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4395 FALMOUTH ROAD/RTE 28
;� �� �I Town of Barnstable Building • 1POst This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and;this Card Must be Kept snxvsrnet t; $ ¢Posted Until Fin Hasa Made.. �o read Where a Certificate of O' cupancy.is Required,such Building shall Not be Occ t6Sp p�0 i upied,until a Final inspection has been made Permit Permit NO. B-20-1689 Applicant Name: JEFFREY STEELE Approvals Date Issued: 07/02/2020 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 01/02/2021 Foundation: Location: 4395 FALMOUTH ROAD/RTE 28,COTUIT Map/Lot: 024-062 Zoning District: RIF Sheathing: Owner on Record: DUARTE, DONALD 1&DEBORAH 7-Contractor Na'm�e'-,sL&P Boston Operating Inc Framing: 1 Address: PO BOX 1953 - Contractor license F°197574 2 t COTUIT, MA 02635 .. s Est. Project Cost: $7,492.00 Chimney: Description: INSTALL( 11) REPLACEMENT WINDOWS N.O STRUCTURAL Permit Fee: $38.21 Insulation: Project Review Req: Fee Paid: $38.21 I Date 7/2/2020 Final: , i ' . Plumbing/Gas Rough Plumbing: - g g: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. -All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly'visible from access street or road and shall be maintained open for public inspection for the entire duration of.the s work until the completion of the same. ' Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:; Service: s• 1.Foundation or Footing 7 Rough: - 2.Sheathing Inspection ��- 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring'&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy _ Low Voltage Final: , Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health, Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in NIGL c.142A). Fire Department .Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT" �,,� Final: �a'"*'�( �r ' '" f�f)��✓�'��'` `r��i(fi�r��y': . +i"`��`" �±�' '�I' °3r�+���5r, 'fl4�`r`t+^-r'-,•.P' 4. p*THE TOWN OF BARNSTABLE .Permit No.30003 BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash ° "° X r> �tar►r' HYANNIS.MASS.02601 Bond ............... CERTIFICATE OF USE AND OCCUPANCY Issued to Cedar Acres Realty Trust Address Lot #4, 4 5, 4395 Route 28 Cotuit, Massachusetts 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. November 21, 19 89 .......................... �:............. Building/Inspector 1 TOWN OF BARNSTABLE _ BUILDING DEPARTMENT _ NA MIT TOWN OFFICE BUILDING rut g i039 � HYANNIS, MASS. 02601 !' �0 MAR� f MEMO TO: Town Clerk FROM: Building Department DATE: oZ 7— An Occupancy Permit has been`issued ;f r the building authorized by BuildingPermit #.. ......,—q 00C .._ ... ......... .............................»....................... issued to .... / ,� ... / %1 / _.�... ... _. . ..». »._.. Please release the performance bond. %f1S-,rEBYCERr1FY THAT 1n15 GOT 15 NOr-1.00ATEO /N FEk.:RA1, F-OOP HA,ZARR ZONE "AS 3110WN ON THE FEOE'FiRAL F(,00P INSURANCE RATE MAP FOR THE TOWN OF COMMUNITY PANEl, NO, EFFECTIVE DATE ROBERT E. RAYMONO, fF I,.S 0,477E NOTE: NORTH ARROW NOT TO BE USED FOR 604,49 PURPOSES. � y LINE BEARING DISTANCE 1 S 55'55'46"W 13.98 2- N 34'04' 14"W 2.00 3: n 3 S 34'04' 14"E 2.00 >� R1 4 S 34'04' 14"E 4.00 O 5 N 55'55'46"E 4.50 y 6 N.34'04' 14"W 4.00 a a y � ft, oC 194.99 I 54. 11 pl pCcn I � I �3•o(o rL5 O --- - -- 44.20 O /_ 5.34 A C-x 1.ST1"6- A O � < D 0 O N �C)�L7�li OI��II L 3 r 29.65 r 20l 35 _._---- - -- - - - - - O ttz O i � a I 0) 195.44 54.56Qi F-ALMC)UTH T2 04-�7 CIO n n mop THIS /0/,0T P1,A-N WAS /11AOE rA:'Oh1 FOUNDATION LOCATION PLAN AN INSTRUMENT SURVEY ANO IS FOR THE USE OF THE BANK ONLY. UNDER NO CIRCUMSTANCES ARE OFFSETS TO BE UAU-'1 O U H 20A0 USED FOR FENCES, WALLS, HEOGES, Erc, O`YNEO BY: R RT E. sa�y�' •4iPi?0kY ENGINEERING INC. o�3 60 EAST' FALMOUTH HIGHWAY _� RAYNJOND EAST FALMOUTH, MA. 02536 No.21583Co, 9FursTE2``;,�� SCALE: DATE! SHEEoT AR,,4WN QY: 011ECKEOBY APPP BY., PkAN NO. 43 Assessor's map and lot number .