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HomeMy WebLinkAbout0015 EATON COURT /S�a�cn CY lr ,c011410:47a TupperCom - 15087,785010 p.1 6K Z1 Z1IY CONSTRUCTION C®. LL-c 546A Higgins Crowell Rd,WEST YARMOUTH,MA 02673 PHONE: 508-778-0111 FAX: 608-778-5010 WWIN.TUPPERCO.COM Date: l Y Town of Barnstable Thomas Perry CBS 200 Main Street s Hyannis, Ma 02601 = (503) 790-6230 fax a E Re: Insulation Permits rp Dear Mr. Perry This affidavit is to certify that all work completed for permit application # � Io ��CP Issued on has been inspected by a certified Building PerFormance`Institute,(BPI) inspector. All work performed meets or exceeds Federal and State requirements_ Sincerely, Permit #.. � qc) 7- S l_,/ ' Address:. �- Richard Tupper License # CS-69056 CJ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 55 Parcel ©/ Application Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address l Village ! Owner A ,d Address Telephone_7 0 J 6 0 9 7q Permit Request 6irj/70 10'rr1joVZ4, aJi JSke Ak7 ezma� bodld i'r7lhdI V&-�IAM Ip �' U ;a;2d Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation* 41'7' 'Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family JP--' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: R`ru'll ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) I,_00 Number of Baths: Full: existing 19— new Half: existing new Number of Bedrooms: 1 3 existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas t'bil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded L-4tp�,, Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �'.l')a 2-6 Z uAoe 2_ Telephone Number Address 6 �Q �I G�9/17S C o���G( License # CY--0(D Q0�� Q ak Home Improvement Contractor# . Email QCjh'lih CL3 Ct)n-) Worker's Compensation SS c1�1�1�(l� ALL CONSTRUCTIO RIS RESULTING FROM THIS PROJECT WILL BETAKEN TO lr f' W42.r,-J ) 1/0 V atno c SIGNATURE DATE G / FOR OFFICIAL USE ONLY APPLICATION# -r DATE ISSUED MAP,/PARCEL NO. F 4 ' ADDRESS. VILLAGE OWNER y DATE OF INSPECTION: FOUNDATION FRAME r INSULATION FIREPLACE h ELECTRICAL: ROUGH FINAL e PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING; DATE? OSED OU: L ! T C E ASSOCIATION,PLAN NO. t k I t 4 � n The Commonwealthi of Massachusetts Department of Industrial Accidents- Office of Investigations . 1 60D Washington Street: Boston,MA 02111 www.mass g6*W Workers' Compensation Insurance Affdavit :Builders/Contractors/Electricians/Plunibers Applicant Information Please P.rit►t Legibly Name(Business(Qrgaruzation/individual):;. Tupper Construction .Co..... LLC . Address: W4 k Higgins Crowell,Rd Cit)/State/Zip: West; Yarmouth, .MA 02673 Phone#: 508-778-0111 Areyou.an employer?Check the:app gpriate'box4 Type`of project(required):. 1 FX ;I am a:e to er with, g 4. ❑ Lama eneral cohttactor and I mP y 6. Q New construction. employees(full and/or part-time):* have hir. the sub-contractors. 2.�,I am a:sole propnetor or partner listed:on the attached sheet.. 7 ❑ Remodeling ship:and have no employees These sub-contractors have. 8. ❑ Demolition workinf workers ' inunce;g ormenanycapacj 9. ❑Building adaition. [No workers' comp.insurance 5, � We are a corporation and its required.] offices have,exercised their: 10.❑Electrical repairs oraddittgns I❑ 'I am a'homeowner doing all work. right of exemptionper MGL 11.0 Plumbing repairs or-additions myself. [No workers'comp: we have no 12>[]Roof repairs; insurance required.]:t employees. [No workers' 13.[J,Other pa#hPrizatiot'i --- comp.insurance required.] - "Any.applicant that cheeks box#1 must also`;fill outtte section below'showing their workers compensation policy information., t-Homeowners who submit this affidavit,indicating they are doing all work and then hire outside co-tracth1, must submit a new afffrdavit indicating=such': }Contractors that.check this box must attached an additional sheet showing the name of the`sub contractors'and their workers'tromp.policy information: I am an employer that is providing workers'compensation insurance for my employees Below is;the policy¢nd job site itrforrnation. Insurance Company Name: .E Z