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0439 OLD POST ROAD
Old ��s� I Town of Barnstable Building Permit Post-This Ca dSo That•�t:i-s V�s�ble From,tFe Street Approved Plans Must be:Retamed on Job and>'this Card Musf be Kept ? DAILSiSl'AB1.L'�, ,� MAC. $ Posted UntihFinal lnspectio"n Has Been Matle .y , r Whe"re a Certificate of Occupancy is Required,such Building shall Not be Occupied`u�ntalaF.nallnspect�on has been made Permit No. B-20-1724 Applicant Name: Moritz Contracting Approvals Date Issued: 07/09/2020 Current Use: Structure r Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 01/09/2021 Foundation: Location: 439 OLD POST ROAD(CT&MM),COTUIT Map/Lot 054-026 Zoning District: RF Sheathing: Owner on Record: HESELBARTH, EDGAR F& RUTH ANNE TRS Contractor Name ': .,MORITZ CONTRACTOR INC. Framing: 1 Address: 514 WELLMAN AVENUE Contractor;t�cense'i,1t 107729 2 NORTH CHELMSFORD, MA 01863 Est Protect Cost: $75,000.00 Chimney: . ' J Description: sidewall and trim on house Permit Fee: $382.50 Insulation: Project Review Req: Fee Paid $382.50 if Date ' 7/9/2020 Final: Plumbing/Gas Rough Plumbing: -Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work author zi ed by this permit is commenced within"` nths ft aer.issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents;for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by,laws:and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public mspeet�on for the entire duration of the work until the completion of the same. ' Electrical The Certificate of Occupancy will not be issued until all applicable signare's bythe Building and'Fire Officals are,prov�ded on thisFpermit. Minimum of Five Call Inspections Required for All Construction Work. -3 y ' Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection �. � _ -- 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT d. _ t i I ♦ f � I 1 1 MASs4o .� ,rp�GNE O Q 'G Ghk /77/7-c - b nth st MICHELE CUDILO,: P.E. �-- DECK Consult'irtg Structural En irieer + . 123,Coftmwood:lane._Centerville: Massochmft 02632 j Drown .By: MC zs !! oo 2 /� Drawing. TU G L '� T r Scale:E t0 _ j . Rev. 0 . Fle :Name:: Project No.: 1�.7 � it E=.orTML • iJ: ,r I ' _ �Ko��iEAssgcyLs ',4 F �`� ` ►O N ''7 s-r MICHELE CUDILO, :P:E. K Consulting Structural .Engineer 123 CatO°nn°°d lane.:C.erdervipe, Massachusetts 02632 ifs �l _ .t D o 3 q D C1pY--moo S Z-- , .-..... �:.►�� �t�_ ' Drawing � AS.NOTED Rev - .Fle tVomet. R.�T . .� Town of Barnstable Building -Post v fined o ���-�-..h x Post This Carii So That rt.is Visible From the;Street=Approved'Plans Must.be Refa` n Job anda is Card Must be Kept en�atvSrnsLE Mbsa `� Posted Until'Final Inspection Has Been'Made. . Perm Where,a tertificate�of Occupancy is Required,'such°Building shall Not be Occupied until a Final In spection has been made. it Permit No. B-20-591 Applicant Name: Moritz Contracting Approvals Date.lssued: 03/03/2020 Current Use: Structure Permit Type: Building-Deck Expiration Date: 09/03/2020 foundation: Location: 439 OLD POST ROAD(CT&MM),COTUIT Map/Lot: 054-026 Zoning District: RF Sheathing: Owner on Record: HESELBARTH, EDGAR F&RUTH ANNE TRSn Contractor Na e`-JMORITZ CONTRACTOR INC. Framing: 1 Address: 514 WELLMAN AVENUE Contractors License 107729 2 NORTH CHELMSFORD, MA 01863 mow. Est. Project Cost: $8,000.00 Chimney: Description: REPLACE EXISTING DECK AND SUPPORT POSTS OF PORCH SYSTEM- Permit Fee: $ 110.00 ON SAME FOOTPRINT-ROOF TO REMAIN AS IS T Insulation: Fee Paid;' $ 110.00 Project Review Req: `Date 3/3/2020 Final: Plumbing/Gas Rough Plumbing: Official This permit shall be deemed abandoned and invalid unless the work authorized by this_�permitis commenced With,insiz months afte�l� i e. Final Plumbing: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: '£ 1.Foundation or Footing Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest fluew lining is installed Rough: 4.Wiring&Plumbing Inspections to be completed prior to.Frame Inspection 5.Prior to Covering Structural Members(Frame inspection) Final: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A). Final: Building plans are to be available on site _� Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT �� Final: 5 � CL TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �o Application Health Division \�O pt�' g•�� Date Issued Conservation Division ��,� Application Fee 0 Planning Dept. �� Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village a4-4t� Owner WuY AKKt .e5AAV`IVV Address Telephone t- I Permit Request -1 V fW rM� �t CIA, W f g f `re q"I o V i �� o k - Square feet: 1 st floor: existing proposed 2nd floor: existing proposed teal new Zoning District Flood Plain Groundwater Overlay Project Valuation �� Construction Type L 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 Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new 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 Telephone Number Address ` A ��� License # Home Improvement Contractor# 6 Email l � cod ��ti�c,la . &Worker's Compensation #W(,E;66' :i �G ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 11 FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER y " f DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of XndustrlalAccidents Y a 1 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass,gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, Applicantinformation � *,;r Please Print Leaibl Name (Buslness/Organizationnndlvldual): Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 Phone#: 508-775-1214 Are you an employer?Cbeck the appropriate boxt Type of project(required): IQ I am a employer with 48 employees(MI and/or parwime).