171380 Type: Corporation , Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 -. - - Update Address and return card.Mark reason for change. . _ Address _ Renewal .`Employment Lost Card , PS-GAi 0 SON1r0M4,G101210 <t --_-__.... �/re�a�ra»zoncaeal�•cll:.=fla:::�rueCG` � ' ' Office of Consumer Affairs&Bdduess Regulation License or registration valid for individui use only - HOME IMPROVEMENT CONTRACTOR +before the expiration date. If found return to: ; ;F Type:• Office of Consumer Affairs and Business Regulation ��_ _ Registration:_:171380 _ � � ' Expiration: 3l142014 Corporation 10 Park Plaza-Suite 5170 ;u Boston,�f:4 02116 CAPE SAVE lNC - - - - WILLIAM McCLUSiCEY: ` •. 7-D FlU"NGTON AVENUE SOUTH YARMOUTH.MA 02664 Undersecremry Not valid Wi& o signal. 9 Massachusetts -Department oi Public Safety Board of Building Reguiations and Standards Construction Supen-isorSpecials`-` ' License: CSSL-102776 fir( .y - WILLIAM J MC CLUSIKEY 37 NAUSET ROAD z West Yarmouth MA 026'73'4 . ? Expiration Commissioner 06/28/2015 Office of Consumer Affairs and usiness Regulation =� 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation Expiration: 3J14/2014 Tr# 222184 CAPE SAVE INC. a WILLIAM MCCLUSKEY =' 7=D HUNTINGTON AVENUE f — SOUTH YARMOUTH, MA 02664 = -- - Update Address and return card.Mark reason for change. --")PS-CAI 0 50Pd-04/04-G101216 1,7 Address [—I Renewal F� Employment L7 Lost Card 0 � �mwnzarauea :1 < _ �\ Office of Consumer Affairs&B siness Regulation License or registration valid for tndividul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: -'171380 Type: Office of Consumer Affairs and Business Regulation — /') Expiration: _3/-14/2014 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAP1=SAVE INC WILLIAM McCLUSk6-- - ; 7-D HUNTINGTON AVENUE SOUTH YARMOUTHr MA 02664' Undersecretary Not valid it o signs ,{ t 1KE r Town of Barnstable �m►t# P�� 0 Expires 6 months from issue date b? : MUMST,,BM : Regulatory Services Fee v " 9. 0� Thomas F.Geiler,Director a Building Division ok cb I l Elbert C.Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION Not Valid without Red X-Press Imprint Map/parcel Number 3 L( LV C f,0--z_ Property Address4 ?,*Residential OR ❑Commercial Value of Work Owner's Name&Address ^ Contractor's Name Telephone Number ✓`G 8 -�����j 5 Home Improvement Contractor License.#(if applicable) 12 C2 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor w SS PE O" ❑ I am the Homeowner r have Worker's Compensation Insurance �� '{ 6 1 Insurance Company Named--�� TOWN OF BARNSTAtKE Workman's Comp.Policy# tX O Permit Request(check box) r '-lRe-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature expmtrg Town of Barnstable GF WE - `� Regulatory Services s � anxx Thomas F.Geiler,Director QED 6 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section 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 caner D e M a ,r K :T: We'se, Print Name Q:FORM&OWNERPERMISSION �j Date:8/29/11 LINNELL ENTERPRISES Job#3154 59 FREEBOARD LANE YARMOUTHPORT,MA 02675 TO: TEL:508-362-1294 Mark Hughes 65 Waterview Circle Centerville, Ma We are pleased to submit the following bid.- Job Descriptfon: Reroof SERVICE DESCRIPTION CHARGES TOTAL Stri &reroof main house Replace with 30 yr.Architect Certainteed shingles(Driftwood)Ridge vent 15 felt paper —_ 18"ice&water barrier Pipe flanges Complete garage roof -- -- - — Clean up, removal&dump fees included - Total service charges: $6,000.00 PAYMENT SCHEDULE Price valid for 30 days Deposit$3500.00 Balance due upon completion$2500.00 ACCEPTED SIGNATURES ) p - Homeowner Date Linnell Enterprises Date A copy of our Workers Comp.and Liability Insurance to be provided upon signed contract. 08/07/2011 04:52 5087527172 PAGE 02/03 ,� �p® CERTIFICATE OF :LIABILITY INSURANCE DATEtMre�DD YY, 08/08/2011 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Blackstone Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 37 Harvard Street Suite 213 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester, MA 01609 INSURERS AFFORDING COVERAGE NAIC a INSURED INSURER A: A.E.I.C. Linnell Enterprises INSURER R 59 Freeboard Lane INSURER C: Yarmouth, MA 02675 INSURER D, INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH . POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTA INERD TYPE OF INSURANCE POLICY NUMBER D LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL I,IARILITY DA A ) CLAIMS MADE OCCUR MED EKES(Any � ca) 5 MEO EXP(Any orle ppr.an 3 PERSONAL L AOV INJURY S GENERAL AGGREGATE S GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 3 POLICY r7PROJFCT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g ANY AUTO (EA=ident) ALL OWNED AUTOS BODILY INJURY . g SCHEDULED AUTOS (Per person) HIRED AUTOS 90DILY INJURY $ NON-OWNED AUTOS (Per swidenp PROPERTY DAMAGE' a _a` (Par amldnnl) GARAGE LIABILITY ` Y' p AUTO ONLY-EA ACCIDENT` S ANY AUTO EA At= S OTHERTHAN AUTOO ONLY; Add" S 7 EXCESSlUMBRELLA.LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE y'. $ S F"sA DEDUCTIBLE S -� 'F7 RETENTION s $ EMP OEY RCS'LIAR LIN A� ✓ TO Y LrhtITS ER A ANY PROPRIETQRJPARTNER/EXECVTNE WCC5007447012011 8/1/2011 8/1/2012 E.L.EACH ACCIDENT $ 100,DOO OFFICERIMPM13ER EXCLUDED? 100,000 If 4e deecrlbe under EL DISE/SE-EA EMPLOYS $ SAL PROVISIONS below E,L.DISEASE•POLICY LIMIT S 500.000 OTHER t David Linnell Is covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION 5NO11LE ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EiFORE THE EXPIRATION Town of BarnstableDATE TmEREOF,THE MSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN Building Department NOTICE TO THE CERTIFICATE HOLDER NAMED TO 7Mfl LEFT.BUT FAILURE TO DO SO SHALL 367 Main Street Hyannis, MA 02601 IMPOSE NO OBUOATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AOENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE i AC ORD 26(2001/08) L ©ACORD CORPORATION 1988 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/Organizatiowlndividual)' J , C CLl e—( Address: Ln City/State/Zip: (� Phone you an employer?Check the appropriat box: Type of project(required):. FAre .0 I am a employer with 4. E] 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 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.$ 9. 0 Building addition required.] 5. 0 We are a corporation and its 10.E Electrical repairs or additions 3.❑ I am a homeowner doingall 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' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. d(01 Insurance Company Name: �7� / / Policy#or Self-ins.Lic.