C` Policy-#or.Self-im:'tic #:.....WCC 59 455 9 3 012 012: Expiration Date: 1073/15 S Job Site Address � ���!C�',/ City/State/Zip: Attach a copy of tke workers'compensation policy declara#ion a showing;.the'poiicy number.and expiration date). Pag Patlu a to secure coverage as required under Section 2SA of MGI c. 15.2i;can.lead.to the imposition of criminal penalties of a fine tip to$1,500.00:and/or.one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER:and a:f'ne: of up to$250'.00 a day a t theviolator, Be:advised that a copy of this statement may be forwarded to the,Office of Investigations of IA for i ce coverage verification: I do:l ereby' A.M.d the p and-peni:dd, `ofPerlury Mai the information,Provided above Iv true and correct -Si ature .... Date: _ Phone#: (5 0 8) 7 8-0111 OfJ cia1 use.only. Op not write in this°area,to he completed by city or town officiaL City or Town::... PermitUcense#.. Issuing Authority(circle ones:; r 1.Board of Health 2.Building:Department 3 CityfrW Clerk. -4 Electr,cal lnspector 5.Plumbing Inspector b.:Othec; Contact,Person:.. ;Phone'#; y AGORq CERTIFICATE OF LIABILITY IRISU:RANCE DATE(AAMlDDlYYYY) 10/03/2014 PRODUCER 0009974061 FAX (S08)990=2731. THIS CERTIFICATE IS ISSUED 11 AS A MATTER OF INFORMATION Southeastern Insurance Agency, .Inc ONLY AND CONFERS NO RIGHTS UPON THE.CER7IFIGATE Q.0 State Rd HOLDER,THIS CERTIFICATE.DOES NOT AMEND,EXTEND OR ALTER`THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, .RA 02747 _.. INSURERS AFFORDING COVERAGE' NAIC-; INSURHD Tupper Construction Co 'LLC wsukkk- Arbella 1pootectipin Insurance' INSURER B:;_ AEIC: 546A Higgins Cowell Road iNSURER c:- West Yarmouth, :MA 02673 INSURER O INSUR ER.E: COVERAGES. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE:FOR THE POLICY PERIOD':INDICATED.NOTWITHSTANDI)VC= ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOGWMENT WITH RESPECT TO WHICH-THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE`POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS;EXCLUSIONS AND CONDITIONS OF SUCHPOLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID:CLAIMS: IL7R. TYPE OF IIV.SURANCE: POLICY NUMBER Iml D�ATVE �� LIMITS GENERAL LIABILITY 8500008743 ll/Ol/2013 11/01/2014- EACH OCCURRENCE S 1,OOO,.OQ PREMISES EaocamanceS X. COMMERCIAL:GENERAL LIABILITY' 100,OO CLAIMS:MADE a OCCUR. MED EXP(Arty am person), $ 5.,U0 PERSONAL&ADV;INJURY $ 1 t 0p0,0 GENERAL AGGREGATE; $. 2,000,00 GEN LAGGREGATE LM APPLIES PER PRODUCTS-COMP/OP AGG S. Z,00000 POLICY ' MEE&I LOC. wIITOMO8ILE ual3lury 566624000Q2 1201/20I3 12/01/2014 ANY AUTO COMBINED SINGLE LIMIT $ 1,004 000, ALL OWNED AUTOS: - .. BDDILY IN lURY A ; X SCHEDULED AUTOS iPer Pe<sm) $, X HIREDAUTOS X NON-OWNEOAUTOS' BODILY INJURY 8 (Per acciderW GE ., PROPERTYDAMA (Per acddent) ' GARAGE LIABILITY. INC AUTO ONLY EA:ACCIDEM ANY,AUTO OTHER THAN EAACC S -. AUTO ONLY: _. ... . - AGO S Exc�ssrUAABRELLALIAfflUTY 4600058368 ;11/O1/2013 Il/aI/20.14 EACH,o000RRENcE s 1 000,0 X OCCUR CLAIMS MADE: AGGREGATE . . $ I1000, DEDUCTIBLE RETENTION _. S Wow COMPENSATION WCC5005 593012007 10 03/2014 10 ;03 2015 X AND EMPLOYERS'LIABILITY Y/N �. / /.. TORY LIMITS X ER _ ANY PROPRIETORIPARTNER/EXEC RICHARD TUPPER, IS EL EACH ACCIDEIJi 3 1,OOO,000 B OFfICER/MEMBER EXCLUDED? (IMaWatory in NIA), --�1 1- DED FOR.WC :COVERAGE U qeS dea"tto ialder, .tL DI§EASE-EA EMPLO $ I,000 s SPECIAL PROVISIONS below': EL DISEASE•POLICY LIMB S 1,000,OTHER; .. . _. r DESCRIPTION OF OPERATIONS!,LOCATIONS I VEMCLES 1 EXCLUSIONS'ADDEOBY ENDORSEMENT,SPECIAL PROVISIONS CERTIFICATE HOLDER._ CANCELLATION SHOULD ANY OF THE ABOVE oEsq"BED POUCI tS BE CANCELLEp BEFORE THE EXPUtATiON DATE THEREOF,THE ISSUING.INSURER YYIL6 ENDEAVOR TO MAIL s DAYS.WRR7EN NOTICE TO THE CERTIFICATE HOLDER NAMED"TO THE LEFT BUT#A1LURE TO DO 50 SFIACL TUPPER` CONSTRUCTION CO LLC IMPOSE NO OBLIGATIOIJ OR LIAB1LIi Y OF ANY iOND UPON`TNE IN$tIRER tiS AGEtd fS OR f 546 A:HIGGINS CROWELL ROAD - REPRESEHTATNES.._....,: s :WEST YARNlDUTH, MA:02673 : . AtmloR¢�u REPREsr�rrnTnr� Lora Lowe m?988.2009 ACORD C.ORPORATIOW All rights reserved. The AC,ORD name and logo are m is4ered marks of:AC.ORD: 1 VW� itTkR i' �7YiLo -3$ R'2 P5 S17A. Use �xt7J�'ti lYtsa a . T S s7T u., lia .v s2ae a sS,a'u v .L3iwfa At9Y'� �•_ 'is!