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0028 LITTLE RIVER ROAD (2)
i �� Town .of arnstable Building ....�B TA }Post This Card So That it is Visible`From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept BAPINS ` iPosted Until Final Inspection Has Been Made. 163 Pey.1111t aa�° Where a Certificate of Occupancy is Required,such,Building shallNot,be Occupied until a Final Inspection has been made. Permit 1 Permit No. B-20-1341 Applicant Name: Russell Cazeault Approvals Date issued: 06/08/2020 Current Use: Structure Permit Type: Building-Addition/Alteration- Residential Expiration Date: 12/08/2020 Foundation: Location: 28 LITTLE RIVER ROAD,COTUIT Map/Lot:- 053-008 Zoning District: RF Sheathing: Owner on Record: PERRY,ARTHUR JR&KOZLOWSKI,JUDITH Contractor Name: PAUL J. CAZEAULT&SONS INC. Framing: 1 Address: 5310 PORTSMOUTH RD Contractor License: 103714 2 BETHESDA, MD 20816 T " Est Project Cost: $3,000.00 Chimney: Description: Replacing roof shingles on the oyster shack. Permit Fee: $85.00 t Insulation: Project Review Req: /A Fee Paid:,, $85.00 �u Date. 6/8/2020 Final: Plumbing/Gas r Rough Plumbing: �\.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. 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 Final Gas: 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: 1.Foundation or footing yN 2.Sheathing Inspection - _ _ a_ - - Rough: 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 MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT p,Lx�.,E iR TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION alr3, = od8' ���o/_ Map Parcel Application # �Y Health Division ��� .3 Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board u_ Historic - OKH _ Preservation / Hyannis Project Street Address .Z 9- L-i rt to Village P'jq Owner r ��i'/`v/ Address �� GiTI`/�� �' PU Telephone Permit Request 1 � �( y L� tw,1q S ,� -,T',e q �, � �� ( � Fw p A 0 /.�Te 4 Square feet: 1 st floor: existingR�20 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation c 0-0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: VVYes ❑ No On Old King's Highway: ❑Yes NNo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sgft) `� Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count- J Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑Other 1/01-49- €2 i i r i C13 =E 9 � Central Air: ❑Yes �lo Fireplaces: Existing New Existing wood coal stove: ❑,Yes ❑ No a w� Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size — Barn: ❑ existing =0 new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: , Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes No If yes, site plan review# Current.Use h� Je _. Proposed Use 0.5�>err APPLICANT INFORMATION (BUILDER OR HOMEOWNER) a Name. �'8 k i -e(e4 0otst-7— Telephone Number -hoar //,Z� ggc>o Address Po PDX- 07V License# ® ��G Home Improvement Contractor# 1 2_�>Y cDS' Worker's Compensation # C 1I ( ,-I 0 yI,?e ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO t SIGNATURE DATE S FOR OFFICIAL USE ONLY APPLICATION# r r DATE ISSUED 2 MAP/PARCEL NO. ADDRESS VILLAGE OWNER P DATE OF INSPECTION: FOUNDATION FRAME INSULATION x r FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL u GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ^F �. f The Commonwealth of Massachusem Department of Industrial Accidena Office of Inveskgatians 600 Washington Street Boston, MA 02111 ww►.massgov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep_ibly Name (Business/Organim ion/lndividban.- ��A—,m 1( dt rir�P / C� b1 Address: PO pax— ff�c9 O City/state/Zip:0 S/P�Vil V ' � Phone#: ,�,7� y 2 � Yq� Are you an employer?Check the appropriate bog: 4. I am a eneral contractor and I Type of project(required): . 1.[ I am a employer with �y ❑ general employees(full and/or part-time).* have hued the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. [ Remodeling ship and have no employees These sub-contractors have g Demolition working for me in any capacity. employees and have workers,' [No workers'comp,insurance comp.insurance,$ , 9. 0 Building addition required_] 1 5. [] We'are a corporation and its, 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their, 11, Plumbing repairs or additions myself [No workers' camp, right of exemption per MGL 12 hoof repairs cr,ra innce regizired.]t c. 152, §1(4), and we]lave no 0 employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they—doing all work and then hire outside contractors must submit a new affidavit indicating such, xContractors that check this box must arischFd an additional sheet showing the name of the sub-contractors and state whether or not those entities have: employees If the mb-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers compensaion insurance for my employees Below is the po&cy and job site informafion. Insurance Company Name: a e, Policy#or Self-ins.Lic.# (i D z Q7 Expiration Date: 2 G Job Site Address: 2 e w-(P City/State/Zip: lV re" � 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 imprisonme4 as well as civil penalties in the foan of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage yerification I do hereby ce under the pains and penalties of perjury that the information provided above is true and correct: Si tore: Date: �e Phone 2 Official use only, Do not write in this area to be completed by city or town offzciaL.. City or Town: Permit/License# Issuing Authority(cirtle.one): 1.Board of Health 2.Building DeP artment�.3' �3/Town Clerk . 4.Electrical Inspector 5.Plumbi n_ g Inspector 6. Other Contact Person: ,: w. Phone#: _ I '`` ; CERTIFICATE OF LIABILITY INSURANCE DATE /14//DD/Y1 L.:� 9/14/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION 1S WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer right to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Zach L nkiewic2 NAME: y Murray & MacDonald Insurance Services, Inc. PHOA/CNE (508)540-2400 FAX (508)ze9-4111 550 MacArthur Blvd. E-MAIL INSURERS AFFORDING COVERAGE NAIC# Bourne MA 02532 INSURERA:Interstate Fire & Casualty INSURED INSURERB:Safety Indemnity 3618 Kendall & Welch Construction Inc INSURERCAce Property & Casualty Ins 874 Main Street INSURER D: PO Box 490 INSURER$: Osterville MA 02655 INSURERF: COVERAGES CERTIFICATE NUMBER:11-12 Master GL REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rA TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS S POLICY NUMBER MM/DD MWDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 10O OOO X CLAIMS MADE F—IOCCUR PREMISES Fz occurrence $ r 1001869 /13/2011 6/13/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 B POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED x SCHEDULED 6207210 /4/2011 /4/2012 BODILY INJURY(Per accident) AUTOS AUTOS x HIRED AUTOS NON-OWNED PROPERTY DAMAGE g AUTOS Peracadent $ PIP-Basic $ 8,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NTORY LIMITS ER ANY PROPRIETOR/PARTNERlEXECUTIVE .