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HomeMy WebLinkAbout0041 FURLONG WAY y Town of Barnstable e ° SHE � Regulatory Services Richard V.Scali,Director BARNMMASS.M Building Division 163s6� �� 3;9 Paul Roma,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-40338 Fax: 508-790-6230 PERMIT# I V FEE: 35.00 SHED REGISTRATION BUILDING.. DEPT RESIDENTIAL ONLY �VN O 9 ..200 square feet or less, 2017 `, ) p TOWN OF 13ARNSTA13LE �' � �� dr� W • r L!J U Location of shed( dress) IJ Village f Property owner's nat6e Telephone number l0 X 1 � D�a/0a0�°� Size of Shed Map/Parcel# qi ,a, S' afore Date Hyannis Main Street Waterfront Historic District? /J Old King's Highway Historic District Commission jurisdiction? itl 0 You must file with Old King's Highway Conservation Commission(signature is required) Sign off fours for Conservation 8:00-9:30&3:304:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMVIISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:06/20/16 �ar� 'e�; 0vfl00k .G06.1 Q • Cw-7 ra �� f wiu_ ann � �1v���..� o N �r1-+ � ;; P��J •�GU�-v tit S f� ��c.A� , I �U = �-� t=7 f �Tc'�. IN � 4 F ���'. ��"TA�C» ��"' �!!�•.� S".�°x��.• Z�� ���:�k���. � � �' � ��a<� Afsessoras map and lot number �, _ 3_'2 "7 SEPTIC SYSfLIA Mus-f- DE 70 IN STALLED IN COMPLIANCE Sewage Permit number ............ .............................................._............................. WITH ARTICLE II STATE SANITP! Y CODE AND TOWN 0FTHEV. TOWN OF BARNS ARLE- Z EARISTA➢LE, i "b BUILDING INSPECTOR APPLICATION FOR PERMIT TO / .:.....- . 's .....a ...ifI.................................................................... TYPEOF CONSTRUCTION ........ ............................................................................................................. �.y....... f�........19J�.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location U 2 f �."� G w/ .............:................................ .... ...................................................................................................................... Proposed Use ........ P�'��'� fc�....... iGrt'�//ti Zoning District " .......................................................Fire District ............... .............................................................................. Name of Owner .D ?�T�RSO A, l�//4 6'/riy/l' /.J AS-S ................//..........................................Address . ......................... ............................................,l../....... .N. 14&110%l (!?r................Address%ZT..!Ce.rn��!v"I Pro/.....A/ �!P/'/0=/ `J• Nameof Builder ........... ................ Name of Architect 5,..��r� ..........................Address .................. ................... .................................................................................... S. 41 ..........................................Foundation ..rl../V-opP...., Number of Rooms .... .................................................. Exierior . i9U0 �.�( ... ..........:.:~ (..`..'S. ...Roofing ...ASfJ/1.q Floors �O .........................................................Interior �G( �cC' Heating /......................................................................Plumbing .......z.. ...................................................................... Fireplace ..... ..t S Approximate Cost . ` / Oct vo �'................................................................. .....�..»......../.. 0.t, Definitive Plan Approved by Planning Board 19________ . Area ....�••....••••.............••......•. . 3S Diagram of Lot and Building with Dimensions Fee .......C77................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..61 .�`L..Q. ................... Peterson, Tpd Oao1 O17 18263 one story, No ................. Permit for .................................... single faml.ly dwelling ............................................................................... Furlong Way Location .................... .......................................... Cotult ............................................................................... It a Ted Peterson woo Owner .................................................................. ti. 'i jr frame 4 Type of Construction .......................................... JI; k; - J� 4k 41 41 ................................................................................ eA i ril Plot ............................ Lot ...........#22 ..................... Permit Granted ......March 29 76.. .........19 ADate of Inspection ZI ...............!t.......19 Date Completed ....71 .............9 PERMIT REFUSED ................................................................ 19 r,/ A ............................................................................... 9r -)/M ............................................................................... C. ............................................................................... 40 fly ............................................................................... Approved ................................................ 