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HomeMy WebLinkAbout0014 COPPER LANE ,e- �, . F G c I C CAPE:-COD N S;UL AT I O-N FIRM GLASS SEAMLESS SPRAY FOAM SUSPEN010 ' SATTS OUTTIRS INSULATION- CEILINGS Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 0260E Date: Dear Building Inspector ;. Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed-&A_ completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to,the specifications listed on the building permit application. All work-has been inspected by a certified Building Performance!Institute '(BPI) inspector. All work preformed meets'or exceeds Federal & State°Requirenletits. f r Property Owner ;: Property Address 'Vila, e l Az£ r Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestri. ted Ceilings ( ) (� ( ) ) ( ), '' M Slopes Floors O ( ) O ( ) (JC) Walls Ne►^� 6VOr l� rror, 1e0l Sincerely H ry E ssri sident pe C Insc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION � Dq ' 'L�pplMap Parcel ' � T ' ication # Health Division -, M r 'date Issued Ib S Conservation Division Application Fee d Planning Dept. hermit Fee pjy4 iE*,�1P . Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address ,/Y- Village G'��✓�r�yliy� Ile \ Owners,-A.#A lj 1&4Z� Address fi9"r� Telephone 72 e, 2 57 Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain /Groundwater Overlay Project Valuation 41 Construction Type�L Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family , Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes A No On Old King's Highway: ❑Yes No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number lea 8 7 1 Z 9!9 5/- Address /�r�d��c✓,r� G'i/� License # /dD 98 e Home Improvement Contractor# Email Worker's Compensation #��d lJ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE r FOR,OFFICIAL USE ONLY j APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' FOUNDATION Y FRAME INSULATION Ir FIREPLACE f. ELECTRICAL: ROUGH FINAL ft PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING I DATE CLOSED OUT j ASSOCIATION PLAN NO. Mass,tcliuSwtt:, .t7dpartnient.of P.ublic.Safety. ..:Board'of Building RZgulations anel Standards' construction Supervisor License: CS.100988 i HENRY E CASSIDA 8 SHED ROW Q�j WEST YARMOUJI'H . .. _ ✓.�.... z r l u • Expiration' Commissioner 11/11/2015 Office of Consumer Affairs and Business Regulation 10 Park Plaza . Suite 5170 Boston; Massachusetts 02116 . Home Improvement Contractor Registration b Registration: .153567 Type: Private Corporation Expiration` 12/15/2016 Tr# 259188 CAPE COD INSULATION,,-INC HENRY CASSIDY - 18 REARDON CIRCLE SO. YARMOUTH,.MA 02664 }.'Update Address and return card, Mark reason,for change, SCA 1 4.5 20M•05/11 [] Address n Renewal 0 Employment Lost Card •cJ/ee cpar�uc�za�acaea�C�a�C�/�/�ccadac%uael� Office of Consumer Afflirs&Business Regulation License or registration valid for mdividui use only IMPROVEMENT CONTRACTOR `before the expiration date. If found return,to: egistratlon 153567 Type: Office of Consumer Affairs and Business Regulation UiOIVIE xplratlon 121:15/2016 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATI' N.;;INC HENRY CASSIDY 18 REARDON CIRCLE-- SO. YARMOUTH; MA 02664 Undersecretary N' valid wi ut sign e s ' i l-- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r i 600 Washington Street f,. Boston, MA 02111 www.mass.gov%dia �> or4�kers�' Compensation Insurance Affidavit;,-Builders/Contractors/Electricians/Plumbers licaut Information Please Print Le ibl Name (Business/Organization/Individual): t/.+1�/ Address: l�' City/State/Zip:! A,` WY' krwi4i Phone.#:+ A Are you an employer? Check th appropriate box; Type of project (required): l. I am a employer with 4. I am a general contractor and I employees(full and/or part-time).*- have hired the sub-contractors 61 ❑ New construction 2.❑ 1 am a sole proprietor or partner- _ listed on the.attached sheet. 7. [] Remodeling ship and have no employees These sub-contractors have 8. Demolition- - working for me in any capacity, employees andhave workers' [No workers' comp. insurance comp, insurance: $ 9. [] Building addition re uired, 5. �. We are a corporation and its 10.0'Electrical repairs or additions q ] 3.❑ I am a homeowner doing all work officers.have exercised=their 11°[]-Plumbing repairs or additions myself. [No workers' comp, right of c exemption per MGL 12:❑ Roof repairs . ,- 4 , w insurance required.) t - � - a- 152 §1 O and e have no l3. ' Other10,k, 00 . employees. [No workers'. comp, insurance required.]