* 7. ❑New construction 2Q 1 am a sole propriator or partnership and have no employees working for me In $, Remodeling any capacity.(No workers'oomp,insurance required,) 371 am a homeowner doing all work myself,.[No workers'comp.Insurance required,)t 9, ❑Demolition 4,F1 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11,[]Electrical repairs or additions proprietors with no employees. 12,M Plumbing repairs or additions I am a general contractor and I have hired the sub-contractors listed on the attached shoat, 13, re airs These sub-contractors have employees and have workers'comp,insurance,; ❑Roof P 6.[�We are a corporation and its officers have exercised their right of exemption per MOL o. 1 ✓�Other W eatherization 152,11(4),and we have no employees,[No workers'comp.Inswuoe required.) 'Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy Information. t Homoownere who submit thla01davlt indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must Maehad an additional sheet showing the name bf the sub•eontraotots and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'oomp,policy number. I am an employer that is provlding workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: Atlantic Charter " Policy#or Self-ins,Lio;#: WCE00431902 Expiration Date, 06/30/2018 Job Site Address: 04 F04- RA— City/State/Zi : C�YJ P j�LA Attach a copy of the wo kers' compensation policy.declaration page(showing the policy number and expiration date), Failure to secure coverage as required under MOL c. 152, §25A is a criminal violation punishable by 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,A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, 1 do hereby cer*under the pains and penaltles of perjury that the lgformation provided above Is rue and correct. Henry Cassidy ;SI R,,J r� Phone#: 508-775-1214 Off ielat 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 St Plumbing lnspector 6,Other Contact Persons Phone#t CAPECOD-27 KDOYLE AIik. O CERTIFICATE OF LIABILITY INSURANCE FDAT6/ 0/23012/Y017 0 7 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, E T EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(3),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION 13 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 Ileu of such endorsement s. PRODUCER ROgors&Gray Insurance Agency,Inc. PHONE FAX 430 Rte 134 A/c No Ext; Alc No:(877)816.2156 South Dennis,MA 02660 Mssv mall ro ers ra .com 19 RER S AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company 24198 INSURED INSURER B•SafGtY Insurance Company 39454• ' Cape Cod Insulation,Inc. INSURER C i Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXPo LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE [X OCCUR CBP8263063 04/01/2017�04/01/2018 OAMAGET RENTED 100,000 MED EXP(Any one person) 51000 PERSONAL&ADV INJURY S 1,000,000 M'OTHER: LAGGRE ATE LIMIT AP LIESPER: ENERAL A RE ATE 2,000,000 POLICY T r LOC PRODUCT MP/OP AG 2,000,000 B AUTOMOBILE LIABILITY g, COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY TEEOAUTO D 6232707 COM 02 04/01/2017 04/01/2018 BODILY INJURY Perperson) $ AUE SCHEDULED OONLY X BODILY NJURY(Per ccidenlX AU705ONLY YReOP.ERIJnt AMAGE C UMBRELLALIAa X OCCUR excEssLlAe CLAIMS-MADE EXC10008835002 04/0112017 EACH OCCURRENCE 210001000 X AGGREGATE $ 2,000,000 OED I RETENTION$ ' D WORKERS COMPENSATION X PER OTH• AND EMPLOYERS'LIABILITY I ANY STATUTE PROPRIETgOERRIPARTNER/EXECUTIVE R/OWCE00431802 06/30/2017 06/30/2018 1,000,000 OFFICE�i/M NH)EXCLUDED? N NIA E.L,EACH ACCIDENT ((�Mand 4 o 11000,000 If yyea deaeAbe under E.L.DISEASE•EA EMPLOYEE DESG�RIPTI N FOP RATIONS below E.L.DISEASE-POLICY LIMIT 1,0001000 r, DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Workers Compensation Includes Officers or Proprietors. Additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE E -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 7,16 ACORD 26(2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a b �S Office of Consumer Affairs and Business Regulation r 10 Park Plaza - Suite 5170 Boston, Ma , usetts 02116 Home Improveme �-�.ovtractor Registration _ t- Type: Corporation 7. J Registraftba;, 153567 Cape Cod Insulation, Inc co In Expiration: 12/14/2018 18 Reardon Circle So. Yarmouth, MA 02664 ,a e Update Address and return card. Mark reason for change. SCA 1 0 20M-05/11 — -----------... ---_-_.. ----- ---------_..._---l�.,gdr��M�s-P...-",.�a�.v:ai_!�-�;•'"�rr�arst.-�l-t.os+.-^arm+..-. .._.-. �s�ar�Unwauaea�o�G�aac/e�aeCld ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only 6 aet: Corporation before the expiration date. If foun urn to: egistration Expiration Office of Consumer Affairs and sf as Regulation == 10 Park Plaza- e 5170 t,E `�MG7 12/14/2018 •_' ems-- �� Boston,MA 11 Cape Cod Insu a�i-wits- - Henry Cassidy 18 Reardon Circe So.Yarmouth,MF a Undersecretary t al Wh0ut tpira�# Commonwealth of Massachusetts Division of Professional Licensure ' -Board of Building Regulations and Standards Constrq.;600§45 ,rvisor q. CS-100988 w � y t J=` l 4 ires: 11111/201.9 i i , HENRY E CAFE IDY. / 8 SHED ROW' WEST YARMO>jT. 11A�1 Commissioner CIL DocuSign Envelope ID:28BA9DB3-98CE-4D90-BC14-B67F5CEB72FC 1HE ropy Town of Barnstable Regulatory Services BawNSTABU, Richard V.Scali,Director MA% m Building Division rFC MAC a. Paul Roma Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must A. -Complete and Sign This Section I, RUTH ANNE HESELBARTH