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0878 MAIN STREET (COTUIT)
�00 f f� iI 7 'f i I i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -374 Map 3S 4 Parcel �� . 7 C/' Permit# J Health Division �'r�9 /�UU �J //��Ol�� � Date Issued 23 Conservation Division ` + ��VL i. Fee Tax Collector - SEPTIC SYSTEM MUST BE Treasurer-3 INSTALLED IN COMPLIANCE Planning Dept. WITH TITLE 5 ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN REGULATIONS Historic-OKH Preservation/Hyannis 0 Project Street Address' ��>�✓ S� /J r Village Gd77�i i r 8 Owner 6P444,e) AEXS1Zi/!/ Address `5 A,0rn—�` : Telephone ` : r Permit Request f�eV_ ' ?652&4 __� Vo 4e;44v6,6 5'1ZF _e�-AP DF ,�c�F. ago ®Q u'/ix/aeu/S �o . Square feet: 1st floor:existing, 3eo. proposed 2nd,floor:existing : © proposed O Total new Estimated Project Cosr&S O Zoning District Flood Plain Groundwater Overlay Construction Type f2 4t,0074 Lot Size /t / tom Grandfathered: ;rYes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family ❑ Two Family O Multi-Family(#units) aEifiefi' /Sbsi,SF x Age of Existing Structure/7�-P & 2WS Historic House: ❑Yes 4rNo, On Old King's Highway: ❑Yes r No Basement Type: ❑Full ❑Crawl ' ❑Walkout drOther Basement Finished Area(sq.ft.) ' Basement Unfinished Area(sq.ft) D Number of Baths: Full: existing ' : d new O Half: existing O new Number of Bedrooms: existing D new F; Total Room Count(not including baths): existing / new. O First Floor Room Count Heat Type and Fuel:y ❑Gas . ❑Oil ❑ Electric ❑Other /WD Central Air: ❑Yes 0o Fireplaces: Existing D New Existing wood/coal stove: ❑Yes Aho „ Detached garage: ❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size { Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other �/�1',/`i� Zoning Board of Appeals Authorization ❑ Appeal# 4 ' ' Recorded❑ Commercial ❑Yes VQo If yes, site plan�revieuv#* Current Proposed Use a -�-- BUILDER INFORMATION �/Name ol/N �E/ /�/� Telephone Number- Address ��S� S��vyw ./ i✓E License# a 2 Z /-mot dU ^41 f/C Home Improvement Contractor# Worker's Compensation# T"C ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO�mr�.tv6 � cld F��L SIGNATURE DATE /O /,-3 FOR OFFICIAL USE ONLY f• 1, A t tL a F $ � PERMI NO. .,. 43 41 - - } ik DATE ISSUED MAP/PARCEL NO. ADDRESS �'' ` } VILLAGE OWNER AT DATE OF INSPECTION: •_ ' ' r :� FOUNDATION- FRAME INSULATION FIREPLACE l ELECTRICAL: ROUGH t•' FINAL rg f 4 PLUMBING: ROUGH -, FINAL UGAS: ROUGH F! ?t FINAL.. • FINAL BUILDING DATE CLOSED OUT ASSOCIATION'PLAN NO. Eta a Engineering Dept. (3rd floor) Map 35 Parcel 7 8- Permit# I' OEM House# Date Issued q' f b 13oard of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee #/q A16 - 00 Conservation Office (4th floor)(8:30-9:30/1:00 2:00) cdAcl Q.6—& pl c - Planning Dept. (1st floor/School Admin. Bldg.) THE rq 3 Definitive Plan Approved by Planning Board N Al "1 19 tf; RNSTABLE. ` MASS j , Y�3eYvG--� a�Yt 'ti '_• ,, ;-� c��'atr� �������C;�m 1�9r���' TO BARNS<T Building Permit Application VOTH T61TLy *y \ Proje Address 8 7 8 Main street `, _ i�� � � `tl"41T ALC�Zb i� . tiw a Village Cotuit, Massachusetts i . Owner Gerald Epstein Address 4 Wheel"house Lane , Mashpee, MA (508) 477-3774 TelephonePermit Request For a 2-12 story wood frame residence and removal of existing 2 story home . Yarosh Associates Architect Plan # 864 . First Floor 3512 square feet Second Floor 2 0 6 5 square feet Construction Type Wood Frame 5 B Estimated Project Cost $ 400, 000 Zoning District R F Flood Plain C/v i i Water Protection Lot Size 119 , 067 s . f. Grandfathered ❑Yes ❑No .P Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 30 Historic House ❑Yes X6 No . On Old King's Highway ❑Yes UNo Basement Type: ®Full ®Crawl ❑Walkout ®Other Partial Basement Finished Area(sq.ft.) 0 Basement Unfinished Area(sq.ft) 3 , 0 0 0 f Number of Baths: Full: Existing N/A New 4 Half: Existing N/A New 1 No. of Bedrooms: Existing N/A New 5 Total Room Count(not including baths): Existing N/A New 11 First Floor Room Count 7 Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air U Yes ❑No Fireplaces: Existing N/A New 1 Existing wood/coal stove ❑Yes X ]No Garage: ❑Detached(size) Other Detached Structures: ®Pool(size) 18 x 38 "w ) M Attached(size) 24 x 36 (3 car ❑Barn.(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded LJ Commercial ❑Yes UNo If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# s NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATEZ 7-10 —C7 BUILDING PERMIT DENIED FOR HE FOLLOWING REASON(S) �4 \ 'sot` ✓ 4 r i .. r. ' 'd! ec a.,r ."!, i ) iY.«..�. /t/�/—�� t q;: t• rl` t � ar!...•. e. Y {. • ! r " r ♦ e j r t. I x e. �'� •t a ` .. a ^ 1� { r .. • A r i i 'rya. a ! j E, 1 f+.• .. 1 s/ � t _ « ... r..«.».. ,.a. �.......-,r+''. W' Mt �• F r� fi..r L:b ' «r l ! �tv_ .. a•. r 1 - r �r r � r L - • a�� « - % ice. l a . .. - \ ', i The Town of Barnstable M �g Department of Health Safety and Environmental Services t639.+ Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner i Inspection Correction Notice I Type of Inspection Location t Permit Number � c', 1 �(Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: �s --�-11=� ✓ Ill �. S ro 1 V -6 1, C. C. u i - to Pal Please call: 508-790-6227 for re-inspection. �V�y 0 _ Inspected by � GV 7 Date L �f' "(-� v(,.v LP 1 6 ('e'- INE i The Town of Barnstable BARNSTABLE.g Department of Health Safety and Environmental Services MASS. t639 ♦0 Eoy° Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection v Location Permit Number Owner Builder One notice to remain on jobsite,,one notice on file in Building Department. r The following items need correcting: \\I VAS U�J Y Lk U ► mac, �L& 6 U -W P u r r ��Lk e n eA, L aO -A,-vim `fu J s iPlease call: 508-790-6227 for re-inspection. Inspected by Date `Assessor's Office..(lst floor) Map /J�L�S Lot . Z Permit# 5 5� Conservation Office(4th floor) i' plo,y I G ?\u Date.Issued I �J Board of Health(3rd floor)(8:30-9:30/1:00-2:00) Fee a Engineering Dept.(3rd floor) House#1 70%5 �� + �J � �,• De _ , e,�,. �, -_. - N. �t 19 6 r J s TOWN OF BARNSTABLE h a Building Permit Application J eet Address X-3 1 MaN, ) !i�;3 Village f Owner GeQs-,\6 Address' Telephone Permit Request QOXVO npU,,,n, OCI Total 1 Story Area(include 1 story.-.,garages&decks) square feet r Total 2 Story Area(total of 1st&2nd stories) square feet ce.) Estimated Project Cost $ O001 Zoning District Flood Plain Water Protection Lot Size `\0\,Qko`l Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use I Proposed Use Construction Type CONxSt u3i61\ Commercial Residential �1 Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached Barn y None Sheds Other Builder Information `Name �N Ci`(1�t� �SLGJ �e Qrn\-. CCA s2 P _ Telephone Number___6&3-�918— Address License# CYIP 12-a 1 S O-Lxol`� Home Improvement Contractor# Worker's Compensation# CQQ. WC k W)tbC#3G NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURESrRES OT. ALL CONSTRUCTION DE RLT G R rIS PROJECT WILL BE TAKEN TO SIGNATURE DATE tO I Z(n 1C1 BUILDING PERMIT DEI IED FOR THE F L 9 REASON(S) FOR OFFICIAL USE ONLY — PERMIT`NO. r DATE ISSUED MAP/PARCEL NOS ! ADDRESS b. VILLAGE OWNER , DATE OF INSPECTION: FOUNDATION t FRAME INSULATION F FIREPLACEi j ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r a DATE CLOSED OUT f ASSOCIATION PLAN NO. B _I T S N M ' N W / Y t { A L1 _ V ti F i S { K 450. t it h- `14. IMPORTANT: a f Mandatory safety rope and float 12"from transition I , ., 16x32 16x35 18x37 2@x4O ` 16'6" 16'6" 17'107/8 20'83/a" 1 4 B; 32'6" 35'6" 36'107/8' 39'83/4" �+ 3,4„ 3,4,, 3,4„ 3,4„ i p, 8,0„ 8,0„ 8,0,> g 01. _ 8,9„ 11,9" 13'17/8" 11'113/4" 7 ` 13'6" 13'6" 13'6" 13'6" G7 6,3„ 6'3„ 6'3" t 10'3 4,0„ 4,0„ 4,0„ t 4,0„ i 4,011 4,0„ 4,0„ I 4,0,E t 8'6" 8'6" 9'10'/8" 12'83/4" 4'81/4" 4'81/4" 48 1/a " 4'81/4" r { M , 4,0„ 4,0„ 4,0�,`,. 4,0„ -,(Slop ) e 6'33/8" 6'43/8" 6/4%" 6'43/8" P (Slope) 14'10" 14'10" 14'10" 14'10" S` 4'3" 4'3" 4'11'h e 6'43/8" t T 24'0" 27'0". 27'0" 27,0„ TM r Pe maCrete 8,0„ 8,0„ 8,0„ 8,0„ W 4,4„ 4,4„ 3'7ii/is" 6'23/4" Pool Systems t x '2'81/a" 2'81/a" 3'8'la" 5'8'/4° Pool Dimensions Grecian v DATE(MWDDIYY) TM 10/8/66 PRODUCER THIS CERTIFICATE IS ISSUED A9 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$ UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT . EXTEND OR 'MCSHEA IN8URANCE AGENCY ER TH y POLICIES 320 WEST MAIN STREET COMPANIES AFFORDING COVERAGE HYANNIS,MA 02601 COMPANY NATIONAL GRANGE MUTUAL INSURED COMPANY M,J, COLEMAN&SON B 313 HOKUM ROCK RD, ' COMPANY DENNIS,MA 02638 C COMPANY D 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 RE$PFCT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED B.Y 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. co L R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I LIMITS DATE(MMIDDIYY) DATE(MMIDDIYY) A GENERAL LIABILITY ;GENERAL AGGREGATF. ! s 2,000.000 MPJ12506 X COMMERCIAL GENERAL LIABILITY 8/29196 8/29/97 PRODUCTS•COMPIOP AGG $ 2 000 000 CLAIMS MADE X OCCUR PERSONAL BADV INJURY S 1,000,000 OWNER'S$CON IFtACTOft'3 PROT EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Anyone fire) $ 500,000 MED GYP (Anyone person) $ 5,000 AUTOMOBILE LIABILITY ANY AUTO COMRINEO SINGLE LIMIT $ i i ALL OWNED AUTO$ I ROOILY INJURY $ SCHEDULED AUTOS j (Per person) HIRED AUTOS ! DOOII.Y INJURY NON-OWNED AUTOS (ParaccdeM) PROPERTY DAMAGE $ GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: j I EACH ACCIDENT I ; I AGGREGATE I $ EXCESS LIABILITY EACH OCCURRENCE s UMBRELLA FORM j AGGREGATE I s .OTHER THAN UMBRELLA FORM I T T I WORKER'S COMPENSATION AND WC I i I Vrf�'Y IL N`I s oiR EMPLOYERS'LIABILITY EL EACH ACCIDENT $ THE PROPRIETpW INCL I EL DISEASE•POLICY LIMIT 1 $ PAWNER5/EXECVTIVE i OFFICERS ARE. EXCL EL DISEASE-EA EMPLOYEE I $ OTHER DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLE818PECIAL ITEMS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ANCHOR POOLS EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 143 UPPER COUNTY RD. 10` DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, DENNISPORT,MA 02639 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KI UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R RESENTATIV OWN �;...