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0701 SANTUIT ROAD
7o/ UO-ntli-71- ?4� . � :. Town of Barnstable ' k Building ing �Post,�This Card So That it3is'U�ibl'eFrom the.Street .A roved'Plans;Must lie Retained omJob and�th�s Card Must be Key t .. rwnarsrn�.c. y � fi , PP� � p-,� ifiyp, aawss Posted Until Final Inspection Has Been Made s i � s Where a Cert�ficate�of O cw�anc ups Re ,wired;such Bwildmgshall Not be O,ccup�ed'until a Final Inspection Mas been made . ' l Permit Permit No. B-19-3252 Applicant Name: Francis Sheehan Approvals Date Issued: 10/02/2019 Current Use: Structure Permit Type: Building-insulation-Residential Expiration Date: 04/02/2020 Foundation: Location: 701 SANTUIT ROAD,COTUIT Map/Lot: 006-024 Zoning District: RF Sheathing: Owner on Record: fERNANDS,ELEANOR Contractor Name: ,JRANCIS S SHEEHAN Framing: 1 Address: 701 SANTUIT ROAD Contractor License:: CSSL-10S941 2 COTUIT, MA 02635 Est Project Cost: _ $ 1,600.00 Chimney: Description: Air sealing,300 SQ Ft 2" rigid to Crawlspace PermitFee: $85.00 Insulation: Fee Paid: $85.00 Project Review Req: Final: Date 10/2/2019 Plumbing/Gas n Rough Plumbing: .. Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authonzed'by this permit is commenced within six months after,'issuance. All work authorized by this permit shall conform to the approved appl cation 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. This permit shall be displayed in a location clearly visible from access streetor road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. : Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on thispermit. Minimum of Five Call Inspections Required for All Construction Work:F'i 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 M 5.Prior to Covering Structural embers(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 All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: IKE r, Application number.-ZK-(2 Date Issued............... .�.... ......... BAR'VSTABI-E. es kl w . .... A'YtiSS. � �.. 1639. ���� 5 Building Inspectors Initials...... .... .. .... .......... q" Map/Parcel....0®(0.......d �................................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 70 I p s NUMBER_ STREET VILLAGE Owner's Name: 6feallor ter,lQnh Phone Number s 08-,-12 f- 7 Email Address: P-rerlit7l, Cell Phone Number Project cost$ /y, g g 0 — Check one Residential y/ Commercial OVVN ER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: S e%- A- ,,h,\a ��-�cG c-� Date: TYPE OF WORK fading El Windows (no header change) D Insulation/Weatherization Doors(no header change)# Ll Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to GJ a s4e-/9,7al?4 1 CONTRACTOR'S IN FORMATION. Contractor's name I���Gn��n�;so✓� Sov� ��n A4� ccl ava 1�fl-I)c ow S Home Improvement Contractors Registration(if applicable)# 17 3 214 5 (attach copy) Construction Supervisor's License# (29 5-7 O (attach copy) Email of Contractor aS WTI Phone number 110I- Z 2 R -�XW ALL PROPERTIES THAT HAVE STRUCTURE VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY 15.fiv A HISTORIC DISTRICT, YOU M UST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT C 4N BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X I X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide-a site plan with the location(s)of each tent pf food is being served at your event please obtain a Health Department approval between the hours of 3:00am-9.30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLIET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S N1V'R'S LICENSE EXEM S YIOlV Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures;specific inspections and documentation required by 780 CM.R and the Town of Barnstable. Signature Date 1C L1LCA1V g 9 S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance R{„J� newal Agreement Document and Payment Terms " dersen. dba:Renewal B Andersen of Southern New En Ian .0 Y . . g d. Eleanor Fernands Legal Name:Southern New England Windows,LLC ;701 Santuit Rd RI#36079, MA#173245,CT#0634555.Lead Firm,#1237: Cotuit,MA 02635 wiRoow RE LAcEMERT 10 Reservoir Rd I.Smithfield,.Rl 02917 H:(508)428-510 ' Phone:866-563-2235 1'Fax:401-633.-6602 1 sales@mnewalsne.com Buyer(s),Name: Eleanor Fernands. _ Contract Date: 08/22/18 Buyer(s)Street Address: 701 Santuit Rd, Cotuit, MA;0205: . Primary Telephone Number: (508)428-5147: Secondary.Telephone Number.:.' Primary Email: efernands4McOmcast.net.' Secondary Email Buyer(s)hereby.jointly and.severally agrees to purchase the products and/otservices of Southern;New England Windows,LLC d76/a Renewal By Andersen of Southern New England("Contractor),in'accordant. with.the terms and cotiditions described in'this Agreement. Document and Payment Terms,any.documents listed in the Table of Contents,and any other.document attached to this Agreement Document, the terms of which are all agreed:to'by the parties and incorpporated herein by reference(collectively,this"Agreement").--'. Buyer(s)hereby:agrees'to sign a completion certificate after Contractor has completed all work under.this Agreement. Total Job Amount: $14,880 By signing this Agreement;you acknowledge that.the.Balance Due;and,the Arnount' Financed must be made by personal.check;bank check,credit card,.or cash Deposit Received: $0 ; Balance Due: $14,880 Estimated Start: Estimated.Completion' 7-9 Amount Financed: _ f Weeks 7-9,weeks $14;880 Method of Payment. Finaneln F . . g We schedule installations based on the date of the signed contiact.'and secondarily on. the date in which we complete the technical measurements:The installation date that: we are providing at this time is only an estimate.We will communicate an official-date and"time'at a later date.Rain arid extre'rne.,weather are the most common causes for ' delay Notes: This sale is contingent on acceptable financing to.customer Buyer(s)agrees and understands that this Agreement constitutes'the entire understandings between die:parties and that.there are no_verbal. understandings changing or modifying any:of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,.writte.n"consent of both,the Buyer(s).and Contractor. Buyer(s)'hereby acknowledges that Buyer(s) 1)hag read this Agreement, understands the terms of this Agreement;and has received a completed,signed;and dated 'copy of this Agreement,-including the,two attached Notices of Cancellation,.on the date first written above and 2)was'orally informed of Buyer's right to canceh this Agreement; NOTICE TO BUYER; Do:not sign this contractif blank'..You are entitled to a copy-of the.contract at the time you`sign. YOU,THE BUYER,MAY CANCEL..THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT. OF 08/25/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF.THIS TRANSACTION; WHICHEVER DATE IS LATER:SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN ; EXPLANATION OF THIS RIGHT 'Legal Name:Southern New England Windows,LLC dba:Renewal ersen of So ern New.England Bu er(s) Y Signature of Sales Person; Signature. Stgnaiure Paul Sandrey Eleanor Fernands Print Name of Sales Person. Print Name: Print Name UPDATED: 08/22/18 - Page 2'/ 10 P. Commonwealth of