•. . _2 r a K EPTIC SYSTEM MUST BE CF THE. a C_ e Taw STALLED IN COMPLIANC P� Sewage Permit number ...... ....'.. ........... .......... d WITH TITLE 5 4�39s...�' .....'.................... VIRONMENTAL CODE A :B�AO&LE. I House number TOWN REG�, ATIONS ' o�ac'a�e0� TOWN OF. ,BARNSTABLE BUILDING.,. INSPECTOR APPLICATION FOR PERMIT TO ........................ �.?W.Ycy�__ ......... ..... ..... r TYPE OF CONSTRUCTION ........................4 .... ..........�.......... .. ... x ....... ....................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location / e ..................... AProposed Use .. .Y .. ......................................e.............................................. G Zoning District ............. ...................................................dire District .............Ia. Name of Owner ... . . 4v. 4..... .Address v ' ............................ Name of Builder .�'�t��G��:C.%"`.:.........Address .........��. {�%'��`�,.l��r� d............... ............................ Nameof Architect ......................``...........................................Address ...........................................//........................................ Number of Rooms .....................K�.........................................Foundation .... .....e . .......................... Exterior .... .� ...C. ...... ..... .......Roofing ...... . Floors ................................... ........ &... ...........+ ......Plumbing ................................................ Fireplace ....................... ......................................................Approximate. Cost ....... ............... Definitive Plan Approved by Planning Board ___• (4____________________19 Area ./.... 1 _ ... ......... .......... Diagram of Lot and Building with Dimensions- Fee ,t....... SUjj6ECT TO APPROVAL OF BOARD OF HEALTH i ?off 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 ..!�/.1�r� ....... ,C-* CEDAR ACRES REALTY TRUST ar jN?�...30003... Permit for .....Que..S.tcLry............ ............. �j4 rWW 7, Location ..... ......4.�.95 e_q2 Cotuit ............................................................................... Cedar Acres Owner ...... �-.ty ............................... . ...Tx.us 1:...... " Type of Construction ...FKaine............................... ................................................................................. Plot ............................ Lot ................................ October 2, Permit Granted .....................................19 86 Date'of-I'nspectionO— ........19 IC ............. 19 DateImpleted ..//:� o BY CERTIFY THA' 1n/5 407 IS NOT LOCATE /N FEk.IfAl, F,LOOP HA,ZARP ,LONE i SHOWN ON THE FEOERA4 F,L000 /NSURANOE RATE MAP FOR THE TOWN OF .- COMMUNITY PANE, NO, EFFECT/YE OATE' ROBERT E. RAYMO/VP, fR L.15: PATE NOTE: NORTH ARROW NOT TO y BE!/SEp FOR S04149 PURPOSES. > y m LINE BEARING DISTANCE y 1 S 55'55'46"W 13.98 Q 2 N 34'04' 14"W 2.00 3 S 34'04' 14"E 2.00 4 S 34*04' 14"E 4.00 O 5 N 55'55'46"E •4.50 �l 6 N 34'04' 14"W 4.00 , \ � o � oC 194.99 I 54. 11 ©-- � a°' O L ' 4 � r cco i y 13.o(, L5 C y r - - N n VJ Q N- -- -- 34 p - 44.20 6. Pi O 0 o Ex.sTle-1 o I A �I O N �Jt�lOL41 IO��A. 1 o D nl Q) p LS 2 35 ------ - - - - - - - r 29.65 r ti-) o IId r 195.44 54.56 Q 1. 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(3rd floor) House# ' BARNSTABLE, MASS.19 .. � peso• .�, a. �EOMIdp j TOWN OF BARNSTABLE Building Per Qmit Application Pr ' reet Address 3�? ri411-neV t f1� J�� �t�:.