�, ��!N 9rJt 'I4: l�►��� C f `�'"� � I . .•.:.•,: . :: .. �15 :. . r' i.-y:C I - { y \ « r_ * 7 •r- �'•Iis�- r �• r r F•� _ >' /, i.. s'�; is �'/2. ,a'r::'J 'r -:Y4i i - - ,:L:-. �'}.• "CO EdLT}��-i• ,,.: �bEP11R7t�cNT O��PUB C SAFETY' . . � � � q r:•. OF L N C%��'r. O E ASHBbRT N pLA E-� J e. 0 R.n i;3� ,., f��::. H X� s� :1,. < SS�CH�1� �5.,.• •�.':,.'-• iJ3A SETT r'• S�'}-•� O�TON MA 02108 '� L. QY Yia.•.'• a- o ri n- �{,,� a i! r•'�. - Y L-hCENSE . p,♦�, :� �/ EX -I '-;ON DATE. - ` 04%t_r_/1907 :. CONSTR. 'SUPERVISOR _�;t- _.-: 1� I' _%; ,:< :�:c:. �' - OR PROTECTION AGAINST j.. ;.,.Ja;..- :x; ,}; ;•r? - `:t:t ; �FFECTIVE BATE LIC-NO.. /rL [:a is _:ir ;�;:. ' 1. 1 4C;� i-..-::' a: - :(';• RESTRICTIONS ry' . . THEFT P r ''-, �: •,� % `'' ''�'e'w .s: r UT RIGHT THUM9'i?4' r �i♦/...:: =: .le .,_ _ •:>•y;C_ ;.._s 1;F'l�^,:' .9. .. . . •-'J• Sr r� :v '4: :U r:;. ' = .r. - t•+• .' PRINT IN APPRCP I . .:r.• ,` - RATE- rrr`ty. .:- .. `./. <;'. '• 00 :';�<;: +r<.: , cL/::_ 02/14/ 1 39/} 06t_rD 1 J -r.;_ a't .1 t�''' 0. a."��-27 ;• ? .�; : - g 9 BOX ON UCEN e=�,: .0 �."C .,�r.: •"'',. ♦•t� '.-: .�'•���,• - ,i :.sse-'. .i :~. _-.ta..:' ry•• .:'..: -r}•'ll.:i!:: _ t:J 1. -)i• .J't,,., `.:li1:r._v'L'h':A• '3.'•_y♦•1: f',. ::,i: .. - •- #'jz� ti :i..a ' 4 t (( ..- '-;: ;.. --a;) - , • . a .. . 2.r BLASTING OP �_' <. ` - ^ A -J -COLEMAN Ek�ATO13S_f�' )J• - :'. M RK. s= .1.`ln• iC i trC J',� :' . -I . . - _.r''' .L•�i: ram,ht'� .. d: :yw•r' ,;•., ,PHOTO`^ TING OPR ONL 'Y•;• O / fl .C3.••:. •tJ'.r;.4:.. +_-.''::'t:>. :+ ;q:J .J' (eLws Y) 'FEE: _ •HARW-I Cl-1 h1A -0�6 f 5 _ :�Ji�:;y ,.:Ls.. .r.J.t-.,,_ ,. t ht - :�i' 1 h ti:i f __Y.. �'' i'3 .y1; P •,� r�i.� 1.s''• i a rs•_•:>" - D N::i 5 BY - �NOT VALID UftI1L ONE LIC'NSEE ANO OFFICIALLY`-�. f. ,r?. .�. L 0 J f�is a ... do A ::�:. r wJ� r>: :� �= >. ' a;r>,J' ''" 't. STAMPED`oR! rDsuTLIr S.'' t tL':j: :VF;a. . is.+;ice: ac`3 '�,`.Z: r�IEIGHT::.. r. s.:.$. �fT!+E .. StlaCAhll�tlS�t r' fJ f:.rj �i:j.:}�,: -,!f,:;L•.v. ..:. .- 1 _ ii: 1: ,Ir' - w ���Yat��d•..�_'�'^:Z / .,t.. :�'i� -i`, ulV r•. - '♦ t''T:r •L IA*Z} .. }+ . •:' a7I,� ..Y _E- t- ?. ;;: t - , f s � i,-:,--J. -.......... : -:-.i / !. 1 .. : - ::�t'��.'t�.�. ri7:-J.i�j •�rl�.•�'• j:•i• . ..i •ry.J.; .7, rt .1.�reY a.4• THIS DOCXIMENT.MVST BE t SIGN NAME pp -}5; :6 •.-, .-/: ,J - ` ._.. . Fllll'If60'VE:SK,IL1Tlwtl Z3+.k' S"�V ��ac- Y`ar,r �..-� .t � {..:;i�. �tj-•.; _ .�! .�.df>- -CA7.7IE60;4�riEPERSONG: t. ':i•, -SIGN;,jAE Ci UCENScc �,,. �,.' .'." - - :�tF• :l:„ki r--;-:_ :r:' ::L ••r+y', c(y'•Xa• r►j•% r-i,"�•. ` :i': ^�• .u),-, W T. HOLDER WHEN EN- `r _ 'n: - �L _ ..'=•t,:..... 7ct �'•,�. ,:. ;: •yt :i-.;: cr:.L. :i._a..,r-.:f•t::i,., .rJ.;='tF., :.-�- ,'�I-.: -�:}J. /J! „'7•:'� .i;...,: xt +�:i•y.:,. vJ,,^- M.�.... GAGED[4THIS A - -+ 't'Oe` r.. '' i_ .-- •'l - ::?Ti': v'/iCr'J RIGHT TALIMS PRINT OCCUP T10N. . 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CaJi?. �•� ..f . t: .. %•�r- Yr .r..r.•A: '+]'• iR+>arJ .+tii!cr-F..i.�i ••%'.•Y'.�rJ3�:..<:-L. ,.:.:<.:-`: --- Cam' .r_- .J o •'•:v_ .-•f.: - :r`:::i�• tL'L" J r[1tYh ! ) .J:, 1,::. :v. :r• T �y�/',. w .. �.t.- :�: .•M. .•.V'7 �•I. `}}i i, '.��'•:�''�: ..JJ. �!'r J,J•� fir' , J•• fi n.;t J., t ii:1• •.Y' .0 Qy' .:f: 9 -�. .: } r .,: .r n•' I• �1 •,<j.,-•/. :/.Ii:1:f-i�3r`I?�.~ .t��es�•49o7:4d?%,f,.. . ... .. . - .. . . .•:J•. ...-::r". . ..:�.'ti':•tj.� . . .c.r...GL'h("�'4� ' The Town of Barnstable �•� De artment of Health Safety and Environmental Services KWL . � Building Division 367 Main Suet.HYaaais MA 02601 Ra1Ph Ctossea Oificc 309-790-6227 Building C F= 508-775--3344 For office use only Permit na - Date AFFIDAM HOME IMPROVEMENT CONTRACtOR LAW SUPPLEMENT TO PERMIT APPLICATION cticn,alterations;renovation. won'convetston,. MQ.c I42A requires that the"ttoonstrn ed impivvemcat,.remotal, demolition, or consa'aaron of an addition to any p adjacent at least one but not more than four dwelling units or to am building wag to such residence or building be done by uugistatd ate.with aatdn cWcpdoM along with other Type of warlc�,> >� ' ti��(3©A -Cost Address of Worker O mcr.Nam� Date of Pamir Application: I hereb<•�'that:.. Regisnation is not rapdred for the follo%ing=nw(s): Work=ftded by law Job under SLOW �Bnilding not oamer-<mx*ed Ownerpuftgownpain t Notice is hereby given th= PULLING THEM OWN PMUaT OR DEALING WffSVNttEGIS�CON"1�M•� OWNERSwom DO NOT HAVE .ACCESS TO FOR APPLICABLE HOIvtE Du1PROV ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I h=:by apply for a permit as the agent of the owner. Registration Na Date Contractor name OR TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL ID 035 078 GEOBASE ID 2114 ADDRESS 878 MAIN STREET (COTUIT) PHONE (508)477-3774 COTUIT ZIP - tLOT B BLOCK '\LOT SIZE 'DBA DEVELOPMENT DISTRICT CT -,PERMIT 25003 DESCRIPTION SINGLE FAMILY DWELLING (BLD PMT #17967) PRRMIT. -rYP BC00 TITLE CERTIFICATE OF OCCUPANCY , CONTRACTOR _ : , Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BOND $.00 O� I CONSTRUCTION COSTS $.00 753 MISC. NOT CODED ELSEWHERE * HARNSTABI.E. G MASS. g OWNER EPSTEIN, GERALD & CORINNE 039• A�0 ADDRESS E�M1�►I PO BOX 1094 BUILDI DY 5I' MASHPEE MA — BY DATE ISSUED 08/13/1997 EXPIRATION DATE ' �_ FROM : HarborsidE f__4)StrLiCtiOrl PHONE 140. : 50,S' 540 57 37 Pal TOWN OF BARNSTA13LE BUI� PINC'i' PAf(C'LeL is 0;' G1?QBA1,s*L4 u) 2114 87e MAIN cut,Ali t' (COTUIT) PHONE (508)47707174. ZIP tlo�L BLOCK DBA DrIVRLOPMENT LOT SIZE DISTRICT PERMIT TYPE PEP14 I T 17967 DESCRIPTION SINGLE FAMILY DWELLING (SEW-PHT. #96-41.5) BUILD TITEX NEW RESIUNTIAL BLDG PMT CONTRACTORS, PROPERTY OWNER ARCHITECTS: Department of Heajtjl, Safety TOTAL FEES: andEhvironmental Services BOND CONSTRUCTION COSTS $400,000.00 101 r-INGLE FAM HOME DETACHED 1 FRIVATR P BAR MAN&, OWNER EPSTEIN, GERALD AD1)RRf-,',8 4 WHEELHOUSE LAr4E MASHPEE, MA Bui. BY DATE ISSUkD o0/j8/1.996 EXPIRATION DATE f THIS PERMIT CONVEYS No RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK On ANY FART THEAEOF.F;iTKER TEMPORARILY UH PtHMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION,STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENTOF PUBLIC WORKS.THE ISSUANCE OP TIJIS PERMIT DO.ES NOT RELEASE TIC APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS MINIMUM OF POUR CALL INSPECTIOW.m7.quipCo I FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST RE RETAINED ON JOD AND 11 FOUNDATIONS OR FOOTING$ THIS CARD KEPT POSTED UNTIL FINAL INSPECTION WHEAE APPLICAB'F, SEPARATE 2.PRIOR TO COVERING STRUCTURAL MEMBERS HAS bEEN MADC,WHERE A CERTIFICATE OF OCCU- PERMITS ARE Ri&IRED FOR (READY TO LATH). PANCY 18'AEOUIRED,SUCH BUILDING S ELECTRICAL,PLUMBING AND MECH- HALL NOT BE $.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE, ANICAL INSTALLATIONS. 4,FINAL INSPECTION BEFORE OCCUPANCY o no FEWINS APPROVALS PLUMBING INSPECTION APPROVALS ftIECTHICAL INSPECTION APPROVALS '-7 7 Z-/" -4 710) 4AUIL� 1 LEATIINU INSPECTION APPROVALS WMINEERINO rD .ARTMFN T.P 94 yij BOARD OF HEALTH 3./if 01 HER: girl PLAN REVIEW APPROVAL Post-it"Fax Note 7(671 FVARIWORK 81HALL NOT rno�ZED UNTIL PERMIT WILL BECO16 'I 'INSPECTOR E NS E THE INSPECTOR HAS APPROVED THE 'STRUCTION WORK 19 Phonc 0 Phone# I CUS STAGES OF CONSTnUC- MONTHS OF DATE T S-00 s- T.1 �j TION, NOTED ABOVE. F it 0, TOWN OF BARNSTABLE BUT�,DTNG PFRMTT I?ARCLL Ili 035 078 GEOBASE ID 2114 ADDRESS CR78 MAIN STREET (COTUIT) PHONE (508 )477--3774 Cotuit ZIP 02635- LOT B BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT OT PEP14IT 17967 DESCRIPTION SINGLE FAMILY DWELLING (SEW.PMT.#96-415) PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT CONTRACTORS: PROPERTY OWNER Department of Health, Safety ARCHITECTS: —� and Environmental Services TOTAL FEES: $1,240.00 r BOND Qx CONSTRUCTION COSTS $400,000-00 ` 101 SINGLE FAM HOME DETACHED 1 PRIVATE P Q _ * �ARNSTABLE, * , MASS., OWNER EPSTEIN, GERALD 1637- ADDRESS 4 WHEELHOUSE LANEMR Ep MASHPEE, MA BUIL S»M • i BY DATE ISSUED 09/18/1996 EXPIRATION DATE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF,EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE THIS CARD KEPT POSTED UNTIL FINAL INSPECTION 1.FOUNDATIONS OR FOOTINGS PERMITS ARE REQUIRED FOR ` 2.PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- " (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN.MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. POSTTHIS , • FROM -STREET BUILDJNG INS ECTION APPROVALS /PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS s 7/z�g7le ' 2 �`t 2 10. �y�h � 2 -57 I 3 1 EATING INSPECTION APPROVALS GINEERING D ARTMEN 2 nn�a L Tz_ t7 7 S.P 96-31/S".BOARD OF�H+.EALTH I • "•VCR U�. J �G-'v�'1 IS /'1 I? I OTHER: SITE PLAN REVIEW APPROVAL I WORK SHALL NOT PRO &ED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS. THEINSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. i .T HOME IMPROVEMENT CONTRACTOR Registration 118507 Type - INDIVIDUAL Expiration . . 