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HomeMy WebLinkAbout0051 LAKE STREET a �' �� a, ,:� i �' Jd 7 • , 4 i �M Assessors map and lot number ............................................ r P Sewage Permit number ��+ n ?,.�:� � !I/ Z MARNSTADLE, i House number ........................................................................ 9 rasa �p 2639• `009 Q YFY p,. TOWN OF BARNSTABLE BUILDING INSPECTOR *` APPLICATION FOR PERMIT TO ....... ....... .. TYPE OF CONSTRUCTION ...............l..:t G c:� ....... ► ? 3 7 ..................................................................... ............. ................. ................19. ' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .....5.. ... T ICC ✓ s <... f,!f. .. .....M A . .................... . . ........ ............... ProposedUse .. ....... � ..!� ..... .... . . ..............................................................................................�. -Zoning District ........................................................................Fire District .........1.............................................................. .tK,/� tf Name of Owner ..{?... r^ f r!YI ,l i....S!'Y1.�. .�i..........Address. �/1...R? ul 5 t�!f - lm n l;S �..... ... ..`��. Name of Builder ......................... .:..� L1 f.TI 1�.......Address .5.�........ � F7 /...................................... ... :�. Name of Architect ...........Y'l.®`^r .......................................Address .................................................................................... .... ..... Number of Rooms Foundation ( vy" ¢ �� � - Exierior .............1..��(?f'f .Roofing �'I, a �'1 �C i ...�A.... .......................................................... ...•........... Floors ...1.1.,2 ...................................................Interior ......> . '?, .1 /C (� .,K ....................... ...:. ............ . .......................................... .1 n� .._ r� r� Heating ..................................................................................Plumbing ..............................:.................................................... Fireplace ..:.............0 (�+rl ........ .�...................................:.............Approximate Cost ........��..a`? ?.�.:.�c.....................:...... Definitive Plan Approved by Planning Board ________________________________19________. Area ...Ds: Diagram of Lot and Building with Dimensions Fee Z ...........r;� 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. /y Name .`.../ �! ° ?a?: ' '� :. 1��,/ ...... SMITH, G. FREEMAN No ... Permit for .ADDITION Single Family Dwelling Location ...51...Lake._.Street........................ Cotuit ............................................................................... Owner ..G..,,,Freem. n.. Smith ........................... Type of Construction ....F m........................ Plot ....................... .....Lot ................................ 5e tember 25 80 Permit Granted ..L_ ...P.........................1..19 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ........... .�.. .. F. ..,...*J/I.. ........... .... . . . t..j �........................ ......................................... .............................. .................... �....................... Approved ..... ............ ...... .. .... ..... ........ 19 ................................... . ............................................................................... •• _ A-) assessor's map and lot number :.......�.�.......�............ THE Sewage Permit number / .V:.tliW %� / 1 STOW Mus STABLE, i House number' C0N1P11 rasa 1639. \0� TOWN OF BARNS ,gC0DE AND T10NS BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......OU!JA.......m.tn. ( '\O8 m rr ' TYPE OF CONSTRUCTION ................Lf�......ov.S:t.....,.....�=.t`......'�............................................................................. .� .:.....�. . ..............19.. � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .....63.... ....�:��........... .A. ..... ......... ................................. ................................... r ProposedUse ...........�.`.. ..�. .�' ...... ?.0.Q k?l....................................................................................I......................... Zoning District ...............................................................:........Fire District .......... paw`j* Name of Owner ... yr t.?:..(�r' .! .... .°.rn..........Address .�... .' ........ ..... t/GTri/1lS Name of Builder .......Address .�.. lit�Ci: v .a... Q. .G�!.. ....................... Name of Architect ............r).or?. ......................................Address ...........................................................:........................ c �r Number of Rooms ....................I.............................................Foundation .......�......o.�.......... ........ ........................................... Exterior .............Wood.......................................................Roofing ..........(1 ��L,.� u.L�....`��!.f„n� r.�-��........ Floors ....................I.....�I.r ....................................................Interior ......5..A.j!�k. .../.�.0..�r!a........................................ Heating .... ....................................:.............Plumbing .................... . . .............................................. Y1 ©01 Fireplace ................. ...............................................................Approximate Cost .................. �...op..................�. ...... Definitive Plan Approved by -Planning Board -------------------------- 3Y�.... S�. ------19--------. Area ..... ... .... ..... .. Diagram of Lot and Building with Dimensions Feed 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. R Name .`/�� .... ..... . .... 1... .. . .. SMITH, G. FREEMAN ADDITION Permit for .................................... V Single Family Dwelling ............................................................................... Location 51 Lake Street ................................................................ cotuit ............................................................................... OwnerG......F.r.ee.m.an....Smith....................... ... .. .. .... .. .... ........... Type of Construction .......Fra.....m.e........................... .. ............. ............................................. .................... Plot .....P....................... Lot ................................ Permit Granted ...... ...2.5-09 80 �Date.of"Inspection ................. k3..i 9 Date Completed ................... ....19SY PERMIT REFUSED ........ . ...... . ................................ 19 . . . ............................................... .. ........ ............................................. ............................................ 0 t: ..............11.1;......0-0........................................... co n .1 Approved .,mi.......�................................. 19 ........................... ............................................................................... 9.;2 o t r I 4 i i i r y. S } r r i { S i I i _�.. ..� ..� -. nil, t i . P vp O .. 1 3 �g i Ale w r�' - i _ . _o 1 D C - '` 1 y y 4 c P I 4 - 9� v- I A.r t) 1 Town of Barnstable#,,-. oz, BARNSTABLE Regulatory Services'1 � • Thomas F.Geiler,Director BAMSTABIX 9� KAM Building Division 'OrEa '�°i Tom Perry,Building Commissioner" 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 00 PERMIT# FEE: $ �i i SHED REGISTRATION 120 square feet or less Location of shed(address) Village a _ Ga 0— f I �� /.�G ��r� (/-9�y �O T o d G S-J a -- Property owner's name Telephone number XI Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature required)' �> PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MIDST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:121901 LAKE STREET PUBLIC - 40' WIDE N 85'33'06' E CONCRETE BOUND 81.42' CONCRETE BOUND W/ DRILL HOLE . W/ DRILL HOLE FOUND FOUND N M I HEREBY CERTIFY THAT THE EXISTING Z STRUCTURES ARE LOqIATED ON LOT 156 AS OWN. N 18.5' Cs F SSIONAL L D S VEYOR EXISTING S EXISTING DATE CESSPOOL 1 1/2 STORY � � WOOD FRAME N HOUSE S 32.3' N.a 19.8 #51 cn � a � THO�IAS JACKSON 15.4' aol 33 2' rn " BUNKER No 32653 iso 49.4 ,� 5 j��t41LL .8' NGA GE PROPOSED AMMON CERTIFIED PLOT PLAN > PREPARED FOR r: b^ BENNETT & CAROL DOTTRIDGE y � 51 LAKE STREET Pe s� Pc 3� (LOT 156) N N EACOTUIT, MASS. u7 � 0I I 4tp . LOT 155 LOT 156 LOT 157 BSS 20,987 SF D E S I G N _J1 UV^^ LAND SURVEYING CIVIL ENGINEERING LANDSCAPE ARCHITECTURE BSS Design, Incorporated 184 Katharine lee Bates &I CONCRETE BOUND CONCRETE BOUND Falmouth Msmachnsetts 02540 W/ DRILL HOLE W/ DRILL HOLE 608.540.8805 VAX 508.54IMS FOUND FOUND 81.44' S 84*15'06" W scale date drawn Job number dwg number 1"= 30' APRIL 13, 98 TJB � 98033 D2-188 * Y ?�� pF Town of Barnstable Permit# - C9,014 P`' p Expires 6 months from issue date Regulatory Services Fee M"M1639. Thomas F.Geflert Director Building Division Tom Perry, Building Commissioner 200 Main Street,.Hyannis,MA 02601 XwPRESS PEMIT Office: 508-862-403.8 Fax: 508-790-6230 J U L 2 5 2005 EXPRESS PERMIT APPLICATION — RESIDENDAT"ONLY Not Valid without Red X Press Imprint F BARNSTABLE Map/parcel Number 0 1 ® 02-8 f r Property Address S ���.� �-T' 1 EM Residential Value of Work U 00 Minimum fee of•$25.00 for work under$6.000.00 Owner's Name&Address G-W to-e—� COO&I S'1 L o,N- Ice Telephone Number Contractor_s_Name i(c} _� �' Home Improvement Contractor License#(if applicable) / 3 b Construction Supervisor's License#(if applicable) EpWorkinan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman%Comp.Policy# /,5 /, 0 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) 12 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. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other tows department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home rov tractors License is required. Signature Q:Forms:expmtrg Revisc063004 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 'Z/ City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.9�I am a employer with !V 4. ❑ I am a general contractor and 1 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 � �• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' eq ] 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 subnritthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractois that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: - Policy#or Self-ins.Lic. #: 79 L/X b l 9 10 Expiration Date: l U Job Site Address: S� �� S T City/State/Zip: jcJ 7 -� 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 hereb(y� r t " s an nalties f perjury that the information provided above is true and correct Signature: Date: fJ D e r 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, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or commonwealth for an or to construct buildings in the co Y renewal of a license or permit to operate a business g 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 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 5-26705 www.mass.gov/dia I Fraser Construction Roofing & Siding Specialists . FRASER CONSTRUCTION Warranties the labor for 10 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTAINTEED Warranties the shingles and labor 100%for the first 10 years, and then on a pro rated basis for the Lifetime if the shingles become defective. CERTAINTEED Warranties the shingles to be ALGAE resistant for a full 10 years. An deviation or alteration from above specification will be executed upon 3' Pe Po written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry fire, tornado and,other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTIION: Carries Workman's Compensation and Public Liability Insurance on the above work. DATE OF ACCEPTANCE: 7 J l �h- SU13MITTED BY: HomeownerrL. Lser-65_n6truction ' 1 L - �e �ar�isnoaaeueal�iz my°✓f/lacxrclu,.oetla . Board of Building Regulations and Standards HOME IMP 0\/EMENT CONTRACTOR or registration valid for individul use only befoc'i the expiration date. If found return to: It®llistraficrt 1.12536 Baal 'of Building Regulations and Standards a #00. 3123/2007 One lshburton Place Rm 1301 �y i A BOsttln,Ma.021.08 ERASER CONSTRUGbbW.-i�6 1 DEAN FRASER 71 TARRAGON CIR` _ COTUIT,MA 02635 L� ° ''� fldministrator Not valid without signature + ' Engineering Dept.(3rd floor) Map 07-C) Parcel O Z_25 Permit# -2 T House# Date Issued 11130A Board of Health(3rd floor)(8:15 -9:30/1:00- ) 2 Fee V 9 60 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Z . f Planning Dept. (1st floor/School Admin. Bldg.) to, SEPTIC S MUST BE INSTAL DANCE Definitive Plan Approved by Planning Board 19 ` ENVIRO E AND C'ATOWN OF BARNSTABLE TOWN TIONs Building Permit Application Project Street Address K_ IL9 S T Village Owner /17P.,V�V4.2Y / e7 r Address �/ P. X T Telephone r Permit Request /1 . X I� Cc Ear <c.ti Ci���' S"y��r:va �vt2� Hai First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 16' c c C Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family U" Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes 2lo On Old King's Highway ❑Yes l/ No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing -3 New 0 Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: [Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes pfVo If yes, site plan review# Current Use Proposed Use �'� /� Builder Information Name_ /04/2or� . 