�. - E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) 46402935 /6/2011 /6/2012 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 5OO 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION (508)79D-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Dept 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 C Finigan, CIC, CRM/C g — ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSO9.r%t9o1nn5i nt Tho Ar_nan name nnrl Innn nro ronicfororl morka of Ar r)Qn Fst+e r Town f B 'o o Barnstable , ti Regulatory Services • snaxsT,+si E 9 - Thomas F.Geiler,Director i639• �� �fo �a Building Division Tom Perry,Building Commissioner 20.0 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Us ing A Builder I, 40kefiew, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized bythis building permit application for: 2 LctIlo fi%fl-e- RAJ (Address of Job) Signature of Owne Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse. side. QTORMS:O WNERPERMISSION Town of Barnstable ��oFt�Teti o� Regulatory Services ST" Thomas F.Geiler,Director MASS. 1639• Building Division . ' �ArEb MA'I a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street. village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildingQermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt fVil»ssuchuscfCx•• i➢�quu'hucnt Ot•I►111)IiC tiufet�•. Boat'd of Building Regu-httions a-11d,S tit ttdut'ds Construction Supervisor Lieonse - License: CS 83484 RONALD W WEL`Ok ° 85 BRIGANTINE DR` HATCHVILLE,.MA 02.536 E„xpiratiolr 1/11/2012 ('nnwdssium r Trll: 29231 massachuscits- Department of Public Jufetv Board of iluiltlin;, Repulntions anti Standards Construction Supervisor License. License: CS 70086 DAMON L KENDALL 48 KOMPASS DRNp} FALMOUTH; MA 02636 Expiration: 11/21/2012 <'uonnl�wlun�r Trll: 9525 Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration s, ~ Registration: 128405 Type: Partnership Expiration: 4/5/2013 Tr# 211402 KENDALL & WELCH CONSTRUCTION. DAMON KENDALL t L 'j F.O. BOX 490 y , OSTERVILLE, MA 02655 Update Address and return card.Mark reason for change. -. Address 0 Renewal F1 Employment Lost Card IS-CAI ao 5OM-04/04-G101216 �'� 1°o�avnzaiu�real �'� Dd7Cd License or registration valid for individul,use onl Office of Consumer Affairs&B siness Regulation g Y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,..128405 Type: Office of Consumer Affairs and Business Regulation s Expiration: -41512013 Partnership 10 Park Plaza-Suite 5170 Boston,MA 02116 K N ALL&WELCHCONSTRU.CTI.ON DAMON KENDALL, =-ti 54 KOMPASS DR z FALMOUTH,MA02536 .°_r;. Undersecretary Not valid without signature __ I OrrI D � j,4 gA�re OA PLeT s lWA i 1 S WARD �� r ti 28 Little River Rd, Marstons Mills 11 /30/2011 yy !. �4 r Sx y 28 Little River Rd , Marstons Mills 11 /30/2011 I I i I l 28 Little River Rd, Marstons Mills 11/30/2011 x � 28 Little River Rd, Marstons Mills 11/30/2011 f I , 28 Little River Rd, Marstons Mills 11/30/2011 - - _ T ` 1 • A 1 1 ZtlALA a I �r 28 Little River Rd , Marstons Mills 11 /30/2011 28 Little River Rd, Marstons Mills 11/30/2011 x t Am� 7T X t i d%- 1 M mgq} i a r, r, v _ i 28 Little River Rd , Marstons Mills 11 /30/2011 4:; F v! 4 Or ` It ''l 28 Little River Rd , Marstons Mills 11 /30/2011 _ T I � I r , t. I t I t � !rl� 28 Little River Rd, Marstons Mills 11/30/2011 r � - -_ k� 1 28 Little River Rd , Marstons Mills 11 /30/2011 �i S •Y� I ' 1 r 28 Little River Rd , Marstons Mills 11 /30/2011 14>-77 6601 - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ®53 Parcel o® ib Application`# lxe g� Health Division Date Issued: Conservation Division Application Fee ,1 Tax Collector Permit Fees 0� Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address L 1 41 tee. 1 V e-rL ®AIJ Village + rZTs M 0 LA 1, Owner ACAAI�X✓ Ne r'A J r Address b 6 S71 te, Telephone 30 l _ Zz q M i Permit Request R e. co'A'.5` -(— c,'i' 1iy A PR I L ]? 7 SToAM AePoxf Mire �sizg- (o x /LA Square feet: 1 st floor:existing 0 proposed- r 2nd floor:existing proposed Total new Zoning District T_ Flood Plain �W I 6 Groundwater Overlay AP Project Valuation i Construction Type J-1 M 6 2- Lot Size ( F Grandfathered: ❑Yes L(No If yes, attach supporting documentation. Dwelling Type: Single Family cTTwo Family ❑ Multi-Family(#units) Age of Existing Structure I �tr� S I Historic House: ❑Yes *0 On Old King's Highway: ❑Yes )dNo Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing t new Number of Bedrooms: existing new _ Total Room Count(not including baths):existing new First Floor RoomCount = 2 Heat Type and Fuel ❑Gas ❑Oil ❑ Electric ❑Other 21 = Central Air: ❑Yes )kNo Fireplaces: Existing _ New _ Existing wood/co I stove:.a-p Ye"- "*S`No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑ isting Unew Size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: i Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes;` No If yes, site plan review# Current Use C-/0CV i 1 sqL 1-11O (S 6 Proposed Use - I -' � ✓1 � �� -ff61CL -- BUILDER INFORMATIO Name AR Hu/x. Telephone Number ZZ d h Address f dw-s lyC)(I r" License# 40/IC 6lu A/� �Z 8 A MD Z O (0 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO (0JA) AJ ® 1,4 // �" SIGNATURE DATE`-. - f . . . . { FOR OFFICIAL U SE ONLY ° / APPLCATIONf \ . { \ . \ \ \ / \ § \ \ / . • DATE ISSUED MAP/PARCELNO. / ADDRESS \ - VILLAGE 7 OWNER 7 . ƒ » • . DATE OF INSPECTION: ! J FOUNDATION k FRAME . . . ` INSULATION FIREPLACE ^ ' \ ELECTRICAL: ROUGH \ FINAL PLUMBING: ROUGH FINAL . \ GAS: ROUGH FINAL / FINAL BUILDING . . . . | • $ DATE CLOSED OUT . / ASSOCIATION PLAN NO. f ) . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibiy Name(Business/Organization/Individual):. AP_n:iu 2 �.er r„( rt- Address: 53io /0&&Md City/State/Zip: l A4Z Sdc,_• o�Jb�l'DPhone.#: Are you an employer? Check the appropriate box: -Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and I + have hired the sub-contractors 6. ❑New construction . . employees(full and/or part-time). • 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9 E]Building addition [No workers' comp.insurance comp.insurance. ' required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.