03/28/97;:.<:.. 1 MARK J COLEMAM MARK J. COLEMAN 313 HOCKUM ROCK RD/P 0 BOX ] ADMINISTRATOR { DENNIS MA 02641 .:� The Commonwealth of 3fassachusetts Deparnnent of ladustrial Accidents Office ot/nvestigalions 600 1lashinrton Street ` ,;.:_Y Bosto►i, Alas. 02111 Workers' Compensation Insurance Affidavit Alinlicantinformation: '"""`�' 'Please PRINT...... y , name: ����1-� S�2\►.� location: U715S city CCo-70, M phone#• 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity _�`A"'- Y k ice'.,"•rP � ':�r,Ztznw�tT rrt-R;6�'�r� n^.+v.+.�>�s.�alr+�s��"�^k7�^m '�.rn`,Y�apDas<• ��'�wpm �y,.+.uY.r... s.aarftr�•r• as..�y.: ...:..?.�.�...�.;.s.,.;.1� z•-.:n,.._�,»e,a:�vaE a¢.�sr. ::^.ta.-.i^...,.. 1:�:r.�..,zr:...-:s.�.as r.��rvEs:.:�. ^.aa...a.. �.�::mL�;.:.:._>.:C:t*:7:G.;.k,S,ei.::�.3,�u.3fa:.�.�..�e....r..��:.;G....<.:....._...�.»... I am an employer providing workers' compensation for my employees working on this job. company name: IJ�'i�Ot1Sl C r S L 9o�L ad(lress: -Pc- l 0,3n;-s- 4 !L1 city: P,-)N SC>8 s\T (�4 phone#: Co l� insurance co. policy# ��� 1 30� 1 ac�ao e+�'�ww,, . ...yrN. t:_�_._ar.,y„.u.;iiw_„,.... ......._.- .��•,,,: .....F - K..,r. ,,,X. � ..:; ,. .. , Ysn'".`7:ra ���•�S:zt:.rX.r.,.. t_,�.:: -........s...x.._ -. 1 am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name address phone#• insurance co. policy# -... - �' - -ire is -•+;:; �'•`n .nx•�°z ""r^i"S rr - h" eS;rn- __>..._s ...-.,........,,...,r..,.,:,::a:.._,:,_-.,r�.u�.:.vr.sy..a.w:.....vie.:a.�a.�:..•.;i:;:Piaryw:i�wS�.,kar.:u :.7a rY�'s�i.trar'- -• -• �:,., � ...,...»..,_:.X�r<x.�aw;..°g$S.a:U�:3atiai �b:::..:i::+.frx�.c�. company name: address city: phone#• insurance co. policy# Attach additional'sheet tf necesgaly Failure to secure coverage as uired nder Section 25 ntGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as ell s tv.. enalties in t for of ST P�1'ORI:ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this It•�tement may c fo arded o the Offs c of 1 sti atio of the DIA for coverage verification. I do herehl cci711Ji'purple the r ins rd pe,nallies of pe rt tha he information provided above is true and correct. Sienature �d-� Date Print name 1 o cr 1tJ Phone# �� `}official use only do not write in this area to be completed by city or town official fr city or town: permit/license# rtltuilding Department ,oLicensino Board check if immediate response is required C]Selectmen's Office 011calth Department contact person: phone#; nOlhcr Irmsed 3f95 P1A) - ' Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an einpl(tvee is defined as every person in the service of another under-any contract of hire, express or implied, oral or written. An enrpl(tver 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 dwellin�� house having not more than three apartments and who resides therein, or the occupant of the dwellino house of another Nvho 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. 77 Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the 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. w 5 0d+ Cite or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. 77 -exw�., x•1--�+rFs9+ea�.,m+yl�...,�ev,ee +;m:, �x�a u,�._rw*�r+nds*z+s�'^<ar�'r�...zrrn rr_ ,-y�m��.es' �«F.'. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 «'ashington Street Q..z Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 ..................... ...... .:................................. ................... .................................... ............................................... ............................................. ........ ................ ....... . ......................... ........ .................... . .......... ... fS 0 ...I... ..................... . ...................................... ISSUE DATE (MMIDDNY) ....................... . .................. ......... ......................... .......... .... . ........... IN RAN'' ::.*..:..,.�:.":::::.:.:.:..:.......:::.:.:.:....................... ....................... .. ...1............ ....... ......... PER..........F F"01 11, 11"I'l, CE... ............ .0 . ............ . .. ......... ...... ..................................... .......... .......................... ......... ................. .......... ...... ......................... . . ..... ..... -x . ..... . ......... . ........ ...... . ........ -X -X....... ................... ...... .... .. .. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER...OF ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE Fradedcke and Gmrdl ...POLI.C.I.ES-BELOW................................................................................................................. .......... ..... ........... Insurance Agency Inc. .......:........... 1313 Belmont Street COMPANIES AFFORDING COVERAGE BrbMon MA 02401- ....................................................................................................................................................................... LcOmPAN Y A CNA INSURANCE COMPANIES ETTER ........................................................................................................... ................................ ...... COMPANY ..........-..................: B INSURED LETTER ....................... ........ ............................................. .. ........................................................................ COMP ANCHOR DESIGN & POOL, INC. LETTERANY C 143 Upper County Road ..................................................................................................................................................................... COMPANY Dennisport MA 026390000 LETTER D ...................................................................................................................................................................... COMPANY LETTER E X .......... ............... . .... 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. .........................................................................................................................................................................:......................................................:.................................................................... Co POLICY EFFECTIVE :POLICY EXPIRATIONTYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE(MM/DDn UNITS ............................................................................................................................................................................................................................................................................................. A GENERAL LUkBLrfY BI 30715576 04/09/96 04/09/97 GENERAL AGGREGATE loom .................................................................................. .X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGO. 1000000 .......................................................................................... CLAIMS MADE X OCCUR. PERSONAL&ADV.INJURY $ 1000000 .......... .......................................I...... .................................. OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE loom ....................................................................................... FIRE DAMAGE(Any one fire) 5M ........................... ................. ......... .......................... ................. MED.EXPENSE(Any one person):$ ......................................................................................................................................................... ............................................................................................................................ a A AUTOMBLE LUwKm BINDER 04109/96 04/09/97 COMBINED SINGLE 1000 LIMIT ANY AUTO ..................................................................................... ALL OWNED AUTOS BODILY INJURY :S X SCHEDULED AUTOS (Per person) .......... ...... ......................................................... X HIRED AUTOS BODILY INJUR.******. Y X NON-OWNED AUTOS (Per accident) .....................11.............................................................. GARAGE LIABILITY PROPERTY DAMAGE ............................................................................ : . ........................................................................................................................................................ EXCESS LIABU" EACH OCCURRENCE ;S .......... UMBRELLA FORM AGGREGATE .......... .......... OTHER THAN UMBRELLA FORM ...................... ........... .............................................. .............................. .............................................................. ................................................ .............. ..................... .................. WORKERS COMPENSATION STATUTORY LIMITS .......... ......................................................................................... A AND WC 1 30718090• 04/09/96 K09197 . EACH ACCIDENT :$ loom '—* ... ..........:............--........... ........... DISEASE-POLICY LIMIT :$ EMPLOYERS'UABUTY 50WW ................. ......*.............................................DISEASE-EACH EMPLOYEE :$ loom ................................................ OTHER ..................................... ............. .......................................................... ........................................... .......................................................................................................... ............ DESCRIPTION OF OPERA'nONSWCATIONSMElilCLES/SPECIAL ITEMS - --------- ........ .......... . ....... ........ ... ....... xx ........ ... ......... .... . .................0-1 ................. ... ... X SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Town of Barnstable MAIL 10— DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Building Department LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR Main SUM LIABILITY Hyannis MA N THE COMPANY, ITS AGENTS OR REPRESENTATIVES. 02601 AUTHORIZED REPRESENTATIVE/ dgry ............................. ....... .... . ............... X x. ... ............ .......................... ................ 2: RM • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION �� (�Z Number Street address Section of town "HOMEOWNER" _ Name Home phone Work phone - PRESENT 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six 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 Stat Building Code and other applicable codes, by-laws, 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 wit aid procedures and requirements. HOMEOWNER'S SIGNATURE-/ APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction Supervisors, Section 2. 15) . This lack of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed- Supervisor. - The Home 'idwner- actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities,. man communities require, as part of the permit application that the H certify � Home Owner 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 to amend and adopt such a form/certification for use in your community. r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 S~ Parcel 79-d,7 9 Permit# /pC__1 ! n _ Date Issued nservation ivision Fee "Tgx_�Collectm' easure.. 9"1 Planning Dept. f Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis ." Project Street Address -! 2,P9,w - S'%= Village 697w" Owner Address S—, �Po7r Telephone W_`0 --/ I 1 Permit Request --%�zPt�3cE Exts r�y� ��9,,eS. 77.E Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost Z.S` 6• Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes,attach suppo'tirig documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) ` Age of Exi ing Structure Historic House: ❑Yes ❑No On Old Kings,Highway: ❑Yes ❑ No Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq. . Basement Unfinished Area(sq.ft) Number of Baths: Full: existing w Half:existing . new •Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor ount Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No .Fireplaces: Existing New Existing wood/coal stove: ❑Yes No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing-❑new size Other: .SrrsreS Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes X No If yes, site plan review# Current Use Proposed Use -y BUILDER INFORMATION Name NN jFke4111f Telephone Number SYo-17 9- Address, License# 0 '/yocL2-7— ��9Lm©y'�! Home Improvement Contractor# 2 /oi376 Worker's Compensation# 7 d 9 9S" -47-0 y ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO aE �ylwd.�ic[ SIGNATURE DATE ,. FOR OFFICIAL USE ONLY _ PERMIT,NO. i• , DATE ISSUED Y` MAP/PARCEL NO. li ADDRESS VILLAGE OWNER' DATE OF INSPECTION_ FOUNDATION FRAME INSULATION . 1 FIREPLACE ' ELECTRICAL: . ROUGH FINAL 16, PLUMBING: ROUGH FINAL ` s GAS: 'ROUGH FINAL '. FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. R _ y:4 Iftel own ot ijarnstaDle 9 Ulm& Department of Health Safety and Environmental Services ram' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 r �. f Building'Commissioner Permit no. 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: Estimated Costt� ----- � 5 r Address of Work: 0 ' Owner's Name: ' Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law OJob Under$1,000 Building not owner-occupied C]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 the agent o the owner. Date Contractor Name Registration No. OR Date Owners Name q:forms:Affidav --- _ - The Commonwealth of Massachusetts t r�-�•.Zip.: --•:.Z + .- = Department of Industrial Accidents - L3 � °_��� OIfiCE Dfl/IYESI%g8U0/IS 600 Washington Street Boston Mass. 02111 Workers' ie Comnsation Insurance davit ', �rrr�'„�C�t"`�'�'�////////%�//////��%%%�%%�%%%%%%//////////%%�%%O///////////.'%,,,<,.... name: �Ot9 N PfKEiVIA location:4W !3 21 .09 ! U s city C"41 y!7" phone# rVe S 7 fr7 ❑ I am a homeowner performing all work myself. any /iiiiiii�iiiii/iiiii have iiiiiaiiii/inii iiii/iiiii/ii/ail/iiiiiiiio/ii/iiiiiiiiiiaii//i/iiiiiiii//iii,,,,,,,.. ® I am an employer providing workers' compensation for Amy employees working on this job. compnnv name: 211�oi-- ��r99.�7r—Cry LdwSJ;' t�a• •. wC Scry address: Z¢S city: Z,nw�-� nn phone#r S VOS"7£r 7 insurance co. 1jSSv92o#9- E poiicv# Tr 9-94"78'6'7e Ify ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors Iisted below who have the folloning porkers' compensation polices: company name: ... ......:. ......... address: dtv phone 0: . insurnnce co. oiicy# i company name: address: city- ... phone#' insurance co. oiicv# Failure to secure coverage as requited 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 fours of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Omce of Investigations of the DIA for coverage verification. 1 do hereby cerri 'under the 'au*Ls and penalties of perjury that the information provided above is true-and correct Signature Date Print name T,00a1 Phone# S 5'a'S7�7 official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (rev$ec*95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any 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 receive, c: trustee of an individual, partnership, association or other legal entity, emploving 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 buildinga urtenant thereto shall not because of such em Io ent be deemed to be an employer.PP Ym P MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa of a license or permit to operate a business onto constru%ct 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 eater 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. N FIRE 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 permit/license number which will be used as a reference number. The affidavits may be rctiuned io 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 investigatlons 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 to 4. 6 '`` HOME IMPROVEMENT CONTRACTOR 1 Registration 101375 ,� e air ` ._ dry jype PRIVATE CORPORATION Expiration � 06725AO " "CAPE HARBORSIDE CONSTR. CO., Y n M John A' Pekenia Scranton-Avenue o ADMINISTRATOR �, Falmouth MA 62540 DEPARTMENT OF PUBLIC SAFETY CONSTRUCT�IOt SUPERVISOR LICENSE NunDer Expires: Restrioted Ta', Be JOHN A PEKENIA J �►'R Vr9do"295 SCRANTON'AVENUE FALMOUTH, MA 02540 ,`— L� - _-_ The Commonwealth of Massachusetts Department of Industrial Accidents I - - f mce oj/m�esaffatfens I 600 Washington Street -•.-•cJ Boston'Mass. 02111 • —" Workers' Co m ensation Insurance Affidavit name: U Od dj Artr!U//4 location: 928 /.Iv/9lAJ -0—, . . city 6.ry/T I Phone# ❑ I am a homeowner performing all work myself. . . ❑ I am a sole rietor and have no one worlds in capacityry /��%%%%/O� %//%%/%%%%%%%%%%%%%%%/%%%%%//G/%%%% %%%%%%%%%/%/%%%%%%%%%///////%%%/%%%%%%%%%/%%%%%%%%%%%%/�///%i�i� lG ® I am an employer providing workers'compensation for my employees working on t""his job. cotaaanv.aatae.::..,.:.+ . �:.:::::::.. �3O^ �:. .a ,�:;;;:.:::::.. ... ::.....:...... . .:::.:::.?:.:::::.. :r..::..:::.:.::. il8ress... . cftw � -pt,I& ,t, f t Diane# : " , ,� "7 ` ,� ` ...:.......:...... ...:..:....::.::::.... .. ......:.:... .... ::..:...:'.....: ............... ...:................................................................................................................ insuranceca,....__ ! .. "i ... . . Pli #.: �,. ..:: .;: . .:..... ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractaft listed below who have ` the following workers'compensation polices: .* n name. ..C0111Da y . ':' ..... v::i:ii::\?iii::i::4 >�:!v}:i:ii:v:%G�::i::"-"-:}:?ii..:....:.iii?i i::i:!:i>:}$iii:ii: ......:.:nisi iii':."..;:iiiiii:,..-,.>iiiii i:�:i.-.i:}:::iji}:iiii:}i i:}:.i;:;:,::is<i::i:iiii:if:`} . .y ::.Y�:::::`:: i`:`;:... :ii.`v,,}'ii.?.....;.:;x.., ;.;i.};.i}�: .. ess..:: :>:s>::>.;:.:.;. »` .ri .. ...............................:::.:::.:.....:....... ....... ...................................................::.....:::::::::'...:::::::::::::.:::..:......:.::.:::::....:,.::::::::::::::::::::::::::::.::::::::::::::::::::::::,.::.............................................................................................................:::::::::..........?::;:::...................................... ::::::::: ................... +e'is :vvJ????i???????:•:<:.?Yi:?Y'.ii:•i???is4iiii?????ii?isv:v:.:.:??'