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HomeMy WebLinkAbout0143 TROUT BROOK ROAD /�3 %rove �roo� �C . f k CAPE C® INSULATION - 11(111 SAM -SIurms INSULAIPRAYfTION iSU3 tj ND[0 - ` QJ1TTl -OUTTIQ! INSUI�TION _C(IlINO! 1-800-696-6611 Town of Barnstable ' Regulatory Services - Building Division .l 200 Main St Hyannis,.MA 02601 F Date:. -711 .. / --a Dear Building Inspector ON Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the"specifications listed on the building permit application. All work has been inspected by a certified Building Performance'.Institute (BPI) inspector. All work'preformed meets or exceeds Federal & State Requirements, Property Owner Property Address Village Insulation Installed: .Fiberglass Cellulose R-Value Restricted. Unrestricted Ceilings ( ( ) ( ) ( ) ( ) T . Slopes Floors Wallsd� ( ) ( . .) ( Ito ( ) ) y Sincerely T . 2eH -yE ssi r, President Ins atop, Inc: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #QC� 0 Health Division Date Issued (P S Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis V Project Street Address / y'dy r�G j�X"I/ Village��/ Owner ,�,�yrl�,���/� G��,S� ,v Address Telephone��,�' G�„Z/G.i Permit Request � " ✓yI 7�A� /�j� i� ///_:f, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation D Construction Type 7l,�111_1 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 A No On Old Kings:Highway:-r0 Yes No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other 1' ivy) Basement Finished Area (sq.ft.) Basement Unfinished Area (s(ft) -_ Number of Baths: Full: existing new Half: existing nEW 140 Number of Bedrooms: existing _new 4 .10 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 ��,�',e Ca ,�,.s�u�/�f 0,�1 Telephone Number Address q License # G1 mz" 7-4 Home Improvement Contractor# ��✓3��� Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY s APPLICATION# DATEISSUED ' MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION h' FRAME I ` `7 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. a V�uWet mass save. PAR111WATING 5sv�gc NOW, COUMAM PERMIT AUTHORIZATION FORM I, SAMANTHA CHRISTIAN ,owner of the property located at: (owner's Name,printed) 143 Trout Brook Rd. COTUIT (Property Street Address) (City) hereby.authorize the Mass Save Home:Energy,Services Program assigned Participating Contractor listed below to act on my behalf and obtain a build' g permit to perform insulation and/or weatherization work on my property. X Owner'sSignatu Date FOR CSG OFFICE USE ONLY b . Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: APE Participating Contractor date - For Orrice Use Onty Rev.12132011 iThe Commonwealth of Massachusetts —- -- Department of Industrial Accidents t -- Office of Investigations 5 _ = 600 Washington Street -_ Boston, MA 02111 ® www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letzibly Name (Business/Organization/Individual): -41 " Address: City/State/Zip: Phone 'Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with #. M,.: 4.` ❑ I am a general contractor and I have hired the sub-contractors 6. ❑New construction employees(full and/or,part-time) *�,`,' 2.❑ I am a sole proprietor or partner-", listed on the-attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition workingfor me in'an ca aci employees and have workers' Y-capacity.` 9. ❑ Building addition [No workers' comp.'insurance comp.insurance:$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp: right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.C,?,[Other �jto/l 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.#:(,I �.��j� 4, 91 Expiration Date: Job Site Address:/,4-� Z� y X_ d/G Xd/ eOYiJI 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. Signature: Date: /J Phone#: �l 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#: -� From:Ropers&Gr p.\t InsuraFax: To:+15087785735 Fax: +16087785735 Page 2 of 2 03/3012015 10:04 AM CAPECOD-27 BDELAWRENCE CERTIFICATE OF LIABILITY INSURANCE DAT/30/2D/Y 33012015 5 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: Rogers&Gray Insurance Agency,Inc. PHONE d6434 Rte 134 A/ Ext: AcNo: (877)816-21 South Dennis, MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURED INSURER B:SAFETY INSURANCE COMPANY 39454 Cape Cod Insulation,Inc, INSURER C:Endurance American Specialty Ins. Co. 18 Reardon Circle INSURER D:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth, MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MM/ODIYYYLICY Y LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR CBP8263063 04/01/2015 04/01/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000:000 X POLICY jECT LOC PRODUCTS-COMP/OPAGG $ 2,000,00� OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00d B ANY AUTO TBD 04/01/2015 04/01/2016 BODILY INJURY(Per person) $ ALL OVMVED X SCHEDULED BODILY INJURY Per accident AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ $ X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 2,060,OO C EXCESS LIAB CLAIMS-MADE EXC10006635000 04/01/2015 04/01/2016 AGGREGATE Aggregate DED X RETENTION$ 10,000 2,000,000,E $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ D ANY PROPRIETOR/PARTNERIEXECUTIVE WCE00431900 06/30/2014 06/30/2015 E.L.EACH ACCIDENT $ 1,000,OQO OFFICER/MEMBER EXCLUDED'? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe u11de1 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,0001 Eli DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WTH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation - 10 Park Plaza - Suite 5170 `S Boston, Massachusetts 021.16 Home Improvement Contractor Registration Registration:, 153567 Type: Private Corporation Expiration: 12/15/201:6 Tres 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card, Markreason for chin c. (�SCA 1 20M-OS/11 .Address Renewal Employment Lost Cnrd {5 � .., U/ZG' U/097L9N•CY7z[UL'CG(C�O/,V/��C(dOCGC�CI�GCYJ -. J _-. � •. �..- _ -'...- Office of Consumer Affairs& Business Regulation License or registration valid for individul use only MOME IMPROVEMENT CONTRACTOR` before the expiration (late: If found return to: egistration: 153567 Type; Office of Consumer.Affairs and Business Regulation' C� -Expiration: 1:27157201.6 Private Corporation. 1.0 Parl(Plaza-Suite 5170 . -, >' Boston,NIA 02116 CAPE COD INSULATION, INC` HENRY CASSIDY 18 REARDON,CIRCLE SO.YARMOUTH,MA 02664 Undersecretary N valid NY tit sign ' e Mas'su( hUsetts )6partment.o( public Safely Board of Bulldl" ' g Regulations anc Standards Co list I'll ction'SuperrisoI. license; cs.100988., HENRY.E CASS1n�V 8 SHED ROW '{� i'd WEST Y ARM 0U � 'Expiration `Comniiss'ioner 11/11/2015 TM�> TOWN OF BARNSTABLE 33964 � . Permit No. ......:......... BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash 670• p �ewY` HYANNIS,MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to David B. MacDonald Address Lot #27 143 Trout Brook Road, Cotuit USE GROUP FIRE GRADING OCCUPANCY LOAD 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. October 14.. ....... .. .. ........ ...... . 19 9.3.......... B ilding Inspector TOWN OF BARNSTABLE BUILDING DEPARTMENT _ �saiar TOWN OFFICE BUILDING r�ua HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: /0/-,�3 An Occupancy Permit has been issued for the building authorized by Building Permit #.......... .��. 2,94�! ................_................................................... ......................................_................ .. ......... . o ,issued t ........................................................_.._ ... ..._..... V v Please release the performance bond. P ' &0 7-3 t q0 Assessor's office(1st Floor): /y d3 K {� C`771C SYSTERn VURST Assessor's map and lot number �/. �^ �.;'A LEM IM ��'r i �o '�*f Board of Health(3rd floor): WFLIE C �,�Q #� Sewage Permit number f °"=?P'��� � �° • Z ']I.. TADLL, i Engineering Department(3rd floorj: ,' �,,� r �� �(� � �, rnsa House number 1 `'C ° 3639. \®� Definitive Plan Approved by Planning Board ' — ( '19c ypY d' APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO �� �.c�e�C';W, �zW—,E'L 4-1AIG TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 417- .@e Proposed Use Zoning District 4EA Fire District Name of Owner i ' Address ��456� s BOX4 8 0903 Name of Builder Address Name of Architect Address Number of Rooms ' Foundation Roofing. Floors !P5 Interior Heating e-;V,,qE i�oT �J� Plumbing / �r Fireplace ® } Approximate Cost �� ®� Area Diagram of Cot and Building with Dimensions FeeJs� 61- , a �/�a, oa/�/ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstab®rrd, g the ab a stru ion. Name j�j� Construction Supervisor's License ;� 7 No 33964 Permit For 1 z Story Single Family dwelling •Location Lot #2 7 , 143 Trout Brook Road-' ` ?} Cotuit { - Owner` " Robert J. Bevilacquia r F Type of Construction Frame ;r ''. Plot Lot Permit Granted Se tember' 11_,. 19 90 Date of Inspection "� 19 Date Completed 19 k ` TOWN OF BARNSTABLE, MASSACHUSETTS tS U I L U I N t FERMI -1 I A=U08•-008 2226 L A T c t (r:b e r 1 1 t ' �—.._ T 19 9 U PRMIT NO. y � APPLICANT ) �.8. a ApCaE55 ..11(�HGV�QI) I Id.', ✓ 'vOJ ISTREETI ICONTR'S LIICCEnSr- - PERMIT TO build llw � l 1 1 YiC' NUMBER OF ,1C11� � r)rTOWELI_ING UNITS ITTPE Or IMPROYEME411 ti 'Pa OPOSEC CSEI y AT (LOCATION) _LQt: #2 J i 143 ii � �13�.�.��..... 1J�1�� ZONING RF, (NO.) :S•RFF•' DISTRICT_ _-..__ 1 � BETWEEN _ AND ICRCSS STPEE'I (CROSS SYREETI SUBDIVISION T LC? BLOCK LOT SIZE BUILDING IS TO BE FT, WIDE By cT L:HG BY FT, IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GRCUD - BASEMENT 'WALLS OR FOUNDATION , (TYPE) REMARKS: — SEWage �9 0-3 3 9 Bond AREA OR VOLUME {' Sa�_� F.ST!MATc_, �n--. PERMIT (/CCU8IICiSSOO/UUAAE LEE'. —._...---"----- _ �� _ nnn_ nn �_E Q d .�+.�, OWNER , U ..(�f'(7L+.1/�/VN/��-I � � . . ADDRESS �� r '4/L C y �7,11, HNi7Lr�l�>y �] BUILDING DEPT. ':,..._FYr'O'ti+'T�'E-"DE"P"Atr'r61'E'NTU�'_cV!g��-r?--N-•r-R- --v'�-....,. --•- -'--...__ .................._. OF ANY APPLICABLE SUSD,VIS'ON RFS+R f."pti S. -•DES '.'O+ RELEASE THE APpLIC ANT FROM THE CONDITIONS MINIMUM OF THREE CALL !AocaO.,EC D:_p.;c M`cT BE RETAINED INSPECTIONS REQUIRED FOR ON JOB AND THIS WHERE APPLICABLE SEPARATE ALL CONSTRUCTION WORKI CAP..KEPT =OS+ED '._ :'Il FIL AL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR I, FOUNDATIONS OR FOOTINGS. I�''ADE• W^,EPE A CEPTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALB1ATIONS.� 2, PRIOR TO COVFRINGIgc�•.S:C� BL LDI•.,(, SHALL MEMBERSIREADY TO LAT'. . NOT BE OCCUPIED UNTIL 7, FINAL INSPECTION SFFORF. F, � UAL Itictoc_•-r:C•,i HAS BEEN MADE. OCCUPANCY. y POST THIS CARD_ SO IT IS ,VISIBLE FROM STREET BUWDIN(,INSPEC•IUk.•,PP:I;\ V." _ - - __--:-_:- E:ECTHICA,.INSPECTION APPROVA:.S� z ��.,w l �'1b - --2 zLEC 7v5,SC�l ?�Lr 3 I HI: %SP CTIjo; .PPaUV:.;< I I 'GINEE DEPARTMENT 7_Gas • �_'e «-�-- - OTHER _...._.__._._. BOARD OF HEALTH V41'a6. tiHA.LL. NUT DW;H:ELU t,'�'' ',,: RI F^�'+ . EF:CwE NUL: AND `�;,'F .'_'Qv STRUCTION !N',PEI:TIUNS INUIi:r,rEU ON THIi, ?i)': H".�APPROVED THi V�?IUI-U� ",,, «^17v S NCT i'A4TF7 'NITHIr.' SIY MDNTHS OF DATE THE' APRA"4(iED FOR BY TELEPHONE OF? V,1111h CONSTRUCTION I AERIAIT IC. :SSUED AS NOTED ABOVE. ) NOTIFICATION. { 1 _ I P 1. , .. —} t_•'f .1 1 -�i ` " # ' ii :{.y i {. .., i }. � ,, G 7�1�_ �� ? a F k.: ' P, , i �o MWofJw �r� �_� �cre�c o G f i { 29 fL- 1 i i t , -r , � I ' t i � •7OioJl -� 1. r 1 �/ •:f, i� . , la i In I /� ,ti �•.. ��K� � ;oaf A/ LaC.4 T/<T/-/,4 T T�-/� f-r�v�J�,:�r�o>>J - S.yOW/V yE,eEO.I/ CO�s'J�L YS �//Ty -5C,gLG- 7`.�/� SETB.�I CMG _ U —•�TE 1,%<; _c .�EQU/.G EivlE✓c/TS O� 7�".�/� Tc�w�t/DF •�.�..Gl�t/ .P_E,�'�,eE�t/C�-: _6TA,3 LIE / %.r Lo7 ,iv ,4it/ .AEG/STECE� L�(�c/O /�t/ST,P_U,ti/�it,/T s"G�2!/EY � • Th�� �STE.e J�/�_�� •� SU.�liLcYa r� D<<,�$-ET.S Sf��L}/.j/S//�l/L.D , � �I•�J.SS. //sEl> 7-,f5l r •1. ,. APPROVED ❑ NOTE CHANGES TOWN OF BARNSTABLE Building Inspection Department IT ) E�� 5EI �� LEFT_ ._..� �EA"P, -F--L-SVQT10111 I_ H-T IT Effil Lo r � ' t I. r ZSAZ4 - 26x1�. GN `S IZ`` � 8 N r 2S X24 2Sh24 - _ 2.Sx Zd 28x2�} 'sue• •e.,, 1 28x24 z8x%to 2bx24 00 5.0"�. 1 I • I I •0 - I fo"ItwCL WAw I� lip _121-oe ------ I Z-=o Z%s 1� 2 1rJE Roof •'.S:�IN(�LE6 -- •- - •-- ..__--__......._.._R��� / - d •;,� f FELTvs, evx / -► IUMA *bloc FA64'A- Zni3 RO.FTEfL�i f. Ile'O.G. ____ ---__'-'_•_ ""'" { r. 'z CAWy/.G. 6NiN4�E6 5' zt. 1 �fiDLS REO�L� w _._..J L4 r — iSe iL..T TAP&O— ILI . Za t iYllo4 (• Ile` O.G. .. ....___.-_. l. sIb G9K " lop Z: 2 xt✓ T.-f +ILL i• �YL� 6oLLY .� e r M L.y 1 t...�1 N �.G-1" I �' ►`-� L�. -- is oaov FItnIAnv tug or,6D..O. S-9 To _ I I I ¢i I GIRDER POLKEIS - •of � z•zx� 1 N: I. M N: VAeFSLApm AALL A / TO WOOL Ii OILM1fD. I I I I 1 —LALLV FooTINbS TYFILAL 3,SLAB k i I 34 0, F U v nl n A i .I U N P L A rI . CT r ��s: iG A�k1f�VTp�i, 1 !W SACHUSETT's TO MfMq►VyYE11'.CFi �1 MAS$.p�Zib` T✓ti EXPIRATION DATE s 1 + Q c� SrRitc� s�. •y �N �I,STfil-r��cTfoI?93 StJ .E$V�Sp.�t:•.` �'` NO9iF EFF TIVE DATE ( - UC-NO y -1J1 990 05314,E SS S..25b-92-7806 O� ,Yx G.,gNELL + , y 68�. PNOTO(6u$TBN op+oNLY, pEE: ` Imou HEIGHT: , b .. DOB: f BTU. C `KiNEO BY UCEN8E I: < <`.:•" SgNATV�6 A MY q Eli 04/25I19 3 ;='JOCUMENi y oNEAB.-0MONi TM �AWI�E7 ON iME'PEq .1 .S•.. .dl VMB 7RE'I 'kpE,H/ TNIS W EN Ccu SKiNATU +t I(% 1 P I 1 I � t � Town of Barnstable *PermitaocoAP Expire from issue dam 41PRESS PERMly Regulatory Services Fe Thomas F. Geiler,Director JUL 0 6 2006 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barristable..ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint , 0.0 3 0 0� lap/parcel Number 'ropertyAddress PY3 Ti''ovf t9r00(( 1-24— ro �u r sid 7 0119 eential Value of Work (o 5-®y Minimum fee of$25.00 for work under$6000.00 )wner's Name&Address D Mke v t.'e 2ontractor's Name �� (�I ct ca 4 ��� i/ Telephone Number Cr Yo Home-Improvement Contractor License#(if applicable) ASS q Construction Supervisor's License#(if applicable) p S-O<or 'R C1 ❑Workman's Compensation Insurance Check one: ❑ I amj sole proprietor ❑ the Homeowner I have Worker's comp/eennsationLbnsuranceo Insurance Company Name (� �"�7 �°rat- �1 S Workman's Comp.Policy# 0 c/ S g G 6 (70 Copy of Insurance Compliance Certificate must be on file. Permit Request ck box) Re-roof(stripping old shingles) All construction debris will be taken to C✓u,5 '� 'sir i'S5 ❑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. ome Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 7/5/06 10 : 10 : 44 AM 4158 0 04/04 ACORD,, DATE( fi)DNYY M CERTIFICATE OF LIABILITY INSURANCE 6/28 MY, 6/28/20062006 PRODUCER (508)540-2400 FAX (508)289-4111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Murray MacDonald Insurance Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 406 Jones Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Falmouth MA 02540 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Hartford Insurance Co. Gilfoy Construction INSURER B: 123 Davisville Road INSURERC: -INSURER D: East FAlmouth MA 02536 INSURER E COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' INSR ADO'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/OD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ CLAIMS MADE OCCUR - MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - ANY AUTO (Eaaccident) $ ALL OWNED AUTOS - BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INJURY NOWOMED AUTOS (Peraccident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: - AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ i DEDUCTIBLE $ RETENTION $ $ TH- A WORKERS COMPENSATION AND WC O EMPLOYERS'LIABILITY - TORY L LIMITIMITS ERR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? 6S60UB1323C96A05 12/24/2005 12/24/2006 E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE THE Town of Barnstable EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Building Inspector 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT 200 Main Street Hyannis, MA 02601 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Michelle Wolf/MJW ACORD 25(2001108) ©ACORD CORPORATION 1988 INS02510108).06 AMS VMP Mortgage Solutions,'Inc.(800)327-0545 Page 1 of 2 ' 5612 1� 1/«i VVllL/liVI..IV"i . Department of Industrial Accidents Office of Investigations a 600 Washington Street +- Boston,MA O2111 . www mass-gov/dia Workers' Compensation'Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/orga�ation/h&vidual): /7 C,w Address: l a 3 9C-.rirs r J r%l/e a City/State/Zip: �a� �'a���/' - Phone#: off Are ou an employer? Check the'appropriate box: Type of project(required): 1.[ I am a employer with �- 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contc'actors ' 2.El I am a sole proprietor or p arwer- listed on the attached sheet $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8: ❑ Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition o workers' wmp.insurance.* 5. El We are a corporation and its - 10.❑ Electrical repairs ox additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LED Plumbing repairs o-x additions myself.(No workers' comp. c. 152, §1(4),and we have no 12.[] Roof repairs insurance required.] t . employees. (No workers' 13.❑ Other comp.insurance required.] *Any applicant thi t checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners wbo submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such tContractors•that checktbis.box.must attached an additional sheet showing The name of the sub-contractors and their workers'comp.policy information. Jam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insinance Comp any Name: 1Y 41 Policy#or Self-ins.Lic. Expiration Date: Job Site Address: l ct 3 ft-S>v_7(__/3r-v a Ile City/State/Zip: . 74v r 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 a penalties of perjury that the information provided above is true and correct: Si afore: C' Date: 76 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): I.Board of Health 2.Building Departinezit 3.CitylTown 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 eirrployees. ` 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 alicense 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 commomvealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 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 I LC 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 at 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 contactyou regarding the applicant . Please be-sure to fill in the permit/license number which will be used as a reference member. In addition, an applicant that must submit multiple permitqicense applications in any given year,need only submit one affidavit indicating current " locations is policy information(if necessary)and under Job Site Address the applicant should write all (city or P cY 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 bum 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 Fax#617-727-7749 Revised 5-26-05 www.mass.gov/cia i .p Town of Barnstable • regulatory Services Thomas F.Geiler,Director Building Division. Tom Perry, Building Commissioner 200 Main Street, Tiywmis,MA'02601 www.town.b arnstable.ma.us 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder j, ��ut ����t p�yr► �� , as Owner of the subject property hereby authorize rl a w CL;/ to act on MY behalf, in all matters relative to work authorized bythis building permit application for, (Address of Job) Signature of Owner Date DcG_(/foe ma__ Print blame Q:FORM&OWNMERMISSIDN Board of Building Regina ions and Standards One Ashburton Place - Room 1301 " Boston. Massachusetts 02108 Home Improvement.Contractor Registration Registration: 126858 Type: DBA Expiration: 7/30/2008 SHAWN GILFOY CONSTRUCTION SHAWN GILFOY 123 DAVISVILLE RD_ FALMOUTH, MA 02536 Update Address and return card.Mark reason for change, 'PS-CAI c'; 50t,4-04105•PC8638 Address Renewal G Employment Lost Card 4-/ � Board of Building egulations One Ashburton Place, Rm 1301 Boston, Ma__1J2108-1618 License: CONSTRUCTION SUPERVISOR LICENSE, = Birthdate: 09/12/1960 Number: CS 050489 Expires:09/12/2006 i2estrictec! 1'0: 00 ik SHAWN D GILFOY 123 DAVISVILLE RD E FALMOUTH. MA 02536 Tr.no: 3771.0 Keep top for receipt and change of address notification- CAS 0 50PA-04104-G101216 •