}3f?'kf447oT-Ei.fii,11(41 �t1s ' .,�L�s`.Dt V�N WE 12.131120.1.4 'SU RFARi S CEPS at-Sealmns f --:e):pl u4'lt3 OA7te 1 3 I i�7P (PfAE77 Tttsh%!r>dlellt d..'j,�f'�F.-+SfSIT£l.�h�=; S' l Y@t[E'rOt'kSitVl(tt'!t!$C Qdk ?' < PCfst�a€ roastsnatri#asrs'&Bus,ncssRulafion befnrQ stzexps dale I€':ft>uad return bQ G-ME.9MPt2LA�lEM G01V i 1'S C R f3f#iee of C`t9 sa s ald$ts anes5 2 u: =sq : egistrauon: t78484: Tyoe- '�y � ION his-80-'SU xpfrattoa 4E tSf3�316' LLCts£ua�t; i�i a U24 . rL1PP=F2 GONSYRUCTtC3 li CHARD TOPPER Ws YARMOOTR 92.6 t lemQcret a ?!g arh0uts gaat�a f �. P�ptetp's�►g�eq;�$�i#�:a.Sa�er 41Uosld!"` _;�. ._.—...�.-�. 17!!ti i�31lit MEMBER �q Rictra€d Tuer j j upper C,6ns€ru esri Sufidin9-Saisty Frotess�onaf.; p Me,MbOrt 81581." x 4130f2.41 , t L s a OWNER AUTHORIZATION FORM (Owner's Name) owner of the property:located at r (Property Address) Crow T, Z.6 3- (-Pro erty.Address) /T hereby authorize 1' V , (Subc .t -Vr). .an authorized subcontractor for IRI.:SE Engineering, to}apt.on my behalf to:obtain a building permit.and:to perform work on my property. "X Owner's Signatur -IbAh- 15ate OF1HE r 'own of Barnstable Permit jb(& ti�P� ti� Expires 6 nroirtl j om issue.date Regulatory Services Fee BARN 'BLE 71 p� 9qj 1639 ,�0' P.SS Pena Thomas F. Geiler, Director SEA . Building Division 2009 Tom Perry,CBO, Building Commissioner $ �� To. / ..\OF 200 Main Street, Hyannis, MA 02601 �� �/-�QLE www.town.barnstable.ma.us Office: 508-862-4038 . Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press fnrprint Map/parcel Number Property Address ,6-- _ z9_ — �i/ i ���'-7-Li 1r% Residential Value of'vVork � -,5:, Minimum fee of$2S.00 for work under$6000.00 C)wncr's Name & Address 4r ,n Contractor's Name6�� �� ,</ Telephone Number I lome Improvement Contractor License#(if applicable) or ?G' �w�Ts Construction Supervisor's License# (if applicable) 5 Y [MWorkmah's Compensation Insurance Check one: ❑,I am a sole proprietor ❑ 1 am the Homeowner I have Worker's Compensation Insurance .Insurance Company Name (�/'l ;�/ L� 5 �j`I- T �� Ty �. Workman's.Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) - Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (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. A copy of the Home Improvement Contractors License is required. PI-ILLSTI)RMS\huilding permit forms\EXPRESS.doc Revised 100608 Fo Rfi. So '. ROOFING. T V P. • c • • - . Contract Number: 10676 Name: Sara Gardner Date:Sep 28,2609 Address: :15 Eaton Curt Phone: 617-529 6807 City: Cotuit State: MA Zip Code: ----- Fax: ------------ email: ---------------- AND CONTRACTOR:F.R.S.ROOFING AND GUTTER SERVICES 4 WQRWAWT�� - GENERAL INFORMATION: 1.Roofing Services to be Started on: Upon phone call back. 2.TOP-PRO Roofing materials and supply are to be used for this work. ROOFING SPECIFICATIONS: Contractor shall work on following areas of the house.On the entire roofing shingles of the house. Remove all layers of shingles on the entire house down to the roof sheathing,Any roof sheathing that may need to be replacement will provide&installed 100 sq ftof board that is rotted,if extensive replacement is needed I'll charge$70.00 per sheet 4'x8'plywood. Provided&install new vent pipe flag boots where applicable.to be properly flashing in with new roof system&use of ice water shield. Provided and install 6'feet of ice water shield on bottom,and 3'feet of ice water shield on valley,and paper for other surfaces. Provided and install 8"white D style aluminum'drip edges along all bottom roof edges horizontally&vertical edges where applicable. Provided and install new shingles style is Architectural Tamko 30 years with the color will�be choose by the-owner. Provided&install a GAF Cobra Roll ridge vent system on peak of the dormers.To include providing sheathing cut out at peak as to related to the installation of this ridge vent system.Provided and install chimney flashing&ice water shield around it. Dispose old shingles debris properly,dumpster will be rented by Frs Roofing And Gutter Services. Protect the house and plants with taps clean and remove all debris when finished. If needed new lead flashing will provide and install new lead flash ing,against at the chimney,to include saw Al cutting into joints of brick wall as related to installation of new lead flashing. Also all shingles to be extra nailed with roofing Gun nail. Provided and install new step flashing with ice water shield around the dormers wall as well. All material,labor,Roof permit and insured&necessary equipment will be provide by FRS Roofing And Gutter Services. 1.Work shall be performed within 4 Days and scheduled according to Homeowner's convenience. 2.Contractor shall furnish qualified supervision to oversee all work. 3.All personnel shall conduct their work in a professional manner,with minimal disturbance to client and neighbors. 4.No personnel shall discard refuse on site. NOTES: 1.The Contractor shall perform all work specified in this contract for the total amout of: $8,100.00 2.Payment shall be made in two installments(33%upon starting date,and balance upon completion of the work). M. LA ME WE '. Contractor shall guarantee workmanship for Ten(10)years,while the shingles have 30 years manufactory warranty. ={ NOT C a-Home owners have three-day cancellation rights under MGL c 93 s 48;MGL:c 1400 s 10 or MGL c 255D s 14 as may be applicable. b-All warranties on the Owner's rights under the provisions of 780 CMR R6 and MGL c 142A c-it shall be the Contractor's obligation to obtain any and all necessary construction related permits as the Owner's agent. d-Owner's who secure their own construction-related permits or deal unregistered contractos shall be excluded from access to the Guarantee Fund. This agreement constitutes the full understanding of the parties,and no oral representations or prior written representations made by either party shall be binding.This agreement shall be modified only in writing signed by both parties.Also this agreement is binding with the signing of bothparties,who represent to each other that they have the authority and ability to comply its provisions. " The Contractor and the Homeowner here by mutually agree in advance that in the event that the Contractor has a dispute concerning this contract,the Contractor may submit such dispute to a private arbitration service with has been approved by the Office of Consumer Affairs and Business Regulation and the Consumer shall be required to submit to a such arbitration as provided in MGL c 142A. Signature of Client a Dater Sep 28,2009 Sara Gardner Signature of Contractor: t Dater Sep 28,2009 a io : �;tIva F.R.S.Roofing&Gutter Services Owner URL: www.frsroofingandgutterservices.com U email: admin@frsroofingandgutterservices.com i Q` 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 LeLribly Name(Business/Organization/Individual): �_� �(��/�/�-. _vs/� �GT 6`�� ��`�.°� f Address: 6 City/State/Zip: ,t4sr lid , Are you an employer? Check the appropriate bog: Type of project(required): 1.® I am a employer with .4. ❑ I am a general contractor and I employees(full and/or part-time).** have hired the shb-contractors 6. ❑New construction .2.El am a sole proprietor or partner-' listed on the attached sheet. 7.. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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. xContractors that check this box must attached an additional sheet showing the name of the subcontractors 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: �/2�/I�;i% ��_�,�i� c%-r�W>D� ��.—L tz!f Policy#or Self-ins.Lie.M IZV(f— • 06-11`1a5 --Do� Expiration Date: Job Site Address: e 4-ZT© City/State/Zip: �jT t/ !P'1__ 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 pains and penalties of perjury that the information provided above is true and correct Signature� v��� 0'L---- 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 Insttuctions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in.the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal 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-contiactor(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 required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials f 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. 