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n of Barnstable *Permit#
Regulatory Services Expires 6 months front issue date
a�ABM : MIT
MASS039 Thomas F.Geiler,Director X.
Building Division APR 17 2013
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us TOWN OF BARNSTABLE
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Map/parcel Number Q�1
Not Valid without Red X-Press Imprint
t�� �—
Property Address '? k C v n h frl
w —
[�Residential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address �,PF
2 S- Cv ' nrf �� �Pn��u'i/ ✓�+/� (J 26� Z
Contractor's Name ly k-ec Telephone Number So 7�U-2 7 d
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) S _0
EgWorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy# o ZZ,t-1 /V 7 — Z—/U
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
[ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken t0—ye LMu
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
requir d.
SIGNATURE:
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZU13N\EXPRESS.doc
Revised 053012
1
The Commonweakh of Massachusetts
Depaphnent ofInduoi d Accidents
Office oflnvestigadons
600 Washington SVroet
Boston,MA 02111 '
wnw.ntas&govIdia
Workers Compensation Insurance Affidavit:Builders/Contractors/Electriciau&4%mbers'
Applicant Information Please Pant Leeibly
Name MudowdOrgsniatimlidividualj: i Lei v,C
Address: S It Lowt'r A.�Wb if e
City/StaWzW: -Cnaw Ullky Phone#. . Svc- 7 1�0
Are you an employer?Check the appropriate box:
1. I am a employer with l .4. Q I am a general contractor and I Type of project(required)•
employees(fall and/or part t me)•# have hired the srb�hactors 6 ❑Newcamstntckian
2.❑ 1 am a sole proprietor or part listed on the attached sheet. 7. Q'Remodeling
slip and have no employees These sob-contractors have, g- Q Demolition
working for me in any capacity- employees and have wars'
[No workers'comp-insurance. comp.iasurance,2 97 ❑Building addition:
repaired.] 5. ❑ We are a corporation and its 10:Q Electrical repairs or additions.
3.❑ I am a homeowner doing aft work officers have eseraised 11.Q Plumbing repairs or,additions
myself[No workers'camp. right of exemption per MGL 12-❑Roof npaics
insurance repaired.]t c. 152,§1(41 and we have no
employees-[Np wo&ers' 13.Q Other
comp-insurance required]"
'Any apph�that checks box#1 most also fill out te.h section below showing their wotkew compewarionpolity infQrm�ti�y
1 Homeowners who submit this affidavit indicating they an doing all trait cad then hk+e outride c=UKr rs mast sub=a new affedavit iatdic tCoat W'm that check this boa mast gMtdmd as additional sbm dhowins the name of&e sub-commcmrs and stare wbr&w or riot those entities
bm
employem If the sub-connectors ham emplWee.%ttW must provide their workers'
comp..policy number.
I ant an employer Matispmift nwrken'comperesatdon rnsnra►rce for my employees BeIory is the li artd' b sft
informa on Po cY Jd
Insurance Company Name: C41A
Policy#or elf-ins-lit- A/3 Expiration Date:/y
Job Site Address: City/State/Z.ip_ �Pr{8 varr'fN VGA 026.?Z
Attach a dopy of the workers'compensation policy declaration page(showing the policy numbei and eq&ation date). .
Failure to secure coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of a.
fine up to$1,500.00 and/or one-year imprisomnent,as,well as civil penalties in-es %e form of s STOP
of to$250.00 a day a WORK ORDER and a fine
up y against the violator. Be,advised that a copy of this statement may be 8arwarded to the Office of
Investigations of the DIA.ior iosuuance coverage verification-
I do hereby csrhfy und9thepam and penalties ofperynry that the information provided above is true and correct
SimDate
2-id
QQ'rcial ase only. Do not state in this area; be completed by city or totrrr officiaL
City or,Town: Permit/License#
Issuing Authority(cirde one):
1..13oard of Hearth 2.13w'lding Department I City/rown Clerk ,4.Electrical Inepeetor 5.Plrtmbing Inspector
6.Qther
i ContactPerson' quite
r
A,
CERTIFICATE OF LIABILITY INSURANCE DATE IMM;DD(YYYY)
F
310 /2013
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 pollcy(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
NAME:
Schlegel & Schlegel Insurance Brokers Inc PHONE
(A/C,No,Eat): _�fA/C,No):
34 MAIN STREET E-MAI -" --
AOORESS:
PROD C '-- -
CUSTOMER lO p:
West Yarmouth, MA 02673 _ � INSURER(S)AFFORDING COVERAGE � NAICA
INSURED —
Timothy Beating Dba Keating Construction INSURER A COLONY INSURANCE
INSURER B CNA
54 Lower Brook Rd — --- _
INSURER C:
INSURERD:
South Yarmouth, MA 02664 INSURERS:
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.