19 0 ............................................................................... ............................................................................... A.9?essor's% map..and lot number ...Z?Z��-2..... ...�� PC 7 Sewage Permit number ............ .............................. ............ 11 iE TOWN OF BARNSTABLE 33A]USTLELL OML 1639- BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO .... ............L�;V..........YA........ tv, ....................... ........ ................. ...............? TYPEOF CONSTRUCTION .......... ................................................................... .......... ....................... ........... ....................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies- for a permit according to the following information: Location ..... 7' �z 1- I U P A -,9 ............................................................................................................................................................................. Proposed Use .........pr A 10 7%F00 1114"47 ....... ............ .................................................:�....... ........:....................... ZoningDistrict ............. ............................Fire District ... ............................................................... ....... -7,2-P pe-7-;.?-R-ro Nameof Owner .......................................................................Address ...........................;......................................01................ Name of Builder ...... . 0!� 1 //. 7400/./z...k/ er ....... ....................................................Address; -A..............I.......................... Nameof Architect ........... ......................................Address .......................................................... ......................... .................................................................... Number of Rooms ..................................................................Foundation r:�? Exterior4 ............................. ................ ................Roofing A.S,;.......................?....... ..........................v.......... &,4 AOP 10'd'4; 7�/j Floors .,......................................................................................Interior ........................................................... ....................... Heating ........................................................................... ........................................................ ................Plumbing Fireplace ..... t�......................... ............................................Approximate Cost ........................ ......... Definitive Plan Approved by Planning Board -------------------------------19-------- - Area ........................................ -1 r-. — Diagram of Lot and Building with Dimensions Fee ....... �nllz , z2 ........... ...... ........... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..............I................................................... . . ' . ` . . Peterson, Ted 'A=22-79 18263 one story, No ---.—.— Permit. = '------'----.. -��__single..family'.dwell1ng_______ . Location _ ,^_� . . . . .����� ' _ �a � Owner -----d-- . 'xr~ .. Construction . . � ~/ Plot ........................... Lot — '� ' ' � �. Permit" Granted ` � oota of Inspection -� _ . ' . � � _—~ Completed \ . �. . . . PERMl' ISED . ' lV . . �. --�—�----------` ---------- , �. ~_--.--~,. ^ . . � .—.—~~-.— --.,------- . + . » ---------.---.---...�---.--.----. ' . ^ A ' ................................................ / . ` Approved 19 ' �. ` . ^ � ---.. ...................... ` ' � ---''ff , A- ru r� s 0 �o 1/7. , . ,5'r.a.,¢.-. ♦agAa.�'+r--^.:r,�«wt�'h+�Y"^+"7d1�°i-:"' ',^^,:;v i+.;". .f`k-.r' t '1"' .. i5'io:' �,�^rf;.;ir�l,r�;h�'':s.^..rz:.rn, ,F•' *a, ..... �;:..,_. .yam ..�;#'.x.......,.._ .. J 1. Assessor's office(1st Floor): Or Assessor's map and lot number - r 1 0* cc Board of Health(3rd floor): r d� Sewage Permit number , ` Engineering Department(3rd floor): j /� L asaMAX& Lt 7/ " J' 1 ° rrua House number 3� ° 1679' Definitive Plan Approved by Planning Board 190 r�r APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only I TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION / ,��mil;? ,�'� �•� I 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location . t 7 c, 7-u j r Proposed Use 61 G Zoning District Fire District Name of Owner A�0TU U YZ Pez T? t 1s0 N Address ��f �"'��U ti I Vl �0�<-i 1 Name of Builder L &4 F )a5 C—O tiS� Address t 4-,c pit �—� 1—ti C Name of Architect Address Number of Rooms Foundation �d vi2 e Exterior w ICE t2`1 Y� Roofing G2� r Floors G �`'' Interior Heating Plumbing Fireplace '� Approximate Coster U� J Area IZ1I ;I S 31C� Diagram of Lot and Building with Dimensions Fee 7-ar,& It t&ti ,eW i4 y_ 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 V. 4� r Construction Supervisor's License �' PETERSON, ARTHUR A=022-079 No 33802 Permit For Build Garage Single Family Dwelling Location 41 Furlong way Cotuit Owner Arthur Peterson Type of Construction Frame Plot Lot Permit Granted June 12, 19 90 Date of Inspection 19 Date Completed '19 PERMIT COMPLETED 1/1/.yl /ate/ ��� / Assessor's office (1st floor); SEPTIC SYSTEM MUST BE Assessor's ma and lot number QQ �t ,1F Ft►+¢T p Q.a.a�.:..Q.� ,.1.... Board of Health (3rd floor): Sewage Permit number :......:..Zlo.'°� �..:. E ': .i i iiEW` ,hL C0C' 9TaLL. Engineering Department (3rd floor): : �f / 1_n TOWN REGULATIONS �O rb 9. House number ...:1--..1....... �11 39a`e ......,........ .................. oM Definitive Plan-Approved by Planning Board __ ::_______19_ ______ . APPLICATIONS PROCESSED 8:30 9:30 A.M. and 1 00:2 00 P.M.' only - TOWN OV BARNSTABLE' r A BUIL0I,HG INSPECTOR APPLICATION FOR PERMIT TO• � � TYPE OF CONSTRUCTION w� ...:... /'.`. .......:........................... . j r .............................. 19 TO THE INSPECTOR OF BUILDINGS: , The undersigned hereby applies for a permit according to the following information: N CIO rt Location `6 . ...... ..........................v.....�.'fi ................................................................. ProposedUse ...............................................................................:......:....................................... Zoning District ..:.....................Fire. District :.......00�-L ......•••• ......... ..................... Name of Owner TT -.......11.` L1:4S0.! ............Address ...LI.t...... 1'/,`l ' ?......2.R..........4 ..Address y r 1 Name of Builder N...1. ^.....:.lr R":1.;1..!®..£�.......... �.3.. � ..........may Vl - Name of Architect ........... -�D.!v.:.............................Address Number of Rooms ........... �...:. Foundation �C3.V. � ........................... ......... Exterior ... '..!.1 �......1..(� J ..............: ...............,.Roofing ....r. ... -.............................................. x Floors. o�T�. ........ a . -.......... `. ..................Interior. .... w .............:.................... Heating- ..:.�y.1W1 t ..Plumbing .........,� 5. Fireplace �u''.'.!-4 .........._.......................................Approximate Cost ...........�(�........ ~ ......... Area ��... ..%.............. Diagram of Lot and Building with Dimensions Fee .......`--:-`� ` OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 -hereby agree to conform to all the Rules and Regulations o wn of Bar table regarding the above construction. YName . ............... ......... ....................................... ll��5,3 Construction Supervisor's License .................................... PETERSON, ARTHUR No 31852 Permit for ..Enclose Deck •� - k F Sinq:le...`.,Fami1Y...Dwe11.in f location :41....FurloncJ..��s=r�=..� ... � �. . .. _ Cotuit 1 ....... ........ 4 Owner Arthur Peterson . ....� ................ . .......... Type of Con'structio'n F•r .. ' . ................................. ......� �' Plot ................... ' : Lot_.. ............................. Permit Granted .....: A Y...2.R ..................19 88 r -Date.of Inspection 71 Date Completed ...... .,c: ..19 3-0 iL 71 I Assessor's office (1st floor): �} Assessor's map and lot number ../1.Q S;....C� �..Q... ��oi TMf to`o Q��♦ Board of Health (3rd floor): Sewage Permit number ...........7 R.7::/ /-�.... ...rlY1.............. 2 BABd9TYDLL, ! Engineering Department (3rd floor): �,.;- �o rasa House number .............................. 0,s� 79 .................. ........................ � 'E'0 YAY Ord Definitive Plan Approved by Planning Board ________________________________19________ . C� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00.2:00 P.M. only TOWN OF BARA) STABLE BUILDING INSPECTOR - APPLICATION FOR PERMIT TO ........................................../.i.,.�............................................................................... TYPE OF CONSTRUCTION ....... gOg........ ...'.`. ......................................................................... e JJ �"........................................ 19«C) TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location iU T $�• G� L�l�................................................................. ....................... ....................... .................................................. ProposedUse r�Y .................................................................................................................................................. ZoningDistrict .........0.......................................................Fire District .........CPOTV. .............................................. Name of Owner .......�... e ��a Address L11 �� � � ..................... ......e. .............. ............�......�...... 1. �. dd�?�V ltic7 1 �1.�}IV K�v1.... !�.........coa 0 Name of Builder .......1................ ../.s.......................................Address ........................ Name of Architect. ............................Address .............. ................................................... Number of Rooms AG ?......... I................................................Foundation .. C .t 1.'�.e ��..........Gd.........n.:k....... .. n Exterior ...� '.!.�yr ......... !T ...................................Roofing �' .�1�_ ! .�............. .................................................... Floors 7�..'L".........1�. ..?........ ,._........... !. ..................Interior ..... Heating ....F� .C� fZ!� s..................................................Plumbing ` . � Fireplace &,M ..............Approximate Cost ....J.�6v Area .................................... ..... Diagram of Lot and Building with Dimensions Fee ...................................... 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 ...:..................(U VA .................................... Construction Supervisor's license .................................... PETERSON, ARTHUR A=022-079 /'�-e2 ?-— 0 �f No .3.1.85.2... Permit for gTjq.jo.s.e...Deck... .......S.jng.je,..FaMjjy...D.W.Q.1.1 i n Location ....4 1..F u r I o x i.g..-D V e Cotuit ............................................................................... Owner Arthur Peterson ....................................... .......................... Type of Construction ......Frame........................ .....................................:......................................... Plot .......................... Lot ................................ Permit Granted ...........M.ay....2................19 88 Date of Inspection ....................................19 Date Completed ......................................19 W CA - C1 c al N a � J 71 v `r_ t� ✓ tIO kA • e Assessor's office(1st Floor): Assessor's ma and lot number " pAf11■ > P Q /9 Q ��✓uC ��14 �Fep mtGCS�� �' �QyO 7NE 0�0 Board of Health(3rd`floor): t+V! (�°E `II;I;L � ^�y» •., �, Cs��•uy'J Sewage•Permit number - fdO� , ru 41��g��y n � • DADd9?ADLL i Engineering Department(3rd floor): House number Definitive Plan Approved by Planning Board 19 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 �,�J / V 1 ' TYPE OF CONSTRUCTION �} C4 19 TO THE INSPECTOR OF BUILDINGS: The undersigned herebyapplies for a permit acco in to the f Ilowing information: Location ` � ` ti C V Proposed Use Zoning District Fire District Name of Owner 14 PTA v� SO ti Address G I I �`"�10 sal C p' Name of Builder (1j®-,�> Co `i Address t 3 �-` �.ti --1-7- Name of Architect, Address ��) Number of Rooms Foundation I" d YX e 5> co 1-6d e T(' .�, §2 2'T Roofing t71� i Exterior 9 Floors w�6`7 e Interior ��T // Heating ~ Plumbing Fireplace � Approximate Cost Area Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barn able regardi the a ve construction. Na Construction Supervisor's License PETERSON, ARTHUR . F c, No 33802 - Permit For Build Garage 1 Single Family Dwelling ' y } Location 41 - Furlong Way y t Cotuit ; s Owner'-' Arthur Peterscin' L f r Type of Construction Frame , 1171 3 Plot t = Lot - a Permit Granted June 12 , 19 90 Date of Inspection D _ 19 - Date Completed ` 9� - 19 f ,t _r Tu�S DOO(L V,/�•-N V�lfNDO�iS3� I i II w � I� r I• i j4r=W GA)ZAG r A,',, .') T!O N - O (i!.DDITIph1 S/ 1E SIZL� XT'END SAME P-O_.)lr t-IWE T} - �11 F V r I r, -� � , I &AR.AGV- A1)DITIC>J-PLUM VI>`W - / _ . ARTNhIZT�. 12E';f�1EM•PET1`RSdN _4-1 PU 9 t�d ti G 'A/AY- C O T U I T _ 15 E DW n-BY SCI�LE s, r . . . I I i I ' i . .......... IL i -G K r o 'r vJ a o F�. V 4�_urzTR�QEr.�r M, T'Et2,so� , - --- 41 CA'ru a o n °Q i � o � , go- i Q GARAGE CS ° , r T p o N 2 M. o r- e} � ♦ �Y Q. q`Y 1 HODS E w a N Z6 35� a 1OUS� LOCA71ON PLAN oN 1+ ONG WAY, COTU 1T,.MASS. FOR _ R iP-ENE M. PETERSON ►NEB`- "iNG14AM I MASS. CAIE%6-t'-O DWN. a/kp 1. p 16o l c� Town of Barnstable . ` *Permit# . P� q. Expires 6 io t6 from 'su date Regulatory Services Fee BARNSTABLE. ' v� 6 MASS. ,�� Thomas F. Geiler,Director �' plFD MP't A Building Division ,Be Tom Perry,CBO, Building Commissioner ® �� 200 Maim Street,Hyannis,MA 02601 20J0 wwwaown.barnstable:ma.us Offi*%862-4038 Fax: 508-790-6230 ��,9�` XPRESS PERMIT APPLICATION - RESIDENTIAL ONLY _ .Not Valid without Red X-Press Imprint Map/parcel Number Property Address 41 -'U tr W Residential Value of Work Q© Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address y\v�c-t ��C�'�✓Cy�� r X Contractor's Name Telephone Number pq -g4o Home Improvement Contractor License#(if applicable) ' � 9 Construction Supervisor's License#(if applicable) EWorkman's Compensation Insurance Check one; ❑ I am a sole proprietor. WI am the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit, Permit Request(check box) 0 R-roof(stripping old shingles) All construction debris will be taken to ❑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. t' t A py of the Home Improvement.Contractors License&Construction Supervisors License is quired. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc r Yi r1 4 'y The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigatio'ns . 600 Washington Street 1 Boston, MA 02111 r. wiviw.niass.govldia r Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly. Name (Business/Organization/Individual): oatb2- Address: City/State/Zip: Phone #` A;71 an employer? Check the appropriate box: Type of project(required): 1. m a employer with --- 4., 0 I am a general contractor and I 6. [] New construction employees (full and/or part-time).