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HomeMy WebLinkAbout0029 OLD KINGS ROAD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 022 Parcel 0G$ Application # Health Division Date Issued 3 2,9 /6 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner L �`` �� Address �AYSAS Telephone� � Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Hi few -yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Bl KDll NP9 Basement Finished Area (sq.ft.) Basement Unfinished Area (s : 10 2016 a Number of Baths: Full: existing new Half: existing WT) 6LE Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas 0 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: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name MWO � MV%k\cn Telephone Number \� r Addressfta&j&� \4License # � G Home Improvement Contractor# Email�Q, ice, i�M �ilrnGt i (•CUf1-, Worker's Compensation # 703 ' ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �cu -mac SIGNATURE DATE \�i.� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 4 FRAME 4 INSULATION FIREPLACE ELECTRICAL: ROUGH ` FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT y. ASSOCIATION PLAN NO. L ' 5 j r , 4 h Federal ID t105-0405629 I RISE Engineering RI Contractor Registration No 8186 I MA Contractor Registration No 120979 A division of Thielsch Engineering CT Contractor Registration No 620120 5 Dupont Avenue,South Yarmouth,.MA 02664 CONTRACT PROGRAM 508-568-1926 FAX 508-568-1933 I R S Page 1 THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENCINEERINC CLC-RCS DESCRIBED BELOW ENGINEERING AND THE CUSTOMER FOR WORK AS CUSTOMER PHONE DATE, CLIENTC WORK ORDER Mark Herder (727)641-1255 02/29/2016 188921 00008 SERVICE STREET --� BILLING STREET ---,—�-- 29 Old Kings Road 29 Old Kings Road SERVICE CITY,STATE,LP `_-- _- _..-._...+._��- ,BILLING CITY,STATE ZIP Cotuit,MA 02635 Cotuit, MA 02635 JOB DESCRIPTION GARAGE CEILING:Provide labor and materials to install 8"R-30 densely packed Class I Cellulose insulation to(576)square feet of garage ceiling located below a heated floor area,by drilling holes in the ceiling from below. Holes drilled will be plugged. Plugs will be spackled and left in a relatively smooth condition.Finish sanding and touch-up priming/painting will be the customer's responsibility. $1,140.48 INCENTIVE:RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact olTers 75%incentive,not to exceed$4,000 per calendar year,and an incentive of 100%for the Air Sealing measures. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the wealherization work is complete.We will also conduct a diagnostic assessment of the combustion fumes in the exhaust flue of your heating system and water heater.This has a value of$90 and is at no cost to you. $90.00 D C C�LOMC MAR 8 2016 l Total: $1,230.48 Program Incentive: $945.36 Customer Total: $285.12 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ""Two Hundred Eighty-Five&121100 Dollars $286.12 UPON FINAL INSP CTION AND APP AL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALAN R 70 DAYS. E REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY B NK SPACES � 1.1 AUTNO U'ED SIGNATURE-RISE EngilreoAng CUSTOMER ACCEPTANCE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTEOWITHIN DATE OF ACCEPTANCE _.�.../�� _.1.. - LLL ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE U DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE C C ,. �TOM>� Town of Barnstable ao �1 Regulatory Services awR\srwsu. =I r�nss. Richard V.Scali,Director �. Building Division Tom Perry,Building Commissioner 200 Main Street,I1yanais,NIA 02601 -wzrnv.tow n.b a rnstabl c.ma.us Office: 508-862-4038 fax: 508-790-6230 Property Owner Must Complete and Sign `.l!'his Section .If Using A.Builder I, Iyta K 11 �iV d'� V ��. --- _ ,as C),cvner of the subject propc:n:y hereby authorize \ t \Y to act on my behalf, in a)l matters rdative to a-orkauthorizedbythis bulclin-pernut application for.: MA 621/35 Pool fences and alartm- are the responsibIty of the applicant. Pools are not.to be filled or utilised before: fence is installed md all fir inspections are pe:rfog7ned end accepted_ flae� �eede.e � . Mark herder(Mar 21,2015). Signature of Owmer SigDature of Applicant Print Name Print Name ]Date Q:FORNIS:O%V ',F,RPF:??AISSI.ONPolo1 S The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations V ° I Congress Street, Suite 100 ,Wt Boston, NIA 02114-2017 ' °J www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): M.T. McMahon and Son, Inc Address: 19 Fieldstone Way City/State/Zip: Plymouth , Ma 02360 Phone #:781-831-1234 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 9 4. ❑ I am a general contractor and I 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 working for me in any capacity. employees and have workers' insurance.* 9. ❑ Building addition comp.[No workers' comp. insurance p• required.] 5. ❑ We are a corporation and its - 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required.] t c. 152, §1(4),and we have no Weatherization employees. [No workers' 13.❑■ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Aim Insurance Policy#or Self-ins. Lic. #:VCW-100-6014109-201 Expiration Date: 12/08/2016 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation p licy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead,to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb17f rt� le s and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 831 234 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#: Massachusetts•Department of Public Safety J/i �firl�.n"o. ,�-u�r l�a �C..'slli xro ucar(f Board of Building Regulations and Stat dards Office of Consumer Afiaws& ausiaesb Reguiatiuo Con%trurtian Supenicor $TOME IMPROVEMENT CONTRACTOR egistration: 16'1816 Type: License:CS-068111 G Expiration.`_ 112412016 Private Corporatic NUCHAEL T MCNfikHOX h MICHAEL T.MCMAHON&' N 1NC. �19 FIELDSTONE.-WAY�4 PLYMOUTH Muk 023fi0 MICHAEL MCMAHON' t - ti 19 FIELDSTONE WAY PL'YNIOUt,H,MA02360 "'41.�� Expiration Undersecretary 08M7/2018. : Commissioner Unrestricted-Buildings`ofany-use group which- cont ain less than 35,000 cubic feet(991m)of l ' a!c4esa.nr registraiicn valid for individul use onty s before the expiratiu.i date. ii`<::tnd return to: enclosed space. Office of Consumer Affairs and Busines;i liooulation 10 Park Plaza-Suite '170 Boston,N1A 02116 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Not valid without signature For DPS licensing Information visit: www.Mass.Gov/DP5 s ,4coR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DdYVYY)12 14 15 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 endorsemen s CONTACT PRODUCER NAME: Thompson Insurance PHONE rd). 781 335-1890 Fax CAICN& (781) 335-9782 and Financial Services ADDRESS: JJTins@Comcast.net 389 Union Street INSURE S AFFORDING COVERAGE NAIC N Weymouth, MA 02190-316 INSURER A:Travelers INSURED INSURERB:AIM Mutual MT McMahon and Son Inc. INSURERC:Torus National 19 Fieldstone Way INSURERD: Plymouth, MA 02360 1NSURERE: INSURERF: 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 ADDL SUBR POLICY EFF POLICY IXP LIMITS TYPE OF INSURANCE POLICY NUMBER MIDDIY MMMDIYYYY C GENERAL LIABILITY y NPP8082574 8/26/15 8/26/16 EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED $ 100 000 X COMM ERCIAL ERCIAL GENERAL LIABILITY PREMISE$(Ea gm Tence) CLAIMS-MADE a OCCUR ME EXP("one person) $ 5.000 PERSONAL&ADV I NJURY $ 11000,000 GENERAL AGGREGATE $ 2,000.000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-OOMPIOPAGG $ 2,000,000 }( POLICY PRO- LOC $ AUTOMOBILE LIABILITY BA 2CB82729 e/31/15 8/31/16 CO aacccideOrtSINGLELIMIT A $ 1,000,000 BODILY INJURY(Per person) $ ANY AUTO ALLOWN ED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROP ERTY DAMAGE NON-OWNED P PER ent $ X X HIREDAUTOS AUTOS C X UMBRELLA LIAB OCCUR 80313L140ALI 11/24/15 11/24/16 EACH OCCURRENCE $ 1,000,00 EXCESSLIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION VWC-100-6014109-201 12/8/15 12/8/16 WCSTA7U- X OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E NIA E.L.EACH ACGDENT $ 500,000 OFFICERIMEMBER EXCLUDED?(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ SOO OOO If YYes describe under DESCR IPTION OFOPE RATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is recid red) Insulation installation and carpentry. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE John J. Thompson CLTC ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a Properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: ABC Disposal Name of Waste Facility 1245 Shawmut BLVD New Bedford Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure. M.G.L. c. 40 s. 54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c. I I 1 s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department. If the debris will not be disposed of as indicated,. the holder of the pennit shall notify the building official, in writing,as to the location where the debris will be disposed. 780 CMR—61h Edition Signature of Permit Applicant (f's VO Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma D Parcel �V p A lication � - pp // Health'Division 4'Y Date Issued Conservation,Division : Application Fee J Planning Dept. Permit Fee 1� 350 Date Definitive Plan.Approved by Planning Board Historic.- OKH _ Preservation/ Hyannis Project Street:Address TP � v MS 2md Village_cc I (� Owner YMY V_ Wi0a Address_IN 0 16 1 Telephone Permit Request ��JI�� ��' y�Q�� W%r Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District _Flood Plain Groundwater Overlay Project Valuation Z Construction Type ` Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King'j lighway 'U Yeq ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq. v� w �- Number of Baths: Full: existing new _ Half: existing nevi M 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:❑ existing ❑ new size_Pool: ❑•existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �Q MC, IYn ) Telephone Number 0--71. 12,Sq Address License# n(ON I i 2 Home Improvement Contractor# Worker's Compensation # 1T7\�C. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO A, "d SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# - y` DATE ISSUED, _ r- MAP/PARCEL N0: ADDRESS VILLAGE OWNER DATE OF INSPECTION: u FOUNDATION FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL t C PLUMBING: ROUGH FINAL-- GAS: ROUGH. . FINAL ,FINAL BUILDINGi_ DATE CLOSED OUT - ASSOCIATION PLAN NO. s ~ T z Town of Barnstable Regulatory Services r3nPW5rAtifi,ASS Ricbard V.Scalie Director DS . �� i 6 Building DlV1S1UII: _ Tom Perry,Building Commissioner 200 Main Stzeet,Hyannis, 02601 www.town.barnstable.ma.us Office: 508-862-1033 'pax` 508-i90-6230 Property Owner Must Complete and Sign This Section If Using ABuilder . as Omer of the subject p1•opqjl:y° hereby audio_riZe r m, Q �0/1� Sc7Y�S to.act.on my behalf, in-all matters relative to work autholizcd'by,this bus lciki7 pezm-lit applicalson for: lq old rllqm 4& A` CZ as (Address of Job) "Pool fences and alarms are the responsibility of the applicant. Pools are.not to be filled or udliced.hefore.fence is installed and all final inspections are: pe:rfolmed acid accepted. - Mark herder(Mar 21.2015) Signature of Owner T Signature of Applicant Print Name Punt Nan tc Date Q:FOnIS:O''o*'•EhPi RIJt)SSIONPWLS . # _ Utfice of,Coiisumer Aia�i &Bu���ies�7Cgwaun" TOME IMPROVEMENT CONTRACTOR c" _ egistration: 61816 Type: xpiration: 11/24/2016 Private Corporatic r MICHAEL T.MCMAHON&SON INC•. MICHAEL MCMAHON,' 19 FIELDSTONE WAYv i PCYMOUT,H„MA 02360- Undersecretary. Massachusetts-Department of Public Safety Board of Buiiding.Regu:atiorts and'Standards: Construction SupeMisor License: CS-068111 .; MICAAEL T MC 11AHON-- 19 FULDSTONE^Wp} PLYMOUTH M.4 U2360 11`i4i� Expirations Commissioner 08/17/2016 4 COMMONWEALTH OF MASSACHUSETTS DEBRIS DISPOSAL IN ACCORDANCE WITH THE PROVISIONS OF MGL C40 S54 A CONDITION OF BUILDING PERMIT NUMBER IS THAT THE DEBRIS RESULTING FROM THIS WORK SHALL BE DISPOSED OF IN A PROPERERLY LICENSED SOLID WASTE DISPOSAL FACILITY AS DEFINED BY MGL C 111, S 150A. LOCATION OF FACILITY ---- 2,cl 0-d k A"�-m ea - CONSTRUC N SITE AADRESS SIGNATURE OF PERMIT APPLICANT DATE J 3I 1 2M.�- DATe(Mrmoaww) Q� LIgB►ILITY INSURANCE 1aa ACCORD® CERTIFICATE TE LDER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Na TRH COVERAGE AFFORDED AB TOE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER BELOW. THIS CERTIFICATE IR INSURANCE DOES NOT CONSTITUTE A CONTRACT t ETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER., ollc R Ali NI'M bje ! POR ANTI I the certl cafe hold®r Is an ADDITIONAL INSURED,the dorsal m must A etatamont on�this certtiifficate does not con%rDrlights to the the terms>and conditions oi°the popcy,cerCain pollclaa may roquire an en cerkiflo8te holder In Ileu of such endorsemen s. pRODUCBR PHONE 78 0 . (781) 333-0782 �homp:eon ynaurana® al I ,TJTins ComCast.net and $inanaial Services - g APPOROING COVERAGE NAIC# 390 union Strrsst INSUt�eR(.rr_...-.--- Weymouth, MA 02190-316 _ ,,.•.... _. _ _ _. _ _ ... _ INSURER B I AIM Mutual .- INSURED MT McMahon and Son Inc. INSURER9C �'T®stern Taorld 2n urazaae ".�0�—: 19 Fieldstone way INSURER us Plymouth, MA 02360 IS RE: INSURER F; REVISION NUMBER: OD COVERAGI:9 CERTIFICATE N UMBERt FOR THE THIS IS TO CERTIF`7hSTANDiNO pJ,)YIREQUIREMENN7ERM OR LISTED CONDIT N OF ANY CONTRACT OR ISSUED TO T�Hq OTHER DOCUMENT wOVHERESPEC OL WHICH�THIB INDICATED. NO1WI CERTIFICATE B I�ITIO D OF SUCH POl1TCIES THE INSURANCE,LIMITS SHOWN MAY AVEE EEN RE CEO BY PAID CLAIIMS HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND — D LIMrs TYPE OF INSURANCE OU NU ER MMI N 9/16/14 9/16/16 G cHbOC��CURREN CE — �. GENERAL LIABILITY j.TPPgQ02464 ..�R p/ a e r�rtencel 5 1 0 000, COMMERCIAL GENE PAL LIABILITY — MED EXP�A orte oreon $ S CLAIMS-MADE ❑OCCUR pERSONALL&ADVINJURY 9 1 - `OENERALAOGREQATE $ — PRODUCr8.00MPIOPAGO $ 0 GEN'LAGGREGATE LIMIT APPLIES PER S POLICY P LOC AUTOMOBILELL431UTY BA 2CS82729 8/91/14 8/31/15VDIFY roA NJURY(Per P00n) $ ANY AUTO BODILY INJURY(Par soaidenq 8 ALLOWNED SCHEDULED AUTOS $ AUTOS �' S X HIREDAUTOS X AUTOSWNED D UhBRLLLALIAB OCCUR 60313L140AL2 11/24/14 11/E4/15 EACH OCCURRENCE S 1,00 000 81casSLIAB CLAIMS•MADE AOORBGATff 9 11000,000 8 WO KERB OMPBNSATION VWC-100"-6014109-201 12/B/ld 12/8/15 STA X H• _ AND IMPLOYERS'LIABILITY 500,000 , ANY PROPRIEICR/PARTNER/EXECUTIVE YIN L.E CH ACI t� OPFICHRMIEMS REXCLUDED? I N/A ,L i Soo,OOO (Mandatory In N ) E,L DIS 9B-POLICY MIT 500 000 If a dIPTION-sarlbo of I N b l DESCRIPTION OP OPERATIONS I LOCATIONS/VEHICLES (ARach ACORD 101,Addhtonal Rsrmtks Schedule,Umore space Is rogdred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPREWNTATIV6 John J. Thom son ease 2010 ACOR15 CORPORATION. All rights reserved. ' The Commonwealth of Massachusetts P�ntform 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): M.T.McMahon and Son;Inc. Address: 19 Fieldstone Way r City/State/Zip: Plymouth,Ma 02360 Phone #: 781-831-1234 Are you an employer?Check the appropriate box: Type of project(required): 1.❑x I am a employer with 8 4. ❑ I am a general contractor and I '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 . working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ , required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.E Other weatherization 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 is providing workers'compensation insurance for my employees. Below is the policy and job site, information. Insurance Company Name: AIM Insurance Policy#or Self-ins. Lic. #: VCW-100-6014109-201 '` Expiration Date: 12-8-2015 F Job Site Address: 29 Old Kings Rd City/State/Zip; Cotuit,MA 02635 , 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 f a STOP WORK ORDER'and.a fin_ e of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ,t Date: 2-10-2015 - Phone#: 781-831-1234 « 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#: i oFZHE To,,, Town of Barnstable *Permit# CO3c�q yV,P O� Expires 6 wontlu from issue date + MASS. ► Regulatory Services Fee ��•�� 9c� 039• ,0� Thomas F. Geiler,Director prED MA�t. Building Division X.PRESS PER MI Tom Perry, Building Commissioner T 200 Main Street, Hyannis,MA 02601 JUL 3 Office: 508-862-4038 200z Fax: 508-790-6230 TOWN OF BARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid rvithotrt Red X-Press Impri»t slap/parcel Number 'roperty Address ✓1 � residential Value of Work. /D , , )wner's Name&Address MIAO J j p2.9 c1 co /v, Telephone Number- contractor's Name o/�Cl O Y1�1P— �1�L7 V th�l i1 Some Improvement Contractor License#(if applicable)___ construction Supervisor's License#(if applicable) C. 5 0 7O3.) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I 3m the Homeowner Ukrhave Worker's Compensation Insurance .nsurance Company Name �a. �(�. co, Grp,,Q Workman's Comp.Policy# C� J,5'0 Q 7 ?ermit Request(check box) [ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) i ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. a Signature Q:Forms:expmtrg Revised 121901 r Assessor's map:and'lot number; ..... � �?. r:Cz � SEPTIC r'l �i IL" :tiff y y , :. O 6 4 `-, TN E Sewage Permit number D �...U�.. !�f ! ....-!/���� a'�!F F .. p f �...., { s� ,i J B AU TA L�9E�, House number S � 39 o , aZ i i } = TOWN . OF BARNSTABL`E; BULLDIN"J� 'NS:PECTOR t {, F 0 . 'APPLICATION FOR PERMIT TO ....... ....... / .......... ....... ...........:.. -TYPE,OF. CONSTRUCTION' L G.l ..'.. ........ .... .... ............ ................... ..,7....'.G...........19 is TO THE INSPECTOR OF BUILDINGS: is , The undersigned hereby plies fora ,per ac rding to th Ilowing information: Location .....:........... . .. .... Ql�.t �rslc�,S ................ ... r ,. ProposedUse .... .�. r.�`c. :h.W:.1. . ........... ................................................ ........... .............................................. Zoning District ..........:.......Fire District .... �T ... Name of x c - Owner .. ...i.. 1STS...:. ��. ..: :...1..��`1-........::Address Nameof Builder. .................... ................. ........................Address ........................... ...................................................... Name of Architect ....... ... :.. Address .................................................. Number of Rooms Foundation......................::..... ..... . . . . ........................................ Exterior. 1. ! S...x............�. .:... . .. ..1. l g S E J P� !.�5.....:.Roofin ......... ..h.n.L!....��... .. ...... ...... .... ... �l Floors 9...... .............................Interior :::....,.... kpo .....�:7 .. f`d.�.t.... b? .. Heatingti O ....Plumbing ..................... ` ....... ... .............. ........... ....•.. .... ..................... y f.. .,Fireplace" ..: ........r ':' ...�?......... .........................................Approximate Cost .r.......��.. ...000 1 Definitive Plan Approved by Planning Board � ____19_ Area /...!.../... .. ,Diagram of Lot and Building with Dimensions Fee .........................el .............. SUBJECT TO PROVAL OF BOARD'OF.HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW- DWELLINGS I hereby agree to conform to all the Rules and Regulations 'of,the Town of B ble regarding the above construction. ' •- Name, .� ..�. ... ..................... ........................ DDZO , Construction Supervisor's License ....................... ........... JM,15�LRTS REALTY TRUST No 267Q::. Permit for .1 .Stogy................. V . ................ s Location ..Lot.-30, 249..01�d.. Kira Road. .. Co a't w� r Owner - .QbQrt. :Realty..T t. ... ......... K$ Type o: Construction ...........ri.. T >ti r. r F ' - = ', i ,,•, ,r :; r� .........................................A .� ............................ ., Plot :........................ ............... "--1 Jul 23 -- " Permit'Granted ......., Y .�...................19 84 Date ofAn p do ..... z 19 Pate .,completed �n'- it YX r .. r Assessors map and lot number ..........�( .. .. .......�..........,. �oF Tod ., T E Sewage Permit number (?.. � 1"4!�...........il.......P11-:. ' Z BJSH9TODLE, i House number • ' r'!� NAM ........ .. ............ ........... 9 �'' �p 1639. 9� a MAY 6' Y TOWN OF BARNSTABLE BUILDINGINSPECTOR �f r APPLICATION FOR PERMIT TO.....,...............: r <% ram. ..........................<—..........s ........... ................... .TYPE OF CONSTRUCTION /- %..;:......... -y........... ` ..................7.'.. .........194� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for. a permit-—according to the following information: Location ......................... 0/............."........ ................. .......... � Pro ...... �.� :c.�1'L'..�9., ................ ........... ........� �.`..... . ................... ... Proposed Use p � ........................... . ............. .Fire District .Cf:.t"n.2�.t.nadh-w .GSU!L..Zoning District .. .�.--::•. ..................................... .....�. ............ Name of Owner ....� .r.�?.M... 1..2.5�ST.........Address ... ,...><.�,c,T.... ?-,,,,,,,,, xw".� Nameof Builder .............................................................Address , ............... ............................................................... Nameof Architect ..................................................................Address ...................................................................................... Number of Rooms ........Foundation .......I.o.. ....`...U!)rt,�;e�.........4:.......................... Exterior 1iG ?! ..x.........f.rJ.n.1....: '.h.th...�.�?.......Roofing ...................... 5.. 1 1f \ ll -TC� 1 Yq..�.l. s CY4� KIS I� P Floors .................. ( Interior ........... ....... 1 ....... ... ............. ....................:... Heating ........... t .:..t!.. Q.! .:. ..................................Plumbing ...............G' ..L ..........�....U:: ........... ... ° Fireplace .....................i. ........... .........................................Approximate. Cost .........�� .. - Definitive Plan Approved by Planning Board _ _ }_l ____19_ Area .............�. . ..:............... Diagram of Lot and Building with Dimensions Fee �''t.. ............ ................... SUBJECT TO APPROVAL'OF BOARD OF HEALTH rN AJOO {OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 hereby agree to conform to all the Rules and Regulations e Town of Barnstable regarding the above construction. Name ` ...t..s.r„ ....... h - ........ ...f..(... ...................... /U�Construction Supervisor's License � ROBERTS REALTY TRUST % A=22-68 No .��.7�.. Permit for L 0 Single Family Dwelling w Lot 30 29 Old Kings Road - Location r...........................:......:........... ...Cotuit ................................................................ Owner Rober.td.RealtY..Pru t Frame . Type of, Construction ...... .. ..... .................. t PlotLot ................................. Permit Granted .. ...Jul 23 84 . ............. '...............19 _ Date of,Inspection ..........................:..........19 Date Completed . i P { 0 t tr y ' TOWN OF. BARNSTABLE Permit No. 25730--_------ I a..,n.a, : Building Inspector . o°a - Cash ----------------- -------- , 014 - OCCUPANCY PERMIT Bond Issued ao Roberts Rea'i_t4"Trusgt Address Lot 3a a 29 Old t Kin-as '�OtlZ7$ _ Wiring Inspector Inspection.date Plumbing Inspector. i t` J f!F Inspection date`.! Gas Inspector J/ •. �. Inspection date Engineering Department Inspection date Yam# r f'r Board of Health � _/ ~ Inspection date L/ - THIS PERMIT WILL.NOT BE VALID, AND jihE'BUILDING SHALL" NOT BE OCCUPIED .UNTII: SIGNED BY THE BUILDING INSPECTOR'UPON SATISFACTORY COMPLIANCE WITH TOWN 3; REQUIREMENTS AND IN.•ACCORDANCE' WITH'SECTION 119.0'OF THE MASSACHUSETTS STATE BUILDING CODE. ' �• ' r `" Building'Inspector N FROM _ TOWN OF 13ARNSTABI E" ...+�(c�4�•y�L'./{1 rii!��,is id-Ahtie✓ziV BUILDING DEPARTMENT . oan Clerk .' wfw9:#Mrtt+i.T'.X^, <•"y er.x�^d.'�Yc<9+s.yy.} - . MAIN STREET HYANNIS, MA '02$I l Phone: 7n5-1124 . SUBJECT: FOLDHERE • - - - + DATE... F'eebruary 15, 1985 MESSAGE 'Work bias t-paT1e `,,ceder-Permit z573� erf s i Zt t),- Please release Band. fi . SIGNED ' f •r r;' 1'. DATE REPLY / SIGNED - d N87-RMI- ,.� - _ - - -RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY PRINTED IN U.S.A. SENDER: SNAP OUT YELLOW COPY ONLY.SEND'WHITE AND PINK COPIES WITH CARBON INTACT., 0k� c Zit � i i s s t cA L.,of 30 t, 4/ r RfCHARD cyGs ' s pv BAXTER u, r Na 24M a f CEe T/.cY TN,1 T TH O�1 h� T� F f'f,�OWiLr f,/E�2E0.�/ COM,�'L Y.5 W/7 SCA L p - S SE'TBACf-:� ,2E4vi�EMENTs of THE 7 oW 10F i .L o CA 7'EU=> WiTh�/N Th�E •�Loaa�G4 �i! /�L,�/ 3 K. Z Z 9 : /;b -Q...r 1 J G� 8,4 XTE,2E.VYE /NC. � ' Tf//S ��•4�//S �t/oT QASEO D.�/ Apt/ .eEG/STE.2E� LSO SU•e✓6Yb I 0�.�v'ETS.Sh'vy✓�V ShbvL1� .t/aT' B� APp�/C,4i✓T j�d�g�Q-r5 �T/ �'z • i.