Loading...
HomeMy WebLinkAbout1355 MAIN STREET (COTUIT) �. ��. �� �� �;.-;ra t RO �,►� Town of Barnstable *Permit# off' Fapires 6 mo the rom' ue Regulatory Services Fee saxNsznara +' '""W Richard V.Scali,Director DMArA Building Division Pier m Tom Perry,CBO,Building Commissioner n 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us n T 212016 Office: 508-862-4038 -790-6230 � �(j����]f'�"STABLE ��, EXPRESS PERMIT APPLICATION RESIDENT BLS �, Not Valid without Red X-Press Imprint Map/parcel Number / Property Address l.3 5',< A l s'f• f v ivy r [Residential Value of Work$ 2A 00V Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 16te' AM Al 4-� gfI'67.4 /�'fYUAI yt F r '� b�U�l /Ci ,i 0� y 1r Contractor's Name ; ✓���� � Telephone Number Home Improvement Contractor License#(if applicable) 1007Ye Email: ,Aewy Construction Supervisor's License#(if applicable) �'(_ BIWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeowner, 91 have Worker's/Compensation Insurance Insurance Company Name f1/y � yaifwt e` 6V,49 !Y Workman's Comp.Policy# l� a2 C. �`��OZ 00 Copy of Insurance Compliance Certificate must accompany each permit. Permit Req st(check box) (nU 6,0,ed/d 0 vj d u e� 6,(1rtD d or w1110 d cl/ OAI V, Re-roof(hurricane nailed)(stnppmg old shingles) All construction debris will be taken to IOW U 44�D ' 0.0 .� l�A (hurricane naile )(not stripping. Goingover existinglayers of roof) fl Re-side 111 h0 ai 4 WC-5 ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Proverty Owner must sign Property Owner Letter of Permission. Abc the Home Imp ent Contractors License&Construction Supervisors License is SIGNATURE: C:\Users\Decollik\AppDindowffemporary Internet Files\Content.OUtlook\2PIOIDHR\EXPRESS.doc Revised 040215 L. .1 Page 7 of 7 jCapizzi Home Improvement Inc: l Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I i I, KEENAN FLYNN, OWN THE PROPERTY LOCATED AT 1355 MAIN STREET IN COTUIT, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: r APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-95I8 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: I i i CCODId CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D YYYY) 12 29 2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS-NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the 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 endorsement(s). PRODUCER CONTACT NAME: ROGERS&GRAY INSURANCE AGENCY, INC. PHONE I FAX C A/C No): 434 Route 134 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# South Dennis MA 02660 INSURERA: AmGUARD Insurance CornDany 42390 INSURED INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURERC: 1645 NEWTOWN ROAD INSURERD: INSURER E: COTUIT MA 02635 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. I�TR TYPE OF INSURANCE ANDR SU D POLICY NUMBER POLICY M DDY� MMIDD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ M _CO OMMERCIAL GENERAL LIABILITY PRE E (RENTED SES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peraccident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN R2WC655250 12/25/2015 12/25/2016 X ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N❑ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) A CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED* ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD t n%/e c�»c�iza�trleall/r a!C/lcuJcrcr Massachusetts Department of Public Safety face of Consumer Affairs&Business Regulation Board-of Building Regulations and Standards l_ IMPROVEMENT CONTRACTOR License: CS-064817 I r Construction Supervisor- i Registration: 100740.:,. Typ Expirati n; 6/23/2018 Supplemen JOHN T STRUMSKI ­INC p IMP +OVEMENT 18 ALDEN AVE w C7 al. L' BUZZARDS BAY MA'02532 r ' 44 !