�,� Dera,67S Village Ownerc�SZ.cQ ? y� Address Telephone Permit Request �'L / First Floor 2, a o square feet u�. -� j Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family 1.,� Two Family Multi-Family r Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name D-e6A/ F( S—Gq Telephone Number -2)c o� Address '1 ( T&rZ d S671 C(R License# 0-55�6 6 3 CC) ag�s_ Home Improvement Contractor# /25-3 G Worker's Compensation# 4&0— /3/a ys a o�y NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE S'G BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) r 3 . FOR OFFICIAL USE ONLY f 4 P PER M N s� DATE. S D ADDRESS VILLAGE ' OWN k DATE F I SPECTION: FOUN,ATION _ t FRAME INSULATION ' FIREPLACE ' ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH -FINAL GAS: ROUGH FINAL FINAL BUILDING F k DATE CLOSED OUT .. ASSOCIATION PLAN NO. 4 ` � i k 1 y ; f 1 k , • { i i • 1 k � � i i i � � t E r � � � i i j r ?-L3-17 Town of Barnstable "Per ' -J o7 - � Expires 6 ont/rs rom issrr date Regulatory Services Fee nnaxsTnsM 9 MASS $ Richard V.Scali,Interim Director 039• �0 prEb MA't A Building Division - Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 - - EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 6 6 Z // y Property`Address 1 55 /u, 7 XResidential Value of Work$ , S 7 7— Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �P d r-a �Dj a r 1 r Contractor's Named P OT Mal , In duets Telephone Number l*7/y`d 3I If Home Improvement Contractor License#(if applicable) !-/_2—78 S__ Email: Construction Supervisor's License#(if applicable) XWQrk&n's Compensation Insurance ® ' �} Check one: • � ❑ I am a sole proprietor J ❑ d I am the Homeowner L'l 12 2017 I have Worker's Compensation Insurance 0 Insurance Company Name / ITT Z1 L J /V D AJ S Workman's Comp.Policy# S� Copy of Insurance Compliance Certificate must accompany each permit. Perini t(check box) e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to -)S4—MAW, e-r L r 'cane nailed)(not stripping. Going over existing layers of roof) -' Re-side ❑ Re ent Windows/doors/sliders.U-Value (maximum 35)#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: P ope caner must sign Property Owner Letter of Permission. o y f the Home Improvement.Contractors License&Construction Supervisors License is . it SIGNATURE: Lie Revised 0613,13 wilding pe f XPRES Revised 061313 ! 7 Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg.#126893 Salesperson Name and Registration Number: Christopher G. Read : R-1-073-13-00024 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: Deborah Duarte Boston North EO:61850 First Name Last Name Branch Name Lead 4395 Falmouth Rd TOTUIT MA 02635 Customer Address City State Zip F(508) 420-1279 Home Phone 1 Work Phoned Cell Phone debdewey51 @yahoo.com Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE.IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN.SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGH CANCEL. Acknow edg by: ' X �. 06/06/2017 Customer's Signature Date i 1 'U assachljsetis Deftment.o "PUbf c 5aet) L'ceseS "low r ; f 3 $ c The Commonwealth of Massachusetts W Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 �,M ,�•'�� www.mass.gov/dia «'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1424LL f? Address: a*(6 City/State/Zip: 1AAp Phone #: g-) Are you an employer?Check the appropriate box: Type of project(required): 1:❑I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.�I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling an capacity. 5 y p ty. [No workers'comp. insurance required.] 3.❑I am a homeowner doing all work myself. (No workers'comp. insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.e I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑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.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of tie 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.