6alowe Telephone Number Z aj 7 IDS � Address- y7 S iT Ti la/rI, Aa�P License# 0 6/ 0 i�O Home Improvement Contractor# Worker's Compensation# 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 s SIGNATURE l2, DATE BUILDING PERMIT DENIED FOR T hHEF(�K1N REASON(S) s _ FOR OFFICIAL USE ONLY s:, .:PERMIT NO. _ � � .• � '� -- _ ` R � i ,. .DATE ISSUED MAP/PARCEL NO. _ ADDRESS k VILLAGE - OWNER DATE OF:INSPECTION: FOUNDATION c FRAME r t INSULATION FIREPLACE t ELECTRICAL: k ROUGH FINAL e ` - PLUMBING: ROUGH FINAL , GAS: x.. ppuGrR a._ FINAL r i k FINAL BUILDINZ • k ' r k ~1D m 0.�Ej�; ' DATE CLOSED OUP e ' •� two 0 cr n�r9 ASSOCIATION PLC MON Z5 ` } LAKE STREET PUBLIC 40' WIDE N 85'33'06" E CONCRETE BOUND 81.42' CONCRETE BOUND W/ DRILL HOLE . W/ DRILL HOLE FOUND FOUND iV M .. HEREBY CERTIFY THAT THE EXISTING Z STRUCTURES ARE LOgkTED ON LOT - 156 AS OWN. - r N 18.5' F SSIONAL L D S VEYOR EXISTING S EXISTING DATE CESSPOOL 1 1/2 STORY (TYP) WOOD FRAME HOUSE S 32.3' 0 0 19.8 #51 nNi THa�s o - JACKS 15.4' 332 5.0 ' rn • BUNKER « No 32653 ! o 49.4' fs o �►��QiYALL N 5.8' �►► GA GE PROPOSED ADDl11ON CERTIFIED PLOT PLAN *NC . PREPARED FOR PAT1° BENNETT & CAROL DOTTRIDGE PB 57 PG 31 51 LAKE STREET (LOT 156) N N COTUIT, MASS. Oo co crnO LOT 155 o LOT 156 LOT 157 BSS 20,987 SF. D E S I G N 4 LAND SURVEYING CIVIL ENGINEERING LANDSCAPE ARCHITECTURE ( BEIS Design, Incorporated 164 Katharine lee Bates Rd CONCRETE BOUND CONCRETE BOUND Fahnaath Mamchusetts 02540 W/ DRILL HOLE W/ DRILL HOLE 6011540.8806 FAX 608.64 &%B FOUND FOUND -z 81.44' S 84*15'06" W scale date drawn job number' dwg number f APRIL 13, 98 TJB 98033 D2-188 FO ............... Yl- I 30 co fi .......... uo�Cte �_, ......................... FE�� c 3 - 45 - -n---- E I Ef i I 1 �I' s i ! S tb The Commonwealth of Massachusetts (I,)V - • ' Department of Industrial Accidents office of/nsestigatians 600 Washington Street Boston,Mass. 02111 Workers' Com .nsation Insurance Affidavit name- D�Niirti +Jlr[ l I o location: city phone# q2 9--' I ❑ I am a homeowner performing all work myself. ❑ I am a sole pro netor and have no one workin in anv capacity %% ❑ I am an employer providing workers' compensation for my employees working on this job company name.: address. city. phone#: insurance co. olicv# I am a sole proprietor eneral contractor, homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name U E�w e/�`Ei� d'i� ✓IV G address. . L` t yyU cityif1�tr .f phone#. �{ `7 insurance co oliev# 1�/ :1{f " company name +(' v1,5 address l :0 k city- AT:.� �Gvt,d�— ✓ Z 1.Q_2� phone# 7 t Dv insurance co. l._f - r✓ olicv# G' ,D <: Faflure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct er Signature /es Print name ©���i �� r�-12t �t°�I� Phone# �Z 7 c 3 official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other ([evmd 9195 PIA) Information and Instructions .:es. Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 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 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance 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 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. 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 peniiit/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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Invesugaflons 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 ACORD CERTIFICATE OF LlA3ILITY INSURANG DATE(MM/°°,>�► P ID -02 PRODUCER YCO-1 07/28/97 McAlpine Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John Mcalpine ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 20D Post Office Sq HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Centerville is 02632 COMPANIES AFFORDING COVERAGE John McAlpine COMPANY Phone No. 508-771-0105 Fax No.508-771-1258 A Trust Insurance Company INSURED / COMPANY B Savers Property&Casualty Ins C Bay Colony Concrete Forms Inc COCANY 32 Third Ave Osterville MA 02655 COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM W HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE MAY BE ISSUED OR MAY CERTAIN,THE INSURANCE CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN M CE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CO AY HAVE BEEN REDUCED BY PAID CLAIMS) LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION GENERAL LIABILITY DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS . A X COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $2,000,000 TMP1004315 03/30/97 03/30/98 PRODUCTS-COMP/OPAGG $2,000,000 CLAIMS MADE 0 OCCUR OWNER'S&CONTRACTOR'S