* have hired the sub-contractors • 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7, ❑ Remodeling ship and have no employees •These sub-contractors have g, � Demolition_ Workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp.insurance•# required.) x 5. O,=We are a corporation and its ]0.❑ Electrical repairs or addition 3.❑ I am a homeowner doing all work officers have exercised their I I.E]Plumbing repairs or addition myself. [No workers',comp. right of exemption per MGL 12r®Roof repairs insurance required.]] t c. 152, §1(4),and we have no I employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box 41 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. lContractors that check this box must attached an additional sheet showing the name of the sub-con tractors.and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is,providing workers'compensation insurance for my employees. Below is thepolicy andjob site information. M Insurance Company Name: F�1 Policy# or Self-ins.Lic.#: Expiration Date: 3 / Job Site Address: �d City/State/Zip: �j u t4 � co -3S Attach a copy of the workers' compensation policy declaration page(showing the policy number Yan 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 fin 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. ; 1 d�hereby ertify cr er hepains andpenalties ofperjury that the informa'tionprovidedebove is true and correct. Si Date: 2) /D. 4 Phone Official itse 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: - InMrrnation 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 writ ten." 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 th6 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 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,affrdavit 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 ajeference number. In addition, an applicant that miist 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. Anew 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 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 4-24-07 www.mass.gov/dia I, ��JYL�(1�i2- ��V21✓P�✓lcj , as owner(s) of the subject property at: hereby authorize Steve White of Caliber Building And Remodeling, LLC (contractor) to act on my behalf in all matters relative to the building permit application. 3 2'f 10 *siatu�re-of owner date signature of owner date �. ,.,:p � ti '� k' . . � � - . _ . ., � s ::�. l � E,*'.... '1 .. ,.;.,;i;:.;n, ,.5: 1 ' h . i �::�j �G! ��/� �L j I ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) TM - 03/30/2010 PRODUCER 508.945.0393 FAX 508.945.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eldredge & Lumpkin Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 697 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chatham, MA 02633 INSURERS AFFORDING COVERAGE NAIC# INSURED Caliber Building and Remodeling LLC INSURERA: National Grange Mutual Ins Co 14788 INSURERB: Commerce Group CIG001 147 Ridgewood Ave INSURERc: Granite State Ins. Co.-ARWC 13102 Hyannis, MA 02601 INSURERD: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITH ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUE MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITION: POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD/YYYY DATE MMIDDIYYYY LIMITS GENERAL LIABILITY MP027360 09/15/2009 09/15/2010 EACH OCCURRENCE $ 500 OO PCOM MERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Eaoccurrence $ 500 00 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 1O OO APERSONAL&ADV INJURY $ 500OO GENERAL AGGREGATE $ 1,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY JEC LOC AUTOMOBILE LIABILITY BBNVCS 02/16/2010 02/16/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALLOWNEDAUTOS BODILY INJURY •$ B X SCHEDULED AUTOS. (Per person) 250,000, HIRED AUTOS BODILY INJURY $ NON-OWNEDAUTOS (Per accident) 500,00 PROPERTY DAMAGE $ (Per accident) 100 ,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - EA ACC $ . OTHER THAN AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERSAND COMPENSATIONLIABILITY YIN WC7425405 03/02/2010 03/02/2011 TORYLIMITS OER ANY PROPRIETOR/PARTNER/EXECUTIVE� E.L.EACH ACCIDENT $ ZOO 00 C OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Barnstable IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Att: Bldg Dept. REPRESENTATIVES. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 Alan R. Long, President ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts- Department of Public Safet. Board of Building Regulations and Standards Construction Supervisor License License: CS 95038 Restricted to: 00 STEVEN WHITE 147 RIDGEWOOD AVENUE HYANNIS, MA 02601 Expiration: 2/28/2012 (nmmi.�i„ner Tr=: 19311 ✓fte Toarniinarttoea�A�o� iGGaClutte+!s�! Board of Building Regulation$and Standards HOME IMPROVEMENT CONTRACTOR Registration .154359 2128/2011 . Tr# 280764 « ' pTypet-Ltd 116bility.cerporation CALIBER BUILDING' S RdELINO,I.I.C. .` STEVEN WHITE s 147 RIDGEWOOD AVE ,tr•, HXANNIS,MA 02601 Administrator License or regestration valid for indrvidul use only before the expiration date. If found return to: Boardof Building Regulations and Standards One Ashburton'Place Rm 1301 Boston,'Ma.02108 ' 000/ Not valid without signature I