[:1 Plumbing repairs or additions rnysel£ [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no . 11AOther 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. 1C6ntractors 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-contractor;have employees,they must providb their workers'comp.policynumber. I am an employer that is providing workers'compensation insurance for my employees Below isthe policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder a pains-and penalties of perjury that the information provided above is true rid correct Sienature: Date: . 1 _ Phone #: . eu)d 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 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 in. ance 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 bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone-and fax number:. The Commonwealth of Massachusetts Dcpa iment of Industrial Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia °FTME��y Town-of Barnstable Regulatory Services BARNSTABM " Thomas F.Geiler,Director 9 MASS. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax; 508-790-6230 Permit no. Date AFFIDAVIT HOME IMTROVEMENT 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: GQ(� l r —�®N 6 ► C W, Estimated Costh IMC) Address of Work: 2� L l 1TLe, R W OL R 16 ejj�J Owner's Name: Date of Application: 7//:7 I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑lob 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 IMPROti1VT WORK DO NOT HAVE r ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES.OF PERJURY Ihereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. to 07fLis Name Q:f=:homear5dav ofIKE, Town of Barnstable " Regulatory Services sAxtvsrAat a Thomas F.Geiler,Director MASS. F%39. - Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION A� Please Print DATE: t) JOB LOCATION: L i I r Lc- I vea- 00TU f number stress C� village "HOMEOWNER": A 1 �kur Z �� ! ""Z� 1 C)(Q 1 name ^ home phhone# work phone# CURRENT MAILING ADDRESS: i C) �)o Ille#SHQ LkTH /Z b i GHQ=SV--)( M 20 l ( city/town s to zip code The current exemption for"homeowners"was extended to include owner-occupied dwellines of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The under ' ed"homeowner"certifies that he/she understands the Town of Barnstable Building Department min im ion p52edures and requirements and that he/she will comply with said procedures and requ' Signature of Homeo er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S.EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. r To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt seynn Ka9s a P°e /an Fna g ce r e LEGEND: a edo� ,3 O Stone.Bound a CB/DH Concrete Bound Assessors Ref.: $� a°� -0 Gay Mop 53, Parcel 8 uoe.woo °` •. 9 ,Q O Utility Pole cemetery �, V sl pe ." Overhead Wire(s)vem Sewer Monhole Overlay District: water hlonhole AP - Aquifer Protection District iJJ .. �. ® Water Gate As Shown on Plan Entitled se/OW O /P Iron Pin "Revised Groundwater Protection t_:'------� Fna —0-0 Post k Rod Fence Overlay Districts'- April 1993 �SSIIIH —0-0 Board Fence n — — Flood Zone: -=_- Zone B, C. AI J(EL 12') ,�--.� y Rmevn & V17(ELIS)see plan. r`aibe Community Panel No. Location�I For Registry Use r is%� s�T— mac` �250oD1 0018 D L l Map 4J:?9 hJ`l July 2, 1992 f•-2000't Q'} v rr�D E fEgP 2 ` e " / FEMA Zone lines were 4q •��i 0 = digitized from FIRM Zpne• / .9B,y far 69 E- Panel g 250001 0018 0 RF-I SJ 4 ?Y/J 4 TAe ps 9 36 C F d (min.) ( ) FrontArea min. in) 15 SF RPOD �- - Width a(min) 150' � _FEuA.V17(ELI S') y Width(min)no e ; r: \ ��`"� P Ta•UL�Si�ecfove` t:hhy ire � /" �` Setbacks: .3 N 4 P office/ \cc / Front 30' • •se:,q- 'S3�8 - Side 15' o / Re 15' References: ces: 01meo, y7 Plan Book 104117 56171 277161 107/ill m N ro-Ron}n r n/N� 74J : u n` 70Br!o \'�� ref ca' *ro "��>R� ueon to.water LCC 8516 a MCW ♦ rna �_____�__ �) y`J/ yy �O FEMAI.1(L'LI7j lJO y1.20J 43,• fF __ _-._ - _ 1 certify to the best of my professional knowledge, information, and belief, that the property lines shown 30.00' .... - - existing ownerships, and se 1P2 hereon are the lines dividing g p !nit t Sty W/F / ueon reign water the lines of streets and ways shown are those of public owelGnq / l or private streets or ways already established, and no new lines for divimon of existing ownership ar for j `/J��.� new ways are shown. � °Ne `Ji �e JT• The above certification is intended to meet Registry of Deeds requirements and is not a certification to the Cd�CB n title or ownership of the property shown. Owners of V tsy, adjoining properties are shown according to current Town of Barnstable Assessors'records. -" JJ• xCl Tp fP I certify that this plan conforms to the rules and _ Fna regulations of the Registry of Deeds of the Commonwealth of Massachusetts. p3 Registered Land urveyor a Registered Land urveyar Title: PREPARED BY: PREPARED FOR. No tes/Re vision: Plan of Land at C a p e S u ry Arthur Perry&Judith Kozlowski 28 Little River Road in 1 T Barnstable r 7 Parker Road COtIDt Osterviue MA 02655 �i�°♦L (509)a20-3994/420-3995fa. °°°°5a «°° ° °Massachusets 30 0 IS Jo 60 120 Field: MHD/WHK/RRL Draft: WHK/RRL Date: a^ryI3 2OOJ Scale: '._r3Or Comp.: RHK/RRL Review: RRL ^Y r Proi k' C428.1 Drawing y C428-Igl Sketcl� Ala r D — � u+tla �►�cr Sul ►3 acso7 ' AGVA Ncrine ,Qonmctocs ,Irc.; Af NNN - ,� W I"W I..y_.I�ivinq %vi`1 6o� _'__ N N N 000 kmO O ^N ^wa aaa N CI{V MMM � F a R4, d• �. wh 1)ec1A Elea O;On = N.ot�.MUA.) act 70 5c41c pusw. Ck c- Spiit Cod,; sect,ccc) to pawl, Loith Ca) 3/4'' CG41v, "e.-A Bolt- eaclk Pu* , St6nCrm. 3%(S,*-ttwQ to split cats wit% 6) '/a"x Ia" Csalv,. pipt Pin eca Spur cap Deck' a"x b' - secuped t� 51rin�eCS with► Ca> Gclu. aoa ►JGdS per ►tltersection All ii,nber pnet6,ur'e -r� Cm,* Scat on a cb'DecL, 5ecurpb ui�th Cad clad�;ls fie!' to ` 00, • -3KS- split CAP 5eoumf__� , Wit', Ca) SA41,CC1V. hex 3 x8 ,Str;n4er5 Secured wa'ti (.)'la' ►a" bolt per fbgf W\), Dcivt.pin per 690- C4? 6 Y, Sr l')o • • s ' . ^ OF BARNSTABLE BUILDING PERMIT APPLICATION � TOWN � mk]pApplication # :Date Issued it Feel _7c) Planning,,Dept. "Perm Date Definitive Plan Approved by Planning Board Historic - OKH Preservation Hyannis Project Street Address � v/nugu Telephone � ^' | 1Gt ' 8x�t �nd � ' o��ue /���. /x/o/. u/ ������ xuuc emyung � |Ol8 n8vv . x Zoning District Fk]0dPh�� Overlay --�--_�-_ . ` \4dU8�nn Dwelling Type: Single Family ,_-,L1 Two Family LJ Multi-Family (# units) � Age of Existing Structure Historic House: Ll Yes Ll No On Old King ighwab� Ll��s Ll No Basement Type: Ll Full LJ Crawl LJ Walkout LJ Other Basement Finished Area (sq ) `s,i7nli NUnnb8r0f BathG: Fu|����tng� n8vv Hd� 8x�tnQ Number OfBedrooms: ` existing —new ' Total Room Count (not including ` baths): existing new First Floor Room Count Heat Type and Fuel: L3G@G 'LJ [)i| [lB8Cthc [J Other Central Air: LlYeG El No Flm9p|8C8G: Existing New _ ExiStingvvOOd/C08| GtOv8: L]Yes LJN0 Detached garage: LJ existing U n8xv size—Pool: L3HxGting U O8vv GiZ8 B8rD: Ll8xiGtiOg Un8vv Siz8___ /#t8Ch8d garage: LJ existing UnSvv size —Shed: U existing L3 new GiZ9 Other: ' Zoning Board Of Appeals Authorization 0 4npeal # ReCOrd8dLl COrnrn8rCi8| LJYeG $N0 if yes, site p|8D review# � � Current Use Proposed Use � APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name N(XYI A P C0Y1+rAC1P(_S JV4- Telephone N 0 umber MA-Sh OZ -e— M A- 6212�19 Home Improvement Contractor# !ntl N Akf' MfbALVJJ o,- Worker's Compensation # WC WS7- 2-E_ ALL CONSTRUCTIO EB R LTING FROM THIS PROJECT WILL BE TAKEN TO S ^ r f FOR OFFICIAL USE ONLYi, . APPLICATION# DATE ISSUED MAP/PARCEL NO. 4 ADDRESS VILLAGE OWNER -DATE OF INSPECTION: a FOUNDATION :3 FRAME ;a INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL h PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING y f DATE CLOSED OUT ASSOCIATION PLAN NO. .a i f �IMEte Town of Barnstable r Regulatory Services �="R" 'KAB& g" Thomas F. Geiler,Director 0 ;l►'0 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, A(- V.r PL,,T ) Z , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address.of Job) Signature of Owner Date A-v,4,LAr Pt 1-,f Vz'- Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RM S:O W N ERP E RM I S S ION Town of Barnstable Regulatory Services .� BARNSfABLE Thomas F.Geiler,Director 1639. ��� Building Division ArfD Ml►�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Tl-tree-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to-do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they,are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC Town of Barnstable Regulatory Services s�wsTes�s, >Haes Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section, If Using A Builder I, A6ayk/- Pcrr� la, ,as Owner of the subject property hereby authorize�N r'a nn c ����f/�C�� err to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) S)i G Signature of 090er V Date rf 1f" Z V � Print Name C. <`, _ If Property Owner is applying for permit please c plete-i~he ' Homeowners License Exemption Form on the reve a side. 3 co QTORMS:OWNERPERMIS SION The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /i Please Print Legibly Name (Business/OrganizatiorOndividual): AGM M��.r i r1-e: Cora a L &s I --r-nL Address: City/State/Zip: peg , MA 02JA ci Phone #: _50(2) y�'� - 8 � 1 kre you an employer?Check the appropriate box: Type of project(required): I am a employer with I_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ 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 working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.N Other_ 10CK comp. insurance required.] ' ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :)ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. ii A surance Company Name: A men C.A n tAt.� Ao is ss(.rt t.1 c-4e— Co dicy#or Self-ins.Lic.#: W C C905 - 3? \Z_ Expiration Date: 61 1 ZO 0 b Site Address: 21b Ll�1,L k,vex '( c� , City/State/Zip: 6664Gr1 MA Q 2(e33 ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). .ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a to 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for ins,jofflVcoverage verification. to hereby certify and e p sand penalties o perjury that the information provided above is true and correct ature: 2� Date: s tone#: — C 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 ' F MARINE CONTRACTORS, INC. r� 30 Echo Rd., Mashpee: MA 02649 [ , 508--177.890t FAX 508-477.8804 r '- - -.._!:^' :•' NXIM CONTRACT DATED: February 2,2009 PROJECT: Timber Pier Reconstruction LOCATION: 28 Little River Road Cotuit,MA OWNER: Mr. Arthur Perry,Jr. 5310 Portsmouth Road Bethesda, MD 20816-2929 SCOPE OF WORK: AGM Marine Contractors, Inc. proposes to furnish all labor, material and equipment to perform the following work: • Mobilization and demobilization of all materials and equipment necessary for construction. • Furnish and install all materials necessary to reconstruct a fixed timber pier consisting of a 4' x 26' walkway from the existing deck to a 16' x 18' pier head. Walkway and pier to be framed in a conventional pier fashion utilizing split caps, cross bracing and longitudinal stringers with transverse decking.Posts to consist of 4"x 4"CCA treated timbers, framing to consist of 3"x 8"CCA treated timbers and deck to consist of 2"x 6".ACQ treated timbers.All frame members to be either thru- bolted or drift pinned with hot dipped galvanized hardware and all decking to be secured with 3" long Stainless Steel screws. 6 , • Furnish and install a two level rail system along the North edge of the walkway and pier head(44' total length)consisting of a top level 2"x 4"rail and a 2"x 6"cap rail.Rail timbers to consist of ACQ treated timbers and be secured to the posts with Stainless Steel screws: ,CONTRACT DOCUMENTS: 1. Plan prepared by Sullivan Engineering,Inc.,titled"Sketch Plan—Proposed Modifications of Pier", with a latest revision date of June 25,2008,sheet 1 of 1 EXCLUSIONS: • Engineering or survey layout required for construction. • Any permits, licenses,fees or notifications that maybe required for this work and we are not asked to obtain. • Any work item not specified above. equal opportunity employer COST OF WORK: All of the above work will be completed in a substantial workmanlike manner for the lump.sum price of Twenty Four Thousand Seven Hundred Seventy Five($24,775.00)Dollars. Administrative costs associated with obtaining any permits required for the project to be billed at Seventy Five($75.00/hr)Dollars per Hour with direct expenses billed at cost plus 15%for overhead. DELAYS BY OWNER: Any delays encountered once equipment and men are on the job site resulting from a stoppage perpetuated by the owner or his representative will be charged at one thousand(S1,000.00)dollars per day. PAYMENT SCHEDULE: 1. Deposit due at signing S8,250.00 2. Mobilization to the site S8,250.00 3. Pier construction complete $8,275.00 4. Additional permit(s)—if required S Cost . * All invoices due in full within seven(7)days of issue^ rya �� ; 1 �t;'i� �!�� ,�,Lk, The entire amount of the contract is to be paid upon completion of the work. Any alteration or deviation from the scope of work specified above will be executed only upon written authorization for the same and the cost will be deducted from or added to the total sum quoted on this contract. All additional agreements must be in writing. AGM Marine Contractors, Inc. agrees to carry Worker's Compensation and Public Liability Insurance on the work to be performed under this contract. A Certificate of Insurance will be provided to the owner. Respectfu�ify.Submitted, AGM�M'aContractors, Inc. Jo a Mikutowicz,Project Manager ACCEPTANCE AGM Marine Contractors, Inc.is hereby authorized to furnish all the labor,materials and equipment to complete the work described in the above,proposal,for which the undersigned agrees to.pay the amount , stated in said proposal in accordance with the terms thereof Dated: i /d5 f Accepted: Printed Name: r ' n 1 AGM ar'n Contractors, In, PV seyow ae a tiEome Nin9° �-'Pone me L.r d I fn LEGEND: �4 d o� .� O Stone Bound A j r.V, o CB/DH Concrete Bound Assessors Ref.: o� O Guy Map 53, P-0 8 M o..... i t pert utility Pole cemerery y9 overhead hole Sewer Manhole Overlay District. e, ® Water Manhole AP- Aquifer Protection District ��OCUS- -- - � s Water Gate As Shown on Plan Entitled sB/De, r O /P Iron Pin 'Revised Groundwater Protection ` Cam_-_:==� me —0-0 Post&Rod Fence __ -� L se�H _o—a Overlay Districts'- Atari, 1993 3° l' Board Fence -. ` — — / ---_ - — — Flood Zone: -- = Zone B. C. A13(EL12') & V17(EL15').see plan. f"------" _ `'me Community Panel No. Location M For Registry Use < W m 15 s,,— E J250001 001E D .. - ; - v h ar•��`v�r 4JZ9 E tE�PPdE July 2. 1992 � CU P 1O EMh E 11 / FEMA Zone Lines were _ 9q. O 2 f AIJ( SJ,7 digilized from FIRM Zpne.. 9By./a]O9 E. .. Pon el,y 250001 0018 0 RF-1 Spz bJ 45. ]ne Rer / 4p`ts' meIp Are.(min.)87.120 SF(RPOO) - _ �+ "i 04; • f 756 U`NM / �fE*IA v�](EU5) - Frontsga(min) 150' Width (min)no bra MAW Sroc+ove /t ` Setbacks: P a,c'e/ Font 30' Sidet5' ( ro"rNw o w 3.1' / Reor 15' References: __ ^�`� \ n•.nee s,r NZ _ ,_ d/Sty°e Fen / •{! - Or„i bJ 93,E / °�® ° / . Plan Book 104/17 €ne \ W ° 56,171 277/61 N. 1071111 .. 0 ` ��N 247 %.M(y, an �M.-to.Water Yv LCC 8516 ra - J FEM AA,3(Lil2-T P7�P\\ �O.yz•zpJ 45 P�SI certify to F"a information,tandbbelief. that professional property Ines shown / _..-._... P s9 122 - hereon are the lines dividing existing ownerships, and =K't I sty w,T / uevn K;gn vole. the lines °/streets and ways shown are those ql public or private streets or ways already established• and o new lines for or of existing ownership or for new ways are shown. Coe ' _ J`'r- - - The above certification is intended to meet Registry rn (� of Deeds requirements and is not a certification to the c9�on _ - title or ownership or the property shown. Owners of V d s3, adjoining properties ore shown according to current Town / J of Barnstable Assessors'records. •Ilk, - �`P- 1p JJ- h/ rTp I certify Ene that this plan conforms to the rules and 'rl regulations of the Registry of Deeds of the Commonwealth JJy.. of Massachusetts. 78- pZ_ eg�stered Land Surveyor as Registered Land Surveyar Dote _ yo. Title: -' - PREPARED BY. PREPARED FOR: Notes/Revision: Plan of Land at C ap e S u n/ Arthur Perry&Judith Kozlowski 28 Little River Road in Barnstable (cotuit) il Parker Rood V Osterviile MA 02655 ° Massachusetts 506,4f0-39,, /Q.p...d toe Cop<Surv420-3 95f,. V r� 30 0 15 30 60 a i40 Field.' MHDIMIK/RRL Draft: WHK/RRL - Date: 4,pril3 tow Scale: ':_qOr Camp.:WHK/RRL Review: RRL ^Y x J Proi 16 C428J Orowin9 Ig C918_191 f .. � r�-��z•,,, �� �,�--•, ��.... '' ^`�-�.-,.a„ .�,--�-, ` ',' ���:,Erzl�,lt�..i i U 4t."t i.� n'131.�-Jri"1�I rli.t�i-���'�kl}I i4�.�,•'����C�i�t�_ �tlfltlltl {rsr-tlhh�l�3�1��5"s�� rt<` �*1 �: _,,, .`t•' r +" -F -ram l' '^ ^ .�` rw -.�„ .e' -A— Construction Superui'sor License License CS 84196 P Restricte �•� 00• - rT rr ,KF.� ��� �- . . - JONAH J MIKUTOWICZ 75 ANTHONY'ST r S DARTMOUTH, MA 02748 Expiration:' 11/25/2010 C' nu»i. ilirr Try:' 6051 r Restricted to: 00 00 - Unrestricted 1G - 1 2 Family Homes Failure to possess a current edition of the j Massachusetts State Building Code is cause for revocation of this license. r W�-�M CERTIFICATE OF LIABILITY INSURANCE Dii%z3jzo s PRObUCER (781) 295-0270 FAX (781) 246-7830 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION International Special Risks, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 50 Salem Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Building B, 3rd Floor Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIC# INSURED AGM Marine Contractors, Inc. INSURER A: St. Paul Fire & Marine Insurance Co. 30 Echo Road INSURERS: OneBeacon America Insurance Company Mashpee, MA 02649 INSURERc: American Home Assurance Co. INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDINt ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY OL069005 55 01/01/2009 01/01/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY _ DAMAGE TO RENTED $ 250,OO CLAIMS MADE a OCCUR MED EXP(Any one person) $ 5,00 A X S&A Pollution PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PROJECT LOC AUTOMOBILE LIABILITY 1E11303 01/01/2009 01/01/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ B X SCHEDULED AUTOS (Per person) X HIRED AUTOS - BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY OX06900281 01/01/2009 01/01/2010 EACH OCCURRENCE $ 1_0,000,000 OCCUR ❑ CLAIMS MADE AGGREGATE $ 10,000,000 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC005-38-5821 01/01/2009 01/01/2010 X I WCSTATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE INCLUDES USL&H E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? m E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 PT�JRand Protection & OX06902978 01/01/2009 01/01/2010 Hull Per Schedule on File A Indemnity $1,000,000 P&I Limit DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIALPROVISIONS C CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL I 67 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AG NTS OR RE,2 NTATIVES. AUTHORIZED REPRESENTATIVE Steve Mac uarrie ACORD 25(2001108) FAX: (508)775-0792 ©ACORD CORPORATION 1988 ` Massachusetts Department of Environmental Protection tt+e Bureau of Resource Protection -Wetlands °� '� DEP File Number: ' WPA Form 813 — Certificate of Compliance : .,, ..XX sE3-1719 f. Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 �0r�o'w„�r�0 Provided by DEP 41 � and Town of Barnstable Ordinances, Artidle XXVII A. Project Information Important: 1. This Certificate of Compliance is issued to: When fillino "fl forms on Ill" Cotuit Oyster Company, Inc. computer, Name only the tql c/o Down Cape Engineering key to movo Mailing Address your cursr-, do not usr' II CitylT outhport MA ' 02675 return key Cfty/T°wn State Zip Code 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Cotuit Oyster Company, Inc: Name Sill 1/4/88 S E3-1719 Dated DEP File Number 3. The project site is located at: ' 28 Little River Road Cotuit _ Street Address Village 053 008 Assessors Map Number Assessors Parcel Number the final Order of Condition was recorded at the Barnstable County Registry of Deeds for: Property Owner(if different) Barnstable transaction#01278 on 1/8/88 County Book Page DOC: Certificate 4. A site inspection was made on: 9/30/2002 Date B. Certification Check all that apply: ® Complete Certification: It is.hereby certified that the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. ❑ Partial Certification: It is hereby certified that only the following portions of work regulated by the above-referenced Order of Conditions have been satisfactorily completed.The project areas or work subject to this partial certification that have been completed and are released from this Order are: WPA form an Page f of 7 Rev.02100 Town of Bamstable Rev.07M6/01 f Massachusetts Department of Environmental Protection tom. Bureau of Resource Protection -Wetlands °` ::.°" DEP File Number. WPA Form 8B -- Certificate of Compliance su3-1719 • Q�Q11Cf.Q/P i Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP �Fo and Town of Barnstable Ordinances, Article XXVII B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above-referenced Order of Conditions never commenced.The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Special Condition Numbers: see attached page 4 C. Authorization on Issued by: ° Town of Barnstable Conservation Commission Date of Issuance This Certificate must be signed by a majority of the Conservation Commission and a copy sent to the applicant and appropriate DEP Regional Office (See Appendix A). Signatures: 6 On Of oc / �aG� Day Month and Year before me personally appeared AIM S' LAN to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/ executed the same s `s/her free act and deed. Norfy 1504My commission expires WPA Form 88 Page 2 017 Rev.07J00 Town of Bamstable Rev.07rosmI Town of Barnstable Conservation Commission Main 200: a Street It :BAM mass:..::" Hyannis Massachusetts 02601 Office: 508-862-3093 FAX: 508-778-24.12 Attachment to WPA Form 8B - Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. 131, 440 and Town of Barnstable Ordinance, Article XXVII B. Certification Ongoing Conditions (continued from page 2) The pier may be maintained (without refiling) for a period not to exceed the term of the Chapter 91 Waterways license currently in force (or forthcoming, if none exists). All maintenance and use shall conform with the Order of Conditions, approved plan, and the Commission's Pier Compliance & Maintenance Regulations. The Conservation Commission (508-862-4093) shall be given two weeks notice of future maintenance. Note on Site Plan Sept.18,1987 and Revised Nov:20: "All timber untreated. Structure adequate for aquaculture operations." Issued To: Cotuit Ovster Companv, Inc. DEP File Number: SE3-1719 Page 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands Q OEP File Number: WPA Form 8113 — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131 §40 SE3-1719 ...NA93 E and Town of Barnstable Ordinances, Article XXVII0 `�� Provided by OE? D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. ------------------------------------------------------------------------------------------------------------------------------- To: Town of Barnstable Conservation Commission Please be advised that the Certificate of Compliance for the project at: 28 Little River Road, Cotuit, MA SE3-1719 Project Locaticn DEP File Number Has been recorded at the Registry of Deeds of: Barnstable County for: Property Owner and has been noted in the chain of title of the affected property on: f b Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land,_the document number which identifies this transaction is: Document Number Signature of Applicant WPA For,613 - - - - Rev.02/00 Town of SamstaDle Rev.07106l0I Page 3 of lei.(508)362-4541 939 main street rt 6a 7nn fax(508)362-9880, Yarmouth port /- mass02675 down cope engineering civil engineers& land surveyors tructural design October 9 2002 j � Arne H.Ojala P.E.,P.L.S. Daniel A.Ojala.P.L.S. tnd court Fred Stepanis, Conservation Assistant r ! othy H.Covell•P.L.S. irveysBarnstable Conservation Commission200 Main Streetto planning Hyannis, MA 02601 ! OGT2 j Re: SE3-1719 Cotuit Oyster Co. .wage system 4TI^ esigns Dear Mr. Stepanis: ispections Enclosed, as per your suggested request, is a revised plan for the above-referenced 1 project. !rmits Deviations from the approved plan include a 6'x 9' platform which is attached to the permitted 6' x 12' platform and a 4"x 4" post. The plan has been corrected in regard to the parcel number and the width of the pier (we had shown the width as 4', which included the posts - the platform is actually 3'). The unpermitted float mentioned is not.on this property. Enclosed is the requested $25.00 revised plan fee. Very truly yours, �/ APPROVED PLAN Arne H. Ojala, PE, PLS Down Cape Engineering, Inc. �S C:�� cc: Joyce Moore a ,/��t%L� C1� GCS C�� :� •:,.,... 7L1 OCT 15 2002 ��� � D ATE fDec 30 2008 15:03 Law Office of M. Ford 508-430-9979 p. 2 Town of Barnstable �— t Conservation Commission Form M ru.a 200 Main Street *�► Hyannis Massachusetts 02601 Office: 508-862-4093 E-mail: conservation@tow•n.barnstable.ma-us FAX: 508-778-2412 Pier Maintenance Form for Marine Contractors Regairernents for Pier Maintenance for Permitted Permanent Piers As a marine contractor doing business within the Town of Barnstable, you are expected to cctnply with the following requirements for mainterance of Docks or piers and their msociated structures. Please uornplete and return to the Conservation office prior to work. When considering maintenance work: II (( (� r 1 Applicant(File)Name: >�t l i)tlZ l 0 �J What is the permit number? SE3- } r/ CUSt0MCTNaMr;Ad_kr 1 Verify that a Certificate of Compliance was issued for the structure.If no Certificate x sts, no u 1 maintenance may be performed. ICJ Review the approved pier plan.To be sure,back-check with the approved plan date in the Order of Conditions. Notify Conservation Division staff of any deviations between the approved pian and the existing structure. If the above conditions are satisfied,move on to... ❑ Notify Natural Resources Division of your intent to perform maintenance and give them an accurate.start-up date. Provide the Conservation Division with an accurate start-up date for your maintenance work. Date: 042od / ❑ Comply with all conditions in the Order of Conditions and Certificate of Complianoc. ❑ Comply with the approved plan. Remember: Where as-built pier footprints are in conflict with the approved plan or special conditions,approved plans and conditions shall govern ❑ Of special note: A. No creosote-treated wood allowed;CCA-treated wood only for large- diameter pilings and structural timber B. Pilings driven;jetting only for initial pilot hole , C. Work raid-tides and higher to avoid grounding D. Deck plank spacing%a",not less E. No lead ca pilings Please call us at 508-862r4093 for assi verification. Thank you for your cooperation. AGM Martnc 0on►rcatocstTilc. csoa>'+'t'1.8BoI �a 3t o8 Business flame on tor's Signature Phone Number Date 0.'ConscrvLIDETPORINSVorm Kdai , rcv.,iv AUG'-eoa LEGEND o - 4"X4" POST UNLESS OTHERWISE NOTED PLATFORM 6' X 9' WOOD STEP 3' WIDE WOOD DOCK WOOD PLATFORM 29.20' EXISTING OFFICE 44.00' /AND SH61P 4"X6" /WOOD FRAME �� ._ 'o POST, j2-4"X4'' �° B ui POSTS 15.40' WOOD 4 X4 4"X6.. PLATFORM POST POST . 1-2"X6"POST 6' X 2-2"X4" POSTS 12' 1-4"X6" POST APPROVED PLAN .......L.�c°° �- 20 p 20 40 SITE PLAN SCALE.-. 1"= f0' DATE.• AUGUST 27, 20( OF 28 LITTLE : RIVER ROAD REVISED °f 80. 2002 - FIX PARCEL. A IN THE TOWN OF: "'qs IN CO T UI T, MA a >: � a 0 PREPARED FOR: JOYCL' MOORLE, TRS. 02-008 SARAH RUSSELL GIFFORD TRUST AR N ,ca E., ,P.L.s. DATE C �. •, , \� .�,. a�•r arm :.•�---�' �J lrr \. / IOUN fop 3yG 10 «� a G OSS -L t R � A Ze Mrw:a.o -/.o . . .rxi�'w.ovvoc,cx t� 1 r WO& icoTfOf1W 0 1 4 G 6 ff6T. f U l (aT�/yo.v.0.trJ o / ivca co -s�� E6n g10py T.4T/On/A,r ZX/D .N.Of►�•l-G ,r.r 4e POSTS zXrrl �'Y/Q• � - CrrPl a r, a 1 . t G 1 ."Ar. O.GIE• ,7• Z Z- ��1,`• ,OL! CAf f LNG/ti',E�R/NG •,,. '09 N4�PBOR TOAD - •x'' ,VYIVMA//S. WtSS: PC.0�/ /J'CCO�fPANy�NG /°fl/T/4N of c-oryir orar� o. iwc. \1A TO M4/•VrO%N A - X/ST/.VO H X/2' wd0O ' P4Arfo/stit: wood oo�t° /�'�ia' W0,0 Pt.S7lfGLlM(.0'LL SPAT/GW.ORYJ/.v.4�i/O DYl•� _ _ Q rNO W.4,?nt3 oF<GOTU/T DA B/,y co//l/I, MAss, scoLF."R.SA110/1-0 /!/LY /F /!��► 50E 420.3151 r'gGc:01 NOV 26 2001 15:31 NOTES Soundings Based on MLW Datum. 0 N/ �Install 2"x 4°Handrail on North Side of �. I�F�D F Tjye P Ramp 6 North�a West Side of Pier.Top of y Living Tr FMcKe/% E Railing tobe.3-0 Above Decking. r Est Joist,,Str.ingers 8,Cross Bracing to be a 3 x 8 Construction.5, �23 /�A: W � I Ar a S/ ysle�ComPony�/riC..22 fo tNHW. . �'/FBui/digg / 44' rn � PLAN VIEW o Scale- 1°=30� / / �8, C ..) mot/ D 44' Total 4' x 26' Timber Ramp 16' x 18' Timber Pier 6 x 12 2 Bents(d)5 =10 2 Bents (a�-8 16, 2 Bents .� 9� = 18, Deck 2°x4°Handrail W/ 2„ 6„C 2"x6"Decking,3/4 x ap . w o; Min.Spacing See Note Above c .2°x 10°Facia board. Al I Around Pier cr- . ' EL.5.5 U_.m MH.W 2.8 SKETCH PLAN SED MODIFICATION 0 PROPO F PIER . �.� 28 LITTLE RIVER ROAD MLW 0.0 Existing ,� a COTUITORMASS. Grade .6 x 8 Timber Post — PERRY,JR. d PROFILE (Ty�.) IS Required. ° ' ARTHT • JUDITH KOZLOWSKI Scale: 1/B�_ 1 ,_ou SCALE AS SHOWN DATE:JUNE 25,2008 SULLIVAN ENGINEERING INC. OSTERVI LLE,MASS. Page 1 of 1 John O'Dea From: Jonah Mikutowicz Uonah.mikutowicz@agmmarine.comj Sent: Thursday, May 07, 2009 4:00 PM To: 'John O'Dea' Subject: Perry Pier Permit Attachments: Permit Items.pdf Jonah Mikutowicz AGM Marine Contractors, Inc. Office: 30 Echo Road Mashpee, MA 02649 Yard: 7 Fish Island New Bedford, MA 02740 (508)477-8801 —office (508)477-8804—fax - (508) 776-9759-cell . Y 5/8/2009 e oFzKKEr Town of Barnstable *Permit# 0 Expires 6 mo hs j.o ssue dal Regulatory Services Fee L(f w BARNSTABLE, - - 9Q Mass Thomas F. Geiler,Director D i639• �0 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street Hyannis, MA 02601 www.tow.n.barnstable.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 Property Address .L ES / J 6.l J WResidential Value of Work -Minimum fee of$35.00 for work under$6000.00 . Owner's Name&Address. _[ rq Contractor's Name Telephone Number 17oF- �J �?�'�� C)O© Home Improvement Contractor License#(if applicable) Construction Supervisor's License'#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor c t s ❑ 1 am the Homeowner rt;,.�. .� E A# ;,. I have Worker's Compensation Insurance _ Insurance Company Name w ,r C Gl'Sl' (i Workman's Comp. Policy#' C-6/ Copy of Insurance Compliance Certificate must accompany each permit: Permit Request(check box) 15"e-roof hurricane nailed (stripping old shingles) All construction debris will be ( )( . PP g g. ) ❑ Re-roof(hurricane nailed)(notstri-ping. Going over existing layers of roof) Re-side #of doors.,.,L Replacement Windows/doors/sliders. U-Value` (maxim ur4.,.j,#of windows. *Where required:-Issuance of this permit does not exempt compliance with other town department regulations,i.e:`Historic,Conservation,etc:_ ***Note:` Property Owner must sign Property Owner Letter of Permission: A copy of the Home Improvement Contractors License & Construction Supervisors License is g required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc' Revised"072110 ; 7 The Commonwealth of Massachusetts r I Department of Industrial Accidents I Office of Investigations 600 Washington Street_ l 1t111s - - u e Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print.Legibly Name (Business Organization/Individual):: .Address: : 0 190k �"v City/State/Zip: J�p, tiJ I e- Phone#: 51,0 'I r-A L Are�y u an employer?Check the appropriate x: Type of project(required): 1.V I am a employer with - _ 41NWm a general contractor and I 6. 0 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. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition ' [No workers' comp. insurance 5: ❑ We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3.0 I am a homeowner doing all work,. right of exemption per MGL 1 LE] Plumbing repairs or additions myself. [Novorkers' comp. c. 152, §](4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' . 13.0`Other comp.insurance required.] *Any applicant that checks box#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 their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicyand job site information.. Insurance Company Name: e- '` nZ C Policy#or Self-ins. Lic.#: �, °Z 2 Sj Z Expiration Date: �. G Job Site Address: �- L i /4,40 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. ]52 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator; Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance'coverage verification. I do hereby certify under the pains and penalties of perjury th he information provided above is true and correct. Si ature: T Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority.(circle'one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6.Other i r 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 renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states."Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of.this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is Tequired. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department_of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition., an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy 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 Ravicar� S_7Fi_(1S .-- 02/09/2011 10: 11 FAX 5085635587 MURRAY&MACDONALD 16 001/001 •a►coRo CERTIFICATE OF LIABILITY INSURANCE OATe(MM,°DrYrrY> 2/8/2011 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(Iee)must be endorsed. If SUBROGATION 19 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER 12Zaah Lynkieoricz Murray & MacDonald Insurance 9ervicea, Inc. PH NE • (508)540-2400 FAx (600)209_4112, 5-90 MacArthur Blvd. -MAIL . PKODUC R 9OD144GO' - - Bourne MA 02532 _" INSURERM AFFORDING COVERAGE NAIC4 INSURED INSURER A:gi=61IIan'8 Fund In9 CO -INQU.RER8iS9Lf8tY indellllinitX 3361e Kendall & Welch COnatruction Inc INSURER C ACE Pro_perty & Casualty ins 874 Main .Street - - INSURER b PO Box 490 INSURERE: Onterville MA 02655 COVERAGES CERTIFICATE NUMBER:10-11 Maater GL REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBR AUDL SUERMMIDDr JjL TYPE OF INSURANCE POLICY NUMBER Ppucr EPP YYYI POLICY IMMIDDrYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTEIT X COMMERCIAL GENERAL LIABILITY S 50,000 A X CLAIMS-MAOE1:1 OCCUR LHai00003143 6/13/2010. 6/13/2011 MED EXP A ny oneperson) S 51000 _ PERSONAL&ADV INJURY S 11 000,000 GENERAL AGGREGATE i 2,000,000 GEN`L AGGREGATE 41MIT APPLIES PER; PRODUCTS-COMP/OP AGO 1 1,000,000 X POLICY 7 PR LOC 6 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Es accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per perecn) S B ALL OWNED AUTOS 6207210 8/4/2010 B/4/2011 BODILY INJURY(Per ewWent) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per aceldent) $ X NON-O%WFOAUTOS PIP.pado $ 9,000 Undedneured molorlst Bl epllt S 250,000 UuBR@LLA LIAB OCCUR- EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE S DEDUCTIBLE , $ RETENTION— C WORKER$COMPENSATION I WC STATU• OT11• CRYFR AND EMPLOYERS'LIABILITY YIN M ANY PROPRIETORIPARTNERIEXECUTIVE ESL.EACH ACCIDENT Ill 500 OOO OFFICERIMEMBEREXCLUDE07 ❑ NIA d6262512 /6/201112 /6/201212 (Mandatory In NW) #. EL.--DISEASE-EA EMPLOYEE S 500,000 Ity n essence under ' DEfidRIPTION OF OPERATIONS below ' E,1.,DISEASE-POLICY LIMIT S 500,000 DEscRIPnoN OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION (508)759.6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of-BarnstableACCORDANCE WITH THE POLICY PROVISIONS. ]Building Dept 200 Main 9t - _ AUTHORIZED REPRESENTATIVE _ Hyannis, MA 02601, .. ACORD 26(2009/09) 01980-2009 ACORD CORPORATION. All rights reserved. - u.wwwn TMw.AN %I2r%.-i--m-A I--- -1.0 -PA 1-wF A&AOrl THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M P�c� C DATA 4 IKEr `own .of Barnstable ., !� / 1 FZegulatory Services ' .'n�xrrsrAs_ Tt-mas F. Geilzr, Director ,Z �63¢ .�; .:i dzro: Divisiolz. . 1 arh Perry, Commissioner EGG Mai S�cet, ?y��is,'i. 0260:_ it vw-tow `-�rastable.rna..us _ Fax: 502-790-6230 O �C8 Prcpe Tiet Lis J Camp eteDara�i Sign T� s Sec i ou 1 : Owner of the subject p!operty o a,,:t on:-ny bet a f>.. la a-: :=li'` .. 1��.JtTi� to worms aut�h.o:,l�Q >ezmit applicklEUI1 OC - - - aTf:SS OIJ" G� Date ro�e'rrv:, �eris a ling for r,erritjpl,ease complete the l_ P Y' P P H rreourners.License_Exemption Form-on the -rewrse side. r =' •i N .. Mass;tchu etts,- Department of Public`Safetv R'`r8*otoma,rd., o°l B�u,i ldi,ng tSConstrucon, Ru,e peurvlaistioo*r m•', L:iEcnedn'Sste.i, '01PZense: CS 834847' ndardti `RONALD�/VWEL'CHrt�t IT, UZI- v85 BRIGANTINE DRY ¢ tHATCHVILLE` MAfit22536 � } � •*� � R�r EapiiaUon: 7/11/2012 , C'ummicsi�inci: Tr#: 29231- Massaehusett.s- Department Of Public Safety Board of Buildino, Re mlations and$tamhwds Construction.Supervisor License License: CS 70086 ' DAMON L KENDALL * ` . 48 KOMPASS�DR r k: `' i FALMOUTH4�°MA d25 6 Expiration: 11/21/2012 -Te#. .9525' ' ` -3 'mob ...�•. -. .. Boar o ui din e ulaton n g g s a tan ar s One Ashburton Place - Room 1301 Boston, Massachusetts'02108 Home Improvement Contractor Registration Registration: 128405 Type: .Partnership Expiration: 4/5/2011 . Tr# 282001 KENDALL & WELCH CONSTRUCTION.' ,- DAMON KENDALL P.O. BOX 490 OSTERVILLE, MA 02655 Update'Address and return card.Mark reason for change. C Address ❑ Renewal 17 Employment F_, Lost Card S-CA1 0 40M-08108-DBSLIFORMCA108212008 Board of Building Regulatio sand Standards- License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:- 128405 Board-of Building Regulations and Standards- Expiration .4/5/2011 1 Tr# 282001 One Ashburton Place Rm 1301 Type Partnership Boston,Ma.02108 KENDALL&WELCH CONSTRUCTION r DAMON KENDALL 'r 54 KOMPASS DR. FALMOUTH,MA 0252 :'' ,j Administrator " Not valid without signature 6771 Board of Building Regula ions and.Standards One Ashburton Place - Room�1301 Boston. Massachusetts 02108 Home Improvement'„Contractor Registration Registration:° 128405 Type: " Supplement Card - Expiration: 4/5/2011 KENDALL & WELCH CONSTRUCTION RONALD WELCH 54 KOMPASS DR. ----- ------ --- - FALMOUTH,,MA 02536 Update Address and return card.Mark reason for change. I-i..Address Renewal _ Employment, j Lost Card i-CA1 0 50M-04/04-GG�1012166p `� ✓fte iJo�mintootcu o�.. ucftet6e�6 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Re tstraton. Board ofBuil ding-Regulations and Standards 9 128405 One Ashburton Place Rm 1301 Expiration 4/5/,2011 Boston,Ma.02108 Type Supplement Card KENDALL&WELCH CONSTRUC I =