� JOHN STRUMSKI + r; 1645 Newton Rd. , Cotuit, MA 02635 Undersecretary Expi ration: . Commissioner 06L18/2018: - Unrestricted-Buildings of any use group which contain less 11=35,000 cubic feet(991.n3)of enclosed space. Failure to•possess a current editiori of the Massachusetts State.Building Code is cause for revocation of this license: For DPS Licensing information visit www.Mass.Gov/DP5 License or registration valid for individual use only. before the expiration date. If found return to: I Office of Consumer Affairs and Business Regulation 10 Park Plaza-'Suite 5170 Boston,MA 02116 f Not valid without signature f, v :. . .tw wua.wrq�r�swsrrvd:irseso.s�swiswuura�. Depa ie)d qfIn*uhWAcddenft I Congress S&e4 Sate 100 Boson,MA 02H A2011 wm=gov/rlw Warkcrs'Compensation InsuraneeAffidavit:BnildwWContractorsWectridw s/Plu nbem . TO BE Fmw wnH Tim P.ERttnTnNG AurHoF=, Antlnfoi9matfan „�_ Please Frhrt Legibly Name • - :CAPIM HOME IMPROVEMENT INC Address:I NEWTOWN ROAD `1 City/Sta#eXjp:COTIAT,MA 02635 Phone#:508428-951 8 areyos an cb]c1MeapProprfdeb= Type Of pro (requhvdD: 1.0I em a mo gWwa 40 ea loyees(hill MWwpa )' 7. Q New COstetnloiiO3i 2.olamasolep*zioWrorpvWmftandhmno=Vbymwm�ug farm9n $. 13$gmodeft eay CkMw.[Na wafts'Gmp.insma me MphVil 9. (�DamaHtion 3.�I am a homaawa�doing aA vvark n�ysal£�I+To w+a�s'o�p,fnawauoer�died.]t ... 4.❑IamahomwvmwendwMboWdagcoatracDmstooa aUvm&onmypq v.Iwi11 100Bldldi4gail don emmow all conbut cs d&w have worm&, on at are WIS 11.p 1 er p 1 ,awi8iwmopioyee$, 12. Phmftgr8PaftSaraddidons SCII am agoams]ead=torandIbmhimdtw'sobcmftamlbWonftaftdmdahed 7hm sulnuntrudws hue eagky=andbaeewoftW comp.farms }3�R�ftegsnS 6.OWearaaecapaaafiananditsol sha9ee tl rri tofwa p�Ii4iC .a 14.QOdeh' 152j1(4ka1.whaeen=AwO s•[Nowt°camp.nuaance j "Anyapplicantthatc bax#1mustalsoffionttheadunbetowAov&g9wkwofas' ' t H=wwnm'v*o aft ft affdavitindfa tiogthey ere doing all wodsend d mt him ouMb ootegnmstsubmttanowaffldwkWkefmgguck Vant wkws tbddm Ws box mat MAW as edd and dw almwiog dw main afihu andstowUlhaarmMossafteshm employ. Fft hwe eWoYM ftms -FV"&* 'MW POMT Xam an&ndvar tlxrilspravi Wwor a campwsid n AMM efnr)v wifteft &OWif McPWIq udjub she Informado& hgu me CompW Name~AmGUARD INSURANCE COMPANY policy#or Self-ins.Lie.#:R2WC627200 Esphution Dates 12/25/2016 Job Site Address• Attach a copy of the workers'catnpowdon policy declamdon page(showing the policy number and egpiratioa date}. Failura to scarce coverage as ragnired uudea MUL a 152,§25A is a Mximival Viola .ptutidiable by a Sae up to$1,500-00 andtor one-yW as.well ae olvil PEWdes in the form of a:STOP'WORK ORDERand a finis dup tO WO-00 a day agaiwt a violator.A cWofftftmnatmay be hrwm*dtb f Office ofkvwdpdm ofjwDIA f !Moray verification. Ida hereby 'nnder0dpadnsandpena ;?FRHn'tfW&eWffMat MPMd"Obo k*uewzd wffeLt �$� � Date► phona#.508428-9518 U [6. tyorTown: PermdtlYkwU# ulagAe�ority(cfrcle one); Board of Heal#h 2.Ba idin Deitartneat 3.CityfTown Clerk 4.ElectricalInspector I Phnnbimg Inspector Otherntact Pia: Phone#: Town of Barnstable *Permit# ri Expires 6 mo from qe C e Regulatory Services Fee swaxsrns M"� $ Richard� V.Scali,Director Building Division PERMIT Tom Perry,CBO,Building Commissioner UL o Z 2015 200 Main Street,Hyannis,MA l2 lI www.town.bamstable.ma.us 11! OF BARNSTABL Office: 508-862-4038 Fax: 08-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number (f YJ Prop Address / Residential Value of Work$ ®®® 9 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name--A Telephone Number Home Improvement Co tractor Lic se# if applicable) XVIEmail: Vnsction Supervisor's License#(if applicable)rkman's Compensation Insurance ,Check one: ❑ I 4m a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name LA ©Qa , Workman's Comp. Policy# Copy of Insurance Compliance 6ertificate must accompany each permit. G Permit Req st(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) Ve-sideplacement Windows/doors/sliders.U-Value y (maximum.32)#of windows #of doors: ; ❑ Smoke/Carbon Monoxide.detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is quire . SIGNATURE: QAWPFILES\FORMS\bu ding p rt fo s XPRE doc Revised 040215 {�• � �i.a•irs_:rl_-a'= ay./:re.ts fir: 1 str/yi•ra r S :arm �-B=i-,CZA Ai. a9Ifia -.:a•Kafi f lr .sf i' 1t rt i a t - i/aai _ l.tal iY. Sflf■wiu • lf�fr .wz _�if2 n aarn -if alr ss ar a .at'tas - G•t1Yf 1'�-: -J'Iftl:fr 1!t al•1L Jf.lrr:11 /I/Il+lil-//..�J/ ._. J.��L� NI UM.,M, \ , LIWA a i :r, -r- :i �w i �n f�■ -r _•r• b ••fit . +• : �Gi.�o. w•n.rlrf•; a •� • . i.a.f�aarti.n-a -- at 1 :na •: w,r •m- •r .,n:.o iir •.aa- w.na::.ra• ■ _t■! \ a.•aa�f•_ •. - eta' ra MI L.-- . mot,►•..,it. V rrt• -i• tr .• ____ ♦a.�� .• •t Ya►:IYT•a � ■ It•�•t.• t••\\ wua • � • tr.+- t.a aw ••.�t 1\• to :ll" r:.I!ant :" ■ G• .2.174. ram••.r ■ IT- .I- r• n•.rn•-■ _n• tr, i •�awn ar: a:n+:la: •, .••urn Xmb •i• •• •••.ra:.a: ••�a•.t ■Jr •] iil��lalf•••:. •ii l �/ . �s■i ■-r••l: _ills + .!: - ■:a �uua• - • +•\:f a'� � •to� - f - H♦ 9.0 flail' - _ r pct:% •i■ru. iM'.'Tb/_ r - a P+r _ i v• i - r,a r/". r r S•fa : f.r.'•a r- •.t.n:.a• :,u- �/ .. ate, ,/r' MW x",WRI _./.lam., . rr. •■ i1 I■ca:: ••in-tw'r.•at .• t •• �t a aaa- n - •1 .r•u■a ae• a.•n sR • u t- \• .war - - �• ftn•s -rabu • i L"'ar �_ia it r .• a1- ins►•..n•.• • ••a ur. •�Lc: •�. •■ _ \: n► c• 1 1 f 1 •,t tu••rsxa.•.nc�n -I •ar - n - u,■r• • - 11 t' ' 1 '�( t• - •1- •■ •.• .. 1 if r: .•snn.� it- + • :a,•. :.t, �::• ia.:!. •.• u itr- r:fsau�n f■r ■- na ••-.a�• n i• � it - • -_wa•Jft•rC • a- , :a. tf-•::.■C wa:f•- llb,RVIt.a ._. yr - rJ a�• sit- -ar, •r,.•ra a rZ:a r i Ii o1 i a a .ra a-, r - ,7:•.,' • ._ ,ri r .�dl—. n■•c ,., . , rt. 7 f •f Aa,a:iru rra rr ,ja fl Ikt - ■i . - 4l•xt1 i as frl■ . nt. f - .r tt- rwr Gain cru 1•:;:ia w.. �a n r- i !1 _ '.!! wr .r at.•i.•:• at,n m •I '•a r• • ■.M C-mcral Laws d 152 reg==all=4h9=to pre 7j&worj''cm:rpdms;Amn fig fl=ploy=• egg y an ffif �I& d 8S a-- p pew r0 foe ace of 4=ffier MAC�EMr,Dart DfhIIei ex press or mm}fled, oral or wr i± " } An�T�pr�is definedf as�n 0MPC dIM Or atlier Iegal e�iiy,or any ttvo or more bffbe k=going=ga$l--d m a3Di3t mtm:�and f Itg-A rCpr=cntdjV=of a deed eanplDYc -Or the red:ezvPa c r trope of an .p�bJp,asso�;�® or Df=legal MtIY,emplDymg=:PIDyers $Dvreyer fbe o44=of a dWellirl-ho:n=havfag not more ffim f n-=apt and who residrs ffieaem,-or ffie Dccupant of the to do mns act m or par waik on well dweHiag house of anotherwha essoas _ � dwelling hawse �P�P to be-an. I }cr. . or an�gerunds or bmlchag agpmtena���shall zinc beDgase Df srtrh eauplDyn�be desmed e�D3 mm r r I�-2, §25CC6)also states fbd¢every,state or local Fcensing agency shag wiffihDId ffie issuance or renewal of a ice or permit to DperaJr-a btmk=or to cow !rand btadmgs in the Common Calth for any apphc=t who has not pmanced acceptable evidrmce of='Hance with the iatar m coverage regrir- d' . igliritiouaIIly,MM chapt=L52, §25C(7)em 1he commonwealth nor any of�s pohdcal subdivisions sh2a erltet irdn arty=ta.at fM fat pdZan=Dfpvbfic wDkuntU acceptable evfd==of ce Wr h the M cr da= mgmTem=Lts of tlas rhapfrr have been pry to fbe=tacbng mffica�r a APPlimnts Please•II o� fha vness'�ensaiion affidavit completty,by Chug boxes t apply to ycnr sifn�lion and,if n �ar5'� PAY srrb-�onta�inr(s)name(s),sddre.s(es)wadphDne zn�mber(s)along with thew Dcrdncaie(s).of ;n.smance. Limii-ed Liability Compamts(LLC)or LmmtrdLiabi3rtp Partneiships( .P)w:dh em oyces other than the members Dr partners,are nDtrDgmrmd tD carry wa:k='compeosstion m m- D`- If as LLC Dr LLP does have emlploy=s;a policy is regvfedi Be advised.that Ibis affidavitmay be submit tD Department of Indvstiial Amidmts for canfnmztion DfiC nCt COV=Bgf' Also be sore to sign and date the affidavit The affidavit should be mtmmed to the city or t nm fbat the applicafion f�r the permit or l=m—is being redoes nd,not the Departri cut of Ind m5tcial Aceidmts. Shonld yDu have any goes i=regmTmg to lam r�you me rei�d to obtain a v*orkexs' comp=s.6an policy,please caIl the Department at the number EstDd below. SDI!fnsrned companies should eater ibcir Self-in cr u=license n=Bcr on the Eppropdaie Hue. City or Town Officials M1 ` Please be smm,tiidtb.e affidaYit is complete andpied legIly. T$e Departmmt'has provided a space atffie blot 6 of the af�dayit fp¢you to fill out in the event the Office o nri. has to mntai t you regaFdmg th e applicant Please be srffe to fill.in the p c=it/l; �member which-wM be used as a refim-mce n=ber. In addition.an applicant t hd must submit ale pennitYIicenm applizmions many given year,need only so f one affidavit fndicatrng r-u=t policy infor nafidm(ifned�y)and under'UDb Site Address't�applicant should write'an locations in (cfiy or ;.own)."A cagy of fine affidavit that has been officially strmdped or mar3�ed by the city or town may be provided to the applicant as prpof that a valid affidayd is on file for furore permits or lid:easm A news affidavit must be hIled out e ach year-Where a borne owner or Cifi=is obtaining a license or pe m3it not re lated to'a ay business Dr commercial y=tore (i e,a dog license or permit to bum leaves etc.)said person is NOT mgaimd to compleis fiis affidMdt The; ffice O of gatims would b1m to I:h Ern you inadrmm RryDm CODPmaiim and shonldyoxzhave any questions, - please do riothr�ate to givets a caIL - The Departmerf s address,telephone and fsxmmmbe$: ma vie'aIth Of Massachmdfs _ • � ��flnalAts _ .• -W . IAA 02111 Revisi--i 4"24-Q F Town of Barnstable ' Regulatory Services t . Thomas F.Geiler,Director m �Ajfva''� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.to wn.barnstabl e.ma.us' Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, et//hP_ ,a`Owrier of the subject property hereby authorize to act on my behatf, 71 in all matters relative to worm autho Zid ythis bdd'n permit application for. 13 G S 1YI41AI ST, Cv 1%&►rt; M� (Address of Job) � c 1 0 1 s- Signature of Owner Date Print Name If Property Owner is applying for permit please complete. the Homeowners License Exemption Form on the reverse -side. • n-znor..tc-nwu�vcr:tturrectnN f Vize c(ana.manrgerrll alp aataclutellt Office of Consumer Affairs&Busi ess Regulation i OME IMPROVEMENT CONTRACTOR f UVelgistration: 125799 Type: f xpiration: 1110/2016. Private Corporaticl C.J.RILEY BUILDER INCt „A CRAIG RILEY x' 10 B WIANNO AVE - ' OSTERVILLE,MA 02655 ' Undersecret ry Massachusetts,-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-066147 CRAIG J RILEY PO BOX 382 t O;terville 1VIA 02555 Expiration Commissioner 02/05/2017 g CERTIFICATE OF LIABILITY INSURANCE DATE(MNVD°mmn FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS tTHISCEFTIFICATE ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE UCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement s PRODUCER CONTACT NAME: DOWLING&O'NEIL INS PHONE FAX 973 IYANNOUGH RD (A/C,No,Ext): (A/C,No): E-MAIL HYANNIS,MA 02601 ADDRESS: 22LGR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY C J RILEY BUILDER INC INSURER B: INSURER C: INSURER D: PO BOX 382 INSURER E: OSTERVILLE,MA 02655 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM1DD\YYYY) (MM1DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ . CLAIMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT❑LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB LJ CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-2E899069-15 05/05/2015 05/05/2016 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? WA E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes, O under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DN DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTA13LE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 20 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL U DELIVEDED IN ACCORDANCE WITH THE POLICY PROV HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25(201 Qt05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP rlg s reserved. l Client#: 10798 2RILEYCJ ,PORDT�., CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Y 06/15/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.If 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 endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil PHONE 508 775-1620 FAX 5087781218 A/C No Ext: A/C,No): Insurance Agency E-MAIL 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC/! INSURER A:National Grange Mutual Insuranc INSURED INSURER B: C.J.Riley Builder, Inc. INSURER C P.0. BOX 382 INSURER D Osterville, MA 02655 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 CONTRACTOR 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. INSpR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY MP059664 5/02/2015 06/0212016 EACH OCCURRENCE $1 '000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1,000 000 GENERAL AGGREGATE $2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS er accident) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STU- OTH- AND EMPLOYERS'LIABILITY Y/N LTAMIS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Certificate of insurance for workers compensation will be issued by the carrier. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S152752/M152751 LS1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION s Map 1W Parcel Permit# l�w Health Division. A00 a4s O &QQ 3)gv,) Date Issued Conservation Division Feed^�0 Tax Collector ' C j � SEPTIC SYSTEM MUST T Eta 1 INSTALLED IN COMPLIANCE Treasurer � c�1dw WITH TITLE 5 Planning Dept. ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address -pens ---d d1l, d�-- Village Owner a� Address TelephoneY Permit Requ st 0,9 AVALUDO Square feet: 1st floor:existing_ proposed 2nd floor: existing proposed Total new EstimatEe Project Cost aoo Zoning District 0& Flood Plain Groundwater Overlay Construct�n Type av Lot Size . Za Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: 11 Full Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:,existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other Central Air: ❑Yes �No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:Cl existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals A thorization ❑ Appeal# Recorded El Commercial ❑Yes No If yes, site.plan review# Current Use Proposed Use a1 UILDER INFORMATION J Name Telephone Number Address License#C&Z't%2�� �cS Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Aw SIGNATURE � DATE f FOR OFFICIAL USE ONLY } PkMIT NO. ' DATE ISSUED MAP/PARCEL NO: ADDRESS VILLAGE .r OWNER- DATE OF INSPECTIOIS a FOUNDATION y, 1 M FRAME r ' r INSULATION • FIREPLACE ; ELECTRICAL: ROUGH M FINAL k PLUMBING: Roi,Gt ¢ YFINAL 4 GAS: ROUGiI �► FINAL Sc in tr FINAL BUILDING -� �' p• rmj F. o l 'lam © iG - DATE CLOSED OUT .. » ttt = Y t b < - • ' ASSOCIATION PLAN NOr;i w _ ofI ..... Department nd strial Accidents OffJce oflAY050,19offs - �' 600 Washington Street Boston,Mass. 02111 Workers''Com ensation Insurance davit r name: location- phone# city ❑ I am a homeowner performing all work myself ❑ I2Ma sole etor and have no one in anv acitn %/!l/////%G,%"//��/////O////%i%/�%/,' � . . , 1 on this job............. limma ensanon myemp : °° aag;:;.::.::;;?:;:.:.,, .:.. em lover ding rAmp.... .. .;:>;:;:::::::;:>;;::::::.:.:::.:?:?.;::}::.:>;>:??.: I am an p ..per................. ::.::...... :::r.:�:;.... ....:: comoanv Hain ;:: ..... :.r..... S. :>'::�: : :�::•'�>: ';::.>:«<::}: =.:•. ... ;:.:..:. :: ,...........:::::.: hone#:.. ......... ... :.. .......:: , �'''` of ' . insurance co. // eral contractor,or homeowner(circle one)and have hired the contractors listed below who ❑ I am a sole proprietor,gen have workers ,..,,v::.::.4}:<?- v:;:: :;�:;<A::'::Yr: : ::'::;>::::;..:::.:;;?:..;<:;.;:::::.:<.:::::::... ..::......::..:.... following ...... ......�:�°Ices...., .. :........:.::.::.:::::::;:: the g .....:.::::::::::::.�;::.:.�.�::.:::.:•::::..::::..::;::.:;::::::.:.. .....:::._::,,:....... ......... ..:::::,.:::.... .. ::...............v:::::•••:?ti•'i.:::vwkk'.`ri•}}-4:•:•}:4 v::riv •<i:i:iii::ifiii;:j{i:: i:;:;:}::;:•y:y:•ii is?.::... COMM v .... ............ ...........r...n...4..,........v..... .... ......v....:v.......:.,:w;,v};•;?.v.}}:4n;;4;:::::.v:x;....•• ................................................ ...:�:::'::.::::. .... }Y.:::•:r:....,.•::.::::•:::+. .. u•:v}..... :•.::�:;:{?:>::iS4t.{:.;;;:?; •+ii;:�:$iii:�:':::sX?::_:?i;}iii:i}:.::;':::ji;:$:::`:<:::':� :J:::.":: addre ':: :::•:':.'::}?:}:k.......:.. ,•?•is4}l�'?{4:i•}i:?v 4'•}:4:?;4:•:;•}:•}X•t}}is 0iv:i:::!;:}:iv{:i:-i'ri:Ji?:•:4:J:4:}j:w::.:1,.::i.,i:i'_ ss-.' .......... ...... .........: ...t..n.... } ..............r.rr. •v•• .r•+4,.r:.. 4r......::..... n.. ........... ......... .tn...• .. ..... v.v...v..v.fi :.{{4pr...hx ........ .............:hhu ....:.... ...0::::4}:+w:;w nv:.' .n� On C v::'v:•:::ii:�ii'ii i�:�l:�iii$jii%;:<ry$}j:'::•��•�_�..:.: ......:..::::::........................ ciiv:L... ........................:::•:•::::.:::: :.::;}}:;}:i :}::>r::•:':?:i:•}i'.fT::::: :SS::.....1...r...rr:::;..... .....................:.v..•...............::.::::::....... .-:::YY.: r..ra•::............}...:5 :•::•::.... .t•:::;}:}:�:::•::::::.,-.v:v;•::•.v:........... ............. ............... ....xrv........ ... .......f...r.}.........N... .... ♦v••.}}}^MYY:}:?'•:ti}:•:/.,r...:.�:,vv+.+iY....... ....... .......::::•............:.v::........•::•:::::.......v.....;..::::.:..\.t.......::..,...... ......::v::.r. v..:w- v.i•.Zvrv.4 rr ..}..ry n.r.:v. rti_..v:,:..:/...:v:v:......:... ' .......... .... ............ ................................ ...:::::::::n..n.v ......... ...... ...... ...... ............ ..... ...... .:hrrr........4y:.... r.:w.:v:::::qr:::w.vn....:.•iS:ri}nv:?:nwtwwww.:;>:.�...::.�::::: ..... ......... ..... ...... .......... .... ....:}n.... ...n 4Y!!"r....r..........v•v 4}w:v ::;::: ............... ........... ................ ............. .......... n..,..........., ................. r.w::•-.. ...na .....:v:r..r:: ...:r:•::;••:.aiG:;::}ia\vnw ..........:��:..........:v:r......r•:•:n:v..........•• ...... :..n..v.t r. ...;..:•. ... w.t. .:.4r.•......., a:. ::....:...:............. r.,v.:vr.:.va:::•:r.:v:n;. ....:..::::.... :...�::•::•.........;.a:•.a.....�::::::::•._.�:.Y::•}>•:.}-•}•::•"'k:.,.....,...,r :<,;.2...... OIIl4'# ..............:::::,,:,t.:•::::•.�:,,.::•:::.:�.:. .:....,.; til ... ...........................x..:........•...:.r .v....rr .. .... ... ..v.... ..... �....... ...+',..m.r.4.}....rv•r:.v:}:v::::-}•..::•..:.:•}'rr:' . ..................................... .............Y...... ......?a.x..n...:v.v:•M. vn ...v..t•.v}....::.:v:•x::......,S,ar.. :%:::::.-: .. tii\vti ..........:........ camean :.r ::::.:.:..........::.:: addresr- citv--- .......... ........... .:::::.:.:...... .:.:.,................ .....},.:......:... }.,.:................,.....,.....:.::-:::{...,:..,.y:;?..::. �;.,:;.:�::;..... Bane'#: .....::.::.:::::::.:::...... ..........::.:i:::.v:::::v?•i}:•}:•i}::•}}:•}:•}}}:::.:}:.}:•}:•:•:.t:•:::::::::•..$:::{•::::.:�ri•:::...;......... .................,,wvL••;{}}:j:�.r. 4+i{}:;4.}•'?4:::. ...:.:............. ..............:..::::::::•:::•::::::•::•}r• .... . ...................•:.....:.,�::::-:::•::•??.�:•:::,�.•r.•::::::rr:}::�;rx;;•}:�r�i: fR•:�i;r}t:..:Y:::.....•.,•::::.,...:..;:.......:::�. ........ .. ........... .............:......................... ................ .r...v............, ...,.,. .,..... ...4{r.... trri.. } ':ii`''r:::':::.::::.:::?:.:.:•..::•:•::•:;:ii:�i:::.:�::�::.�:.:.� ............ . ceder Section ZSA of MGL 1S2 can lead to the impo�of ethaioal penalties of a Sae up w 51,500.00 and/or Fatinre to secure covera;e as regair'ed one years'itnprisomnent as weII m etvII penaitlea is the form of a STOP WORK ORDER and a Sae of 5100.00 a day ataimt one. I�derstand that a copy of this statement may be forwarded to the Once of Iavesti;atlons of the DIA for coverate� • I do hereby certify wider the artd putalties of perjwy that the irtJonnauon prmaded above tt true ro cd - signature Rycezll Phone# , Print name otncial use only do not write in this a7pte completed by city or town oindal permitmcwe# ❑Bonding Department city or town: ULicensmt Board Ogdeetmea's Otnee ❑check if immediate response is required — Oneaith Depulment. contact person• phone#, uevMw 9195 P1A) • • :./•�/ t • q «• •II i• 1 1 � I .•Hsi • a • • • • • • a •1111•i' de • .. •- •. �1•• • • • • i• • •I11 It .11 I I/ / •�/e11 i• • N �/ f1/Oki1 a/1 a • . 1*I I.• 11•a si • a�• :•, • feel• i• ♦ • • �11 • 1 / / L • • 1 i• .16 II• 4 It • ee a e • •« ,1• •11 w11 r•1 .le •II • • 11 a =••i: ://1.1 • .11 • • • ••• / • • • 11 • �/t !�: ' • • • •1 ael a • .e/ • 11 • 1• -010, •1 -t11• • ./ •I •e -. e • 1 1 • •1 I • i I 11.64q..4 1 I Ir •« .1■ •11 • •Is1:•1 w•G i•UI i••II • 11 • i•11• • • • - a •• • •••a •1 • • 1 • 1 • 1 si • 1• Ie • / its 11 _ V.1 Or.tq eel-11•. .11 Its 61.111 Iot 11 Iasi qh 11 • Isi .1/1 • 1614 1wis • 111 • •• •• 1 • e• i1e1• • •�• •11 • 1 • 11 /11 �11 1 •11 • 1 M• •11 •I wr 1 ' u•. •11 1 1 • • I si • • • •7 •11 to J ••••• • • • • • • 1 /�/• tl •e�1 /• 1 I 1 • •i✓•/ • 1 1 i111e • /1 -11 • 1 _w•1 _1 /• • .11 ..111• • 4 IL t • a iwI •11 • Y.IIi. /1 ,1 1 1 ✓•: Y�11 V 11 rl 1 I 1 1 1 1 1 1 : 1 Y' 1 • , 1 1 1 11 1 1 1 1 1 V11 1 1 YI 1 . 1 r 1 11 1111 J. 1 •1 YI 11111 1 1 / 1 1 ' 11 % / _ � . • 1 1 • / , � 1 • 1 1 1 1 1 11 1 : 1 Y' 1 11 - 1 11 1 Y- YI i1 11 �1 • 11• •11 i • 1:•1e•a .• •Iesie •N • �•% 1 1 1 • .11 • • 1•. •• 11 w: 1 • 11 v •11 Yt 1 illy Ilia ,11 • -mull 10- « Is lqhd1 •�1 UI•rl .11 •1 • 1 1 ••1/'. ••• ' • ,✓, • •�11 •1 -m•1111• .11 -m ' 1// •1 IIA /1 1 -m _• 111 �••1�•11►. •) rll w1 •11 1�1 1 •_.w1 • i111_• 1• /1 welsi• • N 1• ������jjjj/���j��jjj��jjjjjjjjj��jj���jj/��jjj����jjjjjjj�/��jj�j��/��j���jjj��� e :/S i1I 11 11 •••1•.�=/•- •'•1111r.•• W.1e •11 ■■ • • 1 •.•1111• �/ 1 ' «1 _ ,�11 • /1 Ile• •1 .e .Isis) le • • 11. vl•• .t• •1/ •si• • • si • •Illlr .11 IY.111 1 •1 .�V. ,I/ • I 1 •11 111111 •�t•. •ill• ' 111 -mti Iel ••:11' •1 11 11 .11 -m I e• • •11, It • • • Illle �• Ap • 1/ 1 w• .e e11.+•1 •1 1 111 v•• •'« .i11•. 1•I -mu•1l 1.11 Y.e1 •II a IIA 11•Yt1 •• •• •w•: '1 1 1 1 1 v Jr. -1. I 1 11 1 III •1:• 1 • 1 VI • 1 • r -sli all--elk Falk 11- wl"As I 10 J.'.1 1T,It .1 II .1• a 4.:1• •11 I.1 11 • 61 -mw1 r�IIe i• 1 i li• 1 1 11 1 e .1 I11 .+/1 •, 1 ell •• •« • UA YI • 1 1 • 1 1✓- tl 1 1 • •11 .•Y.I silt 11 • i• 111 i/ • • l Wel• -11 .t e1 11111/ a.+ 1i1 • • ' e i. . 11 /t .1 I/ :. . • 1 -m•1•/le i1 .11 1 II.111/_• .... 1 1 1 �..Y.1 •le�+11 1 11 e .i1 • -m :1 /1 .. . •1•• :• • 1 let -� • • •II • 11 11 /1 - �••1 /1 :e -m • 1 '-. • •nn ul 1 /• -mu11 Y. w • • 1 �.•Y.1 Ill/ • /1 - .1• • •s111 • 11 • :7I 11 11 •�1.1111 ••w• 111111 • -/ ' 1 •ri/ I • 1 Y_• �•1.• �•• 1' 11t 11viol- II ■■ • • 1� t1Y. • • 11•••�. // 1 • e1/i111 . 11 •I 11 . 11�/ .1•r.11 • 11 IIA / ._w• 11✓. 1 1 , i. • 1 �+ • •Y.le •11 •'• 1 •9 It Ir.is • .11 -m 1.1 ' • 1 -m•• r .le •11 .11 1 e • 1 • • 1 .11 • /R ..• • is •• 1• 1 i.V I Y.1 • •J ' •% I SO /��j/��j����j���j��/�jj����j/R%/ 1 - •.i •e•N••11 FIrL. w r • 1 ell •if • •%►' 11111• •ti 1 1 •11 1 1 1 1 . 1 1 A' 1 1 1 1 . 1 1 1 1 1 ' I I • I I I ' 1 �"E T The Town of Barnstable IM&L Department of Health Safety and Environmental Services '0�i�o N,►�'' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissione: 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 Cost ��• " R n Address of Work: Owner's Name: zz Date of Application: I hereby certify that: Registration is not required for the following reason(s): { Work excluded by law Job Under$1,000 E]Butilding not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby ap fly fo a permit as the agent of the o er. Date ntra r e Registration No. O Date Owner's Name q:forms:Affidav . ...._.z._ ...:__..„,,�le`�arrhrco.uvecr�C a�✓�aaoac�ivael7a BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR r Numb en,CS 066147 Birthdate .02/06/1967 Exp�ress02/05/2001 Tr.no: 7036 'Restricted To: 00 CRAIG.J RILEY ' PO BOX 382 'r' OSTERVILLE, MA 02655 Administrator �3 � r ONE 2PROVENENT CONTRACTOR Expiration y 03/04/2402 £; f Type EPrivate CorporatioRX n "` C J.RILEY'BUILDER INC L� •n RILEY.. , F ADMINISTRATOR 2 NRIN ST-: x� s,� , z< OSTERVILLE z t