#: �W 7 �/ �" 6 a Expiration Date: Job Site Address: 1A 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 cer 'r under t e pal a�p - allies ofperjury that the information provided a ove is true and correct Si afore: v Date: Phone#: / Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: j � ✓lze -�arr�.nanu�ealtli o�,/�aaaac/ivaet�a � � I License or registration valid for individul use only Office of Consumer Affairs&Business Regulation I before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registratio6 ;_j20659, 10 Park Plaza-Suite 5170 Expiration 219/2012 Tr# 294382 Boston,MA 02116 Type , ,;Jndividual LINNELL ENTERPRISES _1 DAVID LINNELL\JR� F ' 59 FREE BOARD YARMOUTHPORT, MA 02675 Undersecretary Not valid without signature ICI issachusctts Department of Public Safct� Boar(I of Building Rc(Fulatittns and Standat-tls•,'i Construction Supervisor License One-and Two- Family Dwellings License: CS 71507 j. DAVID J LINNELL JR Vb 59 FREEBOARD LN YARMOUTHPORT, MA 02675 tiF. Expiration:.8/11/2013 ('unnni.xiuncr Tr#: 2.398 { Assessor's office(1st Floor):• ; �(� �� 71O'S V.')T;ER1 rVIUS�7 BE o� tMtt to Assessor's map and lot n`�ber `^SEP ' Conservation(4th Floor): ` w i _ IWS7�ALLED f.V COMPLIANCE �� JCL Board of Health(3rd floor)': + ' 1 tisa»r = E Sewage Permit number �,�-=�7 �. `: N@i'IROMENTAL ® E AND rua Engineering Department(3rd floor):-' TOWN REGULATIONS �°''pro arr►��� House number �� �S• Definitive Plan Approved by Planning Board i 19' f' APPLICATIONS PROCESSED130-9:30 A.M.,and 1 -2:00 P.M.only i ,•' � �` { TOWN ; OF BARNSTABL-E cow: , ' t BUILDING INSPECTOR APPLICATION FOR PERMIT TO t / TYPE OF CONSTRUCTION 1 ! f 19� 4 TO THE INSPECTOR OF BUILDINGS: The undersigned here' ' pplies r a permit according to the following information: Location Proposed Use 110, Zoning District Fire District Name of Owner zV1 L-de�l cf /���✓/ L.Q Address Name of Builder Address Zujr-ec .,-'Ool Name of Architect Address l/ Number of Rooms Foundation . Exterior /-/Zc Roofing 67-rX Floors L� Interior Heating - L _ ftiG Az- Plumbing Fireplace C/_1 Approximate Cost Area Diagram of Lot and Bu• 'ng with Dimensions Fee ' l eD l�l Z �9 Q Xt OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License lJa2 ,1 NICK.ULAS BUILDING CO. INC. s1io '3 6 3 9 3 Permit For Two Story t S i nq P -Pam; l u nwAllix�r�— Lot 41 , 65 Water View Circle' ' t Location Centerville._ - n. Owner N'ickul.as Building Co. , Inc. fJ" •i ,'� _ Type of Construction Frame r Plot Lot f - f s' n Permit_Gr ted December 16,', 19 93. Date of Inspection: T Frame o2/ .�- 19 -Insulation 7,'Fireplace 19 Date Completed r 19• } i J ` !8 rxrrr# rx � . . q�F�:'ri•`�' �R.ti �:.t, �z :.w7�s":r a' i l ! Id III�Ri l'll 'lino, J p�M. i -mI m _ - 1�1 I III I� ICI C �� MR I ill iil r I�m�"�re,-, 1 IF- II'ir1!117 I ai, II �� '• I-'I �' 'I�Illllii I l I • 1 I � I I s` a I l I Y{fhfr i I li i• Y� -- 'II I m I _ � I I I - I 1 r I ARCH)—TECH ASSOCIATES . z .. =terensTa3L, r� architectural design 3 D =4 center place,unit 4,1550 route 28 (508)771-3900 Q. eente'llle,ma 02632 faz:775-1945 I� yir6l-5L4(xg}} Zt96O - 006fi-ILQ(805) BZ°1na O99t•b-wn Doeld y L4Fo yr? an oa yoar? Yw S31V130GGV HAI-IHD�IV 9NI 4 14 sv I y.IN 4 a 8 a i N la I _• � -. I7;II lo-b Ili ' I 3 v 9 ELLS u I s I = ✓ - -- -o I I � � �I • I I i Y _ I —_y c I I i "o hit -o o3 ` I 8 --=:lalt : Irlll Io-IS 14I4 I - I t I 0 -J ------------ p•'- J � os.q S TI s s.cs I I ! _ pp I n•. n I I I A lo-/I Iv-It: 1'-ly f� 1 ' t } WATER vlekl C/RC[E i s 7/o 00" o/ Z3s ao ff=34,00" Go ' 0 LOT DNE V so' j EX/ST 1 <. �_ �• ce,vC, LA i 'a4 47/ON /57' f o h CE,eT/FY 7t/,1T 1-�fE �OUAIP4770AI P,—P1C MZ> ON LOT N4. CONFDiPMS TO 7M 7MF 2W/V/NG BYLi9JYS OF TtiF 72WAr' OF ,QARNSTABG E. I 3 - t �C�,ej/F/ED FO!