Massachusetts 'V� 3 Division of Professional Licensure Board of Building Regulations and Standards ConstC3�lG 9 1t'JL4. rVI50f •4� J$ CS-095707 i ires: 09/08/2020 r r Jxx BRIAN D DENNISON 8 BLACKWELL DRIVEL % CHARLTON MAA 1607 Comrnissi®rter cz L J Office of Consumer Affairs end Business Reg latuon 10 Park Plaza - Suite 5 70 Boston, Massachusetts 02116 Horne Improvement Contractor Registration Reqistration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9/19/2018 BRIAN DENNISON 26 ALBION RD _... . LINCOLN, RI 02865 Update Address and return card.Mark reason for change. Address = Renewal 7 Employment = Lost Card -0ffice of Consumer Affairs 8 business Regulation Registration valid for individual use only before the _ --HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: __ Office of Consumer Affairs and]Business Regulation Registration: 773245 Type. 10 park Plaza-Suite C170 Expiration: 9i79,20j8 Supplement Card Boston.MA 02116 )UTHERN NEW ENGLAND WINDOWS LLC. .NEWAL BY ANDERSON ;]AN DENNISON r' y ALBION RD ✓ � dCOLN, RI 02865 _Undersecreiary Not valid without signature Elm -Rec;" .. rGi%vrsC 2-,r:'d via~:it�.+.".'J CS-09 A 0 37 i I BRAN D DENNISON f"AMBv POND CIRCLE EARL T ON VIA 01507 '�.vs...; 's'J$1Vi i�"�„r I The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www-mass.gov/dia 11'orkers'Compensatibn Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERM-TING AUTHORITY. Appli'-ant Information Please P ' Name (Business/Organizarion/Individual): rint Le bl` e awl Address: � �1 City/State/Zip: p Phone g�: Are you an employer?Check the appropriate box. Type of project(required): 1 I am a employer with !?D femployees4full and/or pan-time).; 2.❑I am a sole proprietor or partnership and have no employees working for me in New construction anv capacity.[No workers'comp—.insurance required.] 8• n Remodeling I am a homeowner doing all work myself[No workers'comp.insurance renui*ea17 9• ❑Demolition �.❑I am a homeowner and wdl be hiring contractors to conduct all work on my properly_ I will I 10 Building addition entire that all contractors either have workers'compensation insurance or a-e sole 1 Proprietors with no employees. l 1.Q Electrical repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.[]Plumbing repairs or additions These sub-contractors have employees and have worker-,'comp.insurance; 13.F�Roof repairs r I 6.❑We are a corooravon and its officers have exercised their right of exemption.per MGL c 14• Otber 152.6)(4),and we have no employees.(No workers'comp.insurance required.1 'Anv applicant that checks box J.I must also fill out the section bellow showing their workers'compensatior policy mformatiori t Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contactor<must submit a new affidavit indicating such 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractor-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 information for my employees. Below is thepolicJ Ad job She Insurance Company Name: I rle P Q A S j Policy 1;or Self-ins.Lic. �(�C��a{ 7 Z _ 2-0 ExpuatioL Date: / / ! J Job Site Address: City/State./Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder MGL c. 152.§25A is a criminal violation ptaiishable 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 certify under th airs andpenalties ofperjury that the information provided above is true and correct Si afore: Dale: Phone g: CID j- 2Z � Official use only. Do not write in this area,to be completed by C4 or town official City or Town: Permit/License W Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitytTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A AC(:?RE)® CERTIFICATE DATE(MMIDD/YYYY) �,� E OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFO I RMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). -RODUCER CONI'A CT CoBiz insurance, Inc.-CO NAME: 1401 Lawrence St, Ste. 1200 PHONE 303-988-0446 Denver CO 80202 E-MAIL iut No:303-988-0804 D : COMaiI cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC 0 NSURED INSURER A:Acadia Insurance Com an 31325 ESLERCOD1 Southern New England Windows, LLC. ►NsuReR B:Firemens Insurance Company of WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Campany of New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: INSURER F: OVERAGES CERTIFICATE NUMBER: 1252851165 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. ISR TYPE OF INSURANCE ADDL SUBR TO CDY EFF POUCY EXP \ '� POLICY NUMBER M/DD A X COMMERCIAL GENERAL LABILITY Nyyyl LIMITS CPA3158728 1112018 1/12015 EACH OCCURRENCE $7,OGG,GOD CLAIMS-MADE X OCCUR � DAMAGE T NTED 'PREMISES Ea orrurrencel $300.000 i MED EXP(Any one person) $10.000 PERSONAL&ADV INJURY S%ODO,D00 GEN L AGGREGATE LIMB APPLIES PER:PRO- GENERAL AGGREGATE $ 0D0 DM X POLICY C JECT 7 LOC PRODUCTS•COMP/OP AGG $2.00D,DOD OTHER: A AUTOMOBILE LIABILITY N I CPA3158728 V72076 1/72015 COMBINED SINGLE LIMIT X I Fa acctlent $•0D0 ODD ANY ALTO i BODILY INJURY(Per person) $ I ALL OWNED SCHEDULED ALTOS AUTOS I BODILY INJURY(Per accident).$ X HIRED AUTOS X NON-OWNED AUTOS I PROPERTY DAMAGE Is iPer accident A I X UMBRELLA LAB X ' $ OCCUR CPA375872E 111201E 1/1201E EACH OCCURRENCE $10.000,0D0 EXCESS LAB CLAIMS-MADE RETENTION$ AGGREGATE $10.000.000 DED X I B WORKERS COMPENSATION JWCA315MS-20 1/12018 1/1201c PER OTI+ AND EMPLOYERS'LIABILTY YIN. X STATUTE ER ANY PROPRIETORIPARTNEROMCLMVE OFFICE IMEMBER EXCLUDED? ❑ N/A EL EACH ACCIDENT $1,000.000 (Mandatory in NH) N yes describe under E-L DISEASE-EA EMPLOY4S 1,000,00D DESCRIPTION OF OPERATIONS below I ISEASE-POLICY LIMIT $1.000.000 C Pollution Liability 79MO73340000 1112018 1/12019 Each Occurrence $1.000,0m Claims-Made Pdicy Retroactive Date 06202013 Agg�bie $10 0010m )ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more spare Is required) :ERTIFICATE 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. For Informational Purposes AUTHORIZED REPRESENTATIVE ------------- ©1988-2014 ACORD CORPORATION. All rights reserved. 4CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Application number:. Date Issued............... ... ..�.�. ..+��.... .............. ws . . .... . ....... MAM • ��AJ�?'i8'fI4�L�. s �� �yy�� .kp 63 � ," ` Building Inspectors Initials....... .. ... ................. t� JUL 112018 1 Map/Parcel........00.�......6..`!`.1.......................... TOWN OF BARNSTABLE ' o � EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION. PROPERTY INFORMATION ,p Address-of Project: DI�DI S4,A17 �) .a C-07 NUMBER STREET VILLAGE Owner's_Name:> 10L6_4 Nd OQ `F F,,�_0 4- /V umber %/J k Y o��'_ lS �} 7 Email Address:, deE',��V5��� (2V one Number Project cost $_7\ Check o_ne,Residential) Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK _`❑ Siding ❑ Windows(no header change)# ❑ Insulation/Weatherization ❑ Doors (no header change) # Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name ' Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY/S IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* t Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number'S g ,�5 / cf' Cell or Work number �~ I.understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. -Signature ) Date `7._ l/—r,/& APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. s The Commonwealth of Massachusetts { Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: __7D I 6 A V T V i 1— P-,b City/State/Zip:- LU v iPhone#•}- Are you an employer?Check the appropriate box: Type of project(required): l LEI I 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 an capacity. employees and have workers' g Y P tY• x 9. ❑Building addition , [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions r3. I am a homeowner doing all work ❑ g P myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no A, employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing-all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct �Sigrtature': Date CPhone-#f, 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,parnership,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,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cerdficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current ,� "all al locations in ci or policy information(if necessary)and under Job Site Address the applicant should write1 (city town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 4-24-07 www,mass.gov/dia oFrq�, Town of Barnstable *Permit# Expires 6 mondafro issue date ' Regulatory Services Fee _ i RI ANf.TART.F t _ 9cb �659 l � Thomas F.Geiler,Director Building Division Tom Per ry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www-town.barnstable.ma us Office: 508-862-4038 Fax: 508-790=6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Yalid without Red X-Press Imprint Map/parcel Number Property Address / SJ9.1� T c✓ �� / U / / Residential Value of Work Minimum fee of$35.00 for work ender$6000.00 Owner's Name&Address p Al,9 Telephone Nutiibct e contractor's Name �• o� /LAC •come Improvement Contractor License#(if applicable) 'onstruction Supervisor's License#(if applicable) ]Workman's Compensation Insurance X'P. �"iES PERMI Check one: 1 ❑ I am a sole proprietor �® I am the Homeowner MAR 2.3 2012 ❑ I have Worker's Compensation Insurance isurance Company Naive TOWN OF BARNS.TABLE orkman's Camp. Policy# opy of Insurance Compliance Certificate must accompany each permit. :emit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value- maximum.44)#of windows *Where required: Issuance of this permit does not c=pt compliance with other town deparnnent regulations,i.e Historic,Conservation,etc. Property Owner must sign Property Owner Letter of Permission. A copy of.the Home Improvement Contractors License& Construction Supervisors License is required. PFILESTOPIWbuilding perfnit jbnns\EXPRESS Aoc The Comm-onwealth-of Massach se Department of Industrial Accidents d Office of Investigations r a 600 Washington Street Boston.,MA 02111 www.mass.gov/din j Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information r Please Print Legibly_ ---- --Name(Business/Organization/Individual): 1�— - -- -- Address: :2a City/State/Zip: 7-"tJ 7- b 4 Kan e Are you an employer? Check the appropriate box: Type of project(re uiied):•' L❑ I am a employer with .4. ❑ I am a general contractor and I employees(full and/or parttime).* have hired the sub-contractors 6., ❑.New construction . . . - . 2.❑ I am a sole proprietor or partner- listed on the-attached sheet 7. ❑'Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have'workers insurance:$ 9. ❑Building addition comp [No workers' comp.insurance required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their I am a homeowner doing all work' 11.❑Plumbing repairs or additions myself. o workers' co right of exemption per MGL Y � �• 12.❑Roof repairs= - insurance required.]t c. 152, §1(4),and we have no 13.❑ Other ~ employees. [No workers' comp.insurance'required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ` t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have. employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: n Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK.ORDER and a fine of up to$250.00 a day against the violator..Be advised that a copy of this statement may be forwarded to the Office of.. Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signatur Date: } Phone#:r Official use only. Do not write in this area,to be completed by city or town offzciat' City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.ElectricaI Inspector*5.Plumbing Inspector 6.Other Contact Person: Phone#• - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the,' receiver or trustee-of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons 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, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced,acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public wont until acceptable evidence of compliance withthe insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city-or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any.questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. -.The CommonwWth of M=nhusats Department of lndustrial A.cci&,uts Office of Invest gati 604 Washington Steeet Boston,MA 02111 TQ1. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.gov/dia �IHE Town of Barnstable Regulatory Services . -- --- +es Thomas F.Geiler,Director i63q. 1 F '� Eo Building Division - Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: - - Fax:508-790-6230- -' . Property Owner Must- Complete and Sign This Section IfIf IJsi� A Builder - , I, 'as Owner of the subject property . hereby authorize to act on my behalf, in all'rnatters relative to work authorized by this building permit (Address of Job). _ Al **Pool fences and alarms are the responsibility of the applicant. Pools - are not to be filled before fence is installed and pools are not to be Utilized.until all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date j Q:FORMS:OWNERPERMISSIONPOOLS s i THE rqy Town of Barnstable Regulatory Services ' IMIMSrAslr, * Thomas F.Geiler,.Dir'ector Mwss. 9`b,, i639• .•� Building Division . TfD MA'1� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 20,/ /y T (/ f % SQ 7� T U number street' villageo "HOMEO WNER"JTO H N D 1- L—�. C95 A16� /' /�/li /V A N�� V� o �v��16j q� name �Q home phone# CURRENT MAILING ADDRESS:. I c-4- city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and•requirements and that he/she will comply with said procedures and requirements. - 12��.r�ivrJ�„ Signature of Homeowner • r Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the w State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible.. To ensure•that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt +r1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION TOWN OF �' �''��T F Z Map Parcel _ Application # Health Division R -5 Pill 2.-D%Se Issued -2,(a, Conservation Division Application Fee Planning Dept. f� 1 Kermit Fee _ Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis aa Project Street Address '7b StNgTD iT R;p Village= e.mu ri Owner ELeP-1VD9 fFRyPsNQS --Address. -101 -56 11 IT P-6 Telephone Permit Request A-bo rz-v., ceLLV LosE "Tp ®PEX) -C-- Al� c Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District - Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family: ❑ Two Family ❑ Multi-Family (# units) _ Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's 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 C bN-D ALL/ /VegA?n Telephone Number ys�92' 297-3 Address _-32& IS Q License # 10 2 Y7� b 2S13 Home Improvement Contractor# t 6 09 S Worker's Compensation # k ! 2,;5 4 ml 2612. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE t DATE Z�i 711P x t ' y FOR OFFICIAL USE ONLY APPLICATION# 1 i DATE ISSUED':::�c gw _ r ;MAP/PARCEL NO.,.r i ADDRESS VILLAGE OWNER t DATE OF INSPECTION: t. [�FOUNDATION"- FRAME - .t f INSULATION" t FIREPLACE t' ELECTRICAL: ROUGH FINAL K, PLUMBING: ROUGH FINAL GAS;�r; ROUGH -A- FINAL FINAL BUILDING,..2 DATE CLOSED OUT 4 ASSOCIATION PLAN NO. t f r �A 4+ r � The Commonwealth.of Massachusetts Print Form Department of Industrial Accidents Office of Investigations T Congress Street,Suite 100 Boston,MA 02114-201 7 www.mass.guv/die Workers' Compensation InsuranceAffidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/t?rganizatiorvindividual): FRONTIER ENERGY SOLUTIONS' Address:376 ROUTE 130, SUITE C City/State/Zip:SANDWICH, MA 02563 Phone#:339-832-2823 Are you'an employer?Check the appropriate box: J i ype of project(required): 1. I ain a employer with 8 4. Q 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.El I at a sole proprietor or partner- listed on the attached sheet. 7. '❑ Remodeling ship and Have no employees These sub-contras tars have. 8. ❑Demolition working for me in an ca ci employees and have workers' 8 y Pa ty. 9. (] Building addition. [Alit workers'comp. insurance comp, insurance.t ME]Electrical repairs or additions. required.] 5; [] We are a corporation and its 3.❑ 1 am a homeowner doing all work officers have exercised their l i.❑ Plumbing repairs or additions right of exemption per-iviGL myself.:[No workers comp: 12.[]Itual'repxirs insurance required.]t l c. 1.52,§l(4),and we have no ' employees. rNo workers' 13.2)Other 1 comp.insurance required:] •Any.applioant that t hectcd box#1.must also fill out the'section.below showing their woikers'compensation policy infonnation. i Hotneownetswho subtnit this affidavit indicating they fire doing all work and Jhen hire outside contravars must subma a�w affidavit ind,icaling,s such, tConttactctts ihat cheek this box rnwt attached'an additional sheet showing,the name of the sub-contractors and state whether or not those entities have employees. tf the sub-contractors have etnpiuyc",they must provide their woi*,crs'comp,policy number. I am an eigployer that is providing workers'compensation insuronee,/or my employees: Below is the policy and job site information 1 AIM MUTUAL_INSURANCE Insurance Company Marne: Policy 116 r Self-ins.Lic,#:.6t)12954012012 Expiration Date:7/25/2012 t :Iab:Site Address: City/State/Zip' Attach a.eopy of the workers'compensation policy declaration page'(showing the policy number and expiration date). Failure,tolsecure-coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of:a fine up to'$1,500,0'and/or one-year imprisontrtcnt,as well as civil penalties in the form of a S"COP 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. 1 do hereb certi under the eaIns and analties a er`u that the in ormutlUn provided above is true:and,correct a Date] Phone#::339-832-2823 , of cinl use only. Do not write in this area,to be completed by city or town ufficiaL City or;T'ownt Permit/License# Issuing Authority(circle one): ) 1,Board of ftealth 2.Buildleig department 3.City/Town Clerk 4.Electrical Inspector S.Piurilb ng Inspector 6.other Contact Person. Phone#: CERTIFICATE OF LIABILITY INSURANCE FDVrE(hT,VDDIYYy) 10Y18/2011 -THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER..THIS C&RF.IFICATE. DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE'COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSVRRR(S), AUTHORIZED REPRES 10-TIVE OR PRODUCER, AND THE, CERTIFICATE HOLDER. neORTANT:{If the certificate holder is. an ADDITIONAL INSURED, the pol-iey(ies) must be endorsed. If SUBROGATION"IS WAIVED, subject. to the terms and conditions of the policy, certain Policies may require an. end.oraeaent. A statement on this certificate do®p not confer zighta to the certificate holder in lieu of auch andozaemSent(a)f _ Rogers & Gray Insurance Agency Inc ' [NODAi iAZIE NP. e:e); [iA/c. rof; ... I'B-MAIL PO BOX 1601 1 ADORssa. South Dennis, MA 02660DQUkoEr cOspoMER.ID, ' � SH90PEO(«J AFFORUI NG COVBRAi.E NAIC�- INSORESA:A.I.M, ,Mutual Insurance Co 33758. Frontier Energy Solutions LLC LO6DRER R. 39 Siasconset Drive ;.s A C. Sagamore Beach, MA 02562 NSO ER. f r.R6UiViH.'a: COVERAGES C CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE SEEN ISSUED TO THE INSURED NAMED ABOVE BOP.THE POI.IGY PERIOD INDICATED. R—ITHSTANDING ANY REQUIREMENT, TE%d OR CONDITION OF ANY CCNTRAL%' OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE KkY BE ISSUED OR MAY ' PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNS-, EXCLUSIONS AND CONDITIONS OF SUCH.POLICIES. LIMITS SHOWN MAY HAVE BEEN.REDUCED By PAID.CLAIMS. it POLICY.NUMBER - POLICY EFF POLICY EXP L43ITS- r TYRE OF INSURmCE - t:aUmt+^�Y'}i im/mJrriYl IF.EIERAL LIABILITY ❑Y,MPWLAL u"ENEPAL IAEILI?f EACM-/ .. 0 FENtPE 5 � �Q,'LAIMB_4gAIK ❑.�ct'!.f 1 / vneMlsse is rr�). \ . MED SIR iAny ,na Pe-cwn, 9 PFRDiLtA1 G AO'r.__T r G8N6ROL Ai�tEGATB S sii L As33 '+AlE LIN1T AP[LI£ BS: - SfL'GY Pk itECT❑tfti PRODUCTS-COMPIOP ADO 6 - AUTCMOBILE LIABILITY - ✓.' COMBINED IUNrete LIMIT 1...$. - ❑�i RU55 ( mntl f BODILY'ZWURY'1pA W c) $- GALL • DODILY ZMJORY ipox awaAPnt) 5 �(. + PROPERTY,DAMAGE HILEr,Amr.�;. t ; ❑w�P.eLtA a.uw ❑ v:fti�R - enrx oo:NRszrice @ . OB31r.C.'3 LLiO O'v:itC"'t•uZiY - ; *aaNS=ATP ❑NEIRII:i1di S - 5 _ WORRERs COMPENSATION AI70 EMPLOYEES LIABILITY THE PROE'F LE4h5EJ t'AWNIE),S,i I _ ga.•&WH ACCIDENT. 6 1,000,000 !i A EXErUUVE -. . f •1 1 .Itrl E CI ) 6 012 95 40 1201 E.L. OS&E0.5E POLICY LIMIT 5 _ 1,000,000 ` 07/25/2011 07/25/2012 i P.L. alssAss- eA asvLaYsa p °1,000-.,000- gWSUUT8 DEPORIPTICS OF OFERATIONS OR LOCATIONS: ALL MEMBERS,ARE EXCLUDED FROM THE WORXERS'COMPENSATION POLICY, CERTIFICATE HOLDER _ CANCELLATION CONSERVATION SERVSCES GROUP i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1 _ D:BIRATION DATE THEREOF, NOTICE WILL BE DMIVERED IN ACCORDANCE WITH THE _ 50 WASHINGTON STREET ; POLICY PROVISIONS. I AVtNORIE6O REPRR 6ENTA4IYF. /,"�/f''j�� 67E3T$OROU69,, MA .'07:581 � �iW. • i 40 0 zta: . h- cN Ix U n 4 C1 Q (t Q ztt w z3 wo Liceusc or registration valid for inilividul use only 1 �' Wore the,exhirntiou date. if found return to � ! Office of Consumer Affairs and Business Regulatioii ' 1Q Park f'lazn-Suite 517ti i Boston,MA 02116 - r � ._��� ..alidw�thontsignatu , q F 1 \ OWNER.AU°TH®RSZATION FOR (Owner's Name) owner of the property located at 701 7 (Property Address) (Property Address) hereby authorize ( i y� (Su contractor) an authorized subcontractor for RISE Engineering; to act on my behalf to obtain a building permit and to perform work on my property. r Owner's Signature Date JA:N1 6 2G12 " TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION Mapb54 Parcel 607' C01 .Application # -,J01Q,�� ! S Health Division Date Issued I a- Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner �OAV\�� ?{' Address e -- Telephone d �51 Permit Request '- \ Q� Square feet: 1 st floor: existing proposed _ 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation -Construction Type. Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's 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: L14es ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn'P&aexistingl n size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size Other.-, {' Q Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # C a Current Use Proposed Use APPLICANT INFORMATION UILDER OR HOMEOWNER) Name V Telephone Number< ZJ& Address - e,.) License # V 4 lJ Home Improvement Contractor# 0 1- �1 . Worker's Compensation #W c_ V ALL CONSTRUCTION DEBRIS RESULTING FROM M THIS PROJECT WILL BE TAKEN TO O,Y-\ SIGNATURE DATE 2 z FOR OFFICIAL USE ONLY r 3 t, APPLICATION# a k MAP/-PARCEL_NO. t ADDRESS t VILLAGE OWNER r - DATE OFINSPECTION: f ` _.FOUNDATION" w a FRAME _INSULATION r FIREPLACE f P - ELECTRICAL: ROUGH -FINAL p - PLUMBING: ROUGH - FINAL f - GAS:-; ,--- ROUGH FINAL a ..FINAL BUILDING Yr DATE CLOSED OUT ASSOCIATION PLAN NO.� t X The Co,raParonwerlth of llsassachvsetts Department of l' dusi;p-ial Accidents . h 3j f F lee a� svestz ation 6 0 Wasaalpxeton Dre�t a �tl :i Boston, .Vf 02111 e wxvw.nnelss.n ov1dia %oY e rs5 Compensation Irlsanrance Affidavit: tii'deA s/Contr�acto rs/I�I,ect Applicant Information _ — __.� _____ Please�B��t�.��R )Lv NTame- (13usin.cssiorgarization1ndMdua.l): JM OF NEW BEDFORD CO INC .---- Address:423 COGGESHALL STREET City/State%Zip: NEW BEDFORD, MA 02746 phone#:_ . 508-992-5770 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4 4- ❑ 1 am a general contractor and 1 6 .❑ New consmiction employees full and,-or art-tune .' have hired the sub-contractors ( P ) F7. ❑ Remodeling I 2.❑ 1 am a sole proprietor or partner- listed on the ar>zcbcd sheet„t I These sub=contractors have �. ❑ Demolition ship and have no employees working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition I [No workers' comp- insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions required.1 officers have exercised their I a right of exemption per NIGL 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner do.nb all work g i myself. [No workers comp. c. 152, §1(4), and we Lave no 12.❑ Roof repairs f required.] t employees. [r.c workers'-insurance U Ctber_INSULATION camp.insui�al:ce required.] 13 'Any applicant that checks box 1 must also fill out the section below showing th.workers'compensation policy information: t Homeowners who sulnnit this affidavit indicating they are doing all work and then hire outside contractors must sulmtit a new affidavit indicating sLich IContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inf'01 nation. I am an e.neployer that is providing workers'cOrtpc;asafi0ta insurance for my e[rtploy¢¢s. below is the Policy[drlcifioo site information. Insurance Company Name: SAVERS PROPERTY & CASUALTY — Policy:#or Self ins.Lic. r: WC 0 0 0 0 6 5 5 Expiration Date: 1 0/21 /1 2 Job Site Address: �W � � _ City/State/Zip:�,y1 At-Lach a copy of the--corkers' compevsatio;.n policy declaration page(sho'�51ng the policy number and expiration date). i Failure to secure coverage as required under. Section 25A of MGL c. 1.52 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine y of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. ~I do hereb !i fy under the pa"ns nd penalties of perjury that the inform,don prOVEde€l rbove is true and correct- Si ature". _ Date: oG Phone 508-992-5770 ` Official use otaly. lino not write in this area,to be completed.by city or town official. City or Toyra: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plutn$in9Inspector 6. Other o ormation and Instructiollis Massachusetts General laws chapter 152 requires all employers to provide workers' conrpcnsation for their errrployees. Pu.rsuaut.to this statute, an employee is defined as".._every person in the service of another under any contract of hire, express or unplied,oral or written." An employer is defined as "an individual,partnership, association, corporation 6r 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 aparunents and who resides therein, or tote 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, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the-.commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of ludustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the'permidlicense number which will be used as a reference number. In addition, an applicant that must submit multiple perrnit/li.cense applications in any given year,need only submit one affidavit indicating curreut policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof t;at a valid affida� t is on file for future.permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Hav t[ A1'7 '70 7 '77A0 JMOFN-1 OP ID: PC ACL./R O DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/17/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ACT PRODUCER 508-997-3321 NAME: Humphrey,Covill 8:Coleman PHONE FAX Insurance Agency,Inc. Arc No Ext: I A/C No): 195 Kempton St. P.O.Box 1901 E-MAIL New Bedford,MA 02741 ADDRESS: Raymond A.Covill INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Savers Property&Casualty INSURED J.M.of New Bedford Co.,Inc. INSURER B:Atlantic Casualty Ins.Co 423 Coggeshall Street New Bedford,MA 02746 INSURER c:Torus Specialty INSURER D:Norfolk 8:Dedham 123965 INSURER E: 1 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 D POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MM/DD/YYYY GENERAL LIABILITY ` I EACH OCCURRENCE is 1,000,00 AGE TO RENTED B I X COMMERCIAL GENERAL LIABILITY L081000893 11/15/11 11/15/12 1 PREMISES(Ea occurrence $ 50,00 CLAIMS-MADE � OCCUR I MED EXP(Any one person) $ 5,00 f PERSONAL&ADV INJURY j$ 1,000,00 I,GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG is 2,000,000 POLICY I PRO- LOG I I $ AUTOMOBILE LIABILITY Ea ccid.nI)S GLE LIMIT $ 1,000,00 a D I ANY AUTO 91253253A 1 01/05112 01/05/13 i BODILY INJURY(Per person) is JALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED I I PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS I(Per accident) X DOC $ C �X UMBRELLA LIAB I X OCCUR J EACH OCCURRENCE $ 1,000,00 EXCESS LIAR 17 CLAIMS-MADE I 81775C110AL1 12/27/11 12/27/12 AGGREGATE $ DED 1 X I RETENTION$ $ WORKERS COMPENSATION X 1 WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVEY/N I WC0000665 •. 10/21/11 10/21/12 E.L.EACH ACCIDENT Is 1,000,00 OFFICERIMEMBER EXCLUDED? El N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insulation & Roofing Contractor CERTIFICATE HOLDER CANCELLATION MECHANI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . JM of New Bedford Co Inc ACCORDANCE WITH THE POLICY PROVISIONS. 423 Coggeshall Street New Bedford, MA 02746 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD OWNER AUTHORIZATION FOR (Owner's Name) owner of the property located at (Property Address) (Property Address) ( 1 hereby authorize ! �I (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Y Owner's _Signatu — Date e� ✓ Be Office of Consumer & ❑sinesR1 License or registration valid for mdividul use onl HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Y Registration 1.03195 Type: Office of Consumer Affairs and Business Regulation Expiration 7/6/2012 Private Corporation 10 Park Plaza-Suite 5170 JEW BEDFORD CO:INC - Boston,MA 02116 EL WELL PERRY .1 423 COGGESHALL,ST NEW BEDFORD, MA 02746 - —gam Undersecretary - Not vah -without signat__.-' 880bO1 l i,u.n.auuu . CLOZ/OZ/S :uo1jUA1dx3 UZZO VVY 'AEII�?]38 SADIHAVY 9Z .lHH3d �13M�3 00 :ol palauisaa 880bO1 S0 :asu031-1 asu001-1 aoslAaadns uol;onj;suoO --- sp.n:liurlti liar. suiiilaln+��?{ ;�uiplinf{ .{n p.Frul{. •, 77 �a.ilr.� �iiynd .In Ju.uul.mcl,'( - sll�sntlar.s.�'t� VET 'Town of Barnstable ZernQ4 _ 00 3� P�°� °�ti Expires rt�a�tt�sjrar i sue date Regulatory Services Fee * BARNSPABLE, - - - v� b 9. $ Thomas F. Geiler,Director ATfD��p ' 'Building Division Tom Perry,CBO; Building Commissioner 200 Main'Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:.508-790-6230 . EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number_ 7i L l y Property&ddress 24u, esidential Value of Work / Minimum fee of$35.00 for work under$6000.00 Owner's Name & Address L .eag,�✓- F%p r ark 9° �- Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) /1,p tile Construction Supervisor's License#(if applicable) pr orkmaec Compensation Insurance "TRESS` PERMIT Chjeck e: am a sole proprietor JUL am the Homeowner JtJ 2010 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTA►B�E Insurance Company Name 1^ Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. _ Permit Request(check box) ri -roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over. existing layers of roof) y Re-side . : #of doors. Replacement Windows/doors/sliders. U-Value (maximum..44)#of windows *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 requir SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRES a Revised 070110 ` The Comnlloirtt=eraltlt Hof Massachitsetts -- Department of Indristrial Accidents '-- Office of It ves*rgat ans a _ r— 600 Washingtort Street ,a, 7 - (mot Boston, M41 027111 t,. wrtimniass.govIdio. rt Warkei s' Compensation Insurance,Affidavit: Builders/+l on,tractoi-s/Electi-ciansfPfnnxbers Applicant Inforata.t an Please Print Le gib Name(Bs 'ness/OrgzauzationlIndiv d'ual)_ ?/ Y r Address: CityfStt-ttelzip: Plione#: Are you an employer?Check the appropriate bo T}pe of pi-oject(required).. 1.❑ I am a employer math I am a general contractor and I l 6- ❑New constniction, . employees(full and/or part-time).* have fired the sub-contractors 7.. I am a sole listed as the attached sheet 7- Remodeling - ❑ proprietor or partner- These , slip and have no employees These sub-contractors have, 8- working :for,tie in an ca aci employees and have workers' Y p t'- 9. ❑Building.addition [No workers' comp-insurance comp-insurance I required.] 5• ❑.We are a corporation and its 10.❑Electrical repairs or additions 3.❑ :I am a homeowner doing all vrork afEcers have exercised their I I..O Pl ng repair or additions Y right of exemption per 4fGL myself. [No workers'Comp. 1 Z. Roof repairs insurance regpired.)r c. 152, §1(4),and we have no employees.[No workers' 13..❑ IrI comp.insurance.required] 'Any app@ican that checks boa C ruust also fill or,t the,section below,shooting their woiken'compensation polio infor nadoL 1 Homeowners who submit this affidavit indicating they are-daiag all work and then hire outside:contractors must submit a ntm,affidavit indicating such. lContractors that check this box trust attached am additional sheet showing the name of the sub-c'dr,t=_tars and state whether at not those entities have ' employ eEs. If the sub-ontraciors have employees,they must;provide that Workers'comp.policy number. I atn art einployer that is prosvidirig ivarke—rs'.coiriperisaftvit irts trance.for tf�v et1rlrloyees. Below is the pagct•'.nerd jolt site. i�tfOYN'IaCra7L ,- - ,, .. Insurance Company.Name: . Policy#or Self-ins.Lic.9: LU 0 &W Expisxtion Date:: Job Site Address: ~City,°State/Zip: c_ 0 61 !�. Attach a copy of the w rl-ers'cam ensa tion PoH4 declaration page(showing the policynumber and expiration date . Failure to secure coverage:as required 1 penalties of a under'Section.25A of 11rfGL c. 1 SZ can lea d to the irnpt si#ion of cri,t�++�4 " .. fine up to g1,500,.00 and/or one-year in prisanmint,as well as civil penalties in the fort~of a STOP WORK ORDER:and`a fine of up to$250.DO a day against the violator. Be advised that a e-opy=of this statement maybe forwarded to the Office of Investigations of the.DIA for insurance coverage vehfi at on. - I rho hmv,4 cer uncle the pains.andi2aualiLes of perjury that the information prrrtrided above is tat and correct . Si tire: Date: 'Phone#_ O,,lcial use only,. Do not write in f L-area,to be cautpleted by city ar town official Cy.tY or T6,%vn: Permit/License# Issuing Authority(circle.one): 1..Board of Health 2.Building Department 3.Cit}IToum Clerk. 4.Electrical.Inspector• 5.Plumbing Inspector 6.Other Contact Person: Phone 6. ACORD CERTIFICATE OF LIABILITY I SURANOE. DATEj0.tM(DOIYYYYI 01/12/2010 (508)997-6061 FAX (SO8)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 439 State Rd. HOLDER.THIS CERTIFICATE DOES-NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.. P.O. 8w 79399 N. Dartmouth, 14A 02747 INSURERS AFFORDING COVERAGE NA1C# mRw All Cape Exterior Remodeling LLC INsuRERA: Arbella Mutual Ins Co 17000 640 Main Street INSURER AEIC Insurance Suite 3 INSURER C: Hyannis, MA 02601 INSURER0: UsLaam e 3WERAGES TIC PC1WIM OF ViISINWEELWED 3El13f9l1HAVE BEM MMD 3D Td�Rtit9l�E]D l 9 T�8�DL4L"Y9 t �$il AAIY REQUIREMENT TERM OR CCINDf RON DFAMY CONTRACT OR W 1MENT VM IRESPECTTOV011CH rART4FJCA-M WAY BE=UED OR MAY PERTAIN;THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH P AGGREGATE L N4TS SHOWN MY HAVE BEEN REDUCED BY PA®CLAWS.POL - AR TYPEOF�IRANCE POLICY DA �T DATE tam GENERALLIABIUTY SS0004IL933 01/14/2010 01/14/2011 EACH OCCURRENCE $. 1,000,00 X COMnAERCWL GENERAL-L7IABILITY DANIAGE TO RENTED PREMISES Ea=Mae= $ 100,000 CLAI7B5 ..i - i:OCCUR MEDIEWWy:amepemon) A PERSONA.a ADV INJURY $ . 1,00 ;00 GENERAL AGGREGATE Is z Tow,oo GFUL AGGREGATE LIMIT APPLIES PER , PRODUCTS-COMP/OP AGG S Z OOO OOO POLICYFI PRO J LOC e }AUT101100811.EL8USLITY _ { COMBINED SINGLE LIMIT $ �, f J!I%PiTBdU,a�"�i ¢frame . I BODILY INJURY $ SCHEDULED AUTOS (P-P—) HIRED AUTOS BODILY INJURY $ NON-OWNEDAUTOS ! ) PROPERTYDAMAGE $ (Per arlidea) GARAGE LIABUM AUTO ONLY-EA ACCIDENT_ $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $; . EXCESSIUMBAEL1A►Y1BLLriY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION :.WCCS00789fi012009 01114/2010 Ulf14f2011 X AWERWRLUMBM ,IMEMnx Te,aYtoss EB 191NN"Wffl I WRIPARTNER/EXEC H-- 2` oFFJCma R-EXCLUDED7 `7Menaatwy;n NR) I L T�TS�ISE-T�9VIPLO 1,000iwil u�dasba u�c f d �, MCRIPTtONDFDPERAMONSIL TMS.7VEN1CLWiIVa=-ISIMAMEDWENDORSEMENT:I SPECIAL PROVISIONS el: 508-8.15=3099- t TM - n SHOULD ANY OF THE ABOVEDESCRB PoucroseEcANCELLED BEFORE THE EXP ED RATION, DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MWL .10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NADIEDTO TW LEFT,HUT FAII:URE TO DO SO SHALL Corey $r Corey The Roofers WPOSE.NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ..1694 Falmouth Road, -Ste.115 REPRESENTATIVES Centervi 7 i e, MA 02632 AUTHORED REPRESENTATIVE [Joanne Bretton CORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserve red marks of ACORD The ACORD name and logo are registe r 'ICOREY' H,-- A R They RQofer°'s,, Rw,®,fer'' TOTAL INVESTMENT ------------ $ 109830.00 POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards, Plywood Sheathing,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus Labor at the Rate of$ 60.00 per.Hour PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. . WORK SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 30 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Please Make Checks Payable to: CHARLES CORE' CHARLES COREY Warranties the Shingles and Labor for 5 years. CERTAINTEED Warranties the shingles and labor 100% for the First 5 Years and the Shingles your 30 Years if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a CATEGORY II HURRICANE-110 MPH WIND WARRANTY CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. This Proposal May Be Withdrawn By Us If Not Accepted & Deposited Received Within Thirty Days Or Before The Next Price Increase In Materials CHARLES COREY carries Workman's Compensation lic Liability Insur ce on the above work DATE OF ACCEPTANCE: jz ACCEPTED BY: SUBMITTED BY: ELEANOR EERNANDS -HARLES GREY HOMEOWNER 00 ING CO O �� � � e/ • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR- Registration: v,13,6066 Type: Expiration: 616/2012 Individual CO Y&COREY HONIE,IMPROUEMENTS CHARLES COREY , 1694 FALMOUTH RD #1 f5 CENTERVILLE, MA 02632 �: Undersecretary Massachusetts- Department of Public Safet% Board of Building Re"ulations and St.utdartls -`J Construction Supervisor License License: CS 2881 Restricted to: 00 CHARLES E COREY 1694 FALMOUTH RD#115 a v CENTRERVILLE,MA 02632 Expiration: 2/14/2012 Commissioner. Tr#: 14793 t x 1 R r i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map p Parcel U a 4 Permit# 75)$0 Health Division Date Issued 31g)09 Conservation Division a2_G1QJ ph Application Fee Tax Collector I Permit Fee 4 Treasurer SEPTIC SYSTEM MUST I �l Planning Dept. INSTALLED IN COMPLIANCE Date Definitive Plan Approved by Planning Board WITH TITLE 5 ENMRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address / Q l 3QJ'Ybr,(1'f" _KoCi i Village Owner 0-0 h Y 1 C I e Q Y)D r Address 70 t +— lq&cl t f n a � zo3Z_. Telephone � ;>V' ' �2 "5�y 7 Permit Request ro6 1 WX 1 " ; h d Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size • rn� AaeS Grandfathered: U Yes ❑No If yes, attach supporting documentation. S " Dwelling Type: Single Family 1 Two Family ❑ Multi-Family(#units) Age of Existing Structure 4aZ Historic House: ❑Yes ❑ No On Old King's Highway: ®Yes ❑No Basement Type: &rFull ❑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 3 new Total Room Count(not including baths): existing ' (/J new First Floor Room Count Heat Type and Fuel: ❑Gas ,bil ❑ Electric ❑Other Central Air: Cl Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:Cl 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 R .. BUILDER INFORMATION Name QraLA-'21,A kt`l� t ICE wY VAgq Telephone Number 561?• 4-71— S a"(4 Address h5 7rr l'ss,_t St- License# [ a 3� 6 9 Home Improvement Contractor# 1 a.Z l03 y t,t.4J . Worker's Compensation# W G 6 1�1 n c3_1 _ ALL CONSTRUCTION DEBRIS_ RESULTING FROM THIS PROJECT WILL BE TAKEN.� Ina I SIGNATUR DATE 162P FOR OFFICIAL USE ONLY - PERMIT NO: DATE ISSUED - - �. MAP/PARCEL NO. ADDRESS VILLAGE = ' OWNER DATE OF INSPECTION: FOUNDATION 1417JOY FRAME r INSULATION 9% J ' FIREPLACE -_ ELECTRICAL: ROUGH FINAL- I PLUMBING: ROUGI FINAL J; GAS: ROUG p¢ FINAL FINAL BUILDING ra,�� � �� �®f! •���-�4..,a%!�� . _.w if Fri � I— r— ca _ g � rn DATE CLOSED OUT _N A go W R ASSOCIATION PLAN-NO. M 0 p �"^"�----.^✓fie Coo ri�iieo�yul�-ti`lC<i a�•,��i�r�ac�uc6e�Q y� Y BOARD OF BUILDING REGULATIONS :: License: CONSTRUCTION SUP ; Number: CS SUPERVISOR 046234 s Birthdate: 11/30/1959 Expires: 11/30/2004 Tr.no: 3952 + Restricted: 1 G TIMOTHY GRAY 15 TOBISSET ST MASHPEE, MA 02649 Administrator ------- .__.___._._._ ;7 ! l�'dI1Ui)!,(YrGflt2l[GLit, b`�✓'(�f(wa,-X.U.w444 gv:udoft3uiltiiu tteg;tigiiousIII&Standarkis e.�� ,'S HOME IMPROVEMENT CONTRACTOR Registration: 10?G3� Expiration: 702-004 Type: DBA ';'ItAOTIiY'CiRAI' 3l)ii_DiNG&REM, MA 02649 Adtuinisi.rate>r ^. 4 °pYHE Tp� Town of Barnstable Regulatory Services 9s MASS. ,$ Thomas F.Geiler,Director �ATFo M;� 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, aen&h&S as Owner of the subject property, hereby authorizeri QU to act on my behalf,. in all matters relative to work authorized b7 this building permit application for: (Address of Job) Signature of OwnerDate Print Name Q;FORMS:0VRghWERMISSION RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE bu' quare feet x$96/sq. foot (AV x.0031= 1 plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq. foot= x.0031= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >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 permit: square feet x$96/sq. foot= x.0031= F STAND ALONE PERMITS Open Porch x$30.00= , (number) Deck x$30.00= + (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool '$25.00 ` Relocation/Moving $150.00 (plus above if applicable) Permit Fee 77 38 projcost The Commonwealth of Massachusetts Department of Industrial Accidents _ exce OfIUY05998tlOI1S _ — 600 Washington Street Boston,Mass. 02111 = Workers' Com ensation Insurance Affidavit name: M , location- 01 tl l Ca A city b i 4 phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole rietor and have no one worku in any ca acity ///::2:2 21:% %%��/%/%/%/%%%/G/%//////%%%�%% I am an em 1 rovidin workers'g en compsation for mp employees working on this job. { : n.................. .. ..:.....:...:....,nn•n.:.::}%,}}•.?}.4.::.:::•4;;-.}:.; :..,};?::.::::::n.:.,r:;:4i%$$;}�.}:::+:n,.:.}Y.,.,,.}:r•+}•: .:;< �......... ................r..... ... ............... .t....,.n........:.........:.:r............,............ ,r•n:•::... :... ...:,............... + ..%•:;}:}c:'?i:;:;'F:E:{i+.. t.}.v.f....t.....,v.:. n.....: ...... ...........n.n..,}f.%....{.f,.,•.n........r........:A•......:,...........r........}:v.......... ..........n??•:'•;{•.........::..n::h..................r}:;;;{n•:+'4:�$$:{::.........v: v:a,.. :•::w::::••.v::•:%$.v.:v:::•v.......... ..r...........:r........... ....r.......•............. ....,....; .....n:•.•. ..}..... :.....{.v...•:::.:..........•.......v. t............ ...........+.....,...r. ....r....•::......r... ...,.•.;••.n.... ..r•.v:......n..n. 4nr::: ..... ..vv:: .. ....; .v...........:....... ..r........nn n. ...........n.. ...... r ,......... v.:Y:.rv.n.... .. •.x:::.}}Yww:::r. 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XI.I.M X ,...,...... Faitm secure e to sece coverage as required under section 25A of MGL 1s2 can lead to the imposition of cahminal penalties of a fine np to$2,500.00 and/or one years,imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against md. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is truf and correct Signature /� Date Phone#-, Print name official we only do not write in this area to be completed by city or town official city or town: petndtdicense# ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office _ ❑HealthDepartment • contactperson: phone#; ��0r• 4cviud 9l95 PJN 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 e and including the legal representatives of'a',deeeased eiriplQyer,or the receiver or in engaged i joint enterprise, g the foregoing gagn a] dual partnership, association or other legal entity, employing employees. However the owner of a of an individual A trustee P 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 bean employer, _ ',.Y F•....1. .."y,�<li•..,i :."M twr� � �. L 4 Lb: Cim .Ll..x.. h} N � n ;, � • MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license pr permit to operat a business or to construct buildings in the camnionwealth`for any applicant who has • _ , Wl, <�either the ble evidence of tom liance with the insurance eoverage required. Addifiional] , produced acce to P not P P commonwealth nor any'of.its° 61itical "subdivisions shall enter into tany coIItract for the performance of pu he work until acceptable evidence of compliance with the insurance regwregiients ptlus`bhaptr ha^va been presentead`to the contracting authority. Applicants t ,,° `�• E `° : please fill in the workers',compensation affidavit completely,by checking the b`ox that applies to your srtttation and ,.:, supplying company names,'addess and phone numbers along with a certificate of insiirande as all affidavits maybe submitted to the Department of�Industr?a1 A eats for confirms 11ion of insuranice coverage :.*,, s <'e,sure to sign an ccid I o b . y for the permit or license is . r . date the affida"vi't: The affidaWit should;be returned to the city or town that the'application,y 'F Y.� i 77 being requested,not the Department of Industrial Accidents. Should you liave any questions re ar ft the `law or if you • Policy: lease call the artment at the numberlisted below. compensation eP, , . are required to obtain a workers comp p c3'�P , �,�.�.... r.. ,.. • . ,Er .. ! ._ City or Towns Please be sure that the a$idavit°is complete and printed legibly: Th Department has,promdec�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 Peimitnicense number which will be used as a reference number. The affidavits may be retume3 t� the Department by mail or FAX unless other arrangements have been made. you in advance for you cooperation and should you have any questions. d like to thank Y P cce:of Investigations wool y _ T1�e.Offi _ w .: please dd not hesitate td,give us a call FE WA address,telephone and fax number: Department's eP The The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 . ENERGY CONSERVATION APPLICATION FORM FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION AND ADDITIONS 780 CMR APPENDIX J(EFFECTIVE 3/1/98) APPLICANT NAME: //AID z% SITE ADDRESS: APPLICANT ADDRESS: /S ro�isscr �J CITY/TOWN: �J/Jp IA� Q�-��/� USE GROUP: DATE OF APPLICATION: APPLICANT PHONE: CS 'J`hy33` -X APPLICANT SIGNATURE: COMPLIANCE PATH(check one): ❑ Prescriptive Package(Limited to 1-or 2-family wood frame buildings heated with fossil fuels only Package(A through KK from Table J5.2.(b): Heating Degree Days(HDD)from'Table J5.2.(a), (For items d. through i.,fill in all values that apply-from Table J5.2.(b): a.Gross Wall Area 33 sq.ft. f.Wall R-Value R- b.Glazing Area' f 3,f sq.ft. g.Floor R-Value R- c.Glazing%(100 x b-a) C % h.Basement Wall d.Glazing U-Value U-do3 i.Slab Perimeter n R- e. Ceiling R-Value R 30 j.Heating AFUE ❑ Component Performance"Manual Trade-OIT' (Limited to wood or metal framed buildings and Climate Zone(from Figure J6 2 2) Zone 12 Zone 13 Zone 14 Attach Trade-Off Worksheet from Appendix J,(and HVAC Trade-Off Worksheet,if applicable) ❑ MA Scheck Software - Attach Compliance Report and Inspection Checklist printouts ❑ Systems Analysis OR ❑ Renewable Energy Sources Attach Mass Registered Architect or Engineer Analysis ALTERNATIVE FOR ADDITIONS ONLY A.Gross Wall+Ceiling Area sq.ft. b.Glazing Area' ` sq.ft. c.Glazing%(100x b a) ADDITION with Glazing%(c.)up to 40%may use 780 CMR Table J1.1.2.3.1 below: MAXIMUM U-VALUE R-VALUES Fenestration Ceiling Wall Floor Basement Wall Slab Perimeter,Depth 0.39 R-37 R-13 R-19 R-10 R-10,4 ft ❑ "SUNROOM"addition(greater than 40%glazing-to-wall and ceiling gross area) Attach"Consumer Information Form"from 780 CMR Appendix B. Official's Name: Official's Signature: - Application Approved Denied Date of Approval/Denial: . .- Reason(s)for Denial: (Provide additional details as needed on back side) a : 'Glazing Area maybe either Rough opening or Unit dimensions. t>Y - BUYER: �i f7� AAA-�O`?, Z a �a Aj JK rt N ` TAT cs TO THE ( l �- � o�TI� �NNIIW►5 �d�IF� AND ITS TITLE INSURERs. MORTGAGE INSPECTION PLAN I CERTIFY THAT THE BUILDINOS 940VM DO ( ) coVORM TO SETBACK REQUIRDAENTS / NATO IN I.E. (FRONT. SIDE. ! REAR SETBACK ONLY) OF WHEN CONSMOTED. OR ARE DaVT FROki VIOLATION ENFORCEMENT ACTION UNDER I<l.ASc. 0.L- 1TLE VII. CHAPTER 46A. SEOTION 7, MES,S 0 ERWISE NOTED., 111A$SACHUSETTS . I FURTHER CERTIFY THAT THIS PROPERTY IS Xa-r LOCATED IN THE ESTABLISHED FLOOD HAZARD AREA OOMMUNITY PANEL.NO.:t 0001' $CZ I C . DATE: �• �� ` �L''j� DEED (3S� THIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUENT TO THE RECORDED BOOK DATE OF.THE LATEST DEED OF ROODRD.. z PAGE WHENEVER BUILDINGS ARE SWW LESS THAN ONE FOOT FROM THE PROPERTY LANE IT IS ADVISED THAT A MORE PRECISE SURVEY BE WADE TO VERIFY THESE MEASUREW CERT. NO. IETHISCERTIFICATION IS BASED ON THE LOCATION OF SURVEY M -MI R NOT PLAN BK. l`T C� PACE / REITIMENT A PROPERTY GURVEY. VERIFICATION OF SURVEY M SHOMM.MAY BE ACCOMPLISHED .ONLY BY AN ACCURATE; INSTRUMENT IVEWAYS ICTED PLAN f DATFD�9S ON THIS CERTIFICATION .TO BE USED FOR MORT(>Y' RP o TNL r ��., �/�►J ,Y !`3 , OFFSETS AS SHOWN ARE NO ivl USED FOR 114E ESTABLISHMENT OF P SCALP: t•'.�j� BRADFORD . 4r LNGINEERING CO. P.O. BOX 1244 JAMFS W. nn11AlAI eAC HAVERHILL MA. 011131 The Town of Barnstable Department of HebLlth Safety and Bnvironrnental.Services BuildingDivision 367 Main Street,Hyannis,MA 02601 , 8.862.4038 18•790-6230 PLAN REVIEW ►wner. a Mv/Parcel: Doi O��i rojcct Addttss: / I �(Av`�l� � Builder. Che following items were noted on reviewing: l'J t�tS� oa. of kAce--% O'ca ga l` C_Y y jQ 'sa►tios -C ik ci 1 Tom ^ v, Q 4 co awl - • 31�1ay.� 77 Qt ........ '�.q�N 6 .............. .`5 .7 1, 15J vs -ft ft, 7-. .... ... Oaw ........... YVY ...1"Vre, f-,t- RAI 7"agm j; wil 00m .......... VU j WW I............ "..it "mot -ftde:-. ........... ...... All. -.be;do b,th6 1"Clu Opimq,Gp�,tc, Jeoe.J;jj�!j Fall ME U" a W.1 at I. P. "CF Cl'k Ommml.10,11,[he otthee, ........... jy, �Mwb_ "note" ....... .... i t n!r .. ....... ........... ........ Ifi iju �t:s 7:A tv te t.; s 4.F�f ............ wSj ........... ..... "It V PK'f� �M'Me%W`Lilt, tj -f,t L r .......... i7 if. Is .......... 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