#: 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 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 a1-1 gainst the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c nder the pains and penalties of perjury that the information provided above is true and correct. JSignature: Date: L 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 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, S25C(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 required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple 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 obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia r ,: f'f -_ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22/2019 2455 PACES FERRY RD C-11 HSC ATLANTA,GA 30339 - Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑Employment ❑ Lost Card .. i`r.iN7,r.1r.7:.'r"a!d r:�;-•.('(ic;JrYc's;/,'JC��] - ___ office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only -�``=c' TYPE:SuoDlement Card before the expiration date. If found return to: -i.- Reoistration Expiration , Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 OWE DEPOT USA INC Boston,MA 02116 ANDREW SWEET 2455 PACES FERRY RD C-11 HSC ithout signature ATLANTA,GA 30339 Undersecretary S 3 ` The Commonwealth of Massachusetts = Department of Industrial Accidents 0 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name (Business/Organization/Individual): Th2 -tot"le 1 cM A =N nJVI��q/;LPS Address: G 0 u c�-�n �'� K City/State/Zip: Sbfy,wM 1S45 Phone#: (So8� 9 Lf 2- (o6j 4 2 Are you an employer?Check the appropriate box: Type of project(required): LdI am a employer with pit employees(full and/or part-time).* 7. EJ New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition J-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� p Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14;ZOtherC /6//JGo 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. �- 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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: k61-11vha l UniOn Elrio T-65tsC46c-Q Co. Policy#or Self-ins.Lic.#:_)(k[C 6 5ig�,�1 4 I� Expiration Date: Job Site Address: y 3 g S %G lmy t„Gl, �� City/State/Zip: OTu t f 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 opy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificati I do hereby certify u e the pains and pen rjury that the information provided above is true and correct. Signature: Date: Phone#: r: -9 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#: AcoK ® CERTIFICATE OF LIABILITY INSURANCE poi�aa�ii 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 terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CONTACT PRODUCER MAIM a LiSA,INC. PHONE Na ?WO ALLIANCE CENTER 3560 LENOX ROAD,SUITE 2400 ATLANTA,GA 30M INSu S)AFFORDING COVERAGE NAIC 0 TR 100992-HtMneDGA1h'-17-18 INSURER A a WMTZ CO I24147 INSURED INSURER e:�Cened InsUTdrtm Company I42757 THE HOME DEPOT,INC. New Hampshire Ins Co 23841 140ME DEPOT U-SA.,INC. INSURER c 2455 PACES FERRY ROAD INSURER D BUILDING C-20 INSURER E: ATLANTA,GA 30339 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-W3746387-14 REVISION NUMBER:2 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 NTH 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. IL I POLICY EFF POLICY EXPO TYPE OF INSURANCE POLICY NUMBER MMID MMOO A X COMMERCIAL GENERAL LIABILITY MWZY 310022 1031012017 0012018 EACH OCCURRENCE s 9,000.000 r—! PREMISES Eaoetkorence $ 1,0M.000 LGEILiGREGA MADE OCCUR EXCLUDED IUMITS OF POLICY XS MED EXP Wer are person) S OF SIR$1M PER OCC PERSONAL 8 ADV INJURY S 9,OD4000 GENERAL AGGREGATE s 9,000ADD E UM?APPLIES PER: 0 UQO r PRODUCTS-COMPIOPAGG S ) PRO- ' 1 LOC JECT 5 0310112D17 03101I2018 COMBINED Sr UNIT S 1000,0M A AUTOMOBILE LIABILITY MWTB310021Es BODILY INJURY(Pa peson) S X ANY AUTO BODILY INJURY(Peraoddent) S �y 0%NNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS NAON�-0V"Jw PRor DAMADAMAGE S HIRED AUTOS AUTOS S I UMBRELLA LAB OCCUR EACH OCCURRENCE S I EXCESS LIAB CLAIMS-MADE AGGREGATE S 5 I B wORaERS PER COMPENSATC N WlR C49112300 ITM 0310i12017 03f0112At8 X - E�RH I AND EMPLOYERS'LI181UTY YIN WC I)23102423(AK,NH,NJ,VT) �C3101l2017 031DU201: E L EACH ACCIDENT S 1,OOD,000 ANY PRDPRIETOAIPARTNERgmc n'1 N NIA 1000o C OFFICERRAEMBR EXGLUDED7 ❑ JWC 023102424(WI) 103101017 031Q1Y1018 E L DISEASE-EA EMPLO S (Mandatory In NH) 1,OOD,ODO yyeece Cen4mred as Addl"Mnal Page E L DISEASE-POLICY LIMIT i 5 DESCRi p 0 OPERATIONS blow DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.AddRI0112l Remarks Schedule,may be attached Ir more spew Is required) EVIDENCE OF INSURANCE CANCELLATION CERTIFICATE HOLDER HOME DEPOT USA INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED'BEFORE 2455 PACES FERRY ROAD THE EXPIRATION GATE THEREOF, N0110E WILL: BE DELIVERED 1N ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. ' AUTHORIZED REPRESENTATIVE of Marsh USA Inc. r - 'wp�� Manashi Mukhetiee O 19BB-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014MI) The ACORD name and Ingo are registered marks of ACORD AGENCY CUSTOMER ID: 100492 Loc#: Atlanta A`ORV ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. HOME DEPOT U.SA,INC. D1BIA THE HOME DEPOT POLICY NUMBER 2455 PACES FERRY ROAD BUILDING G20 ATLANTA.GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE Certificate of Liability Insurance Workers Compensation Continued: Cartier:Indemnity insurance Company of North America Policy Number.WLR C49112294(AL,AR,FL.ID,IA,KS,KY,LA,MS,MO,NE NM,ND,OK,SC,SD WV,WY) Effective Date:03101=7 Expiration Date:0310112016 (EL)Limit$1,0M.00D Carrier.New Hampshire Insurance Company Policy Number.WC 023102422(DC,DE H1,IN,MD,MN,MT,NY,RI) Effective Date:03101 17 Expiration Date:00112018 (EL)Limit S1,000,0W Carrier.ACE American Insurance Company Policy Number.WCU C49112282(05I)(A2,CA,IL NC,OR,VA,WA) Effective Dale:03101W7 Expiration Dater 0310112018 (EL)Lima S1,0M,001) SIR$1,0D0,000 SIR for the states of a CA,I1,NC,0R VA,WA Cartier.National Union Fire Insurance Company Policy Number.XWC 6M3144(QSI)(CO,CT,GA,ME,MI,NV,OH,PA,UT) Effective Date:03ID112017 Expiration Date:03MI12018 (EL)Limit$1,000,0D0 S1,000,0M SIR for the states of COME NV,MI,OHRA,UT S750,000 SIR for the state of GA S350,000 SIR for the state of CT Cart:NLb. l Union Fire Insurance Company Poli XWC 6583141(QSI)(MA) y / Effe03101/2017 rn (� I✓/L — y Expi :03101/2016 (EL) 00,000 SIR TX Employers XS Indemnity: Carrierlffin:w Union Insurance Company Policy Number.TNS C48613202 FX) Effective Dale:00117817 Expiration Dad:03101/2018 (EL)Limit$10.000,000 SIR SI,ODD,DDD ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts oil _... Department of Industrial Accidents - = 1� . 011lceolloees�►gat/ons � •_ �� itil'.:_ �'�' 600 !f ashin„•tun Street ` Burton,Mass. 02111 Workers' Compensation Insurance.Affidavit �ARnlic�n nformation= Please P fRrje happ w"•'T"�` -� e location- 17- ` !sill' 00 A,..�f phone ❑ I am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ;!;::,am an employer providing workers' compensation for my employees wori:ing on this job. compnny ����Z �y��5�'W G-f-f nv� Cc9 a ddress• inSUrincern L( `% / ` /� CXJ�[ Dolicy# 4V4 j/:x o. 61 ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers compensation polices: 'I company name: address, cih•• phone#! inaurnnce co nolict•# C,Zsic:. N-: _-• — rtn•�-.a. ae�ar-zrs"�•'�,r•ns••eFsT*AF T�cFCO�IIl7R±olrt: :fR �►v^?S'•' T?4!'rt" ;S sompanv name* address: city phone#• nolin# ••. Atiach additional,sheet if need„: �- w_ -s�+„�'•��" +t�r�a - : rtrt. �s ' Failure io secure coverage as required under Section 25A of 51GL 152 can lead to the imposition of criminal penalties of a fine up to$1.500.00 and/or one pears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of S100.00 a day opainst me. I understand that a copy of this statement mad'be forwarded to the Office of Investigations of the DIA for coverage veriflcation. l do hereht•ce Cuntr the pains and penalties of pedury that the information pro►7ded above is true and correct g Date Signature Print name F-A ?/1 Phone# 4 ems? - ass;� ofiicial use only' do not write in this area to be completed by city or town oMcial city or town: permitAlcease# r'ttluilding Department (3trcensing Board, ` 0 check if immediate response is,required C3Seleetmea's Office �liealth Department contact person: phone#; nOther r (revised 3f05 r)A) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law",an empinree is dcfined as every person in the service of another under any contract of hire, express or implied, oral or written. An emphtyer is dcfined as an individual, partnership,association. corporation or other ,cgal entity, orany two or more of the forcuoing`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 1'S2 section 25 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. neither tite 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 hav, been presented to the contracting authority. .r:.....�r.w-e+�.--��� ;�a �f,�;l:� ...r�. �,.y.w ��:;:�.rr.: •.Au '.: �:r-:rA.;r)� ✓".�::';f'L - ` •.-, � .�.�..:..: ..'.:i�.•.-r��,,:T t. •.t:4 .- . ..r...-. �/,i',:. '.►:.w.7!^J1.•1�'.r`1)',ii.rl 'M•n" Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affida�it. 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. �,...r,.�...».;.. ..... . ..... .. . .:•,.o-:.��� '""'�„e. :;.t . _ Wiz'-:,..:-. .. The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street at.. — Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 . The Town of Barnstable Nam$ Department of Health Safety and Environmental Services Building Division �a 367 Main Street,Hyannis MA 02601 Ralph Crassea Office: 508 790-6n7 Building Commissio, Fax» 508 775-3344 For office use only Permit no._. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, impravemem.removal, demolition. or construction of an addition to any preexisting Owner occupied t building containing at least one but not more than four dwelling units or to structures which amto such residence or building be done by registered contractors,with certain=gdOns,along with other requirements. Typeof Work:_n Q IL Imo' Est.Cost 1 06 0 Address of Work: y-3 S /A Oaner.Name: ecry►q'��l Date of Permit Application: 64�6 I hereby certify that: Registration is not required for the following rcason(s): Work excluded by law Job under S1,000 Building not owner-occupied Owner pulling awn permit Notice is hereby given that: CONTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEALING WThIt?NREGIS'fERED FOR APPLICABLE HOME IMPROVE ENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hcrcby apply for a permit as the agent of the o%mer: Date I Contractor name Registration No. OR n,,e Owner's name Assessors map and lot number .t .`�!....:.... 'Y................ CF TN E TO Sewage Permit number .....34.-.0... 1........................ //� Z BAUSTABLE. i House number ......... .? r ' i--f,.-a,,.;, 90 M1639. ,.. _. . .... ......... v �e �o war a' TOWN OF BARNSTABLE BUILDING INSPECTOR l APPLICATION FOR PERMIT TO ...................... // .............................................................................. TYPE OF CONSTRUCTION ....................... ... 6. � � ....�L....: !! k .'L'! ........................... ............. .........................19. , 1._ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...... 6 .....�� .5....... ..... :.c�r.........G .................. .................................. x 4 Proposed Use � � r......... .