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HomeMy WebLinkAbout0020 CHAPPAQUIDDICK ROAD 020 • Y 108298 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 0 Parcel a' Application # Zo I b 0 I 1 Health Division Date Issued 3 3 v l Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board pK 3�3a�io Historic - OKH _ Preservation / Hyannis Project Street Address 20 Chappaquiddick Road Village Centerville Owner Donald Ritchie Address 20 Chappaquiddick Road Telephone 508-771-4268 Permit Request Air sealing, install 1200sq ft of R-38 to attic, insulate the back of the basement bulkhead door, install an insulated stair cover for attic access folding stair install 4 roof vents Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 2772 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 C APPLICANT INFORMATION f ~� 3�1 _ (BUILDER OR HOMEOWNER) •�. Sj s Name RISE Engineering Telephone Number 7s4-37oo ext 150 -ra Address 1341 Elmwood Avenue Cranston, RI 0291Cllcense # 100459 c rn 00 Home Improvement Contractor# —12 9 9 77 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3/5/10 Erik Nerstheimer for RISE Engineering FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: i FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL a` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 9 0 DATE CLOSED OUT ASSOCIATION PLAN NO. The Comar on wea lgh of Massaach��e�rt� Depalrtmeng of llndusgriaal Accidemrts Offic'0®f In esliga pions Bdsgon9 M4 02111 >`ww w.m ass.govldiaa 5Worke>rs9 C®nnpensat6®n Iln.sunat>inee Affidavit-. g>I)liens/C®nt>raet >i ® s/EJleetn-ne>i Ajpp icant Information P➢eoise Plr>Int Lg,>i�➢� Narrfe (Business/Organization/Individual):. RISE Engineering; A Division of Thielsch Engineering Address: 1341 Elmwood Avenue M City/Mate/Zi : Cranston, _stop P RI 02 _ ._91'0 ' Phone � — -� — #,- 401 784 3700 or 1 800m422---5�65 Are you an employer?Check the appropriate box: 1.[9 I am a employer.with 4: ElI,am a general contractor and I 'Type of proj¢ct(required): employees (full and/or part-time). have hired the sub-contractors 6. ❑New' construction 2.❑ 1 am a sole proprietor or partner listed on the attached sheet. 1 7. ❑ 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. ❑ VJe are a corporation and its rr_ required.] officers have exercised their l0.❑ Electrical repairs or additions: 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself..[]�lo workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] ' 13U Other insulation "Any applicant that checks box#1 must also fill out the section below showingtlreir vaorkers'compensation policy information. Homeowners who submit this affidavit:in,dicating they are doing all work and then hire outside contractors must submit anew 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, Y arm any employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: The Preston Agency Policy#o Self--.ins.Lic. #- WC2-M-259874-019 Expiration Date: 04/01/ 10 Job Site Addresses V 6L w aaIN City/State/zip: Attach a copy of.the workers' eo>lual sation policy declaration page(showing the policy number and expiration date). Failure.to_sectire coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up t611,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby certi "un�the *ns an �' e'nalties o' p of perjury that the inforr,nation provided above is true and correct. Signature P=a r Erik Nerstheimer for RISE Enggineering Phone#: 401--784-3700 or 1-800-422-5365 Ext. 133 Official use only. 4)o not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2. wilding Department 3. City/'Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: r rage 1 OI 1 The Official Website of the Executive Office of Public Safety and Security (EOPS) Mass.Gov Home Public Safety: Department of Public Safety Licensee Complaints License Type Construction Supervisor . License t1 10045E F, Restriction WS,IC Name Erik Nerstheimer City, State,Zip North Scituate, RI, 02857 Expiration Date 3/28/2012 Status Current No complaints found for this Licensee. Back To Search m y� ✓fie.�o�n�ncv,zG6 0��/�/laeaG c duueltb c I Board of Building Regulations and Standar 1s I License or registration valid for individiil use only i HOME IMPROVEMENT CONTRACTOR I' before the expiration date. If found return to: Registration 12097E Board of Building Regulations and Standards ! Ezprat�.o.n_;.3725/2010 , One Ashburton Place Rm 1301 Type Supplement Card fw&1(iii,,.Ma. 0210$ iIELSCH ENGINEERING s r ZIK NERSTHEIMER-s 41 ELMWOOD AUE _ •a -�; 2ANSTON,RI 02910 — Admm.isti ttor Not valid without sign. ,re ' hrtp://dn.state.rna.us/dps/llcdetalls.asp?t)ctSearchLN=CSL 100459 o/,)A nn r A RD CERTIFICATE ®F LIABILIT% INSURANCE OP ID 27 ATE tMM1DomYY) PRODUCER THIEL-1 10 15 09 The Preston Agency, Inc. THIS CERTIFICATE IS ISSUED AS A MA I I ER OF INFORMATIO 1350 Division Rd Suite 303 A . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 810 Fes.THIS CERTIFICATE DOES NOT AIIIEND,EXTEND OR East Greenwich RI 02818-0810 ALTER THE COVERAGE AFFORDED By THE POLICIES BELOW Phone: 401-886-8000 Fax:401-885-1700 INSURERS AFFORDING COVERAGE INSURED NAIC# INSURER A--. Hartford Underwritara T.S. Co Thielsch Engineering, Inc INSURER B: Hartford Casual r„e„ranoe Thielsch Group Inc. INS tr Co " 195 H1 Tech Real ty Inc. INSURER Cl: Liberty Mutual T„Q,,�,�h GroupCra Frances Avenue Y INSURER D: North American ci Cranston RI 02910 - COVERAGES INSURER E: 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,POLICIES-AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: EXCLUSIONS AND CONDITIONS OF SUCH LTR NS TYPE OF INSURANCE POLICY NUMBER DATE GENERAL LIABILITY LIMITS, A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1 000,000 02UUNTD5678 04/01/09 04/01/10 CLAIMS MADE PREMISES �aooaoe s300,000 OCCUR MED EXP(Any one person) $10,000 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENLAGGREGATE LIMIT APPLIES PER: . PRODUCTS-ODMP/OP AGG $2,000,000 POLICY X PERCOj LOC AUTOMOBILE LIABILITY 1,0)0,000 B X ANY AUTO 02UENTD4850' COMBINED SINGLE LIMIT 04/01/09 04/01/10 (Ea accident) $1,000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY' $ (Per Person) HIRED AUTOS NON-OWNEDAUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ - ANYAUTO OTHER THAN EA ACC $ - ' AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY B X OCCUR CLAIMS MADE O2XHWF6573:, EACH OCCURRENCE S 10,000 000 04/O1/09 04/O1/10 AGGREGATE $10,000,000 DEDUCTIBLE $ X RETENTION $10,000 - $ WORKERS COMPENSATION AND $ C FIMPLOYERT LIABILITY X TORY UMITS ER ANY PROPRIETORIPARTNERIEXECUfIVE WC2-Zl1-259874-019 04/01/09.OFFICER/MEMBER EXCLUDED? 04/Ol/10 EL EACH ACCIDENT $500,0O0 If yes,describe under E.L DISEASE-EA EMPLOYE $500,000 SPECIAL PROVISIONS below OTHER EL DISEASE-POLICY LIMIT $500,000 D Professional Liab DVL000025902 04/13/09 04/01/10 Prof Liab 2,000,000 A Leased/Rented E 02UUNTD5678 04/01/09 04/01/10 Equipment DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHMES I EXCLUSIONS ADDED BY ENDORSEIIFM I SPECIAL PROVISION 100 00 0 *Except 10 days for non payment of premium. Holder is included as an additional insured when requred.by a written contract with respect to the General Liability coverage., : . . CERTIFICATE HOLDER CANCELLATION TINOAKB SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSMG WSURER WaL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTK�TO 7T CE1t7fTCATE HOLDER NAMED 7D THE LEFT,BUT FAILURE TO DO SO SHALL ' NPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE NOUREp,ITS AGENTS OR SENTATMES. AUTIIOIt ACORD 25(2001/08) ©AC D CORPORATION 1 f ��J�6k! 3."n37 A� 6 7 t Also for RISE Engineering, a division of-Thi.elsch Engineering, Inc. Gaskell Associates, a division of Thielsch Engineering, Inc BAL Laboratory, a division of Thielsch Engineering, Inc. ESS Laboratory, a division of Thielsch Engineering, Inc. ALCO Engineering, a division of Thielsch Engineering, Inc.'.• Water Management Services, a division of Thielsch Engineering, 'Inc. RISE ENGINEERING Federal ID#05-0405629 RI Contractor Registration No 8186 A division of Thielseh Engineering MA Contractor Registration No 120979 CT Contractor Registration No 620120 - 1341 Elmwood Avenue,Cranston,Ik 02910 (401)784-3700 k]T( FAX(401)784-3710 CONTRACT 4. Page 1 R I /1 V �' ��' ��t I THIS CONTRACT IS ENTERED INTO BETWEEN RISE ;Z__ _ G� 1 a" • ( ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING 609 O V`] 17,3 DESCRIBED BELOW CUSTOMER PHONE ^� - -DATE Client# Donald E Ritchie (508)7714268 SERVICE STREET , BILLING STREET 20 Chappaquiddick Road 20 Chappaquiddick Rd SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP i'E,9 1201100 Centerville,MA 02632 Centerville,MA 02632 JOB DESCRIPTION RISE Engineering will provide labor and materials to seal areas of your home against wasteful,excess air leakage. This.work will°be' performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements and other unheated areas(windows are not generally addressed.) This work will be performed at the rate of$66 per man per hour,which includes materials and testing. 12 man hours.This measure is offered at a 100% incentive,beyond the$2000 incentive cap. $792.00 RISE Engineering will provide labor and materials to install a I I"layer of R-38 Class 1 Cellulose added to 1200 square feet of open attic space leaving a T walkway end-to-end. $1,440.00 RISE Engineering will provide labor and materials to insulate the back of the basement bulkhead door with 2"rigid fiberglass board and seal the door edge with weatherstripping to restrict air leakage. - $100.00 RISE Engineering will provide labor and materials to install an easily moved,rigid.foam insulating cover for the attic access folding stair. The cover has integral weatherstripp ing to restrict air leakage. $160.00 RISE Engineering will provide labor and materials to install(4)8"diameter roof vent(s)to increase low ventilation in attic areas. The vent can be supplied in(circle color)blac , ro grey. $280.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for households where total income is less than or equal to 80%ofinedian income, the Cape Light Compact offers 100%incentive toward eligible measures(not to exceed$2,000 total incentive.). $2,772.00 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***00l.Dollars $0.00 ' � I UPON FINAL rNSPECTION D APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTE 3 AYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. f DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES q, , I v . AUTHOAZED IGN TURE-RISE ENGINEERING CUS OMER ACCEPTANCE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE L�( ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE J SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK DAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE .. . : The Town of Barnstable MAM a ,�aNtsP,�BI,E. • Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner SHED REGISTRATION 20 Chappaauidd.ick Rd . Centerville Location of shed(address) Village Donald E. & Carol Ann Ritchie 771-4268 Property owner's name Telephone number 91X10 ' 170/052 Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? No Old King's Highway Historic District Commission jurisdiction? No Conservation Commission(signature required) ��- THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg r MORTGAGE INSPECTION PLAN No Other Use Intended i n MOR.AN SURVEY,INC. Namc co t"I'q 40 P.O.LOX 220 �O CI Z^P-P,4 SHREWSBURY,MA.01545 Location TEL. 842-8757 - C�n�r�.e �� e— _ FAX 842-9740 Scaler Date SF�T l6 A representative of this firm examined the premises as described in the legal description furnished,and in our Deed Book We hereby certify that this property is judgement,all visible enc-oachments and visible ease- not in the S ecial Flood Hazard Area as merits arc shown hereon.including poles,wires,and Plan Book 2 P pipelines and there arc no violations of zoning require- shown on the Hud Federal Insurance merits regarding building to property line offsets. Map# /SC Dated 5--/,—WS Do not use this plot plan to erect fences,shrubbery or ancillary structures. o�EVVA"Uf 4�� c EDWARD.J. Ar M AN No. 12426 r ;rV�PESS\ 04� do f � n � � fi �o 2419 v 7 /0 6-41 V) N \ 0 f\ > p \ Jt Df �i j i Engineering Dept. (3rd floor) Map 170 Parcel :0'4 2 Permit# a. 3(o -, House# �� Q' Date Issued D Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee-77 t Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) ��'/�-•� Planning Dept.(1st floor/School Admin. Bldg.) BIKE \ SEPTIC SY BE Definitiv �an Approved by Planning Board 19 INSTALLED NCE j*ectr WITH ' TOWN OF.BARNSTAB IRONn�ENTA �E AN® Building Permit Application TOWIN REGULATIONS { Prddress "0 C'h oz�aguiddick Road _ ' Village Centerville Owner Doanld E & Carol Ann Ritchie .' Address 20 ' Chappacruiddick Rd. . `Telephone ( rnR) 771 -a2F,R Wnrtc ( -,OR) 7qn-9252:,Permit Request ,Demolish existing, porch & build. 14.X14 family room and 12X14, -porch. First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 1 R ,000 .00 Zoning District R r Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family k! Two Family. ❑ Multi-Family(#units) Age of Existing Structure 9 6 Historic House ❑Yes :]No On Old King's Highway ❑Yes [$No Basement Type: (P Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing 9 New Half: Existing New No.of Bedrooms: Existing 3 New ,s"0/41,e Total Room Count(not including baths): Existing 6 New 1 First Floor Room Count Heat Type and Fuel: IN Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes kJ No Fireplaces: Existing 1New Existing wood/coal stove ❑Yes ®No " Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) QtAttached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes IW No If yes, site plan review# - Current Use Proposed Use Builder Information Name / Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURI�Q i DATE BUILI3aQ P I Pl �' LOWING R ASON(S) � . ,. a s FOR OFFICIAL USE ONLY -PERMIT NO. DATE ISSUED , + MAP/PARCEL NO. ! - l f ADDRESS y VILLAGE- OWNER k DATE OF-INSPECTION: FOUNDATION %2`//Z?-7 s FRAME f♦' • �. p1 " Z . v � -S. ` _ - y . i � ' ' ° � ,•. �.'i INSULATION' , FIREPLACE - ELECTRICAL;.. ROUGH ' FINAL , r t PLUMBING: Re GH ' FINAL Err Y r .tf GAS: v. R FINAL - t FINAL BUILDING DATE CLOSED OUT5 k ASSOCIATION PLAN iO t `« Engilieering-,Dept. (3rd floor) Map 170 Parcel _0_.7 2 Permit# House# 3 Date Issued O Q Board of Health(3rd floor)(8:15 -9:30/1:0n-4:30) /�'►1 - .'ae _5 i 9U Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin.,Bldg.) y�.HE Definitiv an Approved by Planning Board 19 SEPTIC SY BE INSTALLED NCE TOWN OF BARNSTAB w ]MIRONMENTA DE AND ! Building Permit Application TC WN1 I` EGULAMOINS PrL'ectr Address %0 Chanpaauiddick Road Village � Centerville . . Owner Doanld ' E .& Caroj..Ann R2Ltchie Address 20 Chapnaauiddiek Rd . `Telephone : �9QR ) 771 _496P Work ( v 08) 79n 6292 Permit Request Demolish _existing porch & build 14X14 family room and 12XI4 porch. First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 1 R .000 .00 Zoning District R r Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Q Two Family ❑ Multi-Family(#units) Age of Existing Structure 9 ti Historic House ❑Yes �]No On Old King's Highway ❑Yes (I No Basement Type: Q Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing 9 New Half: Existing New No.of Bedrooms: Existing 3 New .SW11!111_t Total Room Count(not including baths): Existing h New 1 First Floor Room Count, Heat Type and Fuel: 14 Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes P No Fireplaces: Existing INew Existing wood/coal stove ❑Yes ®No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) CIAttached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) , Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use in:a.uEa3Q:� Name Telephone Number 1-/7 2 3 .2 Address License# 22 9 `" f �'h 0 e ,�� �fC' Home Improvement Contractor#�%p �/�$' (Worker's Compensation# we it NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO n A CGNATUR ` .DATE BUILDS P I N H V N'b LOWING REASONS) • Tile Cunttr101111•calt/t uf:ltussdcltuselts "'•'ii ' -f = Deptrrtinetrt of Iirdustrial Accidetrts • 1 1• OfI1c9'V/1JVestlgatlons 600 !f a-dibig-tu,r Street Workers' Compensation Insurance ARdavit Anriiiciint inftirmatitin- Please PRINT'le!+ jp t 1, coti nn n rr I I i ri ri IcitV 3vZ jf �' l0 Center ' 1le / y�,, p�6 Y� � Q-2�� 3 "tSrr't in_all work myself. I am a sole proprietor and have no one working_ in any capacity ' [� I am an emplover providing workers' compensation for my employees working on this job. mmm:mr ntimt•: / ICn1/I S / e a.21&- hvlru I/ •t`" ��i nnc 1t• �, r` ��7 D��,�"— inctirnnce-n. ��j/L ill. �c�7 C!a.�/ � nnlic�•# f�/L° i/ c �Q©c�'%�� [i I am a sole proprietor. ;eneral contractor• or homeowner(circle otre) and have hired the contractors listed below who have the following workers compensation polices: comnariy nnme- nddre c: cin•� nhnnc+9• incnr:tncr rn. fniict•# cmm�an� nntnr• add recc- rit�•� nhnnc#• insurnnre re_ neiic�•# Attach additional sheet if necessary R r -Ji' :ar...� _- •r, v. �s.. •..:.. - _ _• ����� Failure to securr ctt�crate as required under Section:SA of i\IGL 152 can lead to the imposition of criminal penalties of aline up t SIS0U.U0 andior one i cars* imprisonment as Wrll as ciVil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. 1 understand that a car} of this statement mal be furm-nrded to the Otiice of investigations of the DIA for coverage verifreation. J do berebt•cerrift•wider the pains attd penalties of perjurr th t lie informatio rowded Pbove is true and correct. ' . n Signature Print name Phone# '•ofticiai time Uniy du not Write in this area to be completed by city or town otTcial s' city or town: permittlicense# r•ttluildint Department C3Ucensint Board [� 0 check irimmcdiate response is required (:Iseieetmen's orrrc Cticaith Department phone#• r—tOther contart Person: ' J R.t kJ f CERTIFICATE OF INSURANCE ISSUE DATE: 11-18-97 I PRODUCER ITHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS I I ING RIGHTS UPON THE CERTIFICATE HOLDER..THIS CERTIFICATE DOES NOT AMEND I I Willis-MacKinnon (EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I I Insurance Agency Inc. I i 1 175 North Main St PO Box 2347 I ------- ------- -1 I Attleboro MA 02703 1 COMPANIES AFFORDING COVERAGE I 1 (508) 222-4000 1 --- ------- --I I ICO LETTER A NATIONAL GRANGE MUTUAL I I ------------- ------------------- ICO LETTER B I I INSURED I-------------- ---------- -i 16irelli Const. _B Remodeling ICO LETTER C I I David 6irelli I------- --- — — ----I 1 32 Highview Avenue ICO LETTER D I I Mashpee MA ON49 1--___—__---___—______—__ ____ 1 t ICO LETTER E I COVERPES= I ITHIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISM TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I IINDICATED-NOTWITHSTANDING ANY REQUIREMENT-TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFI- I ICATE MAY k ISSUED OR MAY PERTAIN; THE 56RANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS;EXCLUSIONS I IAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REINED BY PAID CLAIMS. i IC01 TYPE OF INSURANCE I POLICY NUMBER IPO.ICY EFF. IPOLICY EXP. I LIMITS I ILTI I IDATE (MM/DD/YY)IDATE(MM/DD/YY)I I 1-1 I 16BERAL LIABILITY I i i IGEMERAL A66RECATE If688 ,M I IA I[XICOMMERCIAL Cam. LIABILITY 1 N%9259 1 03-25-97 1 03-25-98 (PROD-M/OPS A66REGATE If600 ,W I I I[ ]CLAIMS MADE [XIOCCURRENCEI I I IPERS 8 ADVER. INJURY If300 ,m I I I[ ]OWNER'S & CONTRACTORS PROT.1 I I TEACH OCCURRENCE If300 ,M I 1 11 ] 1 1 1 IFIRE DAMAGE (ANY ONE FIRE) ISM 080 1 1 1[ ] t 1 1 I IGD EXP (ANY ONE PERSON) 1110 ,M I i !AUTOMOBILE LIABILITY I __---------I---_—____i--- -____i--------------I—�I III I[ ]ANY AUTO I 1 I IC014BINED SINGLE LIMIT I f ,000 I I I[ I ALL OWNED AUTOS I I I I-- — --I I 1 I[ ] SCHEDULED AUTOS I I I (BODILY INJURY (PER PERSON) I f ,000 I I I[ ] HIfED AUTOS I I I I---------------I - I 1 11 ] NON-OWNED AUTOS I i I (BODILY INJURY (PER ACC.) I f ,000 I 1 11 ] GARAGE LIABILITY I I I I-- -- - !- ----1 I (PROPERTY DAMAGE I f ,000 I I (EXCESS LIABILITY I I I I EACH OCCURRENCE I AGGREGATE I I C I[ ] UMBRELLA FORM I I I I f ,000 1 f ,M I 1 11 ] OTHER THAN UMBRELLA FORM I 1 I i f I -� --_=—_=—_=_=----------------------__—---------------—___ -- --- -=i I I I I I (STATUTORY I ID I WORKERS' COMP. 1 I t I f ,000 EACH ACCIDENT I I I AND 1 I I t f ,000 DISEASE POLICY LIMIT I I I —EMPLOYERS LIAB: I I -_—_!_------- —1 f ,006 DISEASE EACH EMPLOYEE I I I OTHER I I I i I I I I I I I ! I I i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS I I I IOperations usual to carpentry I I I==-----------ter=_------------------------------------------------------- -----------_��=��i I CERTIFICATE HOLDER I CANCELLATION I I Donald Ritchie IMOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEI 1 20 Chappaguidick Road (EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MAILI I Centerville, MA 02632 1 10 DAYS WRITTEN NOTICt TO THE CERTIFICATE HOLDER NAMED TO THE I I I THE LEFT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO I I IOBLI6ATI6k OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS I I IOR REPRESENTATIVES. I i (AUTHORIZED REPRESENTATIVE _ f GIRELLI CONSTRIL CERTINS (2/94) r, 3h sy{ ;TASFQRM, • TOWN OF BARNSTABLE ' BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION ��----------------------- = Please print. DATE JOB LOCATION 00 Number Street address Section of town "HOMEOWNER"dAPd N -L7� . /�. 7� aZ 6 6 . . , Name Home phone Work phone - PRESENT MAILING ADDRESS M G9A &,40 /j7D =''•_ City town State Zip code The current exemption for "homeowners" was extended to include owner-occsniE dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re side, on which there is, or is intended to be, a one or two family dwellinc, 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 Offic on a form acceptable to the Building Official, that he/she shall be resaons_. for all such work performed under the building permit. (Section 109.1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the S Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirement_ and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL, OF BUILDING OFFICIAL ote: Three family dwellings 35 , 000 cubic feet, or larger, will be required 0 comply with State Building Code Section 127. 01 Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner 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 Home Owner engages a persons) for hire to do such work, that such Home OWnE shall act as supervisor. " Many Home Owners- who use this exemption, are 'mnaware 'ihat they are assuming the responsibilities' of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction' Supervisors, Section 2.15) . This lack of awarene often results in serious problems, particularly when� the , Home {owner hires unlicensed persons. In this'.case our Board cannot proceed 'against the inlicensed person as it would with licensed Supervisor. The Home '•Owner� act-. as supervisor is ultimately responsible. To ensure that the Home• Owner'ii'fullylaware of'-his/her responsibilities, ma: communities require, as part of the permit application, that the Home, Owner certify that he/she understands the responsibilities of a supervisor. On last page ' of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. 4 • -emu; .�.�:. . Tile Cohtntuntvcalth of.1 fassachusctts Dc partmcn1"ojludustrial.4ccidettts r� Oflicea/lnyest/gal/ons �1\ " 608 ff ashil!t��tu,t Street �:•�'� =, '� Bastun. Alirss. lI2111 ' ' Workers' Compensation Insurance Affidavit Please PRINT le '"`'"!"'-"—�'�—M-'� l P nt infrmatinn• ^i617 name: 'P k, rear T ?� Incition• ?n Centerville 771-4268' cit%- nhc,nc I am a homeowner performing all work myself. ' I am a sole proprietor and have no one working in any capacity [I I am an employer providing workers compensation for my employees working on this job. cnntn•ti name:__ address• cin nhnne f!t insurance rn —"of iry# [j I am a sole proprietor. general contractor. or homeor�ner•(circic one) and have hired the contractors listed below who have the following workers' compensation polices: cnmmim• n•ttne• - addrescr F city• nhnne tl• — incur-inrr rn nnlicv I •f..ram_ ,�-�.._ _ �..t..._.._ ..�::-. � 1� _).��� ��T..f�.w:��.. _��•.•--_ .w•rv.....i.-.-....�_ comp.in.- nitnt•• addresc rite- nhnne#• insur•ince co policy a Attach additiUnai sheet if neees_sary- ••.�+'•i - """'• '~"'"' �`�"``-""' ^' 'mow Fadure to secure cuvernac as required under Section-5A of AIGL 1S2 can lead to the imposition of criminal penaities of a lineup to S1.SOU.UU andiur unc,cars' imprisonment a.well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that n cop} of this statement mns be forwarded to the Once of Investigations of the D1A for coverare verification. 1 do hereht•cerrift•antler Me pains and penalties of pedwy that the information prorided above is true and correct Si=nature 42/i J � Oate Print name Phone>; �ofliciai use only do not write in this area to be completed by cin or town oRcial cin•or tnwn: permit/license ti rnlluilding Department C31-icensing Huard L I]check if immediate response is required C3Scicetmcn•s Omcc t '• 011caith Department �.. contact person: phone tt• r lOthcr s- Information and Instructions • Massiel;.Usetts General Laws chapter 152 section 25 requires all employers to provide workers' conipcnsaticm for :1: employees. As quoted from the "fa++''-. an empharee is deftncd as every person in the service of another under an+- contract of hire, express or implied. oral or+vrinen. An empiot•cr is defined as an individual. partnership, association. corporation or other legal entity. or any IWO or me .tile foregoing_ cn�-a�sed in a joint enterprise. and including the legal representatives of a dcccasctl employer, or the recci%,er or trustee of an individual , partnership. association or other legal entity, employing employees. Howe%er owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwcllin., house of another who employs persons to do maintenance ; construction or repair work on such dwelling_ iic or oil the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio MGL cliapter 152 section 25 also states that even• state or local licensing agency shall withhold the issuance or •,cti+•al of a license or permit to operate a business or to construct buildings in the commonwealth for am . dc::ionall��. neither the commonwealth nor any of its political subdivisions shall enter into any contract performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter been presented to the contracting authorin. Applicants Please f.11 in the %vorkers' compensation affidavit completely, by checking the box that applies to your situation and supplying_ company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial ,accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tice "javit should be returned to the city or town that the application for the permit or license is being requested. n c the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are requires co obtain a workers' compensation policy. please call the Department at the number listed below. Cite• sir Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c the a* davit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pie. be _:.. z to fill in the permit/license number which will be used as a reference number. The affidavits may be returned -he Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questio: please do not hesitate to `ive 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 fax #: (617) 727-7749 nhnnr :1. a;i 71 727-4900 ext. 406. 409 or 375 _ The Town of Barnstable K �' Department of Health Safety and Environmental Services "9. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Cr0ssen Fax: 508-790-6230 Building-Commissic. For office use only Permit no. Date AFFIDAVIT HOME mvROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements Type of Work: c�, � ��� Est.Cost S.s a v o Address of Work: � ' 1'•,-11-I— Owner's Name ��i 6 L 4 VA �� LL L9 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under 51,000. Building not owner-occupied --z7Owner puffing own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date a Registration No. OR , � t �waacss4��d+�dfdY+4641116` iva'tla s"4�1 •�Pi`!? �\�1't i c'T pp . �f _ - ✓ "Coozx�rioryuaea� 0�.,/2ZA46Q:c .. Y DEPARTNENT OF PUBLIC SAFETY j CONSTRUCT 01SUPERVISOR LICENSE 'Nu, � Expires: r �..... DAVID R;XRELLI' ,W 31.HIGHVIEW AVE NASHPEE,_ MA 01649 e�-ia•ces_q�ay^�fiF:,cc`'t 7t.?g .c,.— UMD Y jL MORTGAGE INSPECTION PLAN No Other Use Intended MORAN SURVEY,INC. Nam, l_-)C, n/i¢L �/ TG.h�/f= P.Q.f:OX Location-�O G i_1s+. - S•HREWSBURY,MA.01545 — - - - _ TEL. 842-8757 C��/7-E�e L.-I FAX 942-9740 Scale Datc SAP T l6 A representative of this firm examined the premises as described in die legal description furnished,and in our Deed Book ���y-��� judgement,all visible enc-oachments and visible case- We hereby certify that this property is ments arc shown hereon,including poles,wires,and plan Book Z Z d/-9- 7 not in the Special Flood Hazard Area as1 pipelines and there are no violations of zoning require- shown on the Hud Federal Insurance menu regarding building to property line offsets. Map# /SC Dated 2Z�p :.o not use this plot plan to erect fences,shrubbery or ancillary structures. Xpl OFF i� EDWARD.J. w MORAN .,No. 12426�� ; I \O p o F C. `� 3 ,V A 41 N U 4' G � �0 y JtDI .8G r i E { I 3 y I i 1 � �_ / � V z UN 4 CZN � I •1 4� I X FM i { t� l � i� ,I i ' I is r ; � ' � � I t . , � � \ i ?' _ i __ �. ', 1 �� \�. �' �' ,� ��� \\-- ;.: _� I i � � � �\ \\ , � ' � � f � , _� — t ; , � r . WA Is Office(1st floor) Map R d . Lot d gi Permit# KV.Conservation Office(4th floor) Date Issued o2 6 Board of Health(3rd floor)(8:30-9:30/1:00-2:00) -e,4 a1i9L� M Engineering Dept. (3rd_floor) House#1 Planning Dept.(1st floor/School Admin.Bldg.) `� SEP . � h�oUS1'BE Definitive pp ved by Planning Board 19 1NSTA IQ, MPLIANCF. TLE 5 - TOWN OYBARNSTABLE ENVIRONMENTAL �®�� ' Building Permit Application TOWN REn-e 1a_ Projec Street Addre 2(? (•'� r u; d d; e�� R o a d' Village Centerville , MA Owner n_ F _ k r _ A _ R i t-.r h; a Address 9 n Cb a i a cr u i d e i �k R d Telephone 509_771-4268 Permit Request Install skylight in kitchen Total 1 Story Area(include 1 story garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $ 1800 .00 Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family X Two Family Multi-Family Age of Existing Structure 2 5• y r s , a pn r ox Basement Type: Finished Historic House Unfinished X Old King's Highway Number of Baths 1 �_ No.of Bedrooms Total Room Count(not including baths) 6 First Floor 6 Heat Type and Fuel Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached fy Barn None Sheds r Other Builder Information Name W.F. F 1 d.r i d g e , Jr . Telephone Number r 0n t 6�fT�E} 7TTL. Address Po B o y, 772 License# n 2 41 7 S . Y a r m o r t.'n , T f A 026641 Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 17U ` G DATE_VZZk BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) y FOR OFFICIAL USE ONLY r a - • PERMIT NO. DATE ISSUED i MAP/PARCEL NO. f ADDRESS VILLAGE r f OWNER DATE OF INSPECTION: FOUNDATION FRAME ,INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING --',-,,.. ">� Z42 DATE CLOSED OUT;;;. . ..f ASSOCIATION PLAID M 1 t • -:Reg1>iticatioft' 1383� x � -. - ,.•; w�•too � - 21 COMMONWEALTH UEPARTMENT OF PUBLIC SAFETY I Fallaretoposssssacurrent OF ' ONE ASHBORTON PLACE MassachusettsStatoBollding MASSACHUSETTS BOSTON,MA 02108 k Qoda/seaoss/ornrocallon 61 ?Z7 ?Z& I, ottAts/��s�. 7 ; S I C[SJ S E CAUTION I CUIs1 TR. SUPERVISGR I' EXPIRATION DATE ��' FOR PROTECTION AGAINST Q 1 /2 4 1 9 9 b h�� EFFECTIVE DATE LIC-NO. THEFT, PUT RIGHT THUMB RESTRICTIONS /5��/ p 4 7 r' PRINT IN APPROPRIATE t4ONE" t BOX ON LICENSE. W I L L I A M 11 E L D R I D G E s BLASTING OPERATORS Po BOX 772 _t. - :..--c . :v :�r:ti?ITLi nr } �"•4� � w MUST INCLUDE.PHOTO: `'° GAGED IN THIS OCCUPATION. The Town of Barnstable NAM 1eS Department of Health Safety and Environmental Services Bwfiding Division 367 Main Street,Hyammis MA 02601 Offaw 508-790-6227 Ralph F= 508 775 3344 Et> g Canner For office use only . Permit no. Date ' AFFIDAVIT HOME nffROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERNM APPLICA71ON MGL c. I42A requires that the*r=nstruction,alterations,renovation,repair,modernization,conversion, improvement,.remotal, d=olition. or construction of an addition to any PM-aasting ow= n-cr-,M4 rf building containing at least one but not more than four dwelling units or to Muci=which are�� to such residence or building be done by registered amtraaors,with certain emotions, along with other tequiraaeats. Type of Worts: kk l i Est. Cost S 8 n n u n Address of Work. 20 Chappaquiddick Road, Centerville OR�Gt'NamC: D.E. & C.A. Ritchie Date of Permit Application: 2/01/9 6 I hereby certify that: Registration is not required for the following reason(s): Work cmduded by law Job under SI,000 Building not oww-o=upied Owner pulling own permit Notice is hereby gh-en that: OWNERS PULLING THEIR OWN PERMIT OR DEALING Wf f R UNREGISTERED CONiRACMRS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE .ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. I42A SIGNED UNDER PENALTIES OF PERJURY I hcrcby apply for a permit as the agent of the oazmr: Date Contractor name Registration No. OR The Conmionwealt/t of Afassachusettti Department of Industrial Accidents »�. 1Z - . OfBceotlovesUgatlons �`•ti __-�,� 600 Washing-ton Street Burton.Mass. 02111 ` Workers'Compensation Insurance.Affidavit -•.,-- name tAAA- locnt;on*. 7 Cit3, < VldlL'7 L/ -y alL 1 phnm# 1 am a homeowner performing all work myself. 0-1 am a sole proprietor and have no one working in any capacity 1 am an entplover providing workers' compensation for my employees wori:ing on this job. comannv name: address! cih: phone k insurance co_ policy# 1 am a sole proprietor,general contractor,or homeowner(tdfrde one)and have hired the contractors listed below who have the following workers' compensation polices: comnanx name: address: Coll: phone+t• insurnncc c_n_- pokey!! Lr17C.. ..•. .:T: — KA!:l;r-�'.•:•7!tvslLa�7y^•;�T:R{'i a1L1 - -.._.- - _ - _�.- _ _ -_- ��_—_ _____ - -'•��' '�0)1�'i'�+TM�irS 7F!.^_T!C!!P'� •'w„'>1S ctimnanv name: address: h�tOC insurance co. policy# 'Attachadditional'sheetittieeessaty�;_•:..: w.> t�wrr+,�Ir�;-�•:. .:T ,r. �A.00 • �..• .ice u.m•.as..>.. Euilure to secure coverage as required under Section 25A of XIGL 152 can lead to the imposition of criminal penalties of a fine up to s1,500A0 and/or une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of S100.00 a day against me. I understand that a Copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. t do herehr cerrifj•umler the pains and pena/tics of peduty that cite infortnadon provided above is true and correct SignatureDate /jA1,4:11 Print name-414 A Phone# official use only do not write in this area to be completed by city or town official L[3 r town: permit/license# nBuilding Department oUcensing Board k eckif immediate response is required OSeleetmen's Office�1leaith Department ct person: phone#; nOther Irevised 3,195 PJA) — �i Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers' compensation for their employees. As quoted from the"law", an empint+ee 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 ;cgal 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 tite 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 I'S2 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any ='-I'^Brant who It= not produced' acceptAbic evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. 67, •.77 .�y,� ., t ,.. w Mai.,w ram... N- ,f, °C tM." .Y+� Applicants , Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tile 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. <,�...r.. ..,..,, ,.e.r. ,..-. a..+.riw'...Si♦,J 1�t1+.�'{�'IS•S•{�r+.dY rnw,.r�Sre�,i. ,.'..i 77 a .7W • ., Cite or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the ail davit for you to ,ill out in the eveni tiie of ce ui iTivesubatiuns liaa to contact you regarding the.-pp want. Please be sure to full in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. r-�a!!TT'!-o-:r..r...�.--t..!s.:.o.• �-•;,"� .... ..�:•u. . �. --r.,s.,.�.,.ae...rc.-..eos.• The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents _v Office of Investigations 600 Washington Street " Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 Proposal William H. Eldridge, Jr. P.0- Box 772 So- Yarmouth, Ma- 02664 508-390-7412 License* 02,4172 Registration* 101383 Proposal Submitted to Phone late Carol Ann Ritchie 771-7268 10/31/95 Street Job blame 20 Chappaquidic Skylight City, State, Zip ,lob Location Centerville, Ma. Same General job description_ install skylight into kitchen ceiling. We thereby submit specifications and estimate for labor and materials--- Frame and install one Velux 04 venting skylight into kitchen ceiling. The skylight will be installed and flashed into rear roof and tubed dorm thru attic and into kitchen ceiling. The tube will be framed with 2x4studs and insulated in the attic with 6" unfaced fiberglass insulation and covered with 1/2"sheetrock taped and finished with three coats compound and painted with one coat primer and one coat white paint. The patching and painting of the ceiling around the skylight will not likely match existing ceiling color and therefore should be repainted by the owners. Excluded--- Electrical,and plumbing work Total labor cost 375-00 Total material cost 437-00 Total project cost $812-00 Payments to be made as follows: A deposit of $437-00 upon the signing of this agreement for the purchasing of materials, and the balance, $375_00, upon completion of the work. All labor and material is guaranteed as specified.All labor is guaranteed fora period of five years from leaks and customer satisfaction.A copy of the manufacturer's warranties will accompany final invoice.Any alteration or deviation from above specifications involving extra costs will be executed only upon written agreement between parties,and could become an extra charge over and above the esti mate. Ownerl'Agen t Date Contractor 7A;OofDate I ! THE T I`"'' V)• _ The Town of Barnstable a 'i 9 mum Department of Health Safety and Environmental Services BuiIding Division n 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230' BuiIding Commis: For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any preexisting owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirementL Est.Cost'S i S�: G,-)o Type of Work• Address of Work: " Owner's Name a 62 UZ9 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. BuiIding not owner-occupied wrier puffing own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MWROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER.MGL c- 142A SIGNED UNDER PENALTIES OF PERJURYet I hereby apply for a permit as the agent of the Owner. Uza Date RegistrationRegistration No.