/NI>�4�11/� BAN BU/L T" PSA OF Mqs FOf� /sow. JOHN CyG 4 ; P.DOYLE,III BA.P�1fSTf1BcE MA, N0.33589 y i LOT *t WA7ZR V/EL✓ C/eG'L E k o.938 �q 9FCISTER'��OR- SCALE•'/~��9(4' DEC. 9� /993 N� y S U R\j �oyLE Ass 1,19725' AOOx s9s l _ — c40� COMMONWEALTH SACHU KGS ,'—E� D F-'AR MENTT OF P-MUSTRJAI-acACCIDFNls _ l 600 WASHIT'GTOJ� S t ft1=t1- \—W' fames et. BOSTON, MASSACHUSE-f-hS 02111 �c—n:ss•��e woRKERS'.COMPENSATION INSURANCE AFFIDAVIT (l iccnscc/permi ctcc) I with a principal place of business/residence err. a* (Gry/Stacc/Ztp) do hereby certify, undcr the pains and penalties of perjury; char. j) I am an employer providing the following workcrs' compc isazion coverage for mycmployccs working on this job. 0 7 -Ca c/ i / Z Insurance Company Policy Numbc � ) I am 2 sole proprictor and have no one working for mc: • j J' I am a soIC proprictor,gcncrJ eonmaor or homeowner (circle onc) and hsvc hired the eoritraaors listed bclow who h;v th following workers'compensation insurance policies:. Niame of Contmaor Insuiance Company/Policv Number \2mc ofContraaor Insunncc Company/Policy Number Name:of Conu2aor Insurancc CompanylPolicy Numbu Q 1 am a homeounu performing all the work myself NO.M Plcasc be aKarc 15at while l orscowactt who employ ptirsoas to do raainicamce eoascructioa or repair v ock on a 2•'Jung of not more tbaa tbrcc uaiu is wbicts ut c bomcowacr Ow resides or oa the grounds appssctcoant tbcme arc Dot gcacraUy I considered to be employers undcr the GorJ•crs'Comprms.2t;on/yet(GL C.152.sect. 1(5)),appli itioo by a bomeo-mcr for a lieeDs< or perr:nit r..y evidence the 1eg_l stain of z=cr_rloycr-undcr the Corkers'Cocopensacion Act. i vnccrstanc that a copy of iris statcncnt WiU oc fors vdcd to the Dcpa:t:acnt of IndustriA Acddcnu'OFtjcc of lnsc:ancc for.covcma c ---crifscation and that failure to secure covmcc as required undcr Section 25A cf MGL 152 can Icad to the imposition of-c-riminaJ pcnaJucs consisting of a fine of up to S1500.00 and/or imprisonment of up to one year arsd civil penalties in 6c form of:Scop work Ordcr and a fine of S 100.00 a day against me. h Si;ncd this d2y of i!�� e I9 Lie sce/P rmirrccr r. Licensor/Pcrmittor � 7^f� TOW.! OF BARNSTABLE, MASSACHUSETTS B U I L D N" C" P ERN T f rH=234-89-X01 -X02 Y_ _ _ DATE DEcembk � 16, IS, '93 PERMIT NO. NQ 36393 APPLICANT ;V + ' ii�'% +3 • /'^ (y ADDRESS ..A+cJ BOX 7 . West Barnstable #002265 (NO.) (STREET) - (CONTR'S LICENSEI PERMIT TO Build Dwelling ( 2) STORY Single Family DwellingNUMBERDWELLIN OF G UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) i }� AT (LOCATION) - Lot #1/ 65 Water view Circle, Centerville ZONING RF ' (NO.) (STREET) DISTRICT— • BETWEEN AND ' (CROSS STREET) - ! (CROSS-STREET) I SUBDIVISION LOT LOT BLOCK SIZE' BUILDING IS TO 8E FT. WIDE BY FT. LONG BY FT. IN HEIGHT.AND SHALL CONFORM IN CONSTRUCTION C TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) - REMARKS: Sewage #93-676 i Bond AREA OR VOLUME 952 SQ• ft. ESTIMATED COST $ 80 i 000• 00 FEEMIT 3 005. 75 (CUBIC/SQUARE FEET) OWNER Nickulas Building Co. INC. ADDRESS Box I :'>7. Barns-a E BUILDING DEPT. i. BY I I i OF A APPLICABLE SU NYBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIREO,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MINAL INSPECTION TI TO LATHE FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 ) r%i�p 4'n L"`C ' 3 I HEATING INSPECTION APPROVALS 5 C GINE.ERI4(3 DEPARTMENT S /Nit O L /� A LTH c ; / ? OTHER SITE N REVIEW APPROVAL DIV WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT 'W!L L B E COME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. *7Mf TOWN OF BARNSTABLE Permit No. 36393 ....... BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash � .ML •67y �owY� HYANNIS.MASS.02601 Bond ......X........ CERTIFICATE OF USE AND OCCUPANCY Issued to Nickulas Building Co. , Inc. Address T.nt- #1 a 65 Water View Circle Centerville USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, .AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE ,.• BUILDING CODE. Ap . .. .. ......... ._..........�........... .r . . '... ..... Building Inspector K'vr•c.h. 13 1 r)9 5 Building Commissioner Ralph Crossen Town Hall Hyannis Ma. 02601 RE: NICKULAS BUILDING CO. Dear Mr. Crossen, Pursuant to our conversation on 10 March 1995 I am enclosing a copy of my letter which I sent to Larry Nickulas regarding ongoing problems which I have been having with a home he constructed for. me at 65 Waterview Circle Centerville. I have informed him on previous occasions that these defects existed, . he acknowledged them and as of this date he has yet to rectify them.. He informed me that my home would be guaranteed for one year after purchase. That time period will be up on 13 April 1995 . I am writing you to show that I have put him on notice regarding these defects prior to the anniversary date of my purchase, as well as asserting my expectations that he will cure these defects for which I feel he is responsible. Please contact me if you wish to discuss this matter further. My home phone # is 362-5987 . Very truly y urs, Mark J. Huse March 13 , 1995 Niculas Building Co. Mark J. Huse Larry Niculas 65 Waterview Circle 1064 Main St. Centerville , Ma. Barnstable Ma. 02668 Dear Larry, I am writing you certified mail on this date to re-iterate my request which I hand delivered to your home on March 5, 1995 concerning problems with my home located at 65 Waterview Circle in Centerville. This residence was constructed by your company, and we passed papers on April 13, 1994 . As I have informed you -orally,as well as in writing, I continue to have problems with the home which I must have corrected. These problems consist of, but, are not limited to the following: 1 ) The octogonal windows in the living room leak profusely and fail to close properly. 2) The basement continues to leak in the areas I showed you, and you marked. 3) The garage door continues to leak and is now swelling due to water infiltration. 4 ) Shingles have fallen off of the gable end,West side,of home, and must be replaced. 5) The baseboards in the kitchen have fallen off and must be attatched. 6) There are paint stains on the fireplace which must be removed. 7) The sheetrock on the stairwell is rippling and must be repaired. 8) The sheetrock in the N.E. corner of the living room is cracking at the seam. 9) The garage floor cement is cracking. 10) There is insufficient hot water in the showers, the mixing valves must be adjusted. 12) There are deficiencies in the sheetrock in the hallway,dining area, master bath, master bedroom and half bath. 13) The porcelin sink in the kitchen has a chip on it. 14) The formica countertop in the Master bath is not glued properly. I am again putting you on notice regarding these problems and expect them to be repaired free of charge under the terms of your one year guarantee. SENT CERTIFIED MAIL ON MARCH 13, 1994, RETURN RECEIPT REQUESTED. CERTIFICATE # Z 089 752 740 Very truly y urs, cc. Building Inspector Mark J. Huse o, or e 63 v y v ^r `.._ t 9 �y f ggppH 9 U 1 yptlpaj __ ___ ?,` _.