�.�! ! r! Q�.0 .:.:�C. ................... ..............:" ........................... . . .... . ....,.. • Zoning District .................................... .........� .+F re District .t. 3 �, (.€.CL/d � ... �.Address ......... ......rr�............ ..;... r4 f Name pf Owner ° : ..................... ...........�.. .. M ................ t Name of Builder ..../�� �<a /C 't1�4 ....~/� t, .-.•.............................. .. ............................ ........Address ................. .,. .......................... -', Name of Architect ..................................................................Address .................................................................................... Number of Rooms ..................................................................Foundation .... / ltPv/' ...{,.,. -CCU? Exterior ....�i.� t. l� 4k::....f. ..'� :.......71 ......r:�........Roofing ............... Floors J 1J�: � k r ... �' G� ...............Interior Heating : !.t.... ` .... ...... .............Plumbing .............. ... ..-.. -5 '�!........ ..:.................................. f j Fireplace ....................... ... ..................................................Approximate. Costj.......:......... �- Definitive Plan Approved by Planning Board _________19 M_. Area G/ ....................... Diagram of Lot and Building with Dimensions Fee .....�Q ,......... ...................... S ,SECT TO APPROVAL OF BOARD OF HEALTH �y j� 3 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 i Construction Supervisor's License .. .✓ � 1 CEDAR ACRES REALTY TRUST A=24-62-63 V -��Ii No ....30003.. Permit for ...1..StorY I Single..Family„-Dwell' Lots ��4 & 5 4395 Route,..?.8 Location ......... ....... �. ........,............ Cotuit ............................................................................... Owner ......Cedar Acres Realty Trust Type of Construction Frame ................................................................................ Plot ............................ Lot ................................ Permit Granted October 2, 19 86 I Date of Inspection ....................................19 ' Date' Completed ......................................19 A)n ��i / ///4690 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) MA-- I 1��C&L DATA TOWN 0 BARNSTARE, MASSACHUSETTS BUILDING: "PERMIT DATE 0.rj 4_"L 19 t PERMIT 3-00-03 APPLICANT ADDRESS IN 0.) Is I 1?1:u I licritisr) NUMBER OF PERMIT TO Iiu i i L! 1)W'm I STORY DWELL ING UNITS (TYPE OF IMPROVEMENTf NO, (PPOPOSED USE) I:(.)i�u ZONING i, c AT (LOCATION) ot tr4 �,5, i - DISTRICT (NO.) (STREET) BETWEEN AND (CROSS STREET) (CROSS STREET) LOT SUBDIVISION LOT BLOCK SIZE BUILDING IS TO BE Fr. WIDE BY FT. LONG BY—__ FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE), REMARKS: 4 u AREA OR 12 0 1) 'L i I PERMIT $ VOLUME FEE (CUBIC/SQUARE FEET) OWNER ADDRESS 1.710 Ut 0. BUILDING DEFT, fly THIS PERMIT CONVEYS NO RIGHT 1`0 OCCUPY ANY SrHFF r, ALLEY Of? 'SIDEWALK OR ANY PART I TFMPORARILY Or? PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES As WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN ELECTRICAL, PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS IRE TO LATH). 3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE, OCCUPANCY, POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVAIS IN UMBIN(;INSPI CHON APPHOVAI':; Fl I CIHICAI INSPECTION APPHOVAI S 2 2 3 IIIAIIN(;INSP1,01UNAPPHOVAU; I NGINI I HING Of I'AHIMI N1 ............ WHIM HOA 1()l I I I x 1 0-1-L NOT PROCEED UNTIL THE INSPEC- PERMIT W!LL BECOME NULL AND V011D IF CONSTRUCT I'ON INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIOIJUS STAGES OF WORK 15 NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTIOI\, PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION.