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0294 SANTUIT ROAD
�� So��ui7r � .ra .. ry M�. . 6 R�15P��� C�k «� z 09)9®2 Y76 Town of Barnstable Bulldl �SrA Post This Card So That rt is•Visible From the Street Approved Plans Must be`:Retair ed orr:Job and this Card Must MARK Posted Until Frnallnspectio�n Has Been Made � � i Permit ' Where a Certificate of Occupancy is.Requred,esuch Building shall.Not be.Occupied until a"Final Inspection has been made Permit No. B-20-819 Applicant Name: Russell Cazeault Approvals Date Issued: 03/13/2020 Current Use: , Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 09/13/2020 Foundation: Location: 294 SANTUIT ROAD,COTUIT Map/Lot: 020-058-001 Zoning District: RF Sheathing: Owner on Record: PARKE, LINDSAY W&JOHN L JR TRS Contractor Name,,PAUL J. CAZEAULT&SONS,INC. Framing: 1 s� Address: 11 DAY SCHOOL DRIVE Contractor License: 103714 2 MIDDLEFIELD,CT 06455 r " Est Project Cost: $ 18,000.00 Chimney: Description: Remove the existing shingle roof on.the entire home.lnstall GAF £ Permit Fee: $91.80 t ( Insulation: Timberline HD architectural style shingles. Fee Paid' 5 91.80 Project Review Req: € Date: 3/13/2020 Final: Plumbing/Gas Rough Plumbing: bullaThis permit shall be deemed abandoned and invalid unless the work authorized by this'permif is commenced'within six months after ssuan fficial 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 i' Final Gas: work until the completion of the same. ; The Certificate of Occupancy will not be issued.until all applicable signtures 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 f _ Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installedRough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final:Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. 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" (as set 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: TOWN OF BARNSTABLE BUILDING PERMIT,APPLICATION_,,. s Map Parcel 'Application # Health Division Date Issued Conservation Division Application Fee Planning'Dept: PermitFee: Date Definitive Plan'Approved by Planning BoardG Historic - OKH _ Preservation/ Hyannis v Project Street Address Village yk4lt - e Owner C Address Telephone Permit Request Square feet: 1 st floor: existing proposed '2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation "i V Construction Type � -e- Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure 3 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: VYes ❑ 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: ❑Xisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial— ❑-Yes- allo-=--= 1f yes,_site_#an review_# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) 45, Name Telephone Numbe r /60D Address 664 b License# es Home Improvement Contractor# Is Worker's Compensation # �� 6 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU V44f 4 DATE O r I f t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED k a MAP/PARCEL NO. ` ADDRESS VILLAGE OWNER " DATE OF INSPECTION: FOUNDATION &CQ4 FRAME ®G� 7 07 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING- ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ts DATE CLOSED OUT ASSOCIATION PLAN NO. yRs f Jun '01 09 02:24p SCOTT PEHCOCK BUILDING e. 508 428 7625 P.2 �• Town of Barnstable Regulatory Services Thomas F.Ocher,Dirixtor ►F � Building Division Toni Perry, ZfmMim Conumizioner 200 Main Sbrxt,'HyaroM,MA Or.1601 Office: 50S-862-4038 Fax: 508-790.6230 Property Owner Must Complete and Sign This Section If Using A,BuUder Yrvalv le-el �:is/�rare of the subject property hereby authorize _�j . . y ! to act on my belialf, in all mattes re Alive to work authorized by this buUding penrat application for: Zhu .��I�.4rI(,C,t.T f `� � `.�+'-�`-► (Address of job) Signa Owner Date mfitty IA&) Print Nmne Q:FORINS:O WIvUMMISSION L-d dLO:W 60 l0 unr The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): �f I '1Pj Ir Address: V 0 MOW, T . sk&L3 , City/State/Zip 14 A ® t` - Phone#: Sb$'' ' 7W0 Are you an employer?Check the appropriate box: Type of project(required): I-AI am a employer with_ _ 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.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.f] Other St! ID comp.insurance required.] Al Sf7 d•zc_ *Any applicant that checks box#1 must also till 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. k ,-, 41tm kswuw a. L6 `��� . Insurance Company Name: —Self-in � `? W ZPolicy#orn Expiration Date: Job Site Address: City/State/Zip: ��/ t�uf 11'�� 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 rtify under tthe ins and p nalties of perjury that the information provided/above is true and correct. Si nature Date: C5� C1 Phone#: 70 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): I-Board of:Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: { , ll'1'6i, uu!,.,.1•..:.:•:i:..,, ::!, :t;�..,Wv,,,�l'�, :T •.,:, .,�• .,,1., "Is711Ly117;(..! ;�j}ai;'=.1.. ,,r:.i.., - %4., I, DATE(MNUODIYY) 'I „ it ,I r:j - �p�y�g��..r.,, �� L r:, �,• �... ,I 1,;.,� ��w��;,,I{��ij�t;°��a;:�';'�; t J I.. rM .._[',4i1M..,'r[_....-... ......�a..,.��, .. •, ,: ,�z���-� '��'. .,y',,,� ,.i�G��!(�: t' 8/2 �.... ..:. ....: ..._.,..c..,::u.n:r.4,:,,.,1t-,........r......,..,..,.,,M,l.,.r�1i,•IyiS:.a��l:,;?,. nl._.._,.e9e_� �— -f� .:a':' ::. -_r`:1,,... i ,t- ,n.l':• '1'- �•,.. �. 7 5/200B PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI INSURANCE AGENCY HOLDER. THIS CERTIFICATE DUES NOT AMEND, EXTEND OR 908 MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. OSTERVILLE,MA 02665 COMPANIES AFFORDING COVERAGE COMPANY SAFETY INSURANCE A INSURED COMPANY, SCOTT PEACOCK{ BUILDING&REMODELING g AIG AMERICAN HOME ASSURANCE CO. PO BOX 171 COMPANr OSTERVILLE, MA 02655 C `. 'COMPANY �! ( ,, •; ,...,..,, - d,�I r 1 M. 4:r.,,,.tir .I: ..I. •I„ ;tt C {... 1 k�• �^�i�: `;i! .;'1;'r..t:fr`ii:::k• �=��=�•,�;i.l,t III,,,.._I........:......I�.,, .:'.h.t.m,',:;'=r.;,• r . ..4.,.,..a;?-•_,..}.:: .:{.. "�'.i.._...,:.,�.o Id-!_h. ...�"• :�a... �:5r.i.,:V.S,I.r•,a:•.,v,,...un. l{1 [ ((.tl...:..............F.._..I.. ....__C,._.r. .L..,..:.an,...:l.rl::1.r....fnr.�. I. .r.• [' _. ,. .. , h"F`T7iAA mil', �J.1•n.6,I ukc...:. . ............. r-„ ,1;............_e._.1...—.u.-a.,._,..�IF�!,Na.l..a_ .:n.. mom. a94cJa:o uC;:i'w�l„ THIS 15 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 B Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CD TYPE OF INSURANCE POLICY NUMBER I POLICY EFFECTIVE POLICY EXPIRATION' UMITS LTR DATE(MNIDDIM DAYE(MMIDONY) GENERAL LIABILITY 'GENERAL AGGREGATE S 2,000'000 A '. i CPQOU01152 07/05/08 07/05/09 i ' '—"'—' "' " �( COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO 8 CLAIMS MADE LI OCCUR PERSONAL B ADV INJURY• 1 S L._-- OWNER'S&CONTRACTOR'SPROT, i EACH OCCURRENCE I6 1,000,000- FIRE DAMAGE (Any one O(e) IS MED EXP (Anyone person) 16 AUTOMOBILE LIABILITY I ---•'I � .. GOM®INFO SINGLE LIMIT� I f' ANY AUTO ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person)_ I . �.� HIRED AUTOS — ! NON OWNED AUTOS POerDILY INJURY I S. _._._.E.._ . ..----------- PROPERTY DAMAGE GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT 6 T ANY AUTO OTHER THAN AUTO pNly: EACH ACCIDENT 6 AGGREGATE S i EXCESS LIABILITY I EACH OCCURRENCE E= UMBRELLA FORM ! AGGREGATE i 5 OTHER THAN UMBRELLA FORM ;6 - fT - WC BTATLI OT", WORKER'S COMPENSATION AND ; Toar u1Arta Eq rB , :WC 695-76-62 06/22/08 0B/22/09 EMPLOYERS'LIABILITY EL EACH ACCIDENT 6 T 100 000 1 THE PROPMETOw i�INCL EL QISEASI_-POLICY LIMIT S 500,000 PARTNNA37EXFCUTiVE 'QFFICERB ARE i EKCL' - EL DISEASE-EA_EMPLOYEE 6 100,000 i OTHER y DESCRIPTION OF OPERATIONSILOCATIONSfVEHICLESISPECIAL ITEMS COVER PROPERTIES AT: MARCEL R.POYANT 269.274,282 BARNSTABLE RD.HYANNIS.MA 02501;1620-72 FALMOUTH RD.CENTERVILLE,MA 02 ; PLA2 TWENTY-EIGHT NOMINEE TRUST, 181-196 FALMOUTH RD.HYANNIS,MA 02601;CENTERVILLE SHOPPING CENTER 1 NOMINEE TRUST, 1676-1698 FALMOUTH RD.CENTERVILLE, MA 02632:2"0 OPECHEE RD.CENTERVILLE,MA 02632 y :,,:.a:..,:.::-�:,,..,,,.� ,• •,�..,: .Ir•�....1 ._I,I._. „ti ,I...'°.:. •:;�1'� �•c: i:.;:;.[ I 4 T .HOL..O...E.,,,R,r.-'.d .Il , I,I._u: ..,. ....FG.,o_....�,,.�._!...a...a1__,fr.a,.l.J1,..r1.,in",,:'G•LwLL.,C:it i.r-c..,,..k .t'ti.•:2� .L ,.,,. `q,:!.�I.:(•,.•.i,l.i,t.,,:i:..yy, 1s1 .:.,_9 e..... ,.... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLPD BEFORE THE EXPIRATION DATIR THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ATTN.: SALLY 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO TILE LEFT,- T(JVVi\1 OF BAFZtVST6aBLE BUT FAILURE TO NAIL SUCH NOTICE$HALL IMPOSE NO OBLIGATION ORUAWLrfY OF ANY KIND UPON THE CQrAL^NY, ITS 'AGENTS OR REPRESENTATNEB, FAA#,- 508-790-6230 AUTHOPWP REPRESENTATIVJ , .e ! 11 Hy_ .,.. :. .,.•,.ILI,n _h .. .r,EI t q,. r,..J!.t'ti;: ..I,` "cf.:P,qt.;'6,;�'.,:,,,,.sl.yS lba'm.rr.•I.l;,.•rPlrr!.l',r.l!.(-Lf,,:"k lG,l~'d.i,v.ir ...._. :.:I,ra,:,•� '_{'.� �t'I�r .�.;:�;,,.r.,i:�;. Ih .�'.. ...t.. :� ,�I ,,;,, �R': \Y�� ;�/ce Lrarrorru�ruueall� a �`l-aruzc�tuoeCla `'- Board ol•13uildin � , 6 Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:; 151853 Board of Building Regulations and Standards Expiration 7jq/2010 Tr# 271501 One Ashburton Place Rm 1301 Type Private Corporation Boston,Ma.02108 SCOTT PEACOCK.13UILDING&REMODELING INC s JAMES PEACOCK t 1046 MAIN STREET SUITE 7 OSTERVILLE, MA 02655 - ---- Admiuistrator t. Not valid without siguature r 1y4:sSsS License: CONSTRUCTION SUPERVISOR Y Number: CS 094500 � ? Birthdate:"07/22/1962 Expires: 07/22/2010 Tr.no: 94500 Restricted: 00 JAMES S PEACOCK PO, X 171 OSTEVILLE,,MA 0202 Commissioned r r \ 0200 003 #260 i � \ 020004 1 020058002 / #270 j/ i b ,` 005800 j #294 i IP 9' 4 p ff t i 0 20113 #329 r Pol Q41v^ C - + - e( ♦ 3 -- -" r - - — _ -- e 4 TOWn of Ba'rnsta,hig.geographic Information System New Search yHome Nelp C Map Size Zoom out Parcel Viewer. ustom Map' Abutters ■,■ rip. ® s=]PG Map: 020 Parcel 058 001' Full 'Property t 020119 Location. 294 SANTUIT ROAD;; Info - g ,;, i218. Owner: CULLEN;PATRICK E',&MARY'TAYLOR - �4 d2oo38 Location InformationCA tl244 tlo Map- 'Parcel: 020058001 , ' Location 294 SANTUIT ROAD UK � 2 age 100 acres 020004 ¢ p200680d3 tl0 8200 0200�11d5 tl8 Current Owner t► d2dD68002 Mailing Address CULLEN,PATRICK E&MARY TAYLOR . P 0 BOX 49.1 KIn ' a , tloFRt CO TUIT,MA 02635 - � Appraised Ve31ue(I"Y ZOO ; Extra Features $22300 tl300 Out Buildings'' $0rk ' = $t o2oit3" Land $231,006 �q4 tl32f: tlt1' 020112 Buildings $304,300 t 02011ddD3 tl?b Total Appraised $557 600. 020113002 tl�8 020135 ° #382 620ttoot 02011D g42t tt +d . tl33 ,.. Assessed YaBue(FY. 009) 'Extri Features $22,300 { 021t14 a2otde' [ Out Buildings` $0 d2dtda Land $231000 - nei+ B Buildings $304 300 Tote lAssessed $557,600 Set Scale Aerial,Photos MAP DISCLAIMER " " Copyright 2005-2008 Town of Bamstable,MA All rights reserved.Send questions or comments to GIS, BarnstabteMA v1.2.3357[Production] s , � a h TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ' t Maps Parcel S� Permit# f?�✓�� Health Division�_ fa �3o "T 105/�3 Date Issued <K15f® 3 Conservation Division Z�uo lC Application Fee , Tax Collector Permit Fee SEPTIC SYSTEM MAST EE Treasurer INSTALLED IN COMPLIANCE Planning Dept. WITH TITTLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE ANO Historic-OKH Preservation/Hyannis Project Street Address Zq 511+JTU a �2 Village 4- Owner P/+ 12 Ic rc C _L L e N Address Telephone N 2 O 6 Ll Permit Request ��Ni�� ir2v�jM 4 N 43-L ipyl_P4- G f VVi AcAc�wS X%5 hq CetiC!uLe L VcL Square feet: 1st floor: existing propos d b. 2nd floor: existing proposed Total new 63� Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size q +i$5 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family '� Two Family ❑ Multi-Family(#units) Age of Existing Structure 5 �ry Historic House: ❑Yes 6 No On Old King's Highway: ❑Yes 4 No Basement Type: 0 Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing Z new i Half: existing I new Number of Bedrooms: existing 3 new O Total Room Count(not including baths): existing new First Floor Room Count_ Heat Type and Fuel: J Gas ❑Oil ❑ Electric ❑Other Central Air: �8 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 2$0-1 Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name. Telephone Number 7— Z J 7 Z- Address S5 Lv,•� ��N� !�-P License# C S O72 653 AAA0-5-,uN V�, f L L) Home Improvement Contractor# J Z 7 2- Worker's Compensation# 7 30 6 ",4`f!0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO P/A/1 S /1 IV f 1 dl--1 0 SIGNATURE DATE ___ ,�- Z `f—d 3 FOR OFFICIAL USE ONLY PERMIT NO: DATE ISSUED ' MAP/PARCEL NO. ADDRESS- VILLAGE OWNER r DATE OF INSPECTION: ` { FOUNDATION //��// FRAME t6[ZL6'3 INSULATION p O FIREPLACE ELECTRICAL: ROUGH% FINAL r� PLUMBING: ROUGH4 _ FINAL GAS: ROUGH--: • FINAL s FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' �1ce�ain�na�zurealf/ a�./�aaaac�u 1 j BOARD OF B,UIhLDiNG`REGULA�TiQ;NS License: GONSTRUCTION SUPERVISOR e } Numtter CS 072653 Birttad €e€ 1'f-PF F1s8fi0 �; EprEes 4 /120U3 Tr.no: 11281 Restri,06 ,pn M>A1RC N CASOLI �-. I f 55 LONG POND RD MARSTONS MjIILLS, MA 02648 - Administrator J �fi6'TDomvaEo'nu�ea Board of Building Regulations and Standards ( HOME IMPROVEMENT CONTRACTOR Regrstrati, i 7 14 0, xpir f?(i 97? /2004 p dI`viduaf w MARC N.CASOLI ' MARL CASOLI `----- /D" 55 LONG POND RD � . MARSTONS MILLS,MA 02648 Ad. tosatsatnr. °pTNElpy, Town of Barnstable ti Regulatory Services rBKAS& Thomas F.Geiler,Director 2639. ��ffDMp2(A,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508 790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, pit? 11.Y �vL C. i✓ ,as Owner of the subject property hereby authorize /VtV1xC- I to act on my behalf,. in all matters relative to work authorized by this building permit application for: �a(I 54ti7'v i1-- 12 (Address of Job) Signature of Owner Date vLLtIV Print Name QTORMS:OV NERPERMISSION °FZHE T°� Town of Barnstable °^ Regulatory Services $nxr!srnBi E Thomas F.Geiler,Director mass. 9`6A i639 a��� Building Division QED MA'S Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. (R� Type of Work: ri ANt"5J-) J 100-PN-M 4 Estimated Cost Address of Work: �`�`� S ��%� 7- Owner's Name: ( l:�-7-fZ `c (.'`1 L L C AJ Date of Application: I hereby certify that: Registration is not required for the following reason(s): FWork excluded by law ❑Job Under$1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: � 2'7 ZfLl Date Contractor Name Registration No. OR Date Owner's Name C Q:formslomeaffidav RESIDENTIAL BUILDING-PE RMIT +ES APPLICATION FEE �60 $50.00 New Buildings,Additions $Z5.00 Alterations/Renovations Building Permit Amendment $25.00 FEE VALUE WORKSHEET rjEW L,IMG'SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable)`'L ' / TERATIONSMENOVA IONS OF,EXISTING SPACE d "t D-716/ square feet x W/sq.foot= v x.003 I= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq." y >120 sf-500 sf : . $35.00 >500 sf-750 sf 50.00 >750 sf-1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building perk x.0031= square feet x$96/sq.foot= STAND ALONE PERMITS, ' x$30.00= peen Porch (number) #. x$30.00= Deck r (number) Fireplace/Chimney _x$25.00= _ (number) rund Swimming Pool $60.00 . Ingo_ _ Above Ground Swimming Pool $25.00 r $150.00 Relocation/Moving (plus.above if applicable) Perruit Fee _•_�•_ The Corrimonwett-Ith of Massachusetts Department of Industrial Accidents Offfce ofloyestlgatlaos _ 600 Washington Street - ' t Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit Agg name. A 7 b L I location 2A�'j S4AJ IV 1 c� ci V 1 ❑ I am a homeowner perfa mirig all Fork myself. ❑ I am a sole rietor and have no one worltin in ca acitp /m a soy//g%///or a and / co en5ation for IIry e P QY k:{x.:}.4,:•}.••v};7:;%xx�{fK•'�:{:{},:•;y }w4{.vi^�,...: :"Y}c$?t:{+::.>: n workers :xxff.;Ykxx :x,. :.{•..,{.. ::; Iovidin ::::'fr• ,.4:::;':.:::c:x ::{t{•`. ?;•:J}}Y,.rt.. 'S•. ,fw<: to g ........ ::...... .,•.:t.::r::::t.v.};?.:.s;.}:;.:;:x;�:<:ff::ff::ff::x:::>:<�::>?:.:J•:J.:}:•:••::.,,•}.....$:::: •:::•::•.....:...::.:•.:.�}:..:.f:•:.. am an em y .•.}�iv::?'.:4:x:�:;;•}.::.- .... .F. .. 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Imiderstand that a one years,imprisonment as WER as civil penalties copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under t e pains and Pen 'es of perjury that the information provided above is true and correct M Date '7— k 2 �� 3 signature Z g Z \ M 2 L /9f 5 O Phone Print name official use only do not write in this area to be completed by city or town official peradt/license# ❑❑Buffding Department city or town: Licensing Board ❑selectmen!%Office ❑checkitimmediate response is required ❑Health Department phone#; _ ❑Other contact person: (mviud 9/95 PIAa,. Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or'more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or'renewal of a license or permit to operate a business or to construct.buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate-of insurance as all affidavits maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should ygu have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the Permrt/Ircense number which will be used as a reference number. The affidavits may be retamod to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would litre to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a.call. lo The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents flfflce of Investlgatlons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 .Ko"5S(7/17) �t � - oa�OVtY� Qf a CERTIFICATE OF UABIU l IJ INSURANCE0 THO ATE IS tam M A"T MR.OP BiPOti�A • VE HARMON INSURANdE G0: THiS t 11 f O PO OM 615 509 FALMOL"flOAD ar.� a THe COv AFPORDEo BY THE PO BEtA _ MAS1�,MA QM9 . »naXomm rce r Marc N. Casoli 55 Long,Pond Rd. lllsulana Marston Mills, Ma. 10264E 0e COVE RAGES ,on r arvauaaHoe wrlavemmr TO-Parati mPtu®agaveFORTMpoUOYFEB aQIr=TW1WXWrr WAND NG MAY"WWMWff.Igo on doWn o d oP Alf �:QrFIt3i GOCtA��ff VMrili �To WH M"GERI LATE MAY eE 6SUM OR WY itAfF0i18Y7HEP�.ICIE$DISiSCfY1DML' elEFiJWOCOt7DrTtObS�SUCH rouagsAGOMMUMSSNOWWAYWnem 11 6Y CUe/Fw r s 1 000 0 . ' A aa:w�n.i un�ln 3• x co�iLaammmi w XQ7010 9/261'02 9/26/03- ' DA1""°a_°0''"° s 5 ' aa�wioE❑ooa�a u®� 0 �oau�aa4votinrri► i 1 0 , 0 asp oar a 2 eea`• UWANWOPM ram °�• lCC wa wsun a UwrMAR s AW AM • AiyO�aUICs - 90dLY{At1tAY S ow OMWAN i�AltlOi 9�.TYLRliIY S —• — AIa�01a.Y-lJ►d s UMOW 011�t7F11N1 1�►AOC s /�51111r0 AU an AM X • e�ac s �sstiueam aea�ue a am= 0 axamm ,< oeaendg i B' ° 7308A44103 - el.a�+aoao>�+ s100 000 3/18103 3/18/04 ca.CMWAN•wu►mr Q a za� S19n/•�u1T �Z� • _ - t IMUA" Town -of Barnstable m!lt71101®OF,laB if1�9t•sonar w.s no.�r—eww Building Dept. HE T,._errroreieFrwt-Faaronesoa Caeiw� so F/ tswo opal 1x>:aa+N ns ae0++9 os • ' 1 �� � --• TiDN 5889 ACM.�fhI Es ACORa 70 e' Ip•-0� SMOKED . . � ETECTORS OK. � ° as O � STABLE BUILDING DEP Y Y Y QWAA WO WW-F T.T S $ X M VA < , r ---- ---- --- -- L c4aaw sloe OR ;- r- ------ ------ -r ee .. u�or csalao V 9TOIC e6arr91W . n ^ON414ilm"IN em"No POWATM AS uV 6yb1! r-r - s-ro• IS N0 9• V '= S wwVAl!!oi —r carve rum a'-]Wb* �Lp I AID eAcau hTM \ GM w e VAR CA& SPUM S Olt omm wo c m Foolw L—aR amm M &Eva or m"TW FOND. ___ ______ __ T, �AMWe y-W ABM CKMIW F - _ c wk SLAB. _ " - ' - • ►OIAOAl1011 M iQQn@D n rya x JV4vet - Q 1x{lwtWFq V. ►t AianRAo cur eFernr a sea° l®ee. $ 3 E 3 G _ Dow r0 .. ;' .r.FDIC. ,; OMPLAM Yti§� ,vu�� Q; ��� eeOlenActr N NFJr LVl e1RT a IR' .9lAB. 14'-0' 21,211BILLIARD i iVJWPW STAN AW p ROOM AMreFAOS TO b ..9 ONTTOM Or STAR OF "m p g aka MEGA STAMCAW i E§8b$F 9 3 i yr err.ev. w m lvu N BATH •. 9ora e aasnw cau.w OK 2M W.w am ut ® ware.nave. UM r.T.SU FLAWdleTilO IC)]7I@ MRT �_ L46 F0.1bAT10MMlr \ J L _ EQ. . 7 uj T w �T.V.Wanl7 Q Alb MOT M7R WEATR Zi- a z Q7- J d " v NOv D- SLAB TO BOTTOM OF JOIST T'-Io• ' wq. .roe— CW.2 . Oltte... ,Jv."11,400E .» BASEMENT FLOOR PL ,; N � scAte, lie A-1 �, SHEET I OF x ►�' j SHED REGISTRATION location of shed(address) property owner's name size of shed ��si-g-)na�ture ��������dat�e Old King's Highway Historic District Commission jurisdiction? O THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN shed , AI kl t f • +w 25.00 K Fes . 4#'0 / 1 / 6 / 1 1.00 AC #270 t 5�1-1 t / f `i Q 11 s , a / 1 %/ / k f art ' ijs - � 1 #430 i f #e #0 Z. - - I �1 1 .55K 1 / I . 7R7.11 s382 .As sessor's Office:{1st floor) Map �© Lot � �8, �� hermit# // Conservation Office(4th floor) 'w� � Date Issued `7 �6✓ 9 to Board of Health(3rd floor)(8:30-9:30/1:00-2:00) &_30 3)�J Fee.* Engineering Dept._(3rd floor) House# Planning Dept. (1st floor/School Admin. Bldg.) r N ' Ject )eet an Approved by Planning Board �� /R �19`rw o!N11i NIG' §1,J1 TOWN Of,BA I Buildin .P rmitA licat ong � pp Address Lot ( �_w, LjcV �-O t- 1 oo' ' Village "C:otuit -Owner - School Street Realty Nominee Trust Address 619 Main Street, Centerville Telephone t 5Ut1) 775-1442 .Permit Request construct single family home Total 1 Story Area(include 1 story garages&decks) 2600 square feet Total 2 Story Area(total of 1st&2nd stories) 2600 square feet Estimated Project Cost $ 197,5UU.0U Zoning District RF Flood Plain Water Protection AP Lot Size 1 Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Lot Proposed Use Construct single Construction Type wood family home. Commercial No Residential Yes e Dwelling Type: Single Family X Two Family Multi-Family Age of Existing Structure N/A Basement Type: Finished Historic House No Unfinished X Old King's Highway No Number of Baths 2.5 No.of Bedrooms 3 Total Room Count(not including baths) 6 First Floor 6 Heat Type and Fuel Gas Central Air Yes Fireplaces 1 Garage: Detached Other Detached Structures: Pool No Attached Barn No None Sheds No Other No Builder Information Name Ronald U. Silvia, President Telephone Number, (508) 775-1442 Address Silvia & Silvia Associates, Inc. License# 016932 6i9 Main Street Home Improvement Contractor# 101627 Centerville, MA 02632 Worker's Compensation# 3BY00253900 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO BFI Pick Up SIGNATURE DATE BUILDING PERMIT DENI D FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. q - DATE ISSUED MAP/PARCEL NO. ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME _ INSULATION FIREPLACE. ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING - r DATE CLOSED OUT ASSOCIATION PLAN NO. The Town of Barnstable Permit#�?63, Massachusetts Date � 9 7 s�arier�sr� KAM SOLID FUEL STOVE PERMIT 1e39' . Fee This constitutes an official stove permit after inspection and approval by the building inspector. Owner M AZ—z©G M S 14 C Telephone no. Address of Property, -ProP e Q C e e Village � ocation and Stove Type LC J,10 57W 6-1 y j o 0� d er I,y u e C S TO e Date: Building Inspector `O The solid fuel burning stove at the above location passed: failed:_inspection. _ ' ; :Vie► lRt • 4 e . 1 ` • Yi Sµ�. TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL ID 020 Q58 001 GEOBASE ID 42559 ADDRESS 294 8,ANTUIT ROAD PHONE (508)775--14421 Cotu ? ZIP - LOT 1 BLOCK LOT SIZE j DBA DEVELOPMENT DISTRICT CT PERMIT 21030 DESCRIPTION .SINGLE FAMILY DWELLING (PMT.#16425) PERMIT TYPE BCOO TITLE , "CERTIFICATE OF OCCUPANCY . i CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES BOND $.00 Ox tM1E 1 : CONSTRUCTION COSTS .00 756 CERTIFICATE OF OCCUPANCY f' * BARN3fABLE. MAS& OWNER SCHOOL STREET REALTY NOMINEE TRUST, 1639.AA�� ADDRESS 619 MAIN STREET 'Ile ED Mfg CENTERVILLE, MA BUIL IVI• B ,� I DATE ISSUED 02/10/1997 EXPIRATION DATE i TOWN OF BARNSTABLE v _ "* BUILDING PERMIT PARCEL ID 020 058 0.01 GEOBASE ID 42559 ! ADDRESS 294 SANTUIT ROAD PHONE (508)775-144 i Cotuit } ZIP - LOT 1 Ile. BLOCK LOT SIZE 1DBA DEVELOPMENT DISTRICT CT ! PERMIT 16425 DESCRIPTION SINGLE FAMILY DWELLING (SEW.PMT.496-303) a PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT CONTRACTORS: SILVIA, RONALD J.jARCHITECTS: Department of Health, Safety and Environmental Services TOTAL FEES: $612.25 1 BOND CIE CONSTRUCTION COSTS $197,500.00 v 101 SINGLE FAM HOME DETACHED 1 PRIVATE P • * BARNSTABLE, +*► MASS. OWNER SCHOOL STREET REALTY NOMINEE TRUST, i639• A1�� ADDRESS 619 MAIN STREET EpCl CENTERVILLE, MA BUIL B DATE ISSUED 07/10/1996 EXPIRATION DATE THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR . ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2.PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND M FOR (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. CH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDINg INAPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 8'-13-y h ' �a It o I� 2 41 3 1 HEATING INSPECTION APPROVALS GINEERING PARTME T v 2 Z_ -7 - BOARD OF HEALTH OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT AfiOCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. a/0-Jo I UMBiNG q�. ' M 1 z a APPROVED TOWN OF BARNSTABLE V i 3 � _ ,100 fo40 v� 3 it I pCRIES . . �o { , A a~' LLI �CyGt ti O tvt p No. 19334 I a c r a su �q`. . .:: . _�Ls ov _ CER= +E�FI E D P PL AN LOCATION 7"-. M455. wCER'TIFY'T . AT_THE`FOU,.NDATION -� ; ` +SCALE j'�= o jo:A_A��. ./3, l5'S'G 4.:SHOWN:H-FEON COMPLYS WITH : : 1 I,-THE -SIDELINE AND I-SETBACK - + PLAN R E t=E R E NC E C REQUIREMENTS OF -THE;:TOWN .OF 15/�oxav /�5 Lo7 oN q PL9u �0�2 :BARNSTABLE,ANQ:IS'NOT._ . LOCATED .IN'THE FL- _ IN. ... . . ._ .�_ . r,���,�/�► j/. Yoh _- . :DAB %'IqY 4)?gz DATE ) S 13'1 B.A:XTER: Ir'NYE, fNC: THISmPLAN :IS N90T* BASED 0 :A REGISTERED 'LAND SURVEYORS IINSTRUMENT SURVEY AND THE OSTERVIL.LE MASS. OFFSETS SHOWN SHOULD NET' BE USED -rO-0E-TERAAINE'-1M-'LINES. t ' : - IL : r ' i *-Pot iL Y _ 000 .r 1 r 11 , 1 t�OftA . ILLIAM It& 19334 : . �, q p�� �G . .yam I C• Q Y / e _Cow . a D1;r 'PI IEN'P OF 1'1BLIC `SAL L'rY' .lJ 2, e ONE A:311UURT014 PLACE, I l 1301 OCT 3 U. r BOSTON, till #)210f3-1G1a_ 1995 ; t -CONSTRUCTION SUPERVISl111 LICL 14SE . ��, �o Number. CS vJ1G932 11/1L/ '991 11/.1s3/1949 Restricted 'Fo Oct RONALD J SILVIA Det;v_h boLt(111ly fold siyn on x 619 11AIN ST back, and laminate 1 s i;eise card x CCNTERVILLE, Ilk02G:32 Y.eet> Lop for ieceiiL ��t1d change of iickh.ess n0tific Lj n <' ' (� ��(S 1p0)Jt9JIOJl(!/CfL�IIt'Ow�i(JJJNCIt lIJCl/J I I .� y, + t s ,� x - ? Restricted Tot 00 2 3 3:;9 G `., DEPARPHERP Of PUBLIC SAFETY' C011STRUCPIOH SUPERVISOR LICENSE 00 None i Ir Huwberi Ezpiies� Birthdate: 1A - Hasouy only C5 016932 1111811991 'l/1811949 1G 1 1 6 2 Tamil :m .. Restricted Tot 00 Pa-_ue to Posses:! a current edition of the r /� !W,-- chusetts State Buiildiny Code l 054A %01tw RONALD J SILVIA is cause for eevocati": his lr en�e. a 619 HA14 ST .CENTERV.'LE, HA 02612 A F '�� lie �G��l�/lYGQ�I'i.UX.Q:GCf2 0�✓[�L(�.'dtil,ZCf2C6:S6�i � j�'� # �s� � HOME IMPROVEMENT -CONTRACTORS REGISTRATION oard of Building 'Regulations and Standards: a One Ashburton Place - Room 1301 '' k_111 Boston,: Massachusetts 02108 A ' HOME IMPROVEMENT CONTRACTOR _ Registration 101627 , Expiration 06/26/98 ;. Type PRIVATE CORPORATION oz 'HONE INPROVENENT CONTRACTOR J, rna Registration 101621 SILVIA & '5ILVIJa A�SOCIATES.J IUC . I Type PRIVATE,CORPORATION l�o.na.ld J Sil > a - Ezptration 4b/26l98 ` 619 Main Stra t �.ntervi±lie MA. 02632. . SILVIA S SILVIR �SSOCIATE�, r Ronald Main Street ,t antervtlle MA'32632 S ss" ZMINISTRATOF � ��.-.t � i, �k "1 ,C: (( �� Tlie CllttttttottN'ealth ofAfassacliusetts Dc parttncnt of Industrial Accidents 011ice ollnvestlgallons 600 Washington Street , .:. Boston,A1ass. 02111 Workers',Compensation Insurance Affidavit Annitc.•Int tnformation• • '—" • Plcace PRIIVT1 �Iji(y ""''^` ""'" name: Donald J. Siivia location: Lot 1 (360 School Street) ' city Cotuit phone o (508) 775-1442 I am a homeowner performing all work myself. 0 1 am a sole proprietor and have no one working in any capacity ...� ^'./^-..��' .".Reif-+ytza•aT+''*nr `!5�^•",t'*�'%'.jE 'tT.rT.r!* -='r.Std�• c�.,.;.L....JY..:�..'~'t -Z— — ,.......5r..,...sr s+.�•1 � � ...:aui:.ld..,�_ ( 1 am an emplover providing workers' compensation for my employees working on this job. comnanv name: Silvia & Silvia Associates, Inc. address: 619 Main Street cif.: Centerville, MA 02632 phone#• (508) 775-1442' insurance co. Lumbermens Mutual Casualty polic),# #BY00253900 ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city phone#• insurnnce co. took)•# L".�.ri: -.�..ei-•�"`- - ._..htn�.Y._r,,;.�r��vs-•s�-r•��..'T,R;�'s �43'.'.'r".'"r ' `il'/�Jrff_1• ".►1'.:T'A.7"M•' :�3' R':"•'""?K - -�'�.h£4STrR? ' comnanv name: address: cit: phone#• insurance co. polio.# :Attach additional'sh it if riectjsry'a'""� ._,..:J+�.,.:.yi�:_ --�i Y`:[r _. �+::.=:�"_—�-' *^. yt.Y�.+'in".'•.dwf.•w`L'M.. Failure to secure coverage as required under Section 25A of f11GL 152 can lead to the imposition of criminal penalties of a fine UP to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a COPY of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herehr certff}•undc,r tl1 p its and penalties of erl n,that the information prorided above is true and correct. Signature Date 7"a' Print name Ronald J. Silvia, President Phone# (508) 775-1442 '?official use only do not write in this area to be completed by city or town official city or town: permit/license g ntluilding Department 0Licensing hoard p check if immediate response is required []Selectmen's Office [311calth Department ' ` contact person: phone#; rJOlher .yam (revised V95 P1A) . ISSUE DATE(MM/DD/YY) ERTLF�C/ T .. ::: : E: Ft,1.RACE .......................................... 0 4 0 2 96 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND The Fair Insurance Agency, Inc. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE .O. Box 430 619 Main Street POLICIES BELOW. enterville, Ma 02632 COMPANIES AFFORDING COVERAGE (5 0 8) 7 7 5-3131 COMPANY A LETTER LUMBERMENS MUTUAL CASUALTY COMPANY COMPANY B INSURED LETTER MARYLAND CASUALTY Silvia / Silvia Associates Inc COMPANY c 19 Main Street LETTER COMPANY D Centerville MA 02632 LETTER ( ) COMPANY E LETTER C. V�l ......................................; .::::.;..... :: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR DATE(MM/DDNY) DATE(MMMD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE s 2 M I L COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. s 2 M I L CLAIMS MADE X OCCUR. W 7 D 3 4 7 7 3 8 0 8/O 1/9 5 0 8/0 1/9 6 PERSONAL&ADV.INJURY s 1 M I L OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE s 1 M I L FIRE DAMAGE(Any one fire) s 5 0 0 0 0 MED.EXPENSE(Anyoneperson) s 5 0 0 0 AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) s 500000 HIRED AUTOS CA 9 0 517 2 4 4 0 8/O 1/9 5 0 8/O 1/9 6 BODILY INJURY NON-OWNED AUTOS (Per eccdent) s 1 M I L GARAGE LIABILITY PROPERTY DAMAGE $500000 EXCESS LIABILITY EACH OCCURRENCE $ F1UMBRELLA FORM / / / / AGGREGATE $ OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION AND 3 BY 0 0 2 5 3 9 0 0 0 4/O 1/9 6 0 4/O 1/9 7 EACH ACCIDENT s 5 0 0 0 0 0 I EMPLOYERS'LIABILITY DISEASE--POLICY LIMIT $5 0 0 0 0 0 OTHER DISEASE--EACH EMPLOYEE s 5 0 0 0 0 0 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS e`:.Rr.i E.TI..ICATE.HO.LD ELL CANCAT IQN Own Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Building Inspector EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO South Street MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR yann i s MA 02601 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. 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