as Owner of the subject property hereby authorize cape cod insul at;on to act on my behalf, in all matters relative to work authorized by this building permit application for: ' 439 Old Post Road Cotuit, MA 02635 (Address of Job) DoeusigncU by: - aln In t, Nl,St,uoai'Tu. 2/7/2018 10:44 AM EST ei�7rvre _ Signature of Owner Date Ruth Anne Heselbarth Print Name . If Property Owner is applying for permit;please complete the Homeowners License Exemption Form. C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\L7U69LF2\EXPRESS(2).doc 01/25/17 Town of Barnstable A� AEI RT^ " 200 Main Street, Hyannis MA 02601, 508-862-4038 Application for Building Permit., Application No; TB-17-782 Date Recieved: 3/22/2017 Job Location: 439 OLD POST ROAD(CT&MM),COTUIT Permit For: Building-Insulation-Residential Contractor's Name: MICHAEL T MCMAHON State Lic. No: CS-068111 Address: PLYMOUTH, MA 02360 Applicant Phone: (781) 831-1234 (Home)Owner's Name: HESELBARTH,EDGAR F&RUTH ANNE Phone: (781)831-1234 TRS (Home)Owner's Address: EDGAR F HESELBARTH REV TRUST, NORTH CHELMSFORD,MA 01863 Work Description: Weatherization,air sealing,weather stripping and blown cellulose Total Value Of Work To Be Performed: $3,300.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or.omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Mike McMahon 3/22/2017 (781)831-1234 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees LProjectost: $3,300.00 Date Paid Amount Paid Check q or CC# Pay Typeee: $85.00 3/22/2017 $8s 00 XXXX Xo roc= Credit card 7015 ........ ..... .... ...... ...... .:.. .... ......:..ee Paid: $85.00 s "IN �za ems' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map; C.N Parcel Application Health Division Date Issued c3"15- Conservation Division Application Fee_ Planning Dept. Permit Fee ' � !_ 0.5X Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis .Project Street Address �l �,d �(��� 1W1 O41 V 1 m 15 02 Zr Village cct�r Owner 1C.I � ,,_ e(�i� � Address ,�gP P. Telephone 11' `4-10" 4 On Permit Request �, �� r YAD". bow c ei (() 1(S�s( , Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation _5�ACQ -Construction Type TnSAo�Oh Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) 3 � J Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kinq'.t) iighway:=-:0 Yes ❑ No Basement Type: ❑ Full, Crawl ❑Walkout ❑ Other = �� ' Basement Finished Area (sq.ft.) Basement Unfinished Area (sq. No A Number of Baths: Full: existing new Half: existing nA Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Address MXM& 0 WGIA License # 0,$ — ® ( 1 Home Improvement Contractor# W t{, ��ip i Email EmailhAOWIM I n4l G i (•a_nVorker's Compensation # W J`9-6014 10 q -?Am ALL CONSTRUCTION DE+BwJRIS RESULTING FROMT�\♦HIS PR.'/O�YJEQyCTT�WILL BE TAKEN TO C DX�D l /\ �� to ��'; ■ - SIGNATURE j FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP 1 PARCEL NO. ADDRESS _ _ VILLAGE _ s OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION t FIREPLACE ' ELECTRICAL: ROUGH M FINAL PLUMBING: ROUGH FINAL F _ - GAS: ROUGH FINAL _ FINAL BUILDING DATE CLOSED,OUT ASSOCIATION PLAN NO. _ r (� CZ,44J Federal IDS 064405M29 RISE Engineering RI contractor Registration No 8189 • _ MA Contractor Registration No 120979 A division of Thielsch Engineering CT Contractor Registration No 620120 5 Dupont Avenue,South Yarmouth,MA 02664 CONTRACT. 'A 508-568-1926 X-6197 FAX 508-56&1933 Page 1 PROGRAM . BOWEN CLC-RCS EMOME ANO To EWEMOMER M WORnKA9 - DEsctasEo sw.ow CUMMElt — --- --- PHONE _ .DATE - ,cuawo WORK ORDER Ruth Anne Heselbarth (617)470-4023 02/09/2015 189225 00002 eERV=STREET >GIWR6 STRAW 439 Old Post Road 514Wellman Avenue SERVICE CRY.STAMMP - etu.M Carr,9TAW,VP --- - -_ Cotuit,MA 02635 # :North Chelmsford,MA 01863 JOB DESCRIPTION r STORAGE BARRIER:Homeowner is responsible for the removal of the stored items blocking the installation of weatheriration work in the basement. Removal must occur prior to the scheduled work start. $0.00 STORAGE BARRIER:Hom er is responsible for the removal of the stored items blocking the installation of weatherizetion work in the crawlspace. Remo I must occur prior to the scheduled work start. $0.00 CRAWLSPACE:Provide labor and materials to install(110)square feet of ml polyethylene over open ground in designated crawlspace/earthen basement areas. r $84.70 REMOVAL: Remove(768)square feet of batt style insulation from the crawlspace area main crawl space $744.% REMOVAL: Remove(300)square feet of batt style insulation from the crawlspace area kitchen crawl space w $291.00 CRAWLSPACE:Provide labor and materials to f ne and construct(2)pressure-treated crawlspace access door.Access to be insulated with 2"rigid Thermax board and sealed at the edge with weatherstripping $300.00 CRAWLSPACE:Provide labor and materials to install(670)square feet of R-21 closed cell spray foam insulation to the crawlspace perimeter wall,sill and band joists. Then install a spray applied ignition barrier over all exposed foam. Any crawispace access within the perimeter wall will be weatherstripped and insulated to R-20. Any present crawlspace vents will be permanently sealed. -$3,685.00 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 offers 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 weatherhation work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you.,,,, $90.00 w Federal 10 0 05-MS629 a RISE Engineering RI MA Contraactor Registration tor Registration No 120979 A division or Thielsch Engincering CT Contractor Registration No 620120 i S DuFoutAvenue,South Varmouth,NIA 02G6A CONTRACT 508-568.1926 X-6197 FAX 908-568.1933 . Page 2 PROGRAM - THIS CONTRACT IS ENTERED INTO BETWEEN RISE CLC-RCS ENGINEERING AND THE CUSTOMER FOR WORK AS &SCRISED BELOW F ORDERCUSTOMER PHONE DATE CLIENTO WORK Ruth Anne Heselbarth (617)470-4023 02/09/2015' 189225 00002 SERVICE STREET .. BILLING STREET 439 Old Post Road 514-Wellman Avenue SERVICE CITY,STATE,ZIP - • BILLING CITY,STATE,ZIP _ -�•. `_.�_�� - - - — Cotuit,MA 02635 North Chelmsford,MA 01863 , JOWDESC TION, Total: ' $6,396.66. Program Incentive: -$411090.42 Customer Total: $1,306.24 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF **'One Thousand Three Hundred Five&24/100 Dollars $10305.24 UPON FINAL INSPECTION AN PPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT.AMOUNT OUR IN FULL.INTEREST OF 1%WILL BE CHARGEDMONTHLY ON ANY UNPAID BALANCE AFTER E .SEE 6 FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. 00 NOT SIGN THIS CONTRACT IF THERE RE ANY SLANPPAC S AU ORIZEO GNAYURE•. SE ngIrk a � +. • .CUe OMBR dCCEPTANCE - NOTE: IS CONY CT MdV BE WITHDRAWN BY US IF NOT OJOICUTED WITHIN` DATE OF ACCEPTANCE Y 1_......:.._.......--•-.�-......_•....--a..— v _ ' ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARS AUTHORISED TO DO THE WORK AS SPECIFIED.PAYMENT WILL DE MADE AS OUTLINED ABOVE - - f + I t > , - `.l'oWn of Barnstable Re ulatory Services HA WN IV 9 v Richard V..Scati,Director $ sey� �® � r,a{• Building Division _ Tom Ferry,Building Commissioner .. .. 200'tvfaiu Stieet,l'Iywmis,:bt.A 02G01, imw.town.barnstable.marus ' lfiu;: 508-862-4033 Fax: rS-790-6230 Pro pexty Owp.er i'V1<ust , C:oMplete and Sign This his Section.'. If.IJtiin A Builder of thc suhjO r.4 Prof'(1rt:y heirbymithorim- �1 I. ., e: L W N 4' JcrN5 tea act nip mybehalf., inn;J:l.rrnimx.s rolative.to work autharized by this lai.i]ciigg,pernvt application for: ress of 1 ohs '• ''Pool fences and al� ru a re the respc'�r�5iblt applica�a.' of th;: l7txals ,are not to hi'fillcd,Or w.ilized 1) cue fence is Im' Lallr.'d,and all filml inspections are! peAO'rmed-..md ace.trpL&L " signatw•e of(Ww R Sin- at�rce of Applicam: u7= s I Tint Name . jr1 im Nam , i5a1;C . Q:FO MS,O VaRW):a!di4S10t,'P(x)LC ,a:x,:•,_...r� . . :I;-��•,.. ,�•» '_�• �;; ^..•.._�...�......, r�%/��o»:rrmuraan/N o�'C��l�rr.�rr�.rdoll� ri0�val'ic�for�ndTv�d, 4-0 office of Consnmer.�fftius&)BTisiaess Regnlat3oa 1jeense or esl'�" da$�•� A. g 'h.• ' „ ' oME lMpRpV M Ni CfllV ACTOR 6T�4osathQei<p4 �A fairs and Sul i � auio;r � egislrattcn:; tf1816 Type: 4I26't6 private Corporation ''' a rr Expiration,;;�'1�12 . gp�arlt i : 'gON lM. on �2a� j MICHAEL .MCMAH(�iV';$� i i ! MICKAEL MCMAHOfq ;�, 19 FIELDSTONE WA`t'::. .... � •_�. pLYBMOLITH,MA 02360 Undersecretary Not va d VJmonc s'190e+lu(, Ir • I1 �'VY1W AG , � ••��e,^.^ '„�1r.9�.e':I.nM i�.�w(w.�s✓✓C.1��.i.�.i'4 G;r..i iuik�•'.i••�•ir.��i •e§rtriCted-Bur9da� �����E'�Q ' "J mf�:( ti...9�•G��?.�i�t3�t$!J'd°a` ' Lob less Sm 35, losed spZZe. it Cu edition d'thr?M2 Ll3WSE 51 .. ',��,.,. _ M2 ire to Possess a '� � tE�13�6�2>6 .e aullding Cade is Caul for revocation 04 his III ewe )p5 UCePrsTnB Tn4ornaCTon sic: wvna.Mass Goa/�lAS I — �_ (i , Ia I • :i �i ! I.1 1 II L1AIS(MMIDCVYWY) o® CERTIFICATE CIF LIABILITY" INSURANCE " sz 9 14 AcoR TS UPON THIS CE R71FICA7E IS ISSUED AS A MATTER OF INFORMATION ONLY AND COOK ALTER THE COVERAGE AFFORDED BYTHE POLIC E)S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 0 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE IMPOR ANT; I the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. i SUBR A110N IS oto the terms and candlUons of the policy,certain policies may require an endorsement. A>ttatement on thl s certificate does not Confer rii�tlts to the certificate holder In Iteu of such endorsemen s. PROCUC6R (781) 335-9182 ThomgSon insurance PHON@ 7 3 -189 -_� r and Financial Services - �INSU R6 AFFOR net NAICi 389 Union Street . MA 02190-316 U(3ERA;Travelers -- -„ -. Weymouth, _.._.. _ ._..___..._--..,.... mefl4- World Insurance C -- MT McMahon and son Inc. , INSURER^ g Cb• _ 19 Fieldstone Way INSURERD:To Ll n plymolt:h, MA. 02360 INSURERE: -- INSURER F: COVERAtiE8 CERTIFICATE N UMBER. REVISION NUMBER: T HIS TER THIS , NOTWITHSTANDING ANYIREQUIREMENTNTERM OROCONDITION OF ANY BELNCONTRACT OR OTHER DOCUM TO THE INSURED ENT Also B RESPECT ALL THE TERMS, XCLUs90N5 A D CONISIT ED OR MAY PERTAIN, THE INSU OF SUCH POLICIES,LMITS SHRANCE OWN MAY HAVEEBEEN REDUCEDBYPAID IIMHEREIN 1S SUBJECT TO ALL THE TERM ,uMrs TYPEOFINSURANCE POU NUMBER MMI N MM L 9/16/14 9/16/15 EACHOCCURRENCE $ C GENERAL LIABILITY YPP8202484 DAMA&FT $ - 0 000, COMMERCIAL GENERAL LIASIUTY -EumMERE= ore eraon $ 5,090 CLAIMS-MADE �OOCUR PERSONAL&ADVINJURY $ 10QQ,.p_00 GENERAL AGGREGATE 000 PRODUCTS-COMP/OP AGG $ l 0 GEN'LAGGREGATE LIMIT APPLIES PER S POLICY PR 171 LOC 8/31/14 8/31/15 aaecidant 1 AUTOMOBILE LIABILITY BA2C882729 BODILY INJURY(per parson) $ ANY AUTO BODILY INJURY(Per eccldent) S AUTOS NED X AUTOS LED p OPERd pA�NA�iE` g X HIREDAUTOS X AUT03WNED _I�GP e>lU-- $ D UMBR2LLALIA6 OCCUR 80313L140ALT 11/24/14 11/24/15 $ 11000,000 AGGREGATE S 1 000 000 }[ 8XCE88 LIAB CLAIMS-MADE 'EINTIINS 12/8/14 12/8/15 WCCYTATU- X i H- WORKERS COMPENSATION VWC-100-6014109_203. T JJ 8 AND HMPLOYERS'LIABILITY YINPROPRI i erECU EL.EACH A _500,000 N/A 5 O OOOOI WX try � EXCLE (Mendaop') E.L.DISEASE-POLI YLIMIT S 500 OOO If lbMund D 8 IP IO OPEkTIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 1D1,Additional Rerrattta Schedule,If more apace la roqulrad)' . ♦.. .ink. r 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 01988-2010 ACORD CORPORATION. All riphtEl reserved. The Commonwealth of Massachusetts ". . Department of IndustrialAccidents Office of Investigations d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): 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.X 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 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 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per,MGL. 12.