11 addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtainer 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia Board of Bu .ding.ilRegulat�ons'and Standards License or registration valid.for mdividul use only.,.,. HOME IMPROVEMENT CONTRACTOR before the expiration date.. if found return to: � Registration 141285 l'' Board of Building Regulations and Standards- ` One Ashburton Place Rm 1301 i s Expiration. 4/16/2010 Tr# 26513u x Boston,Ma.02108 Vt, Type DBA FRS ROOFING&GUTTER SERVICES . FABIO DA'SILVAr , 53•MEDFORD ST '� ,� ; MALDEN MA 02148 Admm►strafor Y Not valid without signature ill tssachusetts - Dcp ll-trttcnt of Public Sattt'j Board bl'Buildin�� Construction.Su-Supervisor sor eu �S t ecialtns td Standards p Specialty License License:,CS SL- 99363 Restricted to: RF FABIO D A'S LVA 53 MEDFORD STREET EE r 02 MALDEN, MA 02148 Expiration: 8/12/201, ��` ('onin�issiuncr - -- _— Tr#: 99363 I GRANITE STATE INSURANCE COMPANY 0074530-00 WC 005-09-2883 ----- - --------- -------------------- ----- ----- 13102 013-66-o6o9-oo FABIO ROMULO SILVA 53 MEDFORD ST APT. 02 MALDEN, MA 02i48-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 I.D# MA U#• •" • "•- AMAZONIA INSURANCE AGENCY WORKERS COMPENSATION AND EMPLOYERS 66 BOW ST LIABILITY POLICY INFORMATION PAGE SOMERVILLE, MA 02143-2910 INSURED IS PREVIOUS POLICY NUMBER INDIVIDUAL RENEWAL oo7429237 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATIO C990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's mailing address FROM 06/22/09 06/22/10 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers ompensation La of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ W0,000 policy limit Bodily Injury by Disease $ 500.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC2003o6A D. This policy includes these SEE EXTENSION OF ITEM 3.13. OF THE INFORMATION PAGE - WC990612 ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. Ali information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Classifications Code Number Remuneration $100 OF Re- Premium MV LAJ Annual El Year muneration ®Annual 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754. TAXES/ASSESSMENTS/SURCHARGES $550 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $338 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $9, 1 7 3 If indicated below, interim adjustments of premium shall be made: Semi-Annually Quarterly Monthly DEPOSIT PREMIUM I i f o6/22/09 ASSIGNED RISK 66 1-61.na,n Issuing Office Authorized Representative wC 00 00 01 Assessor's offioe'-(1st floor): ' / �'/ rf /\�.!{ " pFTHETO Assessor's map-and lot number ..... T.............. ..Board of Health (3rd floor): , ��3� Sewage Permit number SEPTIC SYSTkM MUST 02 B6S39TODLE, i Engineering' Department (3rd floor) • Jr— K� h STALLED IN COMPLIANC 'w r ABL 'House number 3e• :.... WITH TITLE 5 '°,�a NO " �IRC� �E�TA L CODE AV OAPPLICATIONS PROCESSED 8:30 9:30 A.M.''and 1:00-2:00- P.M.,onlY TOWN REGULATIONS h TOWN 'OF. BARNSTABLE BURDINS INSPECTOR APPLICATION FOR PERMIT TO ..:... r`'`?�4.�i.......C�. :�.. ..... f .�`.!.:.`.p. ..... w TYPE OFF CONSTRUCTION ..::... (� ................................. ..i ........... ...... . ........................19...- ... TO THE INSPECTOR OF BUILDINGS: " The undersigned hereby applies for a permit according to the following information: Location .....Gv`.... .:5 /u' z�1� �.°'� O'�1......w:`'" ' /� `7�(,l ��...... .... 1.._.i.. 77 .... Proposed Use ' ................................. .... ..... . 1 • Zoning District ..... ..................... ...!:�..............................,..:...........Fire District" ........ Name of Owner .........-S.G...`?!'?..../*...!5. �.:.......:.........Address ...��..��.G .../l�d.l?.....1 '.!....0� c�lr/ia�C �j�• , . -5 �.,�'{> Address S 9 { Name of Builder ..................._......................... ................... ....:....................................................................:.......... ' Nameof Architect ........................................ ........................Address .........................................................................'........... 4 - Number of Rooms .6 `�'2 / ... Foundation C lv.�G GTe Exterior ........�.r. ���'v S y,n .:. Roofing X51,91 ��s ". .... . /............ oofi n ..... ...... .... L Floors" e..w�aC. ..........Interior ........S......�e.c ......... ' Heating /.:f..`7.:c ......... �.......G.. [ ................... . .Plumbing .. . ...1.. ............ '............ . r ....... Fireplace �l9SGr/. .�. .......................Approximate Cost .... 1/O� �yl>C� p Definitive Plan Approved by /Planning Board as_19.7__ . - Area �P. SG', v Diagram of,Lot and Building with Dimensions • Fee .....1..`-'..r........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH 3 OCCUPANCY PERMITS REQUIRED'FOR NEW DWELLINGS . I hereby agree to conform to all the Rules and Regulations of the Town'of Barnstable regar g the above" construction. Name . ................ ' ® � aConstruction Supervisor's License ... ..... _YIcSHANE, JOHiJ _i No 312.97 11 Stor Permit for ....a.............Y............... Single Family Dwellin y-------- - cr Location .....Lot...#58.........15... a4.Ox1..�O.L1Xt :... ................................................ t' Owner ....John h�cShaYle......... - -- :: Type of Construction ............::........... ,..1.. .. ............................................... 1 Plot ......... .."............ Lot ... p ` . October 14 , 87 Permit Granted ........................................19 -Date of Inspection ....//..............QQ... ...:........19 ` Date Completed ....4r.7 �79.`...........19 ' d Assessor's offioe (1st floor): - / - `T Eton Assessor's map and lot number .... .............../............. Board of Health (3rd floor): 34 �� � �Q o d � Sewage Permit number ....,...... ...............`...................�.:.K.. Z MUMBLE. S Engineering Department (3rd floor): . .� 'oo "639. 0� House number �`� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN . OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...... 1.`? .� ... ......�..........7' . kl .f./'.. .................................................. TYPE OF CONSTRUCTION .........�'��?.�?r�....l..`., ,•1 c........................................................................................ .........................•-------. ........ ----19........ TO THE INSPECTOR.OF BUILDINGS: The undersigned hereby applies for fa permit according to the following information: L Location �,f � S� (U7'✓. T &r.� ,S'�o,Ies. �%�7`Un �C> .rQ7 �......................... ............................ ........... ................................................................... Proposed Use ....SJ.U��f..... E{.s''l ....�1!.wC�.. ......................................................................................................... ZoningDistrict ........................................................................Fire District .............................................................................. o.�........JGIe 514•o.1e // cC fb`iCT c� f5 c!l�/i Name of Owner .............................Address ........ ...... ................. .. .............:.............;...Gl�!/� ... -5 Nameof Builder ..................Address .................................................................................... Nameof Architect ..................................................................Address .........................................................../.......................... Number of Rooms :..............�?...............................................Foundation .....f a."/!ew f............................... . ............................... Exterior ....... �.9pwn ra(�.%��.'.'� ./�.............................Roofing ...........I.....j'.i°%.5.................. .......................... Floors Am41C.0d Interior .......:54 e 1 le"I/ ........................................................................ .......................................................................... Heating 7 • '...../"..........................................r..............................Plumbing .............. �............................... ........................... Fireplace / �SGrf {�+j/..............................................Approximate Cost . o Uv Definitive Plan Approved by Planning Board _-----ld-----'----,-a-`-- -19_ `3. Area ......................................... Diagram of Lot and Building with Dimensions "�^ � � '� Fee ............................................. l SUBJECT TO APPROVAL OF BOARD OF HEALTH 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 ............:f................. .. :".................................... Construction Supervisor's License ... r McSHANE, jOHN A=55-14 i No 31297 1 Permit for ... .. Stork + ......in le Family Dwelling Location .i.......1...5.. Cotuit .....................................................................I......... Owner .John... cShane Type of Construction .Frame............................ I ............................................................................... j Plot ............................ Lot ................................ E Permit Granted ......October 14, 19 87 , t Date of Inspection ....................................19 Date Completed ......................................19 f f— *INV TOWN OF BARNSTABLE .Permit No. 31297.... L BUILDING DEPARTMENT I ,Aurr I Cash ...... f... TOWN OFFICE BUILDING HYANNIS,MASS.02601 Bond .... I CERTIFICATE OF USE AND OCCUPANCY Issued to John McShane Address Lot #58, 15 Eaton Court Cotuit, Mass. 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. 4 June 8, �89 ...... ................. . 19................. .................. ..................... Build' g Inspector TOWN OF BARNSTABLE BUILDING DEPARTMENT i Ssaaar TOWN OFFICE BUILDING rua t639' HYANNIS, MASS. 02601 �o r�r a• MEMO TO: Town Clerk FROM: Building Department (� r DATE: ' h ^L An Occupancy Permit has been issued for the building authorized by BuildingPermit #. n 1............... .........................................................................................................._...... ........ ............ `', issued to ............ ��. ..1.......,� ... „(,,, ..................... _. _.. _.... Please release the performance bond. THE FOLLOWING IS/ARE THE BEST ' IMAGES FROM POOR QUALITY ORIGINALS) I M ^ � DATA �fTOWN OF BARNSTABLE, MASSACHUSETTS BU' DINGPERi�1�IT� A=55 14 , i ..•. � I DATE'��.-t'nbpr � 47 19 "�7 .PERMIT 1}-r1 F APPLICANT - a-o} 6.fa' � ADDRESS_ T, TAT?f'lf ynR Road -`.� �'► 46e. IN0 1 (STREET) CO NSE),,, PERMIY TO-- Rli i is: f7i p114�riCy--:( 1 STORY ''NUMBER-'�OF (TYPE OF iMPROVEMENTF. NO WE UNITS�� } .. (P.ROP.OSED E1 ZON6NG AT I LOCAT I ON 1 Z. y NO ) ST 9T ---�A'� - DISTp'j�T + BETWEEN AND ..i .... (CROSS STRE ETI, .. .. -_... '..,. ...(CROSS :ST REET) .._ i.:. SUBDIVISION ~ 'LOT BLOCK SE'. BUILDING IS TO BE F.T. WIDE BY' FT, LONG BY FT,;I,N HEIGHT. AND SHALL CONFORMAIN CONSTRU�TIONt r- TO TYPE USE GROUP BASEMENT WALLS OR. FOUNDATION REMARKS: �.Q(�wagp— 4A7-345 ... - AREA ORf'1M PERMITI r! r VOLUMEc;(.' . ffrVVO• FEE � t t�31•J ---- • • ESTIMATED COST IC JC/SQUARE FEET) OWNER �5hane —_1`1 ATe��+lr BUILD'.ING DEPY ADDRESS P c�x��,Ftr1a �b���— , dui eY 3 n f ; r. i4. r. '.... - s. tr^ tt l t I Z a t 4 t F APPLICABLE SUBDIVISION RESTRICTIONS r OF THREE CALL APPROVED 'LANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE ONS REQUIRED FOR STRUCTION WORK: CARD KEPT PT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING AND ATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. TO COVERING STRUCTURAL QUIRED,SUC.ti BUILDING SHALL NOT BE OCCUPIED UNTIL RS(READY TO LATH)EFORE FINAL INSPECTION HAS BEEN MADE. INSPECTION BEFOREANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS 'PI U BI _ 1 1 k 2 T (� 2 ` tl I., ckayvll� HEATING INSPECTION APPROVALS , �t nv-utrHn I MtN l ' 1 � OTHER - BOARD OF HEALTH { t WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT '+(!L L BECOME NULL AND VOID I F CONSTRUCT ION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS 140T STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. PERMIT ISSUED AS NOTED ABOVE. NOTIFICATION. i dt ` C0T Urr BAY DR A-2so.oo E ho. q��so.oo ' T 1 0) ACRES 44.1a u EXIBTiN c FOUNO�T'lONr � C ' w" Q t .. �.e 62PLOT PLAN OF LAND A TO THE BEST OF MY KNOML EDGE, THE FOUNDA TION L OCA TED ;IN SHOW ON THIS PLAN IS AS IT.ACTUALLY.EXISTS O� �h ,, �A IgNS TA E�L E /V A�j S, THE GROUND. of �;q�' PREPARED FOR DA TE.