PROT PERSONAL&ADV INJURY $ 1,000,000 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one fire) $50,000 AUTOMOBILE LIABILITY MED EXP(Any one person) $5 000 ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON-OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ EXCESS LIABILITY AGGREGATE $ UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WCRKERS COMPENSATION AND a EMPLOYERS'LIABILITY X WC S LIMITS ER B THE PROPRIETOR/ EL EACH ACCIDENT $ 100,000 PARTNERS/EXECUTIVE X INCL WC 0000753-01 03/31/97 03/31/98 EL DISEASE-POLICY LIMIT $500,000 OFFICERS ARE: EXCL - OTHER EL DISEASE-EA EMPLOYEE $ 1 OO 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CONCRETE FOUNDATIONS RE: Jobsite . 51 Truman Way, 'Cotuit ,MA 02635 CERTIFICATE HOLDER CANCELLATION BARNST1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Don Campbell 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, PO BOX 1371 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Cotuit MA 02 635 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25-S(1/95) John McAlpine ©ACORD CORPORATION 1988 Certificate of Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. This is to Certify thatM. _ A.P. LIBERTY INSULATION CO. INC. Name and PO BOX 1309 address of MUTUAL® SAGAMORE BEACH,MA 02562 Insured. Is,at the issue date of this certificate,insured by the Company under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition of any contract or other document with respect to which this certificate may be issued. EXP.DATE * ❑ CONTINUOUS TYPE OF POLICY ❑ EXTENDED POLICY NUMBER LIMIT OF LIABILITY ❑X POLICY TERM WORKERS COVERAGE AFFORDED UNDER WC EMPLOYERS LIABILITY COMPENSATION 11-1-98 WC1-111-252480-017 LAW OF THE FOLLOWING STATES: Bodily MA $500,000 Each Accident Bodily Injury By Disease _. 0.0, Policy 35 - ---:.._ - ----�-- - _ -- - - - ----- . _ 000 � Limit - Bodily Injury By Disease $500,000 Each Person GENERAL General Aggregate-Other than Products/Completed Operations LIABILITY ❑ OCCURRENCE Products/Completed Operations Aggregate ❑ CLAIMS MADE Bodily IniuiV and Property Damaqe Liability Per Occurrence Personal and Advertising Injury Pers ' 'n In'u Per Person/ RETRO DATE Organization Other Other AUTOMOBILE Each Accident-Single Limit LIABILITY B.I.and P.D.Combined ❑ OWNED Each Person ❑ NON-OWNED Each Accident or Occurrence HIRED Each Accident or Occurrence OTHER ADDITIONAL COMMENTS w If the certificate expiration data is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date. SPECIAL NOTICE-OHIO: ANY PERSON WHO,WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE INSURANCE AFFORDED Liberty Mutual Group UNDER THE ABOVE POLICIES UNTIL AT LEAST DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO: &4�;_A DONALD CAMPBELL LISA HIG S CERTIFICATE P.O. 137.1 AUTHORIZED REPRESENTATIVE HOLDER COTUIT, MA 02635 WESTWOOD (781)326-7100 OFFICE PHONE NUMBER DATE ISSUED \g This certificate is executed by LIBERTY MUTUAL GROUP as respects such insurance as is afforded by Those Companies BS 772L R2 1 O A/v _I " C(�/V ��IAI/1� ; �: 1 1 »x - _ �H- ^ 1 w•+� ..' .;:. .. _.. ., ._„1._ r' , - , .. ....._'# .f ...: }. .. - - � }.- -s.] '_ .mow ......r�� �..«....--. •.-•.4-.- S � /? .,.m.�......:.. .� NCl V r u L' 5,,,: ; �j' �� G2 hi`6`Q;✓/} .j:Z t' _r_r'v'i^ Qfi�E.�'CFJ Y�v�?i�' i ' , �. �. _ c ._. .' -..' ..+. a �E-..`... ._-. ;.�.. 1`_( r _ f __.� --•.1 Y-Y'_ j �$ t _•n{"'� w{ t• _ �_. `4.- � ��.". f tM { t .}._. � .. •. 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The Town of Barnstable • ,AWWAI t.E. • 9e '1 Department of Health Safety and Environmental Services rFc " Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. r • Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: /'Y"G 4!U A) Est. Cost Address of Work: s— Owner's Name „f Date of Permit Application: ��/ I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name ' � f ✓lee i�a�cvnzancuea`�o���L�liztsuclruJell�;: . ` Restricted To: 00 DEPARTMENT OF PUBLIC SAFETY 81011 .v" CONSTRUCTION SUPERVISOR LICENSE 00 - None Number:. Expires: 1G - 1 &2 Family Homes Restricted To: 00 Failure to possess a current edition of the Massachusetts State Buiilding Code DONALD G CAMPBELL is cause for revocation of this license. ,�,� ,t✓ 479 PUTMAN AVE/PO BOX 1371 W COTUIT, NA 01635 p•, y f I ME,QIMPRO NT;CONTRACTOR ` egistra on 08799 { i> ya U VJVUAL /y25/98 $� t DONAC MMMM NPBELL y , `? ,. Donald ,,rraapbetl Put a��Aye%PO Boz 1371 �\ .—ADM a W-ul( MA d2635 " „ � K;+. `1tW�J..W.$ i1y�W h.yW�' i' 1t l �^ �liy`• L.\ .:��! 7