NS-k
LTR 1 TYPE OF INSURANCE INSR t NIVD' POLICY NUMBER —� NOTIC EF POL C P "1--- —
(MWDO/YYYYI fm.,DfrYYY) LIMITS
A f,GENERAL LIABILITY l I EACH OCCURRENCE g 1,OOQ,QQO
(X I GL3594908 03/10/2012103J10/2013
$ !COMMERCIAL GENERAL LIABILITY
I r_1 03/10/201-' 03/10/2014 PREMISES(E ece) - $100,000
CLAIMS-MADE 1% �OCCUR ) �—
i- =� {_ i MED EXP(Any one oe!son) l s5,000
r•-'-- -- -- i PERSONAL&ADV INJURY (g 1,OOO,000
GENERAL AGGREGATE E 2,OOO,000
GEWL AGGREGATE LIMIT APPLIES PER -
-- 1 PRODUCTS-COMPIOP AGO 1s2,000,000
' POLICY F JE� LOC
AUTOMOBILE LIABILITY I
- l COMBINED SINGLE LIMIT I g
i ANY AUTO ! I (Ea accident)
L- IIII 1 BODILY INJURY(Per person) g _
I ALL OWNED AUTOS I
C BODILY INJURY'Per accident) I g
SCHEDULED AUTOS I I _
i RED q.UTCiS IIII + PROPERTY DAMAGE •
HI (Per accident) E
• r i NON OWNED AUTOS
I ( I
I !UMBRELLA LIAR i
�g
OCCUR
t— .j EACHOCCURRENCE 5
i EXCESS LIAR -
) --
I AGGREGATE c
I I DEDUCTIBLE "—
II
RETENTION
I KERS COMPENSATION BAWND EMPLOYERS'LIABILITY {j 0224N37-2-10 103/09/2012 03/09/20131_X
C STA U O H-
Y f N TORY LIMITS 1 _ ER _
ANY PROPRIETORIPARTNERIEXECUTIVE ( �03/09/2013103/09/2014 E.L.FJaCH ACCIDENT _ E ZOO,OOO
I OF'FICER;MEMBER EXCLUDED? Y N I A
I(Mandatory in NH) i --
yes D eunder E.L.DISEASE-EA.EMPLOYEE 'E 100,000
) I �_
i DESCRIPTIOPTION _OF OPERATIONS o0low - j. I ( f E.L.DISEASE-POLICY LIMIT E 5OO,OOO `
I ; I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if mare space is required)
TIMOTHY KEATING HAS ELECTED NOT TO BE COVERED ON HIS WORKERS COMPENSATION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE NTH THE POLICY PRO ONS.
r
AUTR64qEO REPRESENTATIVE.
C419 - 09 ACORD CORPORATION. All rights reserved.
ACORD 25(1009109) The ACORD name and logo are registered marks of ACORD
'9 o arras a e
16 gq. 'Town Regulatory, Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
wilding Coiniiiissioner
200'1VIa iStreet; Hyannis,iV k0260I
rvw:torvn larns ma.us
Office: 508-862-4038 Fax: 508-790-6230 ,,, .t Vi
N
'Property OwrierIust
Complete and'Sign'Tlu- t.mac"
s Se"ction
If Usina,,A Builder";
I= �� • �� ;,as:Owner of;�rhl✓subjectproper:�� -
hereby authorize to act on my behalf,
"in ail-natters relative to work aiitli sized by'ti3is Build ng-pertrut apt,ica�fioti for.
(Ad&ess ofjob)
Signature of Owner ate
RL �G_ L G, � �� 0)
Print Name
=if*4$Pert:yawner-is4pplongd'or�pe 4nit3,please-c�mPiete�he-Rumeowntr,s�LiLense�ExvmptionTvrm Q»-the
reverse side.
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outiook\DDV87AAZ\EXPRESS.doe
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finer Affairs&Business gula
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9 stratio�bVE, T CONTRACTOR n.
143053
xpiration F 6/1- -2D!4 TYPe:
KEATING CONST.