-?i::i:v:::;:.?i?i?ii??ii:iti<v::i??:::ti%:i:•:}•?:• .....M\ V?:-::• ............ ............ :Cty.'>.: D.. _ _ _. .....::..::: .: _ ...._ .. .1+ ?...:.tau.::�.A t::}'::i:: ;; i :<?:::`: i: 2;:: ::;i::i:s:;r:::):%i::::::<:;%::::%:} '•':;i:: i:i::c:2{:':t%'Y': :%: is:o:':'c'::::'::5:::: i'i: :i:%:i:i:::::f'•'k:::::.'o::S : :::::::::::::::::::::::::::::::::•:::... ::::::::.......t .. ........................................................................................:.:.:.. :.......:::::.,•::.i•:........................... ...............:.....::::::::->:-:::::.::..................... .fi.:•?i?:n.a: . '-:;-::;.::<::;:•>:-::;<;:,.?:: ::;:>:;::.'..:•:;•:}:::tiffs:}:i:::}k:::i.f...... :$o-w:t'.c w.•�•::.:•::: firanee:ca:... ,:, 01l #::. . ...::..................... . .........:...........:........::..:::::.:::.... /�/.. ...................... ............ >' omnaav :name::::;::::::;>':::>.,......Y>«:<.>;<::}::>:«:>•:::;:::>::;:>•':;::':><>:::>:::;:.;:::>:: ......... .. ...... ......... ........ .......... .::.... .. :..... ................. .......:.........:............:........:..........................,.—........:....:........................................................................::..:.::.:.:......%, ::................. ::.: 'z `, atiiEress. .: ::::...::::::::....... ................................ -XI W :.?::::.:.:::::.::::::::.:.::.....::::::::::::: ............... : ........... ... ............ . ... .. :::.....::::::........................... ............:.. :............::.:......:..:..:.::...:..::..:......::........:................................:::...: ......:....... ..................................................................................,...........................................:::::::::::::::......... ::..,.:::::..::.�.:.: ............ :::.............................................................................................................................:.......:...:::.................................. ........... ..................................................................................... .1.1'.1 :.u• ............... ................................................... .....................v:n�::::.�:::.,A•:::.:::.�:.:::...: :•:::%....:..... .:::::::::::::::::.;............. ...:Ct..... •.....^:::-. -Y:Y:::ijjjj:3?:i y..:.:, :•::••:rat•?:•i Jy isj;{:f:}Si:}Jffiii:i:}}+Jff>Sff:?fx:r}.?:4}:t??:• :nsnrauce�cnz: 6II�.�����::/f:;: !+.+ iii'"}i�?v2:<:<>�S:v:::::::: :::::::.:::::::•::::.:::::::-.�::::::::::::v::::: 13'adme to seem a coverage as required under Section 25A of MGL 152 can feud to the imposition of crhnhml penalties of a One up to$1,500.00 and/or rite 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 Brat a copy of this statement may be fontarded to the Office of Investigations of Brae DIA for coverage verification I do here erns under the ' and penalties of perjury that the information provided above is&z and coned sig08tnre �.�-et�t.c�� Date /9• 3 ' 9 4' Print name �,0� r,kK,r- 1.4 Phone# ,S?>cf s'yOxn-7 ofncial use only do not write in this area to be completed by city or town official . city or town: perndt/Hcetue# ❑Budding Depatftnent . ❑Licensing Board ❑checkff inunediste response is required ❑Selechneies Office ❑Health Department contact person: phone#; ❑Other Or iwd 9195 Pr/U r- 2 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any comract . of hire, express or implied, oral or written. 4•.,, ,, 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 c: 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. Ilk 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 k ' 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. , r Applicants Please fill in the workers' compensation affidavit completely, b checkin the box that applies to our situation and mP Y g PP � Y .'jf supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be t;. :'o 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 " eing requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you i, :'are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rctuined io 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'ui a call. - The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imtestfgatlons 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat 406, 409 or 375 � Theof Barnstable . . _ Department of Health Safely and Environmental Services �aM Building Di tslon 367 Main SUM Hyannis MA=01 Ralph Crosse: Off= 308-790-6m HuildbG Ccmmissi=- Fax: 308-790.4ma For ofte use only Permit no. Oate _ AFFMAVIT HOME ZoROVEMENT'CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL a 14 .A requires that the reconstruction, aftesatfons, renovation. repair, moderairstion, conversion. improvement, removal, demolition, or construction of an addition to any pre-ezistiug o rner occupied building containing at least one but not more than tbur dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain esceptiam along with other requirenentL Type of Work: '�f'°�`}i.e S Est.Cost 2 6—W Address of Work:_<? Owner's Name Cy- J5 � Date of Permit App llcation: !O ' �3 I hereby certify that: Registration is not required for the following reasons): Work mcinded by law Jab under S1.000. Building not owner-occupied Owner pulling own permit Noce is hereby&=that: O nWMM PULLING TMM OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR rMATION APPLICABLE OR GUARANW FUND UNDER MGL 142A � ACCFS.S TO THE ARB MGM UMER FWAMM OF PERIURY I hereby apply for a.Permit . of the �o 3 .Q e Date Contractor Hame tbu No. OR Date Owners 1,42me /ee i�anvr�2a�uu� o`���/�ava�u�eCld DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number Expires: j xr hestr acted.To: 00 JOHN A`'REKENIA �'�'`"295 SCRANTON`AVENUE FALMOUTH, MA 02540 HOME IMPROVEMENT CONTRACTOR :. .: t Registration 101378 . a Type - PRIVATE CORPORATION Expiration 06/25/00 CAPE HARBORSIDE CONSTR. CO., John A. Pekenia -7�- 6�f� Scranton Avenue ADMINISTRATOR Falmouth MA 02540 ,Y a� to a® - `1 �tME Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee �-) s, * BARNSTABLE. tKAss.1639. Thomas F.Geiler,Director �EDMA'tA Building Division X-PRESS PERMIT Tom Perry,_CBO, Building Commissioner 1 200 Main Street,Hyannis,MA 02601. www.town.barnstable.ma.us TOWN.OF BARNSTABLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number n3 5�Q77 S Property Address 8 1 U ��(,� � Loiu l 1 M A Q'Residential Value of Work L 5 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address S1Qn eu , bordon H J r Contractor's Name Telephone Number nor-�,r�, 50i -24 7917 Home Improvement Contractor License#(if applicable) lL�-'�f Construction Supervisor's License#(if applicable) d 7 to p� 34 orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 0-fhave Worker's Compensation Insurance Insurance Company Name -ahILLU Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles). All construction debris will be taken to ❑'Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value t�, 3 4"' (maximum.35)#of windows__4p_ b4a,4C_ • � �'�,trcre �� *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 required. SIGNATURE: C:\Users\decollik\AppData\Local\ icrosoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 gitid� License or registration valid for individul use only HOME IMPROVEMENT'CONTRACTOR before the expiration date. If found return to: Registration: 102634 Type: Office of Consumer Affairs and Business,Regulation % Expiration 7/2/2012 Private Corporatic 10 Park Plaza-Suite.5170 n T HY.GRAY BUILDING&REMODELING Boston,MA 02116 - <, *z� Timothy'Gray ° 68 K NICOLETTAS WAY Mashpee,MA 02649� 4�b . ' ..�° Undersecretary Not va id without signat i `lassuchtisctts- Department of Public Sid, t% ' Bnui A ofBuildim_ Re-ulatims antit.rndartls- Construction Supervisor License Failure to possess.a current edition of the One-and Two-Family Dwellings "Massachusetts State Building Code License: CS 46234 is cause for revocation of this license. A _ TIMOTHY GRAY Refer to: WWW:Mass.Gov/DPS 68K NICOLETTA'S WAY MASHPEE,.MA.02,649 t: Expiration 11/30/2012 t'ommissioiler Tr#r: 4726 04/13/2011 15:19 5084209227 MARK W SYLVIA PAGE 01 GATE(MM(DDIYYYYI A�V CERTIFICATE OF LIABILITY INSURANCE 04N3/2o11 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), AUTHOAIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: 11 the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. It SUBROGATION IS 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 endorsemenH s . PRODUCER NAOMA Ir C Mark Sylvia Insurance Agency PHONE 508 42t1.0440 awg,.Nol: _. 771 Main Street •MABA`6f11-.L ..-:: DORpss: PRODUCER Ostervllle,MA 02655 LSIMEBID-e:. I,N9URERt9�aNDING COVERAGE_, NAIC 0 INSURED INSURfiR A: Farm femlly Cesu9lly Ineurent:C Timothy Grey Building and Remodeling Inc INSURER 8: 68 K Nlcoletta's Way Mashpee,MA 02649 INBURERC,:_ INSURER 0:.. .......... INSURER E',.. . :.,._ _. INSURER.F COVERAGES CERTIFICATE NUMBER: 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. INSR OLIEVEXP TYPE Of INSURANCE POLICY NUMBER POLICY fiFF MWOO LIMITS A OENERAL LIABILITY 20OIX0540 2R6/2011 2/26/2012 EACH OCCURRENCE S 1,000.000 TC R - X COMMERCIAL GENERAL LIABILITY REMISE>z(Ee eawnsoce) 5 50.00D CLAIMS-MADE ,X I OCCUR MEO EXP(Any ono pawn)_ S 5.000 PERSONAL A ADV INJURY E —.__ GENERAL AGGREGATE $ 2.000.000 EN'L AGGREGA TE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGO S 2.000.000 X POIICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGE LIMIT f (Ee Sccldem) ANY AUTO BODILY INJURY(Per poMM) E ALL OWNED AUTOS ---- BODILY INJURY(Par aealdanl) E SCHEDULED AUTOS PROPERTY DAMAGE s HIRED AUTOS (Par accident) NON•OWNEO AUTOS f S UMBRELLA LIAO OCCUR EACH OCCURRENCE I EXCESS LIAR CLAIMS-MAOF- AGGREGATE S DEDUCTIBLE RETENTION S A A WORXEReCOMPENSATION 2001YO340 10/15/2010 10/15/2011 WC STATU• X OTW AND BMPLOYERS•WIOIUT r QeY_LIMRS,. ,ER................ ._.__ ANY PROPRIF.TOWPARTNERIEXECU"nVE YIN NIA E.L.EACH ACCIDENT 8 1,000,000 OPPICERIMEMBER EXCLVDE01 NO -" (Made"In NN) E.L.DISEASE-EA EMPLOYEE 0 __11000,D00 WdeoalEa undo, RIPTION OF OPERATIONS heraw E.L.DISEASE-POLICY LIMIT S. 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAMSh ACORD 101.AdMllomd Remoft Schedule,It mare Space IS rMwIradl CARPENTRY TIMOTHY GRAY IS COVERED BY THE WORKERS COMPENSATION POLICY JOB LOC: 678 Maln Street, CDlult, MA CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20D Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered merke of ACORD Information and Instructions Massachusetts General Laws chapter 152:requires all employersao 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 toAo 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 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 pennit/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 foryouur cooperation and should you have:any questions, please do not hesitate to give us.a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia 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 Legibly Name(Business/Organization/Individual): 1 I i ,,+�' 1 Address; City/State/Zip: MA:1 Phone #: 0 " , 5,3W Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4: YI am a general contractor and T employees(full and/or part-time).* have hired 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 workingfor me in an capacity. employees and have workers' y p ty• 9. ❑Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or.additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑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 13.�Other f LICE employees. [No workers' Vhri ub comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. L Insurance Company Name: Far T &ryulV Oasw& J; Policy#or Self-ins.Lic.#: ?[�� 3� Expiration Date: �d Job Site Address:8 1 Main1 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. Ido hereby certify under_the pains an en hies of perjury that the information provided above is true and correct. Si ature: Date: Phone#: - IOp I c it) 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#: FROM :GORDON SLANEY FAX NO. :7B1B789B50 Apr. 13 2011 02:42PM P2 nw BARMITAWL MAM Town of Barnstable �A Regulatory Services Thomas F.'Qiler,Director Ruildiag Division, Thomas Perry,C116 Buildiog Commissibner 200 Main Street, Hyannis,MA 02601 w ww.town.ba rnsta ble.m a.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and.Sig>ni This Section If Using A Builder I or tom. ,as Owner of the subject property hereby authorize I%CAU l'31rLu1 to act on my behalf, in all matters relative to work authorized by this building permit application for: nOi3j4 �Si (Address of Job) 1( Signs of Owner Date Print Name If Property owner is applying for permit,please complete the'Homeowoers License.Exemption Form on the reverse side. 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Z / 67 a•e a1'a' so y'o =.�• !■iwbm01m"WIIIIM .. 420' I" ■IU9®R/OC[1■BI■■wl IwuO n FL=MM / \_ '400 , 4.hx F CCnRnCT OOCIW[nl n� I..,.yi.nr din Bnanrn Mi'uG. \/. tic ✓ I ti b M L.d..i..Y C...J.R La.c-»vn4cE S*e PROPOSED RESIDENCE FOR ( __._...—.._.._ MR.6 MRS.GERALD EPSTEIN T _ U 6i:+"�-"— MAIN STREET COTUIT.MASS. f + i�iJ�llr_ AS9pClgTES WG YJoROSH ppo0e�fflw ca0 . (acwilY.Yrfr.•.:.wra�+.-.-e tnF[[faJlais rwr not nc iii �Tg•�•�-AN�Bl9 I'EGA (��I>M III I �L'IaiO■11CfD w MiOI[On wn (� �. .E1,..1;•.�o✓f,}"i!-�'�.._. wwlw�.w•+nawwis.oca iii ,c...:Ad��T�I Li.CX rzeH11Jy _— ■ }YY Gr!• VV •Yf� �V 6f 11 M4� JFnOI•y A fW P>F fY /bp -mn G6b" r \ M } , 5 \\ 14 Aoo i irn M[EL 6EFW MLt IFm 0 UHYM n L — e y nM}rW rrKvo...n-i h s �z ` 1 FI 1 r mini�� V •ivrL 3. by ec o s I / z - OFAOWeOp _� _ j re � c w• a. s,� 2ro „C � r �7r:•'evoWa I I I i _ � 6 it r 4'Lv10 E• �GU IJO r%L{Xjf2 F RAM I hlCa �.�hl �Y' ,~ t, •` 3` M ` r T Aef Ml0 INtt Y1 ICW1t' fY111YN16 FEYE4 WON-um toim is FIY im$6 °B b♦ / '? / •i �c L Na 11rFEF 11AM0 Wr U101 W.' ' NEN10011CfD M wrrOlE ON iMf PDe1 EIfF OFtYrErYrOq O�T&ACF Doc~ a— PROPOSED RESIDENCE FOR " F'•�.. ...c< MR.rMRS.GERALD EPSTEIN j MAIN STREET --- COTUIT,MASS, c YAROSH ASSOCIATES r r Nam PI�CFETBGTB' SFivur f4ane RANr.0 AC.4w .rwn[Nm A-lo .r• z f � qYt/t7 a � 4 1� -42 a I $ Y / jv / I LL12 1. N X4 F-d■F.• 1 i a 4 'ofF 4 p,•pNl i'+FTHfS e9 F' � F - =I. /6. r� // ffL[ETdI. RAN WC� 5A %■.+NT =f£SfLTM(j Iv[aT mP a rlWL JI 11 ❑ \/�J� � �. M1Q N �. � Z+/ 1 .r PROPOSED RESIDENCE FOR MR.G MRS.GERALD EPSTEIN MAINSTREET CONIT,MASS. YAROSH ASSOCL47 INC ■■■ AFIC1•L 8=M.!!� u■ . ��� ran:AN •�■H•L1}e .w,wm ..MM ■ A-q� FOLD AT ARROWS TO FIT WINDOW ENVELOPES Message- mo%--wdy a M_ = ( G TM El Urgent l�� ❑ Please Respond By 2421 Cranberry Highway ❑ No reply Necessary Wareham, MA 02571 TO: John Pekenia Date: September 19, 1996 Harborside Const. Subject: Message: The electric service & meter at 878 Main St. , Cotuit , FOLD FOLD No were removed on September 18, 1996. This is the property ~ of Gerald Epstein. Signed: Barbara Trocchi Customer Service Ren. Reply: Signed: Date: MF46E 310 CMR 10.99 Form 5 OEOE Fite No. (To be proviaeo by OEQEi - _ Commonwealth 4wP �0 city.Town Barnstable - — _ of Massachusetts = ReRITS = En t a;n rlua Applicant i Op t639. `♦0 Order of Conditions Massachusetts Wetlands Protection Act G.L. c. 131, §40 TOWN OF BARNSTABLE ORDINANCES, ARTICLE XXVII From Barnstable Conservation Commission Robert A. Sullivan To Gerald & Corinne Epstein Frank Sullivan Jr. (Name of Applicant) (Name of property owner) 166 Harbor Dr.' , #14 11019 Lakeview Dr. Address Key Biscayne, FL 33149 Address Whitehouse, OH 43571 Map Number 35 Parcel Number 78 & 79 This Order is issued and delivered as follows: ❑ by hand delivery to applicant or representative on_ (date) rKk by certified mail. return receipt requested on April 9a. 1 9qA (date) This project is located at 878 Main St. , Cotuit The property is recorded at the Registry of Deeds in Barnstable Book Page Certificate(if registered) 131009 Lots B & C Plan 19606-A The Notice of Intent for this project was filed on March 12, 1996 (date) The public hearing was closed on April 23, 1996 (date) Findings The Barnstable Conservation en„m,;SG;nn has reviewed.the above-referenced Notice of Intent and plans and has held a public hearing on the project. Based on the information available to the Commission at this time.the Commission has determined that the area on which the proposed work is to be done is significant to the following interests in accordance with the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the Act(check as appropriate): ��// ❑ Public water supply ,,E�/Flood control ❑ Land containing shellfish ❑ Private water supply ,L7 Storm damage prevention ❑ Fisheries ❑ Ground water supply L7 Prevention of pollution Protection of wildlife habitat Taal Filing Fee Submitted S250-00 State Share $112.50 Cityfrown Share c i z 7 S n (Ih fee in excess of S2.9 Total Refund Due S Cityfrown Portion S State Portion S ARTICLE 27 Only: (1h total) (1h total) ❑ Public Trost Rights ❑ Agriculture ga,'Srosion control ❑ Aquaculture ❑ Recreational ❑Effective 11/10/89 Historic Er Aesthetic 5.1 Issued By Conservation Commission Signature(s) • U UI.OJ�IRI�. Irr This Order must be signed by a majority of the Conservation Commission. On this day of �t Q 19 before me personally appeared ► , , to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. -\Af\L- �c kr-r,� MY COMMISSION EXPIRES SEPT.27,2002 Notary Public My commission expires The applicant.the owner,any person aggrieved by this Order.any owner of land abutting the land upon which the proposed work is to be done or any ten residents of the city or town in which such land is located are hereby notified of their right to request the Department of Environmental Quality Engineering to issue a Superseding Order. providing the request is made by certified mail or hand delivery to the Department within ten days from the date of issuance of this Order. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and the applicant. Detach on Dotted Line and Submit to the Issuer of this Order Prior to Commencement of Work. To Barnstable Conservation Commission (Issuing Authority) PLEASE BE ADVISED THAT THE ORDER OF CONDITIONS FOR THE PROJECT AT ' 878 Main St. , Cotuit , FILE NUMBER SE3-3021 , HAS BEEN RECORDED AT THE REGISTRY OF ON (DATE) If recorded land. the instrument number which identifies this transaction is If registered land, the document number which identifies this transaction is Signed Applicant SE3-3021---Epstein Approved Plan=February 21, 1996 Revised site plan by Peter Sullivan,PE Findings: 1. The coastal bank is overly steep,and although mostly well-vegetated,is potentially subject to significant toe erosion from velocity waves. It is presently eroded along some reaches of the toe. Special Conditions of Approval: 1. General Conditions 1-12 on the preceding page are binding,and demand both your attention and compliance. 2. Within one month of receipt of this Order of Conditions and prior to the commencement of any work approved herein,General Condition number 8(preceding page)shall be complied with. 3. The applicant shall pay for their legal advertisement as invoiced. 4. Approval shall be contingent upon receipt and approval of a revised plan indicating: • A minimum 50 vegetated buffer between the top of bank and the seaward edge of proposed house • The provision of a 9' wide band of Rugosa rose(or approved substitute)across the top of coastal bank. Plants shall be spaced a minimum of 3' on center and shall be 2 gallon pot size,minimum. • Removal of the stone patio. 5. The work limit shown on the approved revised plan shall be strictly observed. 6. The demolition work limit shall be located 12' seaward of the existing house footprint. The construction work limit shall be located 50' landward of the top of the coastal bank. 7. The work limit line shown on the approved plan shall be staked in the field by the project surveyor/engineer prior to the start of work. 8. Prior to the start of work,staked haybales backed by trenched-in siltation fencing shall be set along the approved work limit line. Effective sediment controls shall remain until the site is stabilized with vegetation. 9. There shall be no disturbance of the site,including cutting of vegetation,beyond the work limit. This restriction shall continue over time. 10. All areas disturbed during construction shall be revegetated immediately following completion of work at the site. No areas shall be left unvegetated or unmulched for more than 30 days. 11. Upon completion of the foundation(s)for the house foundation,project surveyor/engineer shall provide in writing to the commission verification of the proper siting of the foundation(s),and of the location and condition of the sediment controls deployed at the site. 12. This approval is contingent upon the approval by the Board of Health of the subsurface sewage disposal system. 13. Drywells or graveled trenches along the drip lines shall be installed to accommodate roof runoff. 14. The driveway shall be constructed of pervious material. 15. Pool disinfection shall be ozone injection. Drawdown water and shall never be shunted toward or over the coastal bank. 16. All proposed lawn areas shall be underlain with a minimum of 6 inches of organic loam. 17. It is the responsibility of the applicant, owner and/or successor(s) to ensure that all conditions of this Order are complied with. The project engineer and contractors are to be provided with a copy of this Order and referenced documents before the commencement of construction. The foregoing condition shall not be construed to exempt project contractors from responsibility for any work performed in deviation with provisions of the Order of Conditions or with the detail of the plans of record. 18. The Conservation Commission,its employees,and its agents shall have a right of entry to inspect for compliance with the provisions of this Order of Conditions. 19. At the completion of work,or by the expiration of the present permit,the applicant shall request in writing a Certificate of Compliance for the work herein permitted. Where a project has been completed in accordance with plans stamped by a registered professional engineer, architect, landscape architect or land surveyor, a written statement by such a professional person certifying substantial compliance with the plans and setting forth what deviation, if any, exists with the record plans approved in the Order shall accompany the request for a Certificate of Compliance. Therefore, the Barnstable Conservation Commission hereby finds that the following conditions are necessary, in accordance with the Performance standards set forth in the regulations, to protect these interests checked above. The Commission orders that all work shall be performed in accordance with said conditions and with the Notice of Intent referenced above. To the extent that the following conditions modify or differ from the plans, specifications or other proposals submitted with the Notice of Intent, the conditions shall control. General Conditions: 1. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this order. 2. This Order does not grant any property rights or any exclusive privileges; it does not authorize any injury to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state or local statutes, ordinances, by-laws or regulations. 4. The work authorized hereunder shall be completed within three years from the date of this order unless either of the following apply: a) The work is a maintenance dredging project as 'provided for in the Act; or b) The time for completion has been extended to a specified date more than three years, but less than five years, from the date of issuance and both that date and the special circumstances warranting the extended time period are set forth in this Order. S. This order may be extended by the issuing authority for one or more periods of up to three years each upon application to the issuing authority at least 30 days prior to the expiration date of the order. 6. Any fill used in connection with this project shall be clean fill, containing no trash, refuse, rubbish or debris, including but not limited to lumber, bricks, plaster, wire, lath, paper, cardboard, pipe, tires, ashes, refrigerators, motor vehicles or parts of any of the foregoing. 7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or, if such an appeal has been filed, until all proceedings before the Department have been completed. 8. No work shall be. undertaken until the Final Order has been . recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final order shall also be noted in the Registry•s Grantor index under the name of the owner of the land upon which the proposed work is to be done. The recording information shall be submitted to the commission on the form at the end of this order prior to commencement of the work. 9. A sign shall be displayed at the site not less than two square feet or more than three square feet in size bearing the words, "Massachusetts Department of Environmental Protection, Pile Number SE3-3021 •" 10. Where the Department of Environmental Protection is requested to make a determination and to issue a superseding order, the Conservation Commission shall be a•.party to all agency proceedings and hearings before the Department. 11. Upon completion of the work described herein, the applicant shall forthwith request in writing that a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 12. The work shall conform to the following plans .and special conditions. o Cape Cod Division COLONIAL 127 R'hites Path South Yarmout/r,MA 026640 A 8 C 0 M P A N Y 508-760-7400 Fax 508-394-2564 September 12, 1996 Gerald Epstein P.O.B.1094 Mashpee, Ma 02649 508-477-3774 Re: 878 Main St,Cotuit Ma To Whom It May concern, Tliis letter is to C ni rni that there are no underground natural gas facilities to the above referenced property. This was confirmed by our representative on September 11, 1996. Sincerely, Barry Fernandes Distribution Coordinator Colonial Gas Co. The Cunurrutrrt•cult I of massuchusctts pcclw!✓2 Department njludustrial, ccidetin �\- Ofl�ceol/o�estJgat/oas evA 600 If•ashirrton Strict I0, Boston.Mass. (12111 ' Workers' Compensation Insurance Al idavit r nhone 0 I am a homeowner perfoErming all work myself. I am a sole proprietor and have no one working in any capacity _ i.� ' � '.ram•,._•,�n.,��....,r..,..A'F� ..�..1.,.er.Yf�?!--..►�•_ . . .. - + =-- -".•"'_t --'---�-3 �-�'�• �- I am an employer providing workers' compensation for my employees working on this job. nm nv name! address• ' city- Rhone#• incur•rnce co nolicv# J$ 1 am a sole propriet general contracto omeown role one)and have hired the contractors listed below who hay the following workers' compensa I tees: m any n•rmc• 61-e a idres • 7g5— S,e�hv��r,✓ 6,14 c t, �j�L`l jp dl?� �✓19 nhone#• .� �O-S'70 7 insurance co �` ib� -zoos Cc nelicv# �C 16 Z,Lri8- �•- , .. _. urlf!::: - n-s4-=--,-7...�"ce-«4--�iTµ.'4 -see•-+•+..:C-�.-sT..�.w...�..,f.._. +�..,r.-sue?.- •�---s+...9::_^0,.'^'C• '-�t-f. cnm anv name• Ciddre cc city. nhone#• incurince co policy# Attach additional sheet if nece- rya '+i �i"�.-e�:�...' .if vspit� :•at.�. .-•..•n.••.....•ga:..+ -- _.... - •ice �!""'�•"`—•.awas::�:a i4� ,.�rr.r3. '-- Fnilure w secure coverage as required under Section 25A of h1GL 152 can lead to the imposition of criminal penalties of a fine up to SIS00.00 andiur one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. ' !do herehr c T.-tinder t/ ains and penalties of perjun•that the information provided above is true and correct. /Sianature �Ct,�-��- Date 4� !7, 96 •�-- Print name J 40� 4e /,04 Phone# TA42 •--7 17 official use univ do not write in this area to be completed by city or town official city or town: permit/license# riBuilding Department Licensing hoard check if immediate response is required ClSeleetmen's Office C3Iicallh Department contact person• phone#; r l0ther (raised 7;05 ru) I Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the employccs. As quoted from the "law", an enrplmree is defined as every person in the service o1 another under an, contract of hire, express or implied, oral or written. An enrphor r is defined as an individual, partnership, association, corporation or other legal entity. or any two or mor the fore-_oim-, engaged in a joint enterprise, and including the le al representatives of a deceased employer, or the receiver or tn►stee of an individual , partnership, association or other legal entity, employing employees. However th 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_ he or on the ;grounds or building appurtenant thereto shall not because of such employment be deemed to be an employe MGL cha'pter 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 i been presented to the contracting authority. t. ,- Applicants , Please fill in the workers' compensation affidavit coin pletely;;eby'checking the box.that applies to your situation and supplying company names. address and phone numbers as all affidavits may, be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date'thc 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 vdtt have any questions regarding the "law- or if you are requires to obtain a workers' compensation police, please call the Department at the number listed below. Cin- or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple. be sure to fill in the permit/license number which will be used as a reference number. The affidavits maybe returned t 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 question please do not hesitate to give us a call. The Departments address.'telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma 02111 fax#: (617) 727-7749 f nhnne.#: (617) 727- 900 ext. 106. 409 or 375 t i::.:::.:::..,;:::::.:::::..:::T.,.::::.:::::::::i:::::::...............::ii:<::::i::ii;;::i::::<;::::::i::ii:...... iii.............:.....ii::;;:::: i:::;::::i::.........:::::::::::::::i:::i::i:::::::::::::::::::::i:::::;::;::::':<:;<......:::;'<;:c:is2:ii::;i::i:>.:ii::<::i:i:>:::::i:::i:i:ii:>�:::::::: "'> :>: is<:i::::>:....>::::i::::i: DATE MM DD ;e:;: : ::;: 1 / /YYI ACORD . :::: .. . ::>:>:::: ............................................................................................................................................................................................................................... PaooiiceR.................. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Arthur D. Calfee Insurance ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Agency, Inc. COMPANIES AFFORDING COVERAGE 336 Gifford Street COMPANY Falmouth MA 02540-2967 A Le ion' Insurance Company INSURED COMPANY Cape Harborside Construction, Inc B Aetna Life and Casualty Mr. John A. Pekenia. COMPANY 295 Scranton Avenue C Arbella Mutual Insurance Co. Falmouth, MA 02540-3472 COMPANY D 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY), GENERAL LIABILITY GENERAL AGGREGATE $1 0 0 0 0 0 0. X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $1 0 0 O 0 0 0. CLAIMS MADE ❑X OCCUR PERSONAL&ADV INJURY $ 500, 000. A OWNER'S&CONTRACTOR'S PROT 0 0 6MP 0 0 2 5 2 0 310 3 TWF 12/0 9'/9 5 12/0 9/9 6 EACH OCCURRENCE $ 5001000. FIRE DAMAGE(Any one fire) $ 501000. MED EXP(Any one person) $ 5, 000. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO X ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) 100, 000. C HIRED AUTOS 5 QF 512 631, 12/10/9 5 12/10/9 6 BODILY INJURY NON-OWNED AUTOS (Per accident) $3001000. PROPERTY DAMAGE $100, 000. GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND X WC STATU- OTH TORY LIMITSI ER EMPLOYERS'LIABILITY EL EACH ACCIDENT $10 0 O 00. B THE PROPRIETOR/ X INCL WC 1022518 12/13/9 5 12/13/9 6 EL DISEASE-POLICY LIMIT $5 0 O O O O. PARTNERS/EXECUTIVE OFFICERS ARE: EXCL - EL DISEASE-EA EMPLOYEE $10 0 0 0 0. OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS General Contractor :ARii~i ': ...::::::. .:::::::....... ...,:: ..._ . ,:.. GANCELLATIOM _ _ _.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of Barnstable EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL West Main Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Hyannis, MA 02160 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON ffliE COMPANY, IJ&AGENT OR REPRESENTATIVES. AUTHORIZED REPRESENT 1 <>< > <>> > > > >:> <:<::>:»`<:::>:><:> > :>:>;>:> : ::>:>:::>::>::<><:>::>:>> >::<>;>:>:> ::>::>:<::>::>:>::>::>:>:>: '<>> >:>:>:i7ACQ.. ;G 11~?E71£#ATI4At;I:'988 .........}...................................:.....::..:::::::::::::::::::::::::.:.:::::::::.::::.:::.:::::::::.:::::::::::::::::..::::::.:::.:::.:::.:.:.:.:......................................................................................................... rf ur Q' ee INSURANCE AGENCY;INC. d :y..•Y31.� .tu X x .�' i � .h r` Y � Y. din rt ' HOME _IMPROVEMENT, CONTRACTORS REGISTRATIONt �¢ ' . ; ; Board of Building Regulations and, :Standar;ds$ One-Ashburton Place - Room-k 1301 Boston, Massachusetts' "021.08.. i -I HOME :IMPROVEMENT CONTRACTOR - -------------------------- Regist.ration. 101378 Expiration 06/25/98-•.° .;F , , , Type, - .<PRIVATE .C.ORPORATION l .zF 4i a, p ,_ T,rk Z.4I _ HONE�INPROVENEN�T.&TRACTOR.- : .; • . , •,r:,RegistraPtRioIVn ATE101318 IONCAPE HARBORS:IDE CONSTR.'. CORORAT �I John A. Pekena 295 :Scr_anton Avenue, � � qt E Falmouth MA 02540, ,CAPE.-HARBORSIDE,CONSTR..C4. 95'Scranton.:Avenue . ououth=HA'02540 ADMINISTRATOR' -- _. --------- Kv DEPARTMEN-f'OF` PUBLIC SAFETY . .ONE ASHBUR ON PLACE, RM 1301 �. BOS I ulv: r�\0z108-�161E3 NOV4 2 `� CONSTRUCTION SUPERVISOR Number Expires � .•• ,I ..� Restricted To: 00 ' ,:', ire, a m j - tl'el'ach Bottom, fold sign on.- JOHN A f EKENIA. 295 SCRANTON AVENUE , ,w '.back, and laminate license card. FALMOUTH, MA 02540 _ - T,... Keel) top for receipt and change faddress notification. r IN/F Irene R.Morrill,Tr _ ' OCo J� J2 •10' <B ?6 s, ?? N 66.50'38' E `; 1 FfhOF p L ?0 402' t �? ?4i ?p.B J6OST � � � I -PO ?s 000f0 / 0'I k l l0 FCNcF. 9 F 0 nP/ q i f w J p f q / 0 '�qp4 I S N b J 4� Jq .� L 1 ( G+h, �C a . , C oue J !r� � /�l��;�'. �.�� --• 'lam � � ?8 .1` �r l• y W' •� `1w ter/- -_ � / '/ O ' PROPOS ORIVEWAY�' ..���'� '� ' IN LAN DINGi f IANDII.IG - eqI 4 � � 1 9 THREADS I{'-H-3' / C ?s ?• ?I „__ --.;_ .S � ��`• � � ♦', Q� � �� / r L LOT 4N / 1 Sn9 S 72•07 LANDING M THREAPS I I = u=o,► N/F Thomas 81 Terry - -; PLAN VIEW Eastman •F— pit / - _ to 1 : Scale. 1 0� ?0� 1 O RISERSC i POST(TYR) Its I� - ' f• • II �\ 14 TNRE�:A05(@ ql a y., ;.. ., ..raw � � .'� � "' !, • • • i w� A , , A -P 5 1-1 o S �, _. ___..._. _ ko so De- NAND DUG. - t RANboML/ $PACED � � � � ,• ��y-- (o'x 6"STEPS TO Ir REMAIN iN PLACE.-, n J oopi N 1 Bso cc2'X 4 RAILING ;. !•• ,.WuS is t Q' (TY P.) ' 1 N ' P ub tog tUlt 7 1 PCs. . • F SECTION A-A -m► _ - ., J >• Scale 3/8 =1'-Ole • r r LOCUS PLAN Seale:I!=2000' a Assessors: Ma 35 R>_MOVc EXIST STAIRS'' W j AReA d- t Parcel 78 8179 �y e} STR1N66ttS INT1•IIS r An [=X1ST. DGC.N TO REM .1 f j e?ri EXIST._BEACH HouSG `TO REMAIN j , i EXIST. FENCE }- GATS TO t2EMA►N yux pOST�TyP) Zax�l"RAILING.(Typ. EXIST , Dack 150T1.1 S1DrxS,) TO REMAIN ,._ SITE PLAN PROPOSED STAIR REPLACEMENT' AT �o 878 MAIN STREET NW1, COTUIT, MA . : FOR X. GERALD EPSTE IN - Directions to Site From H annis. Proceed on'+ y foute 28 toward Couif. G. 26,1998 Take a Left onto Putnam Ave. thet PLA (at traffic lights)..-, Follow to the end and Clih Fl SCALE'S LLIVAN ENGINEERING N ZINC. I take a left onto Main Street. Site is on the Left#878. OS,TERVILLE, MA MHW: 01-22-96 0 0 a-eb C: 6�0 gOAY OUST. ro 6DECK LOCA-110141 NO PER APO, OWD is \Glll SITE PLAN 0 GOP 0 v .gyp i \ ro (3 0 ,'-'POSED PRE, ,1A T: ASSESSORS MAP 35 PARCELS 78 & 79 FEDERATED TW W 0,m4M. W,,W REF: DEQE FILE No. SE3-3021 C�JURCHI PARIS04NACE G. 7 Its. s FOUNDA10N LOCA71ON PLAN 10 PROPOSED POOL-PA 710-DECK-FENCE LOCA910N S 87*4712" E 239.04' AT S 87 46'23" E --------- #878 MAIN STREET COTUIT, MASS. W A FOR N/F MARION SAWrE_-.FZ GERALD EPSTEIN, ET UX LOT 5 L. C. Pl. 19606 F SCAILF: 1" = 50" NOVEMCER 12, 1996 BAXTER & NYE, INC. S;. 812 MAIN STREET . 4S374 OSTER\ALLE, MASS., 02655 (508)-428-9'131 JITC GRAPSCALE 50 0 25 50 100 200 A IN FEET 1 inch = 50 ft. 95159 (CPP03.DW_- MHW' 01-22-96 11� 1 rbo . � \ EXIS�No BOAT HOUSE \ -d 6 7 5 / so, , �► o 1� 6 ,,fig 96 8 ,elbo P. R. o 0E of M oce {y o sgoc�es i . I O o w N �e FEDERATED CHURCH PAIRSONAGE TOP OF COASTAL BANK t` co ASSESSORS MAP 35 PARCELS 78 & 79 N CO. ASSESSORS DEQE FILE No. SE3-3021 2OO.64 N S 87.47'12" E Z 4 CERTIFIED PLOT PLAN F. L C. PIT 19606 F L0� 3 606 E�/1 O C Pl 19 _ 239.04' 6'S AT s e7.4s'23- E WAY � z #878 MAIN STREET 241.88' 4 W A Y COTUIT, MASS. FOR N/r• MARION SAWYER ` GERALD EPSTEIN, ET UX. LOT 5 L. C. PI. 19606 F I CERTIFY THE FOUNDATION SHOWN HEREON COMPLIES SCALE: 1 50' OCTOBER 17, 1996 WITH THE SIDELINE AND SETBACK REQUIREMENTS OF THE TOWN OF BARNSTABLE AND IS NOT LOCATED WITHIN THy BAXTER & NYE, INC. 10-17-96 812 MAIN STREET '��H F OSTERVILLE, MASS., 02655 JOLS �� (508)-428-9131 BANC. OSTERVILLE, MASS., 02655 298 74 g GRAPHIC SCALE ��-�yCfSg SO 0 25 50 100 200 THIS PLAN IS NOT BASED ON AN INSTRUMENT SURVEY ^k! AND THE OFFSETS SHOWN SHOULD NOT BE USED TO DETERMINE LOT LINES. ( IN FEET ) 1 inch = 50 it. 95195 (CPP01-DWG)