�Y�.4�„ �. ,�. _ �..._-�__ - _,� ' � .. .;.: _ -. _ _. - \� �� / � �� �. �� �� I F� � Town of Barnstable * C, �l(051 o qty Permtt# O 1�q Expires 6 montlts from issue date Regulatory Services Fee3 S , — • BARNSTABLE,MASS + �cb , �� Thomas F. Geiler,Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstab le.ma.us Office: 508,862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not.Val&without Red X-Press Imprint Map/parcel Number ,�-3Y Property Address e4_11 R R sidential Value of Work Minimum fee of$35.00 for work under$6006.00 Owner's Name&Address 14&1 Contractor's Name f � � Telephone Number 5?0 7r� l Home Improvement Contractor License#(if applicable) ! 67 2,�5-1 r' Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance -P R � S IT I am a sole proprietor ❑ lam the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF 5ARNS T y.A2i E Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Le-roof(stripping old shingles) All construction debris will be taken to G2 '\ t ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *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 Im rovement Con ctors-License& Construction Supervisors License is equi d SIGNATURE: Q:\WPFILES\FORMS\building permit formslEXPRESS.doc Revised 070110 XNnd- The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations el;; 600•Washington Street j Boston, MA 02111 . c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbees Applicant Information Please Print Le ibl .4_ Name (Business/Organization/Individual): Address: ,20 69w City/State/Zip: l Phone ���9 �3 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 construction oyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.) ' 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t . employees. [No workers' 13.0 Other 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 their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-iris. Lic.#' Expiration Date: Job Site Address: City/State/Zip: , Attach a copy of the workers'compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MG c. 1,52 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 c i nder pain allies of er' that the information provided a ve is true and correct. Si ature: Date: Phone#: Official use only. Do not write in this area;to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hue, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on.such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or.to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is Tequired. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy infonnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.rnass.gov/dia 1 I� aF Town of Barnstable Regulatory Services MAMABLA ` Thomas F.Geiler,Director Epp 9. Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA b2601 *ww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 4- ,as Owner of the subject property herebp authonze 'dCye to act on nTY behalf, in all matters relative to work authorized by this building permit apphcati ii for: (Address of Job) lj Signature er - ate— Print- —�� Massachusetts Depal-tment of Public SafetN Board of Buildin�-'Regulations and Standards Construction Supervisor License License: CS 18096 RICHARD E LEBOEUF 20 BACON RD ` HYANNIS, MA 02601 Expiration: 6/2312012 ('iminisionrr Tr#: 27920 ''_ an.... Bffslness egn s.ion Office o onnssomer airs HOME'IMP ROVEMENT CONTRACTOR Type Registration 142516 individual —Fy� Expiration 4RL2012 Ri rd E.LeBaeuf.: - Richard. LeBoeuf = 20 Bacon Road Undersecretary Hyahnis,MA 02501 — License or registration valid for individul ust only ` before the expiration date. If found`return'to::. Office,of.Consumer Affairs'and Business R 0egulation j z1 Park:Plaza Suite 5170 + on,:MA02116 Not valid without signature ..