* *Any applicant that checks box 91 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.' I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information, Insurance Company Name: ��, � i $/ & Policy# or Self-ins. Lie. 'e0 1 Expiration Date, 1 Job Site Address:/f:: 40 o efe , ,0 —City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c: 152 can lead to the imposition of criminal'penalties of a fine up to $1,506.00 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 insuraroA coverage verification. I do hereby certify d the pai an .penaltles of perjury that the information provided above is trde and correct. Si nature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. S City or Town: Permit/License# Issuing Authority (circle one); 1. Board of Health 2, Building,,Department 3.-City/Tow6 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other s - k _ CAPECOD-27 BDELAWRENCE CERTIFICATE Of LIABILITY INSURANCE DATE,MM/°°IYYYY) ASCERTIFICATE E IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ES NOT AFFIRMATIVELY OR NEGATIVELY°.AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED iY1TATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, .= WANT: If the certificate holder Is an ADDITIONAL INSURED,the pOlicy(les)must be endorsed, .If SUBROGATION IS WAIVED,subject to Jt'6f�arms and conditions of the policy,certain policies may require an endorsement,�A statement on this certificate does not confer rights to the 1cate holder in lieu of such endorsement(s), a UCER - CONTACT' - ers&Gray Insurance Agency,Inc. , NAME g PHONE 434 RIB 134 DNQ, FAx South Dennis, MA 02660 E•MAa A/c No):(877)816.2156 ' ADDRESS: `' INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURED iNSURERs:ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation,Inc. INSURER c 18 Reardon Circle INSURER South Yarmouth,MA 02664 - INSURER E: INSURERF." COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE 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 LTR TYPE OF INSURANCE D POLICY NUMBER M P M/DD/YYYY OLICY EFF POLIO EXP MM/DD A X COMMERCIAL GENERAL LIABILITY - LIMITS CLAIMS-MADE a OCCUR CBP8263063 EACH OCCURRENCE $ 11000,000 . -04101/2015 04101/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 6,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X POLICY JECT .�LOCH OTHER: PRODUCTS•COMP/OPAGG' $ 2,000,000 . AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO n Ea accident) $ ALL OWNED .SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ ; HIREDAUTOS NON-OWNED AUTOS PROPERTY acci Y tDAMAGE $ UMBRELLA LIAB OCCUR $ EXCESS LIAR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE g 4DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY R PER OTH• B ANY PROPRIETOR/PARTNER/EXECUTIVE ,YIN WCh0431901 STATUTE ER OFFICER/MEMBER EXCLUDED? NIA O6/3O/2016' 06/30/2016 E.U;EACH ACCIDENT $ 1,000,000 . (Mandatory In NH) If yes,describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (CORD 101,Additional Remarks Schedule,may be attached If mo Workers Compensation Includes Officers or Proprlbtors,' re space Is required) Additional Insured status is provided under the General Liability and Auto Llability when required by written contractor agreement with the Certificate Holder, CERTIFICATE HOLDER, CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS. 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 PARTICIPATING. CONTRACTOR! mass save' p'�IAQ,etypnyYl ercw;xjy Mll,tPt��• .. .. - `_ . .. - PERMIT AUTHORIZATION FORM I i , owner of the property located at: (Owner's Name;printed) CUPA"r Limit - ,�t It .. (Property"Street Address), (City/Town) hereby authorize the Mass Save Home Energy Services-Program assigned Participating Contractor listed.below to act on my behalf and obtain A building permit to perform insulation ' and/or"weatherization work on.my property. . 11TA Owner's Signature 09 �5 Date FOR CSG OFFICE USE ONLY Conservation.Services Group has assigned'the following Mass,Save Home EnergyServices Participating Contractor to the above,referenced,project: f Participating Contractor Date Rev.12152011 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# JAX24S Health Division Conservation Division' Permit# Tax Collector Date Issued Treasurer Application FeefZ Planning Dept. Permit Fee *32. ?0, Date Definitive Plan Approved by Planning Board pