Loading...
HomeMy WebLinkAbout0060 CONNERS ROAD/77-7 .. K)l� �r ovl�� � � oF'THE r Town of Barnstable *Permit# Expires 6 months fro`n issue date s# Regulatory Services Fee 0 . -- BAaNseABLE, v "9'039. Richard V.Scali,Interim Director ArED MA'I A - Building Division Tom Perry,CBO,Building Commissioner100PRESSNT 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 APllax 5%8?P�90-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ON, RNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number ��►� ���, ^T' Property Address Residential Value of Work$ bb�, Minimum fee of$35.00 For work under$6000.00 Owner's Name&Address NRI!k Aou Hnr�8 O&aL Co �� ti v A 02 QJ 2- Contractor's Name C e©Y- @ aV C.c r Telephone Number Home Improvement Contractor License#(if applicable) U 16 Email:U(.Q,\/Lcrr� .epry c am t,cf�' Construction Supervisor's License#(if applicable) } G 1,3n OWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance' Insurance Company Name �f C l ���l I ll �� L'�� �{V,�(I ��Ul(✓ Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) :oRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to J°F X Cel ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requir SIGNATURE: TAKEVIN_D\Building Changes\EXPRESS PERMIDEXPRESS.doc Revised 061313 I i ula ery ervices Building v��l;�1 Thamns try,CEO Bantling commissi ntr 2ii0\lain Strtxt Hp;utrrie,I<4r!ooC�t- vt•hw•.Iorrn.bnraslablN.nru.�s . 013:ce: 508-8624038 Fax: 50Fr?90-fi22fi Property Owner Must 's Section i and S' Ttu_ 1 e m e Co P '�' if Using A Builder I, ()wcscr of.the sUlirc►PTr,)prccc hrrrhti aut$cuizc ro Act on-.1v 11ehalf. t in:tli t:IattcrS rciativc tty tirutk aurhuno-J by this bui.k3ing permtt application for. (Address of Job) a e � t � r Sipaturc of Owncr Date Print Natn:. it Property owner k applying for pertain please cotaptete iHe 1(attrrownarx l,irensc F..cemptioa F om,an the rewse Side. C:.Bite;s'aftcttlfiia'•.�s�si)du'+1.w�,:Ali:recauh.lt'calw+Y•:tis�x+rrnirt::actFlFs`Cva7�5tChttlaox••l1FInT.i.`Ii\.LaF4tFtiS.S�ti Revised O13012 e Caamma�2a ea�Cli a�C ��oJaaure \Office of Consumer Affairs&Business Regulation License or registration valid for individul use only IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 16,ENT Type: Office of Consumer Affairs and Business Regulation kWME 10 Park Plaza-Suite 5170 piration: 712/20`16. Private Corporation Boston,MA 02116 GEORGE DAVIS, INC:'; -: GEORGE DAVIS '- 33 NORTH MAIN STREET, SOUTH YARMOUTH, MA 02664 Undersecretary ¢ Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and:Standards ^___` ___<_n Siipe 9 �,uuau_uuiui visor License: CS-056130 F s GEORGE F DAVIa4 33 N MAIN ST S YARMOUTH 1qA O'l664 i1.5 A ` � v- � Expiration Commissioner 03/01/2017 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ir 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ibiy Name (Business/Organization/Individual): G raf'(�i I C, @ o—y L 1', �i1.a _ U Address:y1a Uald,L M�Ctlp tercet City/State/Zip: J t yQ, L ,� Phone #: , - q1 - 6 U Are you an employer? Check the appropriate box: Type of project(required): 1.T�5zI 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 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 121QRoof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for m_y employees. Below is the policy and job site information. Insurance Company Name: A dsocL7GI cd (AA' LC-4 T' (A r 'lbf, Policy#or Self-ins. Lic.#: j CC 006 d! q 6 9 0U w A Expiration Date: r v J Job Site Address: co l,() VLF, cyj ��(ja& City/State/Zip: e_L±�rV l Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde t e pains and penalties of perjury that the information provided above is true and correct. Si�r,nature: Date: T Phone#: Official use only. Do not write in this area, to be completed by city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: GEORDAV-01 BDUQUET YM ACOR00 CERTIFICATE OF LIABILITY INSURANCE DAT123/2D/Y 3 23/2015 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mason&Mason Insurance Agency,Inc. PHONE 781 447-5531 FAX (781)447-7230 458 South Ave. (A/C,No. o Ell:( ) A/C No Whitman,MA 02382 ADDRESS:info@masonandmasoninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:The Travelers Indemnity Compan 25658 INSURED INSURER B:NGM Insurance Company 14788 George Davis Inc. INSURER C:Associated Industries Insuranc 33 North Main St. INSURERD: South Yarmouth,MA 02664-3145 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MMIDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE [)(]OCCUR 1680790OM2261642 01/12/2015 '61/1212016 PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 50,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 1-1PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accdent _ , B ANYAUTO M9M28491 10/26/2014 10/26/2015 BODILY INJURY(Per person) $ 20,000 ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 40,000 AUTOS AUTOS X HIRED AUTOS X NON-OWNED Parr..dZI)DAMAGE $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PER T - AND EMPLOYERS'LIABILITY YIN STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE CC50050143902015A - 0 3/0 512 0 1 5 '03/05/2016 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED9 N❑ N/A - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE George Davis Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 33 North Main Street South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD f -711-3 oFtH r Town of Barnstable *Permit#oxi W317� Regulatory Services Expires 6 mont rom'sued i • BARNSTABLE. 1639MASS Thomas F.Geiler,Director Y� 6;q. �FDMA't�' �� ��� V"•l� Building Division d f A Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address (00 [�Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address j Anh a V I w u d'd (P 6 a 0 f u ( �Ohr VIJI � Contractor's Name lti Irf, f "Do A I' n Telephone Number-9-Y 4 g q_�) 1 Home Improvement Contractor License#(if applicable) I V Construction Supervisor's License#(if applicable) b A. li��. V ❑Workman's Compensation Insurance Check one: '1AY 15 2013 ❑ I am a sole proprietor ❑ lam the Homeowner 7. 'A, OF W1 have Worker's Compensation Insurance ®W/V _ q Insurance Company Name �' {l `y�( ° l TAME Workman's Comp.Policy# 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 to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side (� J q) . #of doors LP Replacement Windows/doors/sliders.U-Value o� 3 (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 co he Home Improvement Contractors License&Construction Supervisors License is re ire . SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 Ward 508 778 2852 p.1 Town of Barnstable Regulatory Services llamas F.Geller,Director Building Division Thomms Perry,CEO Building Commissioner 200 Main street, Hyannis,MA 02601 www.town.barnstablema.us Office: 508-9624038 Fax: 508-7904230 Property Owner Must Complete and Sign This Section If Using A Builder I-11-,S-`�YI,��.l„�I ,as Olvner of the subject property hcrcbyauthorize Geoil(Jt' � Yt:;, TU�r to act on my behalf, in all matters relative to work authorized by this building permit appliention for, (Address of Job) 7l Cc�l S `f' 3 Signature of Oumer Date Anyl MAr le VJA (U� - Print Name If Property Owner is applying for permit,plessecomplete the Homeowners License Exemption Form on the reverse side, C:tUseralderouixwppD=V,o;unNlicrosonllvindowi',�Tempo-.ary Interact FileslContentoudooklQRE6zUB4\EXPRESS.dx Revised 053012 u �6�ria�zant.nrzcaetc�l✓z.a��C��cralccc�ccreL7s !Q\ Office of Consumer Affairs&Busifiess Regulation License or registration valid for individul use only — OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ,1`60164 Type: Of ice of Consumer Affairs and Business Regulation ®= Expiration: 7/2/2014=,_ 10 Park Plaza-Suite 5170 Private Corporation Boston,MA 02116 GEORGE DAVIS, INC. GEORGE DAVIS 33 NORTH MAIN STREET g� SOUTH YARMOUTH,MA 02664 Undersecretary Not valid without signature 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards o Construction Supen isor � , L,ia;ense: CS-056130 GEORGE F DAVIS` ' 33 N MAIN ST k S YARMOUTH MA 02$6:6-e ' Expiration Commissioner 03/01/2015 Y ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Sheet Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business organizadon/lndividual): e U ll�f Inc Address: 3 3 .N00 a In Ef re Ci /State/Zi : So. G rrn 7 V 1 M G 2� e#: O A `D 8 3, Are you an employer?Check the appropriate box: 1. I am a employer with Type of project(required); �_ 4. � I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, Demolition working for me in any capacity. employees and have workers' [No workers'comp:insurance comp. insurance.t 9. ❑Building addition required:] 5. We are a corporation and its 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL insurance required.]t C. 152, §1(4),and we have no 12•0 Roof repairs 3a.❑ I am a homeowner acting as a employees.[No workers' 13.❑Other general contractor(refer to#4) comp.insurance required,] *Any appGcaot checks box#1 must also fill out the section below showing their workers'co �oucY information t Homeowners who submit this affidavit indicating they ate doing all work and then hive outside If the sub-cona s must submit anew affidavit indicating such. tContracWrs that check this box must attached as additional sheet showing the name of the sub-contrwora contractor and state bwhether or not tl>ose entities hav employe e es. scton have employees,they must provide their workers'com p.Policy number. !am an employer drat is providing workers compensation Insurance for my employees. Below is the polley and Job site information. I, Insurance Company Name: Vl O ILL- Policy#or Self-ins. Lic. Expiration Dater [' Job Site Address: City/State/ZiP: Attach a copy of the workers'compensation policy declaration a e(showing Failure to secure coverage as A g ( owing the policy number and expiration date). g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeah 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 eer*under th and penalties of pedury that the Information provided above is true and rontict 13 0,8?cial rue only. Do not write in this area,to be completed by city or town eff7ciaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.CityfTown Clerk 4.Electrical Inspec 6.Other tor S.Plumbing Inspector Contact Person: Phone#: f Rightfax N2-1 4/4/2013 6: 33: 08 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) J 04104190VI IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS • CERTIFICATEDOES NOT AFFIRMATIVELYOR NEGATIVELY AMEND,EXTEND;OR ALTER THE COVERAGE AFFORDED BY THEPOLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOTCONSTITUTE A CONTRACT BETWEEN THE(ISSUING INSURER(S).,AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE:HOLDER. IMPORTANT:If the certificate holder is an ADDITIONA'LINSURED,the policy(ies)must'be endorsed. if SUBROGATIO.N'IS'WAIVED,.subject to he terms and conditions of the policy,certain policies mayrequire and endorsement. A statement on this certificate does not confer rights to he certificate holder'in'lieu of such endorsement(s). ':PRODUCER CONTACT NAME: MASON&MASON INS AGCY PHONE FAX 458 SOUTH AVENUE (AIC,No,'Ezt): (A/C,No): E-MAIL WHITMAN,MA 02382 ADDRESS: 237X1V1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD'UNDERWRITERS INSURANCE COMPANY GEORGE DAVIS INC INSURER'B: INSURER.C: INSURER'D: 33 NORTH MAIN STREET INSURE R,E: .SOUTH YARMOUTH,MA 02664 INSURER'F: COVERAGES CERTIFICATE NUMBER: REVISION'NUMBER: THIS IS TOCERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW'HAVE:BEEN:ISSUED TO THE..INSURED.NAMED:ABOVE'.FOR THE POLICY PERIOD INDICATED_ :NOT MTHSTANDING A'NY REQUIREMENT,'.TERM OR CONDITION'OF ANYCONTRACT FOR OTHER!DOCUMENT WITH RESPECT TO WHICH TH6,CERTIFICATE:MAY'BE ISSUEDO R IMAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRBED IHFRE N iIS SUBJECT TO ALL THE TERMS,iEXCLUSIONS.AND CONDITIONS OF SUCH POLICIES.-:LIMITS'SHOWN.MAY HAVE BEEN REDUCED'BY'PAID CLAIMS. DISK ADD'SUB POLICY:EFF DATE POLICY!EXP DATE ILTR TYPEDFINSURANCE !L R .POLICYNUhBER ""DWYYY) ,(69 MIXYYYY) :LIMITS GENERAL LIABILITY zACH-OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS!MADE DAMAGEITOIRENTED $ [--]OCCUR- EMISES.(Ea occurrence) I VIED EXP(Arty one person)H $ RSONAL&ADV INJURY "$ GENL.AGGREGATE LIMIT APPLIES'PER; ENERAL,AGGREEGATE $ :POLICY F]PROJECT E LOC RODUCTS-COMP/FP AGG '$ AUTOMOBILELIA'BILITY COMBINED SINGLE ANY AUTO LIMIT(Ea accident) ALLOWNED AUTOS BODILYIINJURY :'$ SCHEDULE AUTOS (Per,person) iHIRED AUTOS ODILYIINJU.RY $ {,Per accident) NON-OWNED AUTOS PROPERTY'DAMAGE $ (Per accident) UMBRELLA:L'IAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-:MADE AGGREGATE $ (DEDUCTIBLE $ RETENTION'$ $ A 'WORKER'S COMPENSATION.AND X WcsT,ATUTORY OTHER' EMPLOYERS LIABILITY YIN UB-5B850127.13 031052013 031052014 :LIMITS ANY PROPER'rfOR7PARTNERIEXECUTIVE r NIA E.!L EACH ACCIDENT $ 100,000 OFFICERIME MBER EXCLUDED? :(Mandatory:in:NH) EL-DISEASE-EA''EMRLOYEE .$ 1.00,;000 ilfESCRIPTIO OFO E'L.ID:ISEASE-POLICYLIMIT '$ 500;000 der DESCRIPTION OF ORERATIONS�trelow DESCRIPTION-OF OPERA?IONSILOCA710NSAIEHICLESIRESTR(CTIONSISPECIAL•ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO'THE CERTIFICATE HOLDER AFFECTING WORSERS COMP COVERAGE. I CERTIFICATE HOLDER CANCELLATION GEORGE DAVI'S INC SHOULD ANY OF THE ABOVEDESCRIBED',POUCIESiBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 33 NORTH MAIN ST IN ACCORDANCE WITH'THE POLICYIPROVISION9:7 AUTHORIZE]REPRESENTATIVE SOUTH YARMOUTH,MA 02664 ACORD 25:(201,0105) The ACORD name and'logo are registered marks of ACORD 1988-2010 ACORD CORPO. TION?'-AVr o's reserved. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION . Map (✓� I Parcel A4 Application# " d Health Division Conservation Division . Permit# Tax Collector Date Issued /hk7 Treasurer Application.4e $S6. 0n Planning Dept. Permit Fee - s30 Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Addrs U o n at(s a. Village lst�ti�� Owner t �� Address 1. 7 • o . A_ Telephone 03' Permit Request u 1.s W �0 , AD Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 00 Construction Typej Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family W,--' Two Family ❑ Multi-Family(#units) Age of Existing Structure 3�0 )!s'S '� Historic House: ❑Yes U46' On Old King's Highway: ❑Yes p4o Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) I umber 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 ❑ it ❑yp 0 Electric ❑Other Central Air: ❑Yes VNIo Fireplaces: Existing V New Existing wood/coal stove: ❑Ye-9 allo(.:I' Detached garage:❑existing ❑new size Pool:❑existing ❑new size . Barn:❑existing ❑newer sizez Attached garage: existing ❑new size Shed:❑existing ❑new size Other: <j i Icn Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ONO If yes, site plan review# _ m r-Y- Current Use Proposed Use BUILDER INFORMATION Name U Q Telephone Number "�oil? 9 l � Address 1 License# S' Home Improvement Contractor# Worker's Compensation# u t C! ALL CONSTRUCTION DEBRIS RESULTING F OM THIS PROJECT WILL BE TAKEN TO N1,51 SIGNATURE r DATE /19.1 FOR OFFICIAL USE ONLY = i � 1 • f PERMIT NO. �i DATE ISSUED r MAP/PARCEL NO. 1 1 1 1 ADDRESS VILLAGE t. OWNER I 1 DATE OF INSPECTION: FOUNDATIONo i FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL i PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING ri9 51 � 7 ff( , ' DATE CLOSED OUT r , ASSOCIATION PLAN NO. ' wf The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street y` Boston, MA 02111 GSM S"•' wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individuala_ t, ln(-, Address:—Q- tLb VW --7[+ City/State/Zip:S .. N n o j 5. Phone#: 27 Are yo an employer? Check the appropriate box: Type of project(required): 1.NK 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 2.El am a sole proprietor or partner- listed on the attached sheet t ❑ Remodeling ship and have no employees These sub,contractors have' 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have.no 12.❑ Roof r irs insurance required.] t employees. [No workers' 13. ther comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information, I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,� , Policy#or Self-ins.Lic. � Expiration Date: Job Site Addres City/State/Zip: W'P_ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of e DIA for insurance coverage verification. I do hereby certify under the pal d enalti of ry that the information provided above is true and correct: Signature: Date: 2 Phone#: �,, Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• E�q Town of Barnstable ti Regulatory Services sT"B Thomas F.Geiler,Director o.39..,a�. Building Division Tom-Perry,Building Conunissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IlVIPROVEMENT 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 ini 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)rAh other. requirements. Type of Work: Ulna" IA.+ Estimated Cost '-f l a 600 i i Address of Work:. /1 g/ t er s Name: Vl i Own i Date of Application: 1 ILI I hereby certify that: Registration is not required for the following reason(s): Work excluded by law ❑lob Under$1,000 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 IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SiGNE ER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the er: A_ K Date C'n rSignature — Registration No. OR Date Owner's Signature Q:wpfileshrms:homeaffi day Rev: 060606 ✓�ie Laavrrnrwrau�eat�� a�'���Z�uuuc,lu�ella Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 107333 Expiration: 7/31/2008 Type: Private Corporation GEORGE DAVIS BUILDERS, INC. George Davis , 9 NEW VENTURE DR.UNIT 7 So. Dennis, MA 02660 Deputy Administrator _ G �aauu�aaelGt fie �Joorrmzartct,ecr�i a�.�BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number CS 056130 Birthdate 0212911968 Tr.no: 8332.0 Ezp►ces:03/01 t2007 . Restneted: Ilq • GEORGE F DAVIS. 4 ,,e� 9 NEW VENTURE S DENNIS, A 02660 Commissioner February 19, 2001 Page 4 of 4 I.Entire Agreement This Agreement represents and contains the entire agreement'between the parties. Prior discussions or verbal representations by the parties that are not contained in this Agreement are not part of the Agreement. IV.HOME IMPROVEMENT CONTRACTOR REGISTRATION COMPLIANCE LANGUAGE A. All home improvement contractors and subcontractors shall be registered. Inquiries concerning a contractor or subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration One Ashburton Place,Room 1301 Boston,MA 02108 B. The owner may have three-day cancellation rights under MGL c.93, §48;MGL c. 140D, §10,or MGL c.2551), §14,as may be applicable. C. All warranties and the owner's rights under the provisions of 780 CMR R6 and MGL c. 142A ` D. In the event that the Owner does not pay the contractor per this contract,the property is subject to a mechanic's lien. E. No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the holder deems himself to be insecure. However,where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the contract,which are in the possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and owner for withdrawal. F. No work shall begin prior to the signing of the contract and transmittal to the owner a copy of such contract. I guarantee that all our workmanship and materials will be of high quality. Additionally,we are licensed, registered,and fully insured. Our signatures indicate that we have read,we understand,and we accept all provisions of this agreement. Do not sign this contract if there a an blank spaces. Owner CG��i t ���t.� Date . 1 d-A)-(/66 Mrs.Ann Marie Ward or Mr rank W r ) Contractor / —Date George Pravis,President George Davis Builders,Inc. Page 3 of 4 Lic.#056130 Reg.#107333 Thursday,.December 21,2006 America Online: AWard41995 George Davis 1-2-07 A,ArkwinogrodNay.I�D�IlII� Ward 11:33am$uilding'1'omorrow #60 Connors Road,Centerville 1 of 2 KeyBeam®4.410k kmBeamEngine 4.413t ' Materials Database 546 Member Data Description: Deck Beam Member Type: Beam Application: Floor Lateral Bracing: Continuous Top Standard Load: Moisture Condition: Dry Building Code: IBC/IRC Live Load: 240 PLF Deflection Criteria: L/360 live, L/240 total Dead Load: 60 PLF Deck Connection: Nailed Member Weight: 11.8 PLF DOL: 100% Filename : G Davis Ward 16 0 0 16 0 0 Product Data D B Sx A Fb Fbn Ix Fv E in in in3 in2 psi psi in4 psi psi 11.875 3.500 82.26 41.562 2400 2400 ' 488.41 300 1.8x10^6 EI K Live Total Fcperp + LBS.in2 psi 879.lx10^6 0.000 L/360 L/240 740 Load Case Dead Load 90 % Cv= 1.0000 Ma = 14806'# Va = 7481# Span(ft) Lift) Cv Ma('#)' i 0.00 - 15.56 15 1.0000 14806 Load Case Total Load 100.8 Cv= 1.0000 Ma = 16451'# Va = 8312# ' Span(ft) Lift) Cv Ma('#)' , 0.00 - 15.56 15 1.0000 16451 Bearings and Reactions Input Minimum Worst Case Location Type Length Length Total 100% Dead Total 1 0'0.00" Wall 3.50" 1.50" 2427# 1868# 559# 2427# 2 15'6.75" Wall 3.50" 1.50" 2427# 1868# 559# 2427# Design spans 15'6.75" Product:31/2x11 7/8 Rosboro Treated Beam 1 ply Component Member Design has Passed Design Checks.** Minimum 1.50"bearing required at bearing#1 Minimum 1.50"bearing required at bearing#2 Design assumes continuous lateral bracing along the top chord. All product names are trademarks of their respective owners - Joe Madera Shepley Wood Products 216 Thornton Drive t Copyright(C)l989-2005 by Keymark Enterprises,LLC.ALL RIGHTS RESERVED. Hyannis,MA 02601 f.�l rY�P[�Ll I.IA: Passing is defined as when the member,floor joist,beam or girder,shown on this " awing meets applicable design criteria for Loads,Loading Conditions,and Spans ;led on this sheet.The design must be reviewed by a qualified designer or design nfessianal as required for approval.This design assumes product installation :cording to the manufacturers specifications. - _ George Davis 1-2-07 D +�D�Il°� Ward 11:33am Growing Today.Build nng'I'omorrow.!' 460 Connors Road,Centerville 2 of 2 KeyBeam®4.410k kmBeamEngme 4.413t Materials Database 546 Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 94394 164524 57% 7.78' Total load 100% Positive Unbrcd N/A Negative Moment N/A Negative Unbrcd N/A Shear 2118.# 83124 25% 0.01, Total load 100% Max.Reaction 2426.# 9065.# 26% 0' Dead load LL Deflection 0.3603" 0.5188" U518 7.78' Total load 100% TL Deflection 0.4681" 0.7781" L/398 7.78' Total load 100% LL Defl.,Lt. N/A TL Defl.,Lt. N/A LL Defl.,Rt. N/A TL Defl.,Rt. N/A ' Control: LL Deflection All product names are trademarks of their respective owners doe Madera Shepley Wood Products 216 Thornton Drive f Copyright(C)1989-2005 by Keymark Enterprises,LLC.ALL RIGHTS RESERVED. Hyannis,.MA 02601 , eymark� • [.�TCkln[N1 LIA" Passing is defined as when the member,floor Joist,beam or girder,shown on this 'awing meets applicable design criteria for Loads,Loading Conditions,and Spans led on this sheet.The design must be reviewed by a qualified designer or design nfessional as required for approval.This design assumes product installation :carding to the manufacturers specifications. ' Jan, 02 07 01:05p prank Ward 508-W-0144 p.2 APPLICANT wAR'L TO WN _uARjw.7AtgLE /zlf UA Q�1T.� T�00 j LAKE ' LOT 14 a`� SOT 15 LO7' 13A f / � n f 6 l.iO,t 13 �� h V41, lZ PZG0,7 PAAEL 25L_L10� GGOur G_ FLOOD ZONE- i?AYM- 0B-.I9-85 t' he,-e8p cer!ify tftY�tf�iS trro:Aeare fnspec;ron Galen-was prepared ton Ylar €. Far IAIVK 0 .41�P�.c"iC'4 _ _ _ Bank. TJsc Cnl The location of Sfs hvvlditag sAa3vn Goers _ Pall witAln a specisJ flood hazard zo7e. DEED RED'. = Per 4 d urspeCV0n it eppsars tlia JCOA4+0r. of duelling dare .--__. cwntoeg, !o the laoat by-Jaws In effect 09 the llme cl eat►atructfon rrlth —i-Cl to harywRi tl &MUnsianaf setback tro UIMMvnLs PLAN REF = 89--63 or Is exempt Pam Kalstlan enioreement a0ban wader Yeah. Centre? axx Ch 40.4 -sec. 7. 1 l�tarencrd Deed subject to and rsitl: Else be4eff! .of all jirh.�, r4fh&s of n.K ees^»renL� reswrveUons SCr��t° - �--- FT aa�f FCXWC' an3 al maid; it any dery Pee sad fruster •s dJis se, e,V of:mgal leroe and e!lesC Da tE,: _�`�'-t°J- NLMSB NOM The structures on this I49peeflian W&M loratad by tape got Jw&:tmeni end arc ap,�rvsllarets .nly. An col"al surrey is necrssary - far a prr_Isr d6ferminfition of the building toestion and Rncrbeeh,ment.r. U an,exist ardhor ray se.mae proiarty IL7aa. nfia feepeatio:� n.m »oZ be usorf Aar r�oardh,C prrrposys ar,br wa fo p. ering deed desrrfpulaws rYrd mulct pot be uwd tar sariaoce or blulding plan i,arrpet es F7sis ins}recliae must not b® vsed to MMM.1e.prropr►rl.7 Im= Naril,'p Ucn of brl/dfxg tec*tfasst pr�rpe.•tr rime aWnevsfan.� t,^acea cr;nZ rontgrare.°l*,h rrtt. only be scc2L7pll.^,red by an decorate instrumen! sur rey which rimy terkvi dtirnrenryt anfornriL'an Shen Wsat :a shown tierean Mk i.'mP ctr"on is nod to t,e uttsd far any pUPpwv Miner Lla.7A�/{!F'6' $8. :a21�C.•J S�uTs��yfafec Ls no re�sp`+ons•IDidty�Pa-trTdw�>imess restttl�Lgir4 Iron --did re4ance- PHJ.`rlr` 5f18-428-tJG$•5 1 .d"11 Y l l FE SURVEY V EY l� O�ri...) UL T �6( MCY O Piz fie-ezo-3�63 UNIT 1, 40 1NDUSTRY RD MARSTOX3 MIS MA 02648 371438 J!" JAM-05-2007 10 :09 AM GEORGE DAVIS BUILDERS 5083945460 P. 01 rt'All.orauwtutwlntruuu At,r19rM*3r nsurnnwx9onvy nwiu.iNang4,w muranus tv,vAwmwwwwrormlt wd&AW40mv r_ I "ATR Wiotx"m AC CERTIFICATE OF LIABILITY INSURANCE �s8 6 de ae ofi a -- T NIB C CA E 16 t$$VGC A8 A MATTER QR INPORNA N ONLY AND C WIR9 NO RIOH1'3 UPION THE CERT11CATE Borthstar Ins. 9erviaes, Inc. HOLDER,THIS CERnFiCATR 00E8 NOT AMINO,EXTEND OR 65 walnut Btzeet Ste, 380 ALTER THE COVERAft APIOROP5 BY THE POUCIEg BELOW. Wellesley Wk 0268i R 6%hOri®f 791-431-25d0 lnN:701-931-81.94 f a INSURERS R, W*ftk �NAIC 0 INN-AeAA Alb Ce >�Ipflri — fdec►rga saris guilders, Inc. ----- t._...._._..._.,...,.....,,." r,lear m 10avim 9 N ventx A Dsou h Deno a Y 7 it llmsuaeR` ..J ��.. COYpRAMS r1F.F^.%;C*A X INfl;RATCr•.I ISTE.O C.E".OV Rkj OEEN*Ak.Eri'v)Tl-F-NrJ.FEC'N,'aNEU 150YF.PCR THE POLICY ftWJC 4 CICAUt.N INP4y5T4W L< eivY PF•:lt. t- .�u..err l Q r.gNl111:ih or MY G"a•n€1.4CT OR OWr nnCUML';J W;UJ MIIF"Uy 1'e)WHI^;M tul8 CEPTI°!GATE t.W.W vtavKRTAB(T14IN;y; 4SCEVFc".FP0 lyI'`-E! K0:LICTI')ALL J.-h A�{kkk-,Xft LIN1Tt15p,5'v\1'4 MCY HAVE VkiN REiIIC.'EC BY PAD LLA11g6 TY Ti Mti1C+ ►B?/ 7St4RA+1tB ACL,rt'�IJaAq C1TRG" .._,._.._......._.._._ LT -..___.._. I'O&ENN.LldGllfl" ��_ �--,--•' '�.!�wlrit'C!:' i' .®.....�.. i I 1.,GMMt:Rr;tS1.0EWRALLP81L:—, J.�i�rl,ip I ` M- hv Ex.-( Try 011 p?tl.l4S� _--..._..— I S f�-� � ,' j r Fafr NA,a An;v JQPY 1 4 j tAbYt.4,130RPUAft..I.:Lbl APFL IF FIE 4 I � R 1G•.,Ic 9.C0.1r,'(7r C�i��u............, ., .. t r,IfEC•SIN, E Llml', (fill Ait.li;o�, I _i S:�ECr:jLE'?GJ"vz j I(`'3rFDr4o1) ! ry I hI.4El5.WT!Ya i I I E1;'Ltft'r Ir,•;IJRb j —. rnw^nti1 lt,Ajr..'.9 I I (Pa xt;dartl j� ----'--- ' I I Ff.de'CRTv C+'G14tt� I S i f gAf!40!LIPO—IL ffY fixCiZ9(LMBAGLLALIhBlllt•Y ._._ I ,., i eA,CHt";t;�rJfLtY:B •., . 1 r�OCCUF L J,:LA.,ms e. FG-erIMI I xl. 9,PL0VfR5:LV&LlrY 03/QS/06I I E'• _1.__...e_._.._...-.--.._"___._.._ a rpNC.;.a=,,�'-v.F.,tFR.E.��I;•1Yc I CBg�Oe 1 03/OS/'07 EL.FhCNPrCtDPrir rL00.000 OFFCER,%kSW-R EK+aLrEOi I -- t kS.7G6Gr m:Jrn'Bi I j _— __=r_EtiCL;iE4»ll H ,00 r 000 vic _ t;L C'KV!GI m� m s low - j l CI'SE.Sn•ROL;:.�tIMl4„I..n fib®r',40 -`) � --- f -�-�— c�ernwi9Sric`JF�i�>;'IonJniLn:ArwN�1VR.na,KreKausceaanooroeti'ee3 !► �AtSi'RA�(5io`��"".....".'.•'"".. -I--� � Cn _ Co CERTIFICATE HOLDER T�. CANClLLAT!0N tYT �899'i'A �41iWL0 ANY t9F twB JuBaVd f�R02RfBl0 Poucle.as euvasLL�r„fS Furkf2 rH6 axrirteTluu DAMT41RIOP.TM WING I l0UMP ALL INUAVOR TO MAL CAYt WRMN Town of Barnstable h]119ITO TM CERMCATi NCILDIR riAMBC rO TNi LOFT,BUT FAILLRTR TJS CC VI WL'. building Dept, IMPOSE No com ilcm M MAKRY OF Am"xwp kPON TNi MBUw,rl'B A(MiN UR 200 main street Ryannis uk 02001 Rop'nsw1m4B. }� r. _,�. ._.....,M._ _ r�►z tllt'�It Kax�ltll _ >iCt}NC 1S{2dUIIdU) 0ACCRD CORPORATION19811 I j �F114E l Town of Barnstable *Permit# O,^ Expires 6 months from issue date iMASS. Regulatory Servic eS Fee 98 i639 " Thomas F.Geiler,Director A'FDN1°`p Building Division Tom Perry, Building Commissioner "94 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 ' ". Fax: 508-790-6230 � EXPRESS PERMIT APPLICATION - RESIDENTIAL O1�T'R 1 6 2005 Not Valid without Red X-Press Imprint TOWN OF BARNSTABLE Map/parcel Number Property Address (190&Wn P m 2009 Ce n-fer\r 11 L-e, ['Residential Value of Work _7 8-00 . Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �_ e. n Cc- t . Ate, tort /" \ — A rix3 n y 4' (A a 9 r1 1 I t Contractor's Name Telephone Number S)B -(o 7 Q 2- T Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner `❑ 3 have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) >C*y oof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature — Q:Forms:expmtrg Revise063004 The Commonwealth of Massachusetts ERR Department of Industrial Accidents — Office of lnmtigations 600 Washington Street, 7�Floor Boston,Mass. 02111 g� Workers'Com ensatioyn Insurance.Affidavit: �B�uildinig/Plumbing/Eiectri�cal Contractors- MEl a Fa�hu„ v�`'idy l .. r } 4.M:B.• ,y. - '•• T� 4e•'} name: address: L o C)YI y1e r-.s ;�oad city, P e) ec SC I L l e— state: zi ` . �/� n: �to3 Z phone# 5(] -7 7 8 'S Z work site location(full address): µ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel iuu I am•a sole proprietor and have no one working in an capacity. Building Addition Y:a�r;ti:.aP•• r''"R '''•s`'3�'.•.°- ''•••..4'�t'[i`�'.'�*sf' aS;fitw'. .'.G:t� ' a: 'F'�"•.:i?«� ,.•i �k•[`+�k`a•ri:Y;7t;`':,?'Mi:,�o-^ i�..nt:45.'••'�•,'':•'Y.'`•�'' ,n'., ,.,^,. 7�} :'p^��ntibynM - _ ❑ I am,an employer providing workers'compensation for my employees working on this job. company name: address:' city phone#• . insurance to. 13olicy s€':r<1�13i�;ob."•�K�'7. :�dGS?ri�:3:$.'�I�tb.1�:m�8vm1'��ti;�''u ..n';q� :^ca���ud.��9r%„�:�ti3"s•`a•K.4;�%w:z�•':�6�e+���.3�4.?ltui§K''w`.��:='.t:'vf'ar!4r�E,3.•�•f:ii :�•�:x�'�-:•6�:;,�"�r�`�`�'.;e�'eti�:•:rw... ❑ 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: phone M ------------ insurance co. IDOHV# 'q%1:�'sf:•br y..r.;�•j�`�•;u�. .t••d'}i R'�' .t '71„ ... ;•e..o ypi µ`��1� '^ ;;:`v,.�,'•o •„fsfy•: rx,. `r.. ��g..�.». yf. °7h;';,-.r'•1,3 . :�:: ;s�•.:.�. �':. .lr,•5ta��'G°a�'�i'xi?ti:�'''.•. 7�':i°iF.•,....r,n•�e, -company name: address: city: phone#•. �ijn sur��an,,..�a CO. - - oli # 3�7.•'"itrdli:i0��.aietilltC�e�j4�5d- 'e ter '-q 4 { 'w`t�r u3`^s, z. Rv :•••.� 3;' �'a.:u•�...§.L•• •e tih W.'��iK+s+`'t.1— +�'M!'�++�slt '41 Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition-of criminal penalties of a fine up to S1400.00 and/or one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement maybe forwarded to the Office of investigations of the DIA for coverage verification. ' r do hereby certi under the pains andpennaaltiJes ofperjury that the information provided above is true and correc4 Signature — tit/ Date I6 AS Print name 141011/— ,40 C' LA-a S) Phone# official use only do not write in this area to be completed by city or town official city or town: permitnicense# " :Octmen's ding Department ❑check if immediate response is required nsing Board Office contact person: phone#;' lth Departmenter. (revised SepL 2003) , Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all-employers to provide workers' compensation for their . employees. As quoted from the"law", an employee is defined as every person in the service of another under.any contract of hire,express or implied;oral or written}. . An employer is defined as an individual,-partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However-the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to,do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 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 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 have been presented to the contracting authority. } ! _ a :y .kt: .P. ie ? �ar'q ., e , F '•. ".i}�:, {�,,•,�•. -L •.S �4► •i�;Le�R i .�•r.!'fi$1' i `x.. .�7. tY.+r.Rai i'.. !!},. '+ - Applicants Please fill in 'the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance 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 policy,please call the Department at the number listed.below. "°', .� '_7 +i? ¢ at 9C: ,A, per, •.f1�ry.'',s•�s�.:�y��, ,:1 +ti},,yi.< •.'+ (;� •g �"'�. .,ff �t ��.ri•. �''y_ • 1. `* $ ti T�iL' wl�l:. e!^. Gf i'./'! !'I.^�V.F.!�. .ft,,^,+ti# !}%S 1 �+, City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference.number. 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. .t.:���+"e •r ati�. �^e:4 Y�ri M'Y i b � . Y' ' Dom l �;51+t�6�:1�j.e�1,tx•"•�.X•t..3`�•:.ti]�.,a:'i"..,Ii,v.A- n Ntk".•'Y�• The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,?h Floor Boston,Ma. 02111 fax M(617)727-7749 phone#: (617)727-4900 ext. 406 . ��� � � n�/�- �d� �5 � -Q�� a C�2-- TOWN OF BARNSTABLE Building Application Ref: 200700079 m it BARNSTABLE, Issue Date: 01/09/07 Perl l I 9 MASS. i639• Applicant: DAVIS,GEORGE Permit Number: B 20070056 A Ar f0 � Proposed Use: RESIDENTIAL Expiration Date: 07/09/07 Location 60 CONNERS ROAD Zoning District RD-1 Permit Type: DECK/PORCH RESIDENTIAL Map Parcel 251024 Permit Fee$ 30.00 Contractor DAVIS, GEORGE Village CENTERVILLE App Fee$ 50.00 License Num 056130 Est Construction Cost$ 40,000 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND REPLACE EXISTING DECK WITH NEW NO CHANGE IN FOOTPRINT THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: WARD, FRANCIS P u ANN MARIE S BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 2 COURTNEY PL INSPECTION HAS BEEN MADE. NORTH ATTLEBORO,MA 02760 Application Entered by: JL Building Permit Issued By: THIS PERMIT CONVEYS NO'RIGHT TO OCCUPY ANY STREET ALLY OR SIDEWALK OR A PART T TEMPORARILY ORPERMANENTLY ENCROACHEMENTS ON PUBLICfPROPERTY NOT SPECIFICALLY PER,;IITTED UNfDER TH BUILDING CODE MUST B APPROVED BY THE JURISDICTION= STREET ORALLY GRADES A:S WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROMTHE DEPARTMENT OF PUBLIC WORKS THE ISSUANCFOF THIS PERMIT DOES'NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). la a .D ... . ... . ® r MD BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health t _ , e 19'-0" Existing Home D Deck co ti Existing Home Deck a, I . Ask IDN r 13'-3" y 27'-5 1/2" c Approximate Location of Footings - Typical J m Deck o !: DECK NOTES: �j 10" Concrete Piers set on 48" below grade 4 x 4 or 4 x 6 P.T. Posts secured to the top of the piers • lip 2 x 10 P.T. Joists @ 16" o.c. 5/4" x 6 Decking — Material T.B.D. 36" Railing = Material T.B.D. M 16'-0" 12'-3 1/4" J,,�, 2'-2 3/4" t" 3 1/2" x 11 7/8" Rosboro Treated Beam }� See Report DECK to HOUSE DETAIL I _ Ice & Water barrier applied to exposed sheathing. o 2 x 10 p.t. ledger bolted or lagged to house @24" centers Continuous metal flashing over ledger, under decking Joists "hung" off ledger, fastened per code. l Ward Desk George Davis Builders, Inc. (page 9 New Venture Drive; Unit 7 1/2/07 Property of George Davis Builders, Inc. 60 Connors Road _ South Dennis, MA 02660 1/4" = 1'-0" Do Not Reproduce Centerville, MA (508) 394-0832