� = -- DB
1 Yn 'i
TIMOTHY KEATING T�
54 LOWER B f. J
ROOK RD
SO. YARMOUTH, MA 02664==- � -- _ !J
Under.,ecret ry 3
11% .Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty- '-
License: CSSL-099351 . .
TIM B.KEATING
54 Loeser Brook IYd.
South Yarmouth N11A 02
Expiration
i Commissioner 05/11/2014
Town of Barnstable- *Permit#
ZV 6 1a frma hm date
IT Regulatory Services
Thomas Ir.Goner,Director
MAY. 16 2007 Building Division dw
®�� ®F SAi�(VSTf��I. Tom Perry,CBO, DAding Commissioner
200 Maim Street:Hyannis,MA 02601
www.town.bamstablemmiis
Office: 508-862-4038 Fax:508 79tf-623fl
MPRESS PERMIT APPLICATION — RESIDENTIAL ONLY
Not Vaud withowRcdx--Press Imprhd
Properly Address l lS d C)Z[Q 3
Rwwaniiai Vahu of Work I ,4q 0 Q
minimum fog of 525.80 for work Hader$6000.00
owna 's Na=&Address sM?,
Conttactar's Idame��� �vlX�Z �..._Teleph=N;urabvr_�j
Home improvermnt Contractor License#(if applicable) 121 7l3
's License# if Hcable 6,Flo 0
Conshu�aa S�vasoat.._ __-•-•-- -•(_SFp )
[:]Woskmaa's C0mpe0satiM1nswceuce
one:
I am a sole proprietor
I GM&C HM=Wner-
[] I Dave Wodmes C``--, (� II !on I ce
Insurance Ca oVny Name I if�l i� ,� c�� �1V/! �►v\�1-�c1[Q,'
# C7 2 O 2-0 Z i cA,L-a'(l i�-�d.T„�kS
Copy of Insurance Compliance Certlficate must be on file.
permit Request(cluck box) _
�f(�PPmB old ) AU constro oa debns ivM be taken to Il f�i �u yl�t-�M1l
D _
[]Re-roof(not stripping. Going aver existing layers of roof)
a
R,q& nt Windows. U-value (maxim•44)
- �Whaera{aisea: df szis permicaoea Hat exempt���o8�er fawn atragolations,i.e.tic,Conservation,etc. -
***Note: Property Owner Una sign Property Owner Letter of Permission.
Home IMMOVet Contracbars License is required.
SIGNATURE:
Q:Farmxncpa�rg ..
Revise071405
SD
DepartmeW ofbMWs6WACcidents
Office.of Investigations• -- . .
600 Washington S"
Boston,MA 02111
. -- wrvrw.massgov/din -
Workers's Compensation Insurance Affidavit:Binders/ContractorsMectricians/Pldmbers
Am#cant Information please Print Leti?%I .
Name . O N�V(11Z
Address:
C*/State&ip: o S -l� one#: � � 1� �Y .
Are you an employer?Gfiiecktheapproprlate box:
. Type of project(re9uired)- .
1.Q 1 am a emphryea with 4. ❑ I am a general contractor and I 6. ❑Now contrwcaon
employees(fntf and/or part-*w).* have hired flu sub-couitactors
2. I am a sole proprietor or partner listed an flee attached sleek t 7. 0
Remodeling
ship and have no employees' These sab-contractors have 8. 0 DemolWoar
workers' imp-insurance.
working for mein any capacity. 9. ❑Bai'lding additiOII
[No workeW comp.insurance S. ❑ We area corporation and its
required.] officers have eiercised their ' i0.❑Biectricai repass or.additions
3.❑ I am a honeawaet doft all work right of eaemipfi auger MGL n.0 8**s Cw additions
Msez-[No + gip, _ c. 152,§1(4),and we haw nu 12.[]Roof
=requi t&]t cov •[No workers'- 13. Other
camp.iasMca r4lired l
•Any appficant8mt dltft box#i moat also fin catm aac tion below ahowmg**wa&eze ea on policyiai3o=idow
Hommwners�vho 3, m *s affidavit indicating Stay we doing all work and•t mbiw o de canmract q moot submit&new alH&*in+dicati ng such. - .
tCo &at checkft bob mom attached an additional cheat sWwing to—dffe andibeir wad'camp.policy Wormmdon.
am / .
tnformatioi;. LleT-n nnce any Name: /. .:.
