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HomeMy WebLinkAbout0034 STUB TOE ROAD 9 � 1 i fg17YJ oFt Town of Barnstable *Permit# C IPAI �.� Building Department Txkees6nront/rsrronr issue date t sAaxsrast.e, " Brian Florence,CBO PP ,t� ,0� - Building Commissioner Ado �6. 200 Main Street,Hyannis, MA 02601 www.town.bamstable.i-na.us Office: 508-862-4038 Fax: 508-790-6230 aek -al -lL EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Pi•ess Imprint Map/parcel Number _`% i 0 � J �/ Property Address �f S�(f �0�. `\ C—"q Residential Value of Work$ 9 a l 0ft .. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A II A"J✓ `1 V-rH AI PO 6o;( / 9 72- Carr/>Tf H4 12(43)/ Contractor's Name J OJ 14 1✓ab e-Al Telephone Number C,412i,z-A ! r��c� m �t6✓e t�Re�-•,rv� Home Improvement Contractor License#(if applicable /oe,7 0 Email: 0i`.j C cA/y %n/ hme, Construction Supervisor's License#(if applicable) - 0 Vil o 114orkinan's Compensation Insurance Check one: ❑ I am a sole proprietor E�Ilhave am the Homeowner �Worker's Compensation Insurance FEB 20 20Ia Insurance Company Name 4 � I �U���� _ TOWN OF BARNS TABLE Workman's Comp. Policy# Z C. 7_7 3 2,4 Copy of Insurance Compliance Certificate must accompany each permit. Pen-nit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane npile k(not stripping. Going over existing layers of roof) E 'Re-side tU je. C&elG tfeet., icy)j1y d<-ilwy C/4t 6o ixi' ❑ Replacement Windows/doors/sliders. U-Value (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations.i.e.Historic,Conservation,etc. ***Vote: Prop y Owner must sign Property Owner Letter of Permission. A c of the Improvement Contractors License&Construction Supervisors License is re gyred. SIGNATURE: C:\Users\decolIik\AppData\Local\Microsolt\Windows\1NetCache\Coutem.Outlook\9NNOKXY WARESIDENTILONLYEX PRESS.doc 09/26/17 r ;5 Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, AL RUTMAN, OWN THE PROPERTY LOCATED AT 34 STUB TOE ROAD IN COTUIT, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODEE..j SIGNATURE OF OWNER: / VCR. OWNER'S ADDRESS: 34 Stub Toe Road, Cotuit,MA 02635 OWNER'S TELEPHONE: 508-873-8679 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: �t . t e t a, Commonwealth of Massachusetts ,mcmrnruwr(/(i F?14ac�aeM a Division of Professional Licensure Office of consumer atfatrs&•eusinessAegulation _+, Board of Building Regulations and Standards .HOME IMPROVEMENT CONTRACTOR I Cons r ' TYPE:Su pletnentGard yl�tt4` i5p�rvisor Resist on b,. Upi_,_ration 100740 06/22/2018 I CS-071402 E ires: 12/31/2019 INC. CAPITA HOME IMPROVEMEI`IT, i JOSHUA L C9HENI', al f 10132 OLDS TAGE RDA JOSHUACOHEN �~ CENTERVILLE Nl�'02632 1645 NEWTON RD. �01 COTUIT,MA 02635 Undersecretary -- ---- -' Commissioner r 'Construction Supervisor 1 Restricted to: Unrestricted-Buildings of any use group which contain ; - Registration valid for individual use:only I nr 9 Reg cubic feet 991 cubic meters)of � �. he ira#lon date. If.found returmto: less than 35 000 cu beforet exp -_ 'rs.and Business Regulation enclosed space. •,i Office of Consumer At(ai. 10 Park Plaza-Suite 5170 Boston,MA 0211:6 , I Failure to possess a current edition'of the Massachusetts ; Not vapid without signature State Building Code is cause for revocation of this,license. DPS Licensing information visit: WWW..MASS.GOV/DPS ------ - --' "`"""— — - - r t1 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): Capizzi Home Improvement, Inc. Address: 1645 Newtown Road City/State/Zip: Cotuit, MA 02635 Phone#: 508-428-4613 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 40 4. I am a general contractor and 1 6. New construction employees(full and/or part-time).* have hired the sub-contractors 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' [No workers' comp. insurance comp.insurance.$ 9. Building addition 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.V1 Other V _d iiV# 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: AMGUARD INSURANCE COMPANY/NAIC#42390 Policy#or Self-ins.Lic.#: R2WC775326 Expiration Date: 12/25/2017 Job Site Address: 3y d�y '7aZ 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 undg;the pains and penalt s ofperjury that the information provided above is true and Corr t Signature: Date: Phone#: 508-4 -9518 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#: 712/27/2017 E WUDD/YYYY) ACOR& CERTIFICATE OF LIABILITY INSURANCE '`.� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT __ g y_ Ro er5 and Gra Processin . ._.. __... .._.. _...-_...—g-- ROGERS & GRAY INSURANCE AGENCY INC P NNo,Ext): (508)398-7980 FC ,� _ ADDRESS: mailgro ersgray.com 434 ROUTE 134 — _ INSURER(SZ AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AMGUARD INSURANCE CO 42390 INSURED _INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURERC: INSURER D: 1645 NEWTOWN ROAD INSURERE: COTUIT MA 02635 INSURER'F: COVERAGES CERTIFICATE NUMBER: 225451 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 ADOLINSD 3SUBR'WVD POLICY NUMBER -- POLID YfF POLIC( WDY EYP ILTR ---- —�YI LIMBS ------ C 0 MMERCIALGENERA L LIABILITY ; I EACH OCCURRENCE S CLAIMS-MADE ;OCCUR ; _PREMISES Ea occutettce_ S _L i MED EXP(Any one person) 's - _----- - ---- I NIA ; I PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER I ;GENERAL AGGREGATE }S POLICY PRO- I JECT ,LOC ! PRODUCTS-COMP/OPAGG IS i OTHER: i y ! - - 5 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY S k i Ea accident) t ANY AUTO I BODILY INJURY(Per person) i S I i ALL OWNED SCHEDULED I AUTOS AUTOS N/A ( I BODILY INJURY(Per accident) S — --- € NON-OWNED ? ��--`"- HIRED AUTOS `,• + PROPERTY DAMAGE S AUTOS _LPer accident)__-_.________ UMBRELLALIA6 — OCCUR E EACH OCCURRENCE I S ._, EXCESSLIAB 1 t -----_--------- --I---�_...--------- i I CLAIMS-MADE r N/A i AGGREGATE i 5 DED RETENTIONS I i I S WORKERS COMPENSATION i PER OTH- I .AND EMPLOYERS'LIABILITY X STATUTE ER I ANYPROPRIETOWPARTNER/EXECUTIVE Y/--, j E.L. ACCIDENT S 1,000,000 A :OFFICERIMEMBEREXCLUDED? NIA NIA :NIA R2WC863728 s 12/25/2017 12/25/2018 I (Mandatory in NH) ( E.L.DISEASE:FA EMPLOYEE!S 1,000,000 If As,doscribe under _.._ ... .... DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT S 1,000,000 . j s N/A ' ) � I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. A CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601-0000 Daniel M.Cro I ey,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2014 ACORD CORPORATION. All fights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Permit: Town of Barnstable Regulatory Services D ate: ofWE Thomas F.Geiler,Director ` Building Division ears, r Tom perry, Building Commissioner 200 Main Street, Hyannis,MA 0260, v Ep d www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-740-5230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: � Yl u�M0,0 � _Phone: Install at:��_I 06 ae . P Village:_,_0o4u I Map/Parcel: Date:_C 1 a 1 I It Stove A. New 1.s� B. Type; adi f irculating C. Manufacturer: o12,� Lab. No. D. Model No.: koO Chimney A. New/ xistin If existing,please note date of last cleaning-tt, b2 C-6aw B. Flue Size - r) := L' Ci C. Are other appliances attached to Floe? Yn Q. D. Pre-lab Type and Yamifacturer Sim�,on NMy n B. Masonry: Line Wined Hearth A. Materials: la ,rah 8- Saab floor Construction: o A - r r+ Installer ( � Name: p Sv. �>? In & � Address: l�lo 94 rCat Unw_+ M DQ5M Phone: -s 7 Location of Installation: exis+rnq�rQxcR_ N.I.C. Registration# Construction Supervisor# J Q(g W� OR check Homeowner Installing,no cease requir APPLICANTS SIG A URE ° APPROVED B'Y: Lea Please make checks a a le to the Town of Barnstable *This constitutes`an official stove permit after inspection, photographed, and approved by the Building Inspector Q:�forms:stove Rev 103107 1 SAVEOOOI.BNV https://mail.google.com/ /scs/mail-static/ /js/1--gmail.main.en.W K Town cf Bamftble R toy Servg€es T6c"t F"caner,star $ui3diag I�llvlsf�►i 16MIMq,H�sug COMEdWa®er, o SD9462�4E� Fax.�98-79o-fi230 lr*Iq der Must cmuple#e and Sig.n This'Section if LTsiis�.A hmoib gatsize TW&knp- in Yo aoa. ybrhe , a man=miada to worm :by d&ba4 PGA gnkaeM far • ,4id�s�'asf Ja J Tyngr perbiftpose cople�e ltrovne�Licer :rer �m Fvon;the ise side. i I Af 1 1/21/2015 9:00 A P�, Prlr�t 1=orm� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Cape Cod Pond Supplies Inc/The Stove Center Address: 1220 Route 28A, PO Box 700 City/State/Zip: Cataumet, MA 02534 Phone #: 508-564-7663 Are you an employer? Check the appropriate box: Type of project(required): 1.[3 I am a employer with 6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ 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 pp� II_ insurance required.] t c. 152, §1(4),and we have no 13.[ OtherT �` �ppd �[p��. 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: AmGUARD Insurance Company Policy#or Self-ins. Lic. #: R2WC619865 Expiration Date: 01/01/2016 3 Job Site Address: A Jlyccb � (g2. Rh City/State/Zip:rckA m{\ 0 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th ' s and penalties p ry that the information provided above is true and correct. Si ature: Date: al 6 Phone#: 508-564-7663 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: a ;, as a.•.«k cry 4' 4¢aasa�d.d.�J$ 1{ i!�e of "Mfrs&i or e iR O ,_ .,- E IMPROVEMENT CONTRACTOR before the eapiratirm daft ;Ilford-ewe to: n ; egla�a�®w: 17 50 Tye; Office of Consumer Affairs and Business Regulation expiratlon: $2012016 Private Corporation 10 Park Plaza-Suite 5170 _. ;:... "?�::• Boston,MA 02116 CAPE COD POND SUPPLIES,INC. l THE STOVE CENTER ' - ROB€RT HANFLIC 1220 RTE 28A CATAUMET,MA 02a34 . Underuecremry Not valid without sig�nature Massachusetts-Department of Public Safety - Y- Board of Building Regulations and Standards Restrided To: CSSL-SF-Solid Fuel Burning Devoe Construction Supervisor Specialty' �. License: CSSL-108001 "= ROBERT MURPI 27S LAKE SNORE Marstons Mills M� tx— F t li �� � Expiration- Failure to possess a current edition of the Massachusetts commissioner V I/2017 State Building Code is cause for revocation of this license. For DPS Uwvdng Ird"matlon visit' wvwwv.Mws.Gov/DPS tir' I y3 ^ 06.01.2015 23:57:57 Guard Insurance Guard Insurance Group 2/4 A__ CERTIFICATE OF LIABILITY INSURANCE D�ro6/2015"") THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: STARKWEATHER&SHEPLEY INSURANCE CORP OF MA PHONE FAX PO Box 549 MIL E,rt): (Arc,No): MAIL Providence, RI 02901 ADDRESS: INSURER(S)AFFORDING COVERAGE NAICO INSURER A: INSURED INSURERB: AmGUARD Insurance Company 42390 CAPE COD POND SUPPLIES INC INSURER C: P.O, BOX 700 INSURER D: Cataumet, MA 02534 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP g POLICYNUMBER MMIDDP/YYY MIWDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 0 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence S 0 CLAIMS-MADE OCCUR MED EXP(Any one person) S 0 PERSONAL&ADV INJURY S 0 GENERAL AGGREGATE S 0 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP,'OP AGG S 0 POLICY PRO- LOC S AUTOMOBILE LIABILITY COMBINED BIKED SINGLE LIMIT S ANYAUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED P BODILY INJURY reraaidten AUTOS AUTOS ) S NON-OWNED PROPERTY DAMAGE S' HIREDAUTOS AUTOS (Peraccident) S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DELI I I RETENTIONS S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN X O Y LIMITS ER ANY PROPRIETORIPARTNEWEXECUTIVE E.L EACH ACCIDENT S 100,000 B OFFICERT.IEMBEREXCLUDED? ❑N NIA R2WC619865 01/0112015 01/01/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS r VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Starkweather&She le THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Shepley ACCORDANCE WITH THE POLICY PROVISIONS. 1 University Drive Westwood, MA 02090 AUTHORIZED REPRESENTATIVE i > k Z ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Town of Barnstable *Permit# 'Y Explres 6 months from issue date Regulatory Services Fee_ �� d D s ' MAO&BIX Thomas F.Geiler,Director E� �a Building Division Tom.Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us ' Oer %fir Office: 508-862-4038 Fax: tk7�0-62302 '2006 E � EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY OPARC Not Valid without Red X-Press Imprint STigeC Map/parcel Number property Address k r 2 Residential Value of Work 6 1 e4d Minimum fee of$25.00'for work under$6000.00 owner's Name&Address contractor's Name Z2 ��t Z Telephone Number Home Improvement Contractor License#(if applicable) ` v� i Construction Supervisor's License#(if applicable) [jWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ,VI have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy#-7 f�.� Copy of Insurance Compliance Certificate must be on file. A permit Request(check box) [P/Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) { ❑ Re-side ❑ Replacement.Windows. U-Value (maximum .44) *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. Ho Improvement Contractors License is required. r SIGNATURE: Q:Forms:expmtrg gevise071405 r s r The Commonwealth of Massachusetts �; Department of Industrial Accidents E Office of Investigations ti; s l 600 Washington Street Boston,MA 02111 y �Sr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): //✓l�J ��vc Address: ,�� ,�i/�1 �1J4 City/State/Zip: / Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.VI am a employer with� 4. El am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9• ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.VRoof repairs insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compecsation 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 their workers'comp.policy information. 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.#: / /�J4 � Expiration Date: Job Site Address: o��� 1�� City/State/Zip: e!� lLZ�� 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 un the pains and nal ' s of perjury that the information provided above is true and correct. S i ature: Date: . Phone#: ­7 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#: f-, t11E r 'Town of Barnstable tAitiVBTABLE, "* �+snss: 1654. , Regulatory Services , F°tea Thomas F. Geiler,Director 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 Property Owner Must Complete and Sign.This Section If Using A Builder 07 , as Owner of the subject property hereby authorize.? f�1 / K to act on my behalf, in all matters relative to work authorized by this building'permit application for: (Address of Job) Signatu e of Owner ate i Print Name_ Q:Forms:expmtrg Reyise071405 Iw. Date: 1CJ4. 006 1 1 21 W Senoers ran:v:ovoov".<e v rage z oT QR.v. CERTIFICATE ®F LIABILITY INSURANCE CSR xp DATE(Idl4DDZ06 DAVID-2 .10 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NortAwood L"shbaugh Its. AgencY HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR SOS West Main stroet ALTER THE COVERAGE AFFORDED BY THE POUCIE3 BELOW. Hyannis MA'02601 Phone:508-711-1632 Lrax:508-862-9270 INSURERS AFFORDING COVERAGE - y_ NAtC.4 INauREa 'INSURER A NOPXOLK is DSDHAX _ _ 5 INSURER a ST I?AUL TRAVELERS --I---i. -�— ald Cox, Inc. !NSURER . , Box 401 INSURER S Yarmouth HK 02664 LNSURER E COVERAGES 1 D-F POLICIES OF IV51,P.ANCF LISTED BELOW HAVE BEEN ISSUED TO THE INSJPEC w.IED ABOVE=OR THE POLK.Y PERIOD INDb;ATED NCT✓iTHSTANNNG Aril RE HEIAEWI 1'ERM JK CGNWTION OF-FV+Y'.�O "RACE C1P?)THEE?C'CvP EIJT YWH RE$PECT TC':'✓HILI -rl$ F-Ri IFICATE MAY SE iSSLED OP KAI,P£RV.W.THE.I143i.;WCE AFFORCEO B'r THE FOL IC ES C`=SCF.ISED IEREN IS SU9JECT-0 ALL-HE-ERNS,EXC-I:SIS'ya.tom CCIJCITI':,45 CF SLKf- POLIOIES AGGIPEGATE LIMITS 31-OWN MAY HAVE FJEE`•I RMLK;EJ Ev PAID CLIWS. now LlR NSR LiMI M TYPE OR k+SLNdANCH POLICY NUMBER' D%N(MMIDD:YYI DATE IiN6 llCDfYY'I CENIM LMILRY EACH OCCI PRENCE S 1000000 IGOrA64ERC`PLGENERAL_IA �.ver BILITY i �MI:ES,Eaec. rc t;M e; 50000 1 CLANS \CiE 0"i UPI �MEC=K9(.my;na Dwtunt S 5000 A ; JC ;Business owners I R0030954� 0.3/14/06 03/14/07 �Eke'Cr BAU; NJ_RY 12000000 I } 1 GENERA.ACOPE';HTE $2000000 c�'•.AOGREGA'L•L11dITA '.{ESPC^.P,' IPPODUG�'••:OMFY�iP.43:i S2000000 "POLICY pE`}7 LOC ICSL 2000000 AUT011iMLE LIA<9LM ; COW,814EO SINGLE LIMP S FA NY AI.I'0 I (Es a:cidcn:) �I ALL CL'YNED AUTOS I BJDIL"IN,IIJRV �•^--{ -. IPar persm- S I SCHF!DvLEC+AU705 HIPEG P.LRJE 9XV INXJ Y ;P3r aaidmti i NOr�AWNE^'A,0'6: I I F'POPERTY CA"A*e 1Par awdardi ! WAGE LL4B8 ITY I I Aljlrf)JLY-EA.A.CCCeNIT EA 47" S ANY A'J'0 I AU T _. AUTO ONLNL'V. qgg j a' EXCOSSA M8RILLA LIABILITY F 6'H OCCURP-ENCE OCCUR �CLAIMS MAL1E i I AG'I PI EGPT= I•� S CECUaIfI!E � RETENTOf, 8 I ~�-- WORKSRSCOMPGN9ATIONAND { IIX TCR1_LIFnII:, _ CEP _ PLOYER8'LIABILR7 I EL.EACHACCI�O1Jr __._..9100000 �_...._ S EN A14YFRWR,ETr�?�arrtTrEREYECu"I'✓E 16KUS9107C742205 07/15/06 ! 07/15/07 _ CT°CERIMEMBEP EXCUXED9 I j E.L.DISEASE•EA EAP.C;YEE 33.00000 As,describe under j E -mL D!gE.kSE•Fc}Iri LIMITS�j00000 G PL PRCvIv0NS 00101 OTHER i � ! I i p@. BR—A-fDN$)CO—WONVtVrMIC�iiltXCLUSIONSAOMDBYEf4COPSEMENTISPSCIALPR011S10NS 144 rinquiekset Rd, , Cotuit, MA CERTIFICATE HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE OEDCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER.WILL ENDEAVOR TO NWL 20 DavS WRtMN NOTICE TO THE CCRTIFICATE HOLDER NAW�D TO THE LEFT,BUT FAILURE TO DO SO 94ALL TOM 0V BAMSTABLB IMPOSE NO OSLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 367 MIN STRIK ET RerREsa+TAT1vEs, HYANNIS M 02601 HOR ACORD 25(2W1108) 0 ACORD CORPORATION 1988 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Re gistraron 100497 E4-1 xatrat 18/,.2668 t, 1 ate Privte Cor o P ration DAVID COX,INC � :.J David Cox a r w 19 LAVENDER LN W.YAR MOUTH,MAC g Deputy Administrator :; Assessors map"and lot number � ".�.!s�—.......�t',2,t�t,P..1, ............... Sewage Permit number ........................................................ kro r v 2 BAUSTa LE, .. i Housenumber .................................. .................................... e ' 9 rA Apo,i639. 0 MAI a' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Construct TYPE OF CONSTRUCTION Wood Frame TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....Lot 44 Stub Toe........Road. ,...Cot. uit. .......M.a.... ....... ....... ..... ....... .. . .. ............................................................................................ ProposedUse ................Residential...........................................................................................................I......................... j Zoning District RC ...............Fire District COtuit, Ma. ......................................................... .............................................................................. Name of Owner .Cedar Acres Realty Trust Address 24 Great Pond Dr So. Yarmouth Ma. ............... ......................!................................... .1. Nameof Builder same ...................Address................................................. .................................................................................... Name of Architect ...................NSA.......................................Address .................................................................................... ........ Number of Rooms "5 Foundation ....POurs4. Concrete .......................................................... .......................................................... Exierior ..........cedar shingle ....R'bofing asphalt shingle ............ ................................................... plywood ......................:.....:... .Interior ..........sheetrock Floors ......I........................... .......................................................I................ Heating FEi 'v— ids..................................... ..........Plumbing ........ ::.. .,/.?...kba;thy..:.......................................... r Fireplace ..:...............one........................................................Approximate Cost ....................25 ,,OOQ................................ Definitive Plan Approved by Planning Board S_ent:__21 '______19_'73, Area .......................................... Diadram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD!OF HEALTH A I hereby agree to conform to all the Rules and Regulations of the Town of Barnsta`ble,regarding the above construction. Const. Suv. Lici. 016681 Nam F �/ - ... _ _ CEDAR ACRES REALTY TRUST A=40-112 J 14-4o-11,2 No 25716 Permit for One StorX , Single FamilX Dwelling Location ,Lot„44 34.. Stub Toe Rd, Cotuit ............................................................................... Owner Cedar Acres Re .T'r a.lty.. 0 t.. Type of Construction ........Frame.................................. ................................................................................ Plot ........................:... Lot ................................ October 28, 83 Permit Granted .......... Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ....................................'............................................ I WO-6 S - z 1 ass' ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... �0 - 11 bilc A essor's map and lot number ............... �- ` 'y� y�yy�� 9R :. i / ��F THE Tp1` 3� �° Q Sewage Permit number ........ d� o� ................... .... ..... BARNSTADLE, i House number ................................. ... tMAea .........I............. p S R:p 0. ➢/11�A�'� »j' 0-MAI Or• 'RNSTI ETA'L IE TOWN OF BA BUILDING . INSPECTOR APPLICATION .FOR PERMIT TO Con.s.tr�act ..:...........................tr)................................................................................:......... TYPE OF CONSTRUCTION ......... Wood„Frame................................................................................ J.•�. ..... ........ ...............19.... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .,. Lot 44 Stub Toe Road, Cotuit, Ila. ........................................................................................................................................................................ Proposed Use Residential ........................................................................................................................ Zoning District RC ...............................................Fire District Cotuit Ma Name of Owner ,Cedar Acres Realty Trust Address 24 Grea.t Pond Dr. , So. Yarmouth, Ma. ........................... ..... ....................................................................... Nameof Builder Same ................Address.................................................... .................................................................................... Nameof Architect N/p' ....Address.................. ...................................... .................................................................................... Number of Rooms .5................................................Foundation ...poured concrete ............... ................................................................ Exterior ..........cedar...shingle........................................Roofing ..........asphalt...shingle................................... Floors Ply,wood.............................. .Interior .........sheetrock ................. ................... ............................................................... g Plumbing ........A...7.�k...J?s J;1115............................................. Heating FF3���7- r.-aS .................. Fireplace ...................QAQ........................................................Approximate Cost ....................25.r.OQQ.................................. Definitive Plan Approved by Planning Board ________19---7.3 . Area ...... `.. ....�.................. Diagram of Lot and Building with Dimensions Fee / SLJAJECT TO APPROVAL OF BOARD OF HEALTH 1��11 N - I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Const. Suv. Lic. 016681 � 0100, Name. ! - . ................. ......... ............. CIEDAR ACRES REALTY TRUST No Permit for .Build..One On.e...S.tory. .... .. .... ..... .. .. ..... Family Dwellin ............................. Dwe.11ing................ g................. Location ...Lot„43.4...S.tub...Toe. ...Road .. .. .. ....... .. ..... ..... ..... Cotuit ............................................................................... Owner ......Cedar Acres Realty Trust .............................................Realty, Type of Construction ..T-KAMQ............................ ................................................................................ Plot ......................... Lot ................................ Permit Granted ....October...2.8...........19 83 ............. .. Date of Inspection .. ...........................119 Date Completed ......... .... . .........19 PERMIT REFUSED 11................................................................ 19 ........................................................................... . ............................................................................... ....................*...... ................. ............................................................................... Approved ............................................... 19 ............................................................................... TOWN OF BARNSTABLE Permit No. Building Inspector VA"ITAU Cash --- ---- ---------- ----- - OCCUPANCY PERMIT Bond ------------ ---- ------ ls^,:-d to edar Acres R-a-LLy L;.U-' L Addre.-s Int #44 34 Stub Toe Road- lCwuir Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department � yi Inspection date Board of Health 9i': Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ....................................................... 19............ ....... ................. ............................................... Building Inspector FROM Taws OF BARNSTABL E � a Mr. Francis Lahteine BUILDING DEPARTMENT Town Clerk 367 MAIN STREET H'YANNIS, MA -02M Phone: 776-1120 SUBJECT: FOLD HERE • • T - DATE _ - -January 11, 1985 - M E S S A G E Work has been completed under Building Permit ##25716 (Cedar Acres Realty Trust) . Please release Bond.' Y. DATE REPLY t - - SIGNED - - rieT•Rml RECIPIENT:RETAIN,WHlTE COPY,RETURN PINK COPY ,PRINTED IN U.S.A.. SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH,CARBON INTACT. • .. ����.. 1 /� /�r Imo/ W � [j+'�. 1 1. . '• Y cl O A � t y 1 t. tZA All PLAN SHOWING LOCATION HOWL O. FOUNDATION pp��rss►a Q GMUy COTUI T, MASSACHUSE TTS sD OWNE O BY. :a4t .G1 .S Fy ��-t` T ZZ�zoo w SCALE : DATE: z�,°, wQ a `• d.J to W IYORM A'M AN GROSSN-----— REGISTERED LAND SURVEYOR OW a 1 HEREBY CERTIFY THAT THIS I=OUNDATION IS LOCATED OF lAggS =a W w a ON THE LOT AS SHOWN AND CONFORMS TO THE TOWN q�yG F.i z c`Z�i OF SARNSTABLE ZONING0 REGULATIONS REGARDING o con W .�0 N � Q � Ir • �i, SETBACKS FROM STREET LINES AND LOT LINES MORUM GROSSMAN R.L.S. DATE