❑ Roof re 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#I 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. lContractors 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: 1'2/08/2015 „• !�n o L a } Job Site Address: �'1 ` 6 S 11�., ' City/State/Zip: A 1MR Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be`forwarded to the Office'of Investigations of the DIA for insurance coverage verification. I do hereby certi der the pains and penalties of perjury that the information provided above is true and correct. Signature: Dat e: :� 1 781831.1234 Phone#: Official use only. Do not write in this area,to be completed by city or town official' City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 C111, S I SOA. LOCATION OF FACILITY �q (�L��c���- CONSTRUCTION SI E A DRED SS SIGNATURE OF PERMIT APPLICANT ads 03 4t EVE Town of Barnstable -*Permit# Expires 6 mont s frQLrt issue date Regulatory Services Fee j . w snxrtsrnsis .MASS. Richard V. Scali,Director 039. Building Division Tom Perry,CBO,Building Commissioner DEC 10 1015 200 Main Street,Hyannis,MA-02601 .�-®UVN �F BARN www.town.bamstable.ma.us TOWN STAB L Office: 508-862-4038 Fax: 508-790-623 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address C3 0' PO-ST� f (26 Ty Residential Value of Work Minimum fee of$35.00 for work under$6000.00 ^ Owner's Name&Address e u T►A A-Ij�-j i4�--S�z L 18 A-a T 14 - Contractor's Name n, a 1R +i Zo c,&w r2*Lc.,Yn P--t ki G Telephone Number Home Improvement Contractor License#(if applicable) 1 07-7 Z k Email: Construction Supervisor's License#(if applicable) CSC GHQ�IS� 3 f ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Lam the Homeowner, [ I have Worker's Compensation Insurance Insurance Company Name Oyu ru 4-C_ Workman's Comp.Policy# WC-Iii�- 'B I S 3 3 Z Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to,- ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side 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: Property.Owner must sign Property Owner Letter of Permission. . A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QAVvTFILES\FORMS\building permit forms\EXPR6c Revised 040215 Jun. 24. 2015 9:27AM No. 9745 P. 1 DWfYYYj ��! CERTIFICATE aF LIABILITY INSURANCE ' 'E`�r6/24/ 6 24/15 THIS CERTIFICATE IS ISSUED AS A MATTER OF WORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. T'19S CERTIFICATE OF INSURANCE DOES NDT CONSTITUTE A CONTRACT BETWEN THE ISSUING INSURER(S),AUTHORIZED REPRESMATIVE.ORPf=UCF.R,.AND Tf1E.CVMF=7MH.QLDER.. -IMPORTANT., N the certificate holder is an ADUMONAL INSURED,1he pc es)must he endorsed. SU OG IS ,su t the teems and cmditions.ofthe policy,certain policies may require an endorsement A aalement on this certificate does not confar rights to the certificate holder in Hou of such endorsemen s. PRODUCER N John E Patterson Insurance Agy PHONE Emo 7$ ) 29-10 0 p . (781) 320-6674 190 Washington Street .ArAIL 80 Box 36INSU S AFFORDING COVERAGE NAEC C Westwood, MA 02090 INMRMA!Nor£olk & Pedham Mutual INSURED jNquitma:LibertV Mutual Insurance Om Moritz Contraotors, Inc, IMURERC!Liberty Mutual Insurance Comps. 15 Hoover Road INSURER D: Walpole, NA 02081 INSURER Er INSURER F COVERAGES €WW40ATE I UMBER., R€V1om NUNN"- 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 REQUAEMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERIIrIC/ATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORD BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCRM LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, lMR a TYPEOFINsuRAMCB A _-----POUCYPX3NBER XIAMDAIrm (MMIXYMI —_ LLMYS A GENERALum'Lmr R0205927 2/6/15 2/6/16 EACHOCCURRENCE 6 1 000.000 DAAGI!TO X C ERCNALGENERALLIABILITY N 50,000 CLAM4WADE D OCCUR NRD EXP(AryasPWM) S 51000 PERSONAL&ADV INJURY 3 1,000,000 GENERAL,AGGREGATE S 2,000,000 C,EWLAGOREGATELKTAPPLIESPER PRODUCTS•OOMPlOPAM 5 2,000,000 }L POLICYE-71-M. LOC & A tUiTOMOBLELLWUW $10214dE A 2/7115 2/7/16 aeeem & yA BODILY INJURY(Pet j*" $ ILL OWNED x SCHEDULED BODILYINJURY(PumWeno S AUTOS AUTOS NON-OWNED $ MNEDAUTOS —AUTOS per acodem 91 UNIMUL A LIAS OCCUR EACH OCCURRENCE S EXCESS LIAS CLAIMS-MADE AGGREGATE I; DEG RETOITION$ C -V0)RKMc4>V ENSdLTION WCS-318-332366 5/1/15 5l1/1B W; M H AND EMPLAYERS'LIAeIL1TY I ANY PROPRIEIORIPARTNEWRXE MIE NIA L C Nr 8 100,000 OFF1rERMEMBER EXCLUDED? N EA 100 000 frardabry In NMI 1 P R r RATIONS w EL.O -PGA Lmerr, 500,000 ASCRIPTION OF OPERATIONS I LOCAIION6!VENtCLi:S U ACORD 9er,Ad6tlonal Ree►ar11a Srhedula,6 Mao opa�Le roqu red) e-mail: egora@falmoutbmass.us CERTIFICATE HOLDER CANCELLATION R SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE � Eka s5. � THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N Town of 11111116mmlih ACCORDANCE WITH THE POLICY PROVISIDN6. inaapeotional Services 59 Town Hall Square TM0 Falmouth, MA 02540 �.