• SEPT.24, 19®7 k ='DAViD �` ' :CNARLES ' «,1 • Mc SHA NE CONS TRUC T.I'QN [c i DA TE. SEPT.24 , 1987 SCALE.• S 60 F CAPE 6 ISLANDS SURVEYING, FLOOD ZONE C (NON—HAZARDI ��J�� i AW TEA TICKET .— MASS. �4, SYSTEM PROFILE NOT TO SCALE TOP FDN. FINISH GRADE -� FINISH GRADE OVER EL • 4�• :o::.eo:.,. FINISH GRADE OVER DIST. BOX 4`J. Z FINISH GRADE OVER ::�.;►.'o°•; SEPTIC TAW ,- 2 LEACHING PIT Z ° VARIES p..•.d •. :'y�::o d o' ° °o.'e:t Q:e 'e '°.e:�,o;�'n:�;'o•:o.�. . a:e�•�.:e�' e',d°'eke: °o — 12" MAX 3" OF 1/B" J/2" ASHED PEA STONE PRECAST CONC. OR 3„ • BRICK 6 MORTAR OUTLET PIPE LEVEL TO 12" BEL ON GRADE D:o.'• 0 4 FOR 2 FT. MIN. °�•'4:�s, d' O :s•oe;•:o:oe�o:o:p: •q• •°•••a' °'•°'••o.: •e o "T•� � l t "G:::!,:..i..'a•.i •O•'p;.Q.- 'V: .a "C' Q'e O ;0'D 0 0. p'. C. I. OR PVC TEES .o, .p .e• , p..p. •.e 4 f.� 1 BSMT. FLR. - 1000 GALLON DISTRIBUTION BOX EL . 56- JO ° o oe ,. PRECAST CONCRETE o INSTALL ON LEVEL BASE 3/4" TO J—J/2" 6 PRECAST 4 ?� WASHED :o .a H— l 0 REINFORCED CONCRETE 0 o CRUSHED e o. .o. o- ..o ..o:b:: e• b:o;. e::• ' STONE o e•.4... o-:o,• o p•:o:o p'. e' •d. 'o.' e:o'.'o: .C:;o.•o• o..o.°?.o:o p••o,•o•o:.•e•••q•.e.o:•,o,o o•:oo•.• ;e:. o;.•o•o.•°: ; :� .e H— I 0 REINF. SEPTIC TANK INSTALL ON LEVEL BASE NOTE.• EXCAVATE TO ELEV. 32.8'm OR ° ° ° ° � � ° ° o:a 0. : : . . .. v� �•. '�---- -�.w.�,�___ ,`._-._,__ ._.---�' LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEA TH THE L EA CHING AREA 2 '-0 2 '-0 u REPLACE EXCA VA TED MA TERIAL WI TH 5 '—0 " CL EAN. CL A Y FREE SANG , EFFECTI VE DIAMETER °` , _ . .- _ � �• . e- - ``, . - GENERAL NOTES LEACHING PIT 1000 GALLON _ �`_ INSTALL ON LEVEL BASE PRECAST CONCRETEi-� '� 1. ALL ELEVATIONS SHOWN ARE BASED ON ASSUMED SEPTIC TANK 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON` � .4- - • ' OR SCHEDULE 40 PVC. ®®SER VA TION PIT 3. THE BOARD OF HEAL TH MUST BE NOTIFIED q 2 ' WHEN CONSTRUCTION IS COMPLETE PRIOR WA L TER P. OLOHAM TO BA CKFIL L ING PERCOL A TION RA TE.• 44 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED 2 MIN./IN. _ WI TNESSED B Y.- BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS PRECAST CONCRETE SURVEYING CO. , INC. V �' R. GIFFORD 1 LEACHING PIT _J `` ,, l� a , � '• \ MATERIALS AND INSTALLATION SHALL BE IN j c d BARNS TABL E&RD. OF HEALTH i COMPLIANCE WITH THE STATE SANITARY — DESIGN DA TA DA TE.' OC T_ 8. 198- .,• _� �� �±i , 4` CODE — TITLE V — AND LOCAL APPL ICABL E o . �, c RULES AND REGULATIONS 6. NORTH ARROW IS FROM RECORD PLANS AND 0 �'7* 1 t=L_4 Z.3 Z �L L.43. NUMBER OF BEDROOMS 3 t / 2 `r D _�_� : IS NOT TO BE USED FOR SOLAR PURPOSES GA RBA GE DISPOSAL NO 7. FLOOD HA ZARD ZONE C TOPSOIL 6 DA I L Y FLOW 330 GA L . u N 8. WA TER SUPPL Y TOWN WA TER SUBSOIL 16" SEPTIC TANK REO 'D. 1000 GAL . SEPTIC TANK PROVIDED 1000 GAL . L EA CHING PEGUIRED 330 GPD. 4, MEDIUM SAND SMALL STONE SIDEWAL L AREA 188 S. F. l9 1� 188S. F. X 2. 5G/S. F. = 471GPD BOTTOM AREA = 79 S. F. 4C�, FT LEGEND 79 S. F. X 1 . 0 G/S. F. = 5 9 GPD 4 4 LEACHING PROVIDED GPO i PROPOSED EL EVA TION 168" NO GROUNDWA TER # Z L_ ? •� l --4 0 -- EXISTING CONTOUR SINGLE FAMIL Y RESIDENCE OBSER VA TION PIT ❑ DISTRIBUTION BOX , t ; / RICHARD PROPOSED SEWAGE DISPOSAL SYSTEM i t 0 LEACHING PIT No. i PREPARED FOR " J c o SEPTIC TANK , Mc SHA NEE' CONS TRUC TION / l R P I RESERVE ya4 w^ LOT 58 EA TON COUP T -` CO TUI T - BA PNS TA BL E - MASS. DAB,,: PIPE INVERT ELEVA TION CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN SCALE AS NOTED P. O. BOX 334 SCALE.• J "= ?,J 42__ _ ... . I �+ 5E15 r r^ 4�3 A 4 MAP SEC PCL LOT HSE :" PLAN NO. S a�'(37 TEA TICKET, MASS. �, +� ,� �