Policy# Self' Lic #: 0 7_C� Eapna&n Date:
Job Site Addrass: a � [J2 Gy�TIX� City13 � 2 1/'�//~I_(� #Zv 31
Attach a copy of the workers'compensation policy declaration page(showing the policy number and VTkation date).
Faihae to secure coverage as required under Section.25A gfMGL c. 152 can lead to the imposition of crinaimalpenalties of a
fine up to$.1,50q,M and/or one-year inaprisamantnl;as welt as•civa penalties is$te form of a STOF ORDER and a fine
of up to$250.00 a day against to violatr r. $e advised that a copy ofthis stat=cnf may$ for a warded to the Office of
Invesfiptidns of the DIA for instuanca coverage verifkation.
I do hereby c under the andp of perjury that the in}btmadon proW"above is due and comsat
Ofi W use only. Do not write In ft area,to,be completed by c*.or town official '
City or Town: - Per iltlLicense#
Issuing Authority(tdicie.one)z
L Board of Health 2.Building Department3.CitylTown Clerk.,4.Electrical Inspector S.Plumbing Inspector
6.Other'
Contact Person: Phone#:
T0j� �� � 300
VASCO NUNEZ.:':CARPENTRY
79 May#afr Rd .
SOUTH;DENNI.S,.MA 02660
{VfA Ltc 069680
H1 C #124793
(866) 398 151 i • Tol{ Free
(508) 398 151 i Dennts, MA '
PHONE,j; DATE
MYS ,-,.,.Curren: .
508 .778 8352 11f26/2.0.
6 Beechwood Rd ;
JOB NAME I LOCATION
'enterville MA 02632 ::
An dersen 9 Rright Insert Windows`:
And ersen,:Casement ..Sash
JOB NUMBER JOB;PHONE
8352 SAME ,
We hereby submit peclficatlons and estimates for':
1: Remove eighteen pair of 'wooderi double hung windows with; balances, :three dead late: windows,
and replacewith`.Andersen.' Woodwright<anse..rt windows: Remove five Andersen vinyl casement: sash:_
from kitchen area and replace with five new Andersen' casenent .'sash 'with :applied grilles--to
the interior and: ext.erior '.New:casement .wndow ':sash. wilh.'have::whit:e:' interiorJexteror with
tahite;:..grilles applied, to :the exterior and,interior. New :Woodwright `insert windows:.will :have
white.°vinyl' exterior•.with natural wood interior,:.stone. colored.,:hardware ': full:;scre.e.ns.;:.and
applied gr lles;`;to .the interior and exteriors- New Woodwright :windows will have tilt wash'
;ability, anct have Low-E4 a.rgon gas filled insulated (.: the 4;00 series window;)
* This count of..:twenty six.windows. represents the. total of al windows :in garage and house on :::
.... irst.,floor:
2 Supply a:own building:'permit`:`:
3 Tak'e al3 old windows :.to .town landfill.
4 Make ar:r cre ent: for _del.ivery o.f new Andersen windows_ described 'above.
* This proposal .does.: not< include any,painting or staining.
All Andersen products-:described above will be prepaid. by:home owner. .
** If this proposal .is:satisfactory,' please sign the YELLOW., copy and return with payment
schedule, . .
** Please make. a. check payable to Botello Home Center in the -amount of $1379.0..93 for your.
new Andersen products: described above and please include-this`.check.' 'th. yo:ur signed proposal. .
Allow. 6 weeks for: .delivery.
We Propose hereby to furnish material and labor-complete in accordance with the above specifications,for%the sum of:
Sixteen Thousand Four Hundred Ninety and _93/100 Dollars dollars($ 16,490.93 ).
Payment to be made as follows:
Labor: 50% Down payment to start at time of start. . . . . . . . . . . . . . . . : _. . '$1350.00
Labor: 50o ,Upon completion at time of completion. . . . . . . . . . . . . . . . . . . `.$13.50.00
All material is guaranteed to be as specified.All work to be completed in a professional
manner according to standard practices.Any alteration or deviation from above specifications T Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature '
charge over and above the estimate.All agreements contingent upon strikes,accidents or
delays beyond our control.Owner to carry fire,tornado,and other necessary insurance.Our Note:This proposal may be
workers are fully covered by Worker's.Compensation insurance. withdrawn by us if not accepted within 3 0 J days.
Acceptance Of Proposal—The above prices,specifications and con-
ditions are satisfactory and are hereby accepted.You are authorized to do the work ash
specified.Payment will be-made as outlined above. Signa e
✓1 S_ �'� Signature
Date of AcceptXWIT.H
C „
PRODUCT 13128M U ENVELOPE a NEBS TO Reorder:1-800-225-6380 or www.nebs.com PRINTED IN U-SA.
;.'ij�, •i. . „r.rnvrr�r,� ,I r f..:fr- .. � .. o - -
Board of Building Regulations and Standards ,
HOME IMPROVEMENT CONTRACTOR
Registration: 124793
Expiration: .$128/2007
7Ypq, individual
Vasco E.Nunez,III
Vasco Nunez,111 p
79 Mayfair Rd. ,.,.
S.Dennis,MA 02660 Adminfgtrator
License: CO ON SUi?ERVISOR
Number CS 069680 #
j Birthdate /1948
E>ZphWi 10/03/2008 Tr.no: 2714.0'
• " Re t fc -
-
VAS , E NUN
EZ 111
79 MAYFAIR RD G.�e..
S DENNIS, MA 02680
Commissioner
r
PERMIT PAYMENT RECEIPT
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
200 MAIN STREET
HYANNIS, MA 02601
DATE: 09/01/06
TIME: 08:55
------------------TOTALS-----------------
PERMIT $ PAID 25.00
AMT TENDERED: 25.00
AMT APPLIED: 25.00
CHANGE: .00
APPLICATION NUMBER: 200629343
PAYMENT METH: CHECK
PAYMENT REF: �� 373
4 /
' Town of Barnstable *Permit p�(j(Q� t/
#
Fxpires 6 months from issue date
Regulatory Services
Fee tj
Thomas F.Geiler,Director I
Building Division
X. PRESS PERMIXm Perry,CBO, Building Commissioner
r r"" 200 Main Street,Hyannis,MA 02601
SEP U 12006 www.town.barnstable.ma.us
Office: 508-862-403 8 .
LE
TOWN CIEA' 5 PERMIT APPLICATION - RESIDENTIAL O ,y X' 508-790-6230
Not.Valid without Red X-Press Imprint
Map/parcel Number a j/06 j
Property Address Go Pf p „ A
/ 1
P-esidential Value of Work Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address �C
�' � C.(�y1✓921�
Contractor's Name ,1,
Telephone Number 56T-9 1,6 -305
Home,Improvement Contractor License#(if applicable)_LI 39%6 CI
Construction Supervisor's License#(if applicable)
]Workmen's Compensation Insurance
Check one:
I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
nsurance Company Name
Vorkman's Comp.Policy#
;opy of Insurance Compliance Certificate must be on file.
emit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
XRe-side
❑ Replacement Windows/doors/sliders. 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.
A o of the Home Improvement Contractors License is required.
GNATURE:
'orms:expmtrg
rise061306
f
Department of Industrial Accidents
n
Office.of Investigations:
' a 600 Washington Street
,t Boston,1114 02111'.
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Va]rie (Business/orpnization/In&vidual): Arr air A+(
Address: 2_3 i H) )ws ry..w I j �
City/State/Zip: /f,� raw pZ• 7C 3 Phone#: S W4?90-5�w �7
►re you an employer? Check the-appropriate box:. Type of project(required):-
El 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-contractors
I am a sole proprietor or partner- listed on the attached sheet t 7. Remodeling
ship and have no employees These sub-contractors have 8. F1 Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We area corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or.additions
❑ I am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or 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.]
ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information
romeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information .
cm an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
Formation.
,urance Company Name:
]icy#or Self-ins.Lic..#: Expiration Date:
b Site Address: City/State/zip:
tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ilure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
e up to$1,500,.00 an one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
restigations of the DIA for insurance coverage verification.
'v hereby certify fy under t ins and penalties of perjury that the information provided above is true and correct:
atilre:. Date _31-66
one#:.
Official use only. Do not write in this area,to be completed by city.or town o,ff�cia
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
iassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
arsuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
xpress or implied,oral or written."
�n employer is defined as individual,.partnership,,association,corporation or other legal entity,or any two or more
f the foregoing engaged m a joint enterprise, and including the legal representatives of a deceased employer,or the
eceiver or trustee of an individual,partnership, association or other legal entity,employing employees.'However of
,er the
wner of a dwelling house having not more than three apartments and who resides therein, or.the occupant el the
welling house of another who employs persons to do maintenance, construction or repair woik on such dwelling house
it on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
AGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
-eni.wal of a license or.permit to operate a business or to construct buildings in the commonwealth for any
ipplicant who has not produced acceptable evidence-of compliance with the insurance coverage required."
kdditionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
,rater into any contract for the performance of public work until acceptable:evidence of compliance with the insurance
-eq�iirements of this chapter have been presented to the contracting authority."
4,pplicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if.
necessary,supply sub-contractors)name(s),address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,* are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be we to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their.-.
self-insurance license number on the appropriate line.
City or Town Officials .
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you W a out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the-affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that-a valid affidavit is-on file for_future permits.or-licenses..A new affidavit must be filled out.each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affi.davit.
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 .
• : Depar ent of Industrial.Accidents
> office of Iinvestigations
- 600-Washington Street .
Boston,MA 02111..
' `Tel.#617-727-4900 ext 406 or-1-877-MASSAFE
Fax#617-7274749 .
wised 5-26705 www.mass.gov/dia
r v
. - on, S _ .d of Re ENT CONTACTOR
Wilding
Board of B M
HOME►MPRO"
943264
_ Re9�st !un.
AVOW 6929 2
a ! TER Ctrator
ARP
Rs
CA IAM CARTS �dmin
WILL GINS CR - pep y
231 O- G MA 02673
WES T YARM�UTH,
J
i
Carter Carpentry Contractor: Bill Carter
cartercarpentry.net MA.Licence# 231 Higgins Crowell Rd
Proposal/Contract CS 072350 West Yarmouth
Proposal valid for 60 days August 30 2006 508-790-3673
JOB INFORMATION
PROPOSAL SURNUT TED TO
Mrs. Curran
PHONE
508-775-8352
STREET ADDRESS
6 Beachwood Rd.
CITY STATE ZIP
Centerville MA
JOB DESCRIPTION
THE UNDERSIGNED PROPOSES TO FIIRNM ALL MATERIALS AND PERFORM ALL LABOR NECESSARY TO COMPLETE
THE FOLLOWIlft-WORK.
The removal of the existing shingles on the one side and back of the garage, two walls in the courtyard and the
small check in the courtyard. The installation of Typar house wrap over the plywood. The installation of
Maibec Nantucket grey shingles on the above mentioned sides. The singles will be fastened with 1 3/16"
galvanized staples. Shingles to.be provided by home owner.
All construction debris will be disposed of by Bill Carter
AGREEMENT AND TERMS OF PAYMENT
CONTRACT PRICE $2600 PAYMENT SCHEDULE $0 to be paid one week prior to
start of job,balance upon completion
All of the above work is to be competed in a substantial and workmanlike manner according to standard
practices. Any alteration or deviation from the above specifications involving extra cost of materials or labor
will only be executed upon written orders for the same, and will become an extra charge over the sum
mentioned in this contract. All agreements must be made in writing. No contractual rights arise until.this
proposal is accepted in writing.
This proposal is hereby accepted according to the terms thereof and the owner agrees to pay the
amounts mentioned in said propos 1 an according to the terms thereof.
Signature of Owner Date Signature of Contractor Date
NOTICE TO OWNER
Mechanics Lien Law-"Under the Mechanics Lien Law, any contractor, subcontractor, laborer, material man,
or other person who helps to improve your property and is not paid for his labor, services or material, has a
right to enforce his claim against your property."
Assessor's map and lot number
�0*THE
Se�rvage Permit number SEPTIC SYSTEM IlylV 2 STdDLE, i
IftStALLE� IA COAHouse number .................................................. aea
639-
�a
WITH TITLE fi o MAY a-.
TOWN OF B A R.N N� CODE AND
L TIONS
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION ........................ 1 .. .a.......................................................
10
.> ..............
...... ...I.
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
�1
�,tJ r/zy
Location ............. ..`.. Afz
............ .....�....�.................................... .. .........................
ProposedUse .................... ..........................................................................................................................................
Zoning District ..................................
............................ District ..............................................................................
Name of Owner �!!...... .�` ..� 4' Address ../... GtG� wee �... .....................
. . f'. .............. .... .. ..f.. l..
Name of Builder 1��:..4�!....� .......................Address .................... .... .... ' �."J 1�
.Name of Architect ..................................................................Address ....................................................................................
d
Number of Rooms ............../................................................Found n at .....
/Un�.. ...�. .......................
Exierior a ...... ,6..............
Roofing ........ h.....`.....................................................
Floors
�f r'`" Interior ......•/•L�/� tet -(/f� Q/- �
ti
Heating ..............................................:Plumbing ...........
Fireplace ............................Approximate Cost ® dam
Definitive Plan Approved by Planning Board ---------------______---------19________. Area ...... .........................
Diagram of Lot and Building with Dimensions Fee `
SUBJECT TO APPf OVAL OF BOARD OF HEALTH
t r d
'tL
C �
U
3'v
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable reg ding the above
construction.
Name :z.................. ........................... ...........................
BURGESS, JOSEPH
No 2.214.2.... Permit for ...Addi.tion............
.. . .......
Location ..�. o�rinors
Centerville
..................................
Owner ....Joseph....Burgess................................. ....... .... ....... .. .
Type of Construction ....Fra.....me...........................
.......
................................................................................
Plot ............................ Lot ................................
Permit Granted ...tp�zil...23...... .........19 80
. ..... .....
Date of Inspection .....................................19
Date Completed .....................'71.1 0 19
rWRMIT REFUSED
.......... . .............................. 19
C)
........... ..................... ....................Ct
............ 4z W............................................
............A-M..
...........................................
..........
..........................................
MS
Approved . ......0 !C ...... 19
...........................
...............................................................................
...............................................................................
Assessor's map and lot number .r :`����... .: Q
� Py�F TN F tp��
Serwage-'`Permit number ...... ..../..P..................................... row
Z BAWSTADLE. i
House number ................... ....................................., yO MU&
psi 1639• `00
f�MAY
TOWN OF BARNSTABLE
VA
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO . .......f�!�u !... %1 d..rye!' ✓.................................
TYPE OF CONSTRUCTION ....................... ................... ' !?•f!::^ ..: .............................
........ ' rfj?..' .:� .... ........19. ....'
' TO THE INSPECTOR OF BUILDINGS:
The undersigned he applies for a permit according to the following information: f
location ................. .....................................................` r lcr: .....::..................:.......... ..`..:.......r' ..... ..........................�.........
Proposed Use ...................
.' ".`
Zoning District ........Fire District ..............................................................................
Name o Owner ... �i? .c+. �� ../ t<i.1 r7✓r,�7 .:....Address ..:`. :... ...� rJf. '.................... ... ... .... .................. .. . .....
.'Name of Builder ... �'�... ..... ........................Address !�-r �� �",�. � �
_ f ........................ ..... ...................t.............+ . ....... /
.Name of Architect .................. ..............................................Address ....................................................................................
Number of Rooms Foundation .....• .�"'' /�-.............................................. .......................a.......................
r"'Exterior 1 Roofing .......... ......✓...r.....`
1................... .. ...//t w ,
Floors ......................................................Interior .........
......................................................
Heatingr. .....Plumbing ..................................................................................
Fireplace ..................................................................................Approximate Cost ....... ...f......'.!..:...:.....................................
Definitive Plan Approved by Planning Board -------------------_-----------19________. Area ...... .....................
&1v
Diagram of Lot and Building with Dimensions Fee .......! .... ............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
/ C+ .
r
J
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
"I construction. sr •�
.{ _r��d-C..�.✓-�`'ems;�.�.�s c�.'%-,
Name. ............................................................................
BURGESS , JOSEPB A=351-05 �
No .2.2-1-42.— Permit for .............. �
�
`
........ —._ gle ---..
-
Locotfp ...R1.—^&'1�0000za
----..Can±eroiIle.......................:...........
Ovvne, . -Borgxass--------- '
Type of Construction .J7zaoua............................
................................................................................
Plot ............................ Lot ----------'
`
Permit Granted —.....�Rr +---lg 80
Dote of Inspection ------------lV
Date Completed ------------..lV
�
�
PERMIT REFUSED
� ---------------------. lV
� \
i .......... .. ______
/ .
........................ —'''f ': .. . ------- '
-------o-----...----,..--.--..
�
...........................'..................,,...'.......'............,...
Approved ---------------- lA
--------~-----...-----.—..--..
...................................................
-
�
Engineering Dept.(3rd floor) Map Parcel Permit#
House# Date Issued a /�
ea th 3rd floor)(8:1 -9:30 Fee 02�� 0
ice
00 THE
19 '
BARNSTABLE.
TOWN OF BARNSTABLE ,
Building Permit Application. `
Project Street Address aA3
Village � r �� 1l4^ci I l�
Owner V ��lcc1 Address
Telephone
Permit Request Ae S h 1 nC U_
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ 6&4pn
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
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
No.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
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(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
Builder Information
Name T, —)Q Flo Telephone Number �Lj;�) a
Address `7/ % 2ez yri License#
Home Improvement Contractor#
Worker's Compensation# _6crC''
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
6 n/
SIGNATURE Z2 - DATE 2 Lo F,/:,
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
L%\
'J'S 'al$'. .....i.... .
�Y�., �yy-;fit K,%:,r�+,:<t33tra65�C5f�5»^Pr?Y. w•�'s•:"s,�d�^S''?�8�53'�""8C'.
V O i
V
�Y
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y
The Commonwealth of fassachusetts
Department of Industrial Accidents
tom .
_ Olficeolinv9SMffZUotts
\_"f'.:._=_7;;'� 600 Washingron Street
Boston. A1ass. 02111
Workers' Compensation Insurance Affidavit
Amy_ -hc�in reformation• _ '�' Please PRINT 1E
_. b 1
name:
locition-
Jlv �CJ f cA� - /9 [!hone#
1 am a homeowner performing all work myself-
I am a sole proprietor and have no one working in any capacity
r.._.taw..,u,ewr{.+++-+..nw••^`.T ..r >,1E'D�:?a717+n«rr_'�E472S7�"R+rRNA'..�s?;��•. _ 'n".�. �..�Y''c���.••.".'.r
2�4,am an entplover providing workers' compensation for
�m�yemployees working on this job.
(c
company name: Y✓t4 s/ew,e— Uhl
address• ` � S/�s�Q .
city: `+ nhone#:
insurance co. olicy# IMe 9_ 6 0�
I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city nhone#•
insurance co nolicy#
'_ ._... +fYTr' .T1�eq --',••>• „'T•.Y,�ri•.' r+ -�i_c.:""`'f•r-r•nti's"�^,iy-Ta!'ra+;�r•r.• s,rr_ -wn. :r_,r-+r►•'�".7'm_"^'�'.a
company name:
address-
city Rhone#•
insurance co policy#
Attach additional sheet if necessa ^w' +t— '+ J� r-'sf �• 'i'-"''"ram"`"� • ''" 'r" '�
_!�'.:.:.�.�._ - ._ �,.�.:�:;�:,'_�_. .� ••ems. � ...:3=��rrr�:.oc.•.se,.r.:'r..,a.
Fsiilure to secure coverage as required under Section 25A of 51GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 anJior
one.cars'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a
cope of this statement may be forwarded to the Olricc of investigations of the DIA for coverage verification.
I do herebt•certij• ender tie er' at penaiti of perjure•that the information provided above is true and correct.
Sisnaturc Date La� /Sr7
Print name 2 �� S�¢O� Phone#
official use use only do not write in this area to be completed by city or town official
city or town: permit/license# r113uilding Department
E C3Licensing Board-—
E :
�check if immediate response is required ❑Selectmen's 011icc
C311ealth Department
contact person: phone#; rJOthcr
Irevised 3,94 PJAI
Information and Instructions -
Massachusetts General Laws chapter 152 section 25 requires all emplovees to provide workers' compensation for their
employees. As quoted from the "law-, an einploree is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An enipl( rer is def incd as an individual, partnership, association, corporation or other legal entity, or anv iwo or more
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
rcceiver 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
dwclling house of another who employs persons to do maintenance , construction or repair work on such dwelling hous
or on the ;,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance of-
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter lta•,
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names. address and phone numbers 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. 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 polic}t, please call the Department at the number listed below.
Ciry or"Towns
Please be sure that the affidavit is complete and printed legibly. Tile Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas:
be sure to fill in the permit/]icense 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.
Tile Office of Investigations would like to thank you in advance for you cooperation and should you have am' questions.
please do not hesitate to give us a call.
.. • .. .. .. .... a .M..
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
phone #: (617) 727-4900 ext. 406, 409 or 375
A
• �-41 "E d.
The Town of Barnstable
MAM• ,nsNST�. • --
���' Department of Health Safety and Environmental Services
6 59.o.�• Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
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 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: Est.Cost �-
Address of Work:—
Owner's Name
Date of Permit Application: 5 g
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME UdpROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY `
I hereby apply or a permit as the agent of the owner.
-e?a
D e Contractor Name egistration No.
OR
Date Owner's Name