�� M. at rson CPCU 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(201 05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (508) 548-4290 E-Mail: Public Massachusetts Department at onofand Standards ty Board of Building Reg y License: CS-029456 Construction Supervisor EDWARD C MORITZ 16 HOOVER RD , WALPOLE MA 02081 ' �_�► Expiration: Commissioner 09111/2017 d 680Z0`dW'alodlerA Cisia�aa..:Eap (L p-d1enooH 56 ' •- ry���'�� z}uoW piennp3 i ONI 2i01OV,61N00 Z1NOW t 960Z151g cuol;e,jdx h, 101, !odioo ajeNd , ! :addl 6ZLLOl :u01;ejjoi6a �-}��-�_L -3010tRI1N001NgW3A02ldW13W0 n8a ssa isnq.�g s�!�3IV jawnsooO;o aaip , •r , .' Ile Comitromirealth o,f Vassachrtsetts De ar-Univit r�,f rudush ial Accidews Offire d,f Investigations T b00 Washington Street_. y... Boston,MA 02111 wnw.nzasmgrnvldia Wcwkers' Campensat an Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant InfGnnatian Please.Print 1,m. 'b Name(Business,'1DtganQabonlladal}. Yt� Address: /J-/SLve v g� Y" City/Stater: )ff4hA _ 6h Phaneir": 66- Are you an employer?Check the appropriate box: T of project(required): 1.® I am a employer with / 4- ❑I am a general contractor and I Y� 1? ] employees(full audlor part-time)-* have hired the sub-contractors 6. 0 New eonstructicm 2.❑ I am a sole proprietor or partner- listed on the attached sheet ,7. ❑Remodeling ship and have no employees. These sob-co f ac#ors have g. ❑Demolition woding for me in any capacity. employees and have wodoers' c l 9. ❑Building addition 11do worlcers'camp.ir�ctrranre comp-tnsurant� . rewired-] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.El am.a homeaumer doing all work 11.0 Plumbing repairs or'$dditions self- o workers' right:of exemption per MGL cerequired]i c.152,§1(4,andwehavema 12.❑Roof repairs im l�++ employees-[No workers' 13.❑Other 1 � camp.insurance required.] *Any&"Hcwt ihat checks Egos 91 mnst also filloutflie section belowshming the mess'compaL%tioupwicyinfocma:im 1 liomeo zters who submit This affidavit indicating they are doing all wak aid dum lire outside contractors— submit anew affidavit indicoing,sach- fC*=-actm that check this boat must attached an addiiinna2 sheet showing the name of the sob-c==ctaxs and state whether or not those Mires bay employees.Ifthe sub-coatn=oEs have employees,theynnutpimide their workers'ramp.policy number. I arrr an grrepI per f£tat is pra�zrJirrg yvorkers'coertperesaiiart iztsurarzce fvr xtS*enuplpy�ees Below is tltepo£iry ant job site iTlformadon. Insurance Company Name: L t 6�t2-i-`1q- Policy#or Self--ins.Lic. Wd,5-- 3 i S ^332 3 lixpirationDate: Job Site Address ��P (T(�A �a�r 1U City/StaW25p: CC'7-U r 7- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a fine up to$1,5aD.00 andlor one-year imprisonment,as welt as civil penalties.in the form of a STOP WORK ORDER and a fine of up to WO-00 a day against the-violator. Be advised that a copy of this statement may be forwarded to the Office of. Investigations ofthe DIA for insurance coverage verification. Ida Itarzby ccet ifj,aetdar thtrpauta rUrdpt;riatEies nfpegury thatthe in,fonnationprotzded abvi a fs bw and correct Signature. Date: Phone ik S Official use only. Do not write in f£ris area,to be cornp£e ad by city orlown officia£ City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.Cityl own,Clerk d.Electrical Inspector 5.Phumbiug Inspector 6.Other Contact Person: Phone 9: Information and Instructions Massaa-husetfs Geheral Laws chapter 152 requires all employers tD provide workers'compensation for their employees. Puasuantto this statute . in " e hvinner nay contract of hie, , pyf _. vrype e d express or implied,oral or wdttnu." An.EVTIayeT is defined as"an individual,pa fnersbip,associafi=y 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 mdividml,part amisbip,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,constracfion or repair work on such dweIIing house or on the grounds or building appurbmn thereto shallnotbecause 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 prod-acedacceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)sties'Neither the commanwealth nor any of its political subdivisions shall entex MtD any contact for the performance ofpublic work until acceptable evidence of compliance with the i„ armce.. requirements of this chapter have Been presented to the contracting anihodtyf Applicants Please fill out the workers'compensation affidavit completely,by cherkmg the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), addresses)and phone number(s)along with their eertif cate(s) of hinu nce. Limited LiabRity Companies(LLC)or Limited Liabiay 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 affidayitmaybe snbmit ed to the Department of Industrial Accidents for confirmation of msarance coverage. Also be sure to sign and date the affidavit The affidavit should be retnmed to the city or town that the application for the permit or license is being requested,not the Department of fit rh,girt a1 Accidents. Should you have any questions regarding the law or if you are regaaed to obtain a workers' compensation policy,please call the Department at the number lisiDd below. Self-insured companies should enter their self-ir sura ce license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and prided legibly. The Department has provided a space at the bottom of the affidavit for you to ER out in the event the Office of Investigations has to contact you regarding the applicant- Please;be sine to fill in the pemlitlliceme;number which will be used as a reference number. In addition,sit applicant that must suibmit multiple per litEcamse applications in any given year,need only submit one affidavit indicating current p olicy ffif6=atiom(if necessary)and under"Job Site Address"the applicant should write"all locations in (ci Ly or town)_"A copy of the affidavit that has been officially stamped or maiked by the city or towh may be provided to the applicant as proof that a valid affidavit is on file for furore pena#s 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 (Le. a dog license or permit to bum leaves etc.)said person is NOT re:qaired to complete this affidavit Tlie Office of Investigations would hke to thank you ita advance for your cooperation and should you have any questions, please do not hesitate to give in a cad L The Department's address,telephone and fax number: COMMMWealt1l of MR-ssachusu--tts Depa d mment of lziduiziak Accidents Office of laves-igatio= �Q�l�aslii�tan Sint Bastou .MA G� I II TeL 4 617'27-4900 4-06 ar 1-977-MASgAFI� Fax 9 617-727-774 Revised 4-24-07 m gQFldia MORITZ CONTRACTOR INC ,. 23 ATWATER DR. FALMOUTH, MA. 02536 ph.&fx. 508-540-8253 Ms. Ruth Anne Heselbarth 439 Old Post Rd Cotuit, Ma. 11-3-15 Enclosed please find a proposal for repairs at the above address Mansard Roof- approximately 800 sq.'-natural white cedar shingles Materials- shingles, Tyvek house wrap; fasteners $1600.00 Labor-demolition $1000.00 Installation $2200.00 . ------------ Total $4800.00 Finish shingling addition root $ 275.00 Homeowner. Contractor: . Ed Moritz, Moritz Contractor Inc. y�TTNEtO TOWN OF BARNSTABLE M63q. MASSACHUSETTS - �O MRl M� Solid Fuel Stove Permit DATE OF APPLICATION ........... ......................... . ............... FIRE DEPT. ISSUING PERMIT .......... . .................................... NAME (owner) �r .�C.......,�j s G .C.Y.�.:r�l ... NAME (Installer) .................... .............................................. �j ADDRESS �3F.......... ........./..L..0............ ADDRESS .......................................................................................................................... STOVE TYPE ...................../...11 J 1! .4I.T.................................................. CHIMNEY: NEW ........................ EXISTING ....................... Manufacturer ................ A....!..!��0�............................................... CHIMNEY: Masonry ........... /." .............................................. Mass. Approval .................................................. . .................................................. CHIMNEY: Metal ................................................................................................... This is to certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the ................................................................................................... Fire Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. Issued By: .......................... .......I................. ....... .................................................Titles ..,......... Date . . Permit to install expires 60 days after issue date Stovek..l.:. f. .f ....... .. ... . Tl. .l.!/............................................................................................................................................................................. StoveClearance ....................� r.&.....//........................................................................................................................................................................ Floor ............... 4 i), .........................................................................................................................g�1�...q—.... ................................5................................................ SmokePipe ................T................,....................................................................................................................................................................................................................................................... SmokePipe Clearance ................................................................................................................................................................................................................................................................ Chimney .................................................................................................................................................................................................................................................. SmokeDetector ............T .................................................................................................................................................................................................................................................... The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated .�'..: ..-. �...... has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ........................................................................ Installer INSTALLATION APPROVED � ........ By ......................... Title.31 1 s.... ..... WHITE: FIRE DEPARTMENT - CANARY: BUILDING INSPECTOR - PINK: APPLICANT 'Assessor's map and lot numb -' ��.. , 6': ' THE poi Tod♦ Sewage Permit number a' 8 ASa L House number .... `.. . ... ... ... i639• \0� �O MA a' TOWN ? OF , .-BARNSTABLE h BUILDING -;]'NSPECTOR APPLICATION FOR PERMIV TO ............ ...................................................:.................................... • TYPE OF CONSTRUCTION ........:....l �B ... '1: ......................................................... .. ........ `� .... . ..... ... .......19.a 7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies .for .a permit according to the following information: Location .............7... a-.-4f .....P �".�.............©S..1 ��.....Ca'.®...�....1..�.1...Via. ....................... ProposedUse .......... ................. .. .........................................................n.......... ...................................... . . cb Zoning District ..... ......!... Fire District ................ ��/....Y.. .............................. H£S£L"3RnTN� p Name of Owner A s:e 4 A.c r.Tli�. .�'-a!�.�.Y.`.......Address .�/e� �®����1......... Name of Builder" . -. ..� t .........................Address .` ...� .�e .... .... "�....C =' ? .1. %{�?d� Nameof Architect ......................................:...........................Address ................................................................................. Number of Rooms Foundation Exterior ....................................................................................Roofing .................................................................................... Floors ..Interior .................. Heating ...................................................................:..............Plumbing ........................... ...................................................... Fireplace .............. . .............. .........Approximate Cost . ...... ..®.......... .... .. . . ..... Definitive Plan Approved by Planning Board -----------_______-----------19__ . Area ........ ... ....... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL 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.Barnstable regarding the above construction. Name ............ ................................. HESELBARTH, EDGAR No ..261a5.. Permit-for ..:A!Rp�ITION ...... ........ TI.ONI . .............. ....... 11in .........�jimqj.q E4Milv Dwe.1_1.i.n. ........... ... ............................ ............Location 4.3.9...0..1d....P..p.q..t... 0 a... ................cotuit ..........................................................i:................... lbarth, Owner Hase .................................. Edgar r ..................... FrmeTpe"of Construction L. ......................................................................I.......... Plot ......................... Lot ................................. March -5, 84 Permit Granted .........................................19 Date o-'filffis-pection ... ..............................19II Dciie Completed ............. . ..............19 Assessor's map and lot number ch �_� /" :... ..../ .j. TH Er TO Sewage Permit number A:�k?: f... s C Z B,SB9TODLE, i House number ....,� � .... : Mass _ ...............«.............. Op 1639 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ............ ........................................................................................... TYPE OF CONSTRUCTION ...:............... ...•. �.z..... .............................................................. .................19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information:: Location ...... ..` ..e:�� . ....... T 11 .: ...... � .. .. I ProposedUse .......... ..1............................... ....................... ... ........................................................ Zoning District ........ ....... ...............................Fire District ................6i ...... .. ............................... HE,r Name of Owner r *'.5. v.-. ; �5....... .. ... .. . . '........Address .Qf�1... a j t ... �, 'mac ..... .. ..�........ ........... Name of Builder' t � a-,f� �-�-tt ..`......................Address .� x C ...xuc: .... ......... ........` ........`.'�.: a F.....;. .. f.. Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation ............:................................................................. r Exierior ....................................................................................Roofing ..........................:......................................................... t Floors .................:....................................................................Interior .................................................................................... tHeating .................................................................:................Plumbing ........................ ....................................................... Fireplace ..................................................................................Approximate Cost :..,.t�,��G�C .Q.:... ...`................ Definitive Plan Approved by Planning Board -----------_______-----------19_ . Area �� ............ ........................... Diagram of Lot and Building with Dimensions Fee � , SUBJECT TO APPROVAL OF BOARD OF HEALTH A { 4 i i f OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. A i Name .:..:.............. HASELBARTH, EDGAR A=54-26 26135 ADDITION No ................. Permit for .................................... Single Family Dwelling............. Location ...4.39...01 c1..P.ost,...R aad................ Cotuit ............................................................................... Owner .......Edgar Haselbartn................ Type of Construction .....Frame ............................................................................... Plot ............................ Lot ................................ Permit Granted ...March 5,................19 84 Date of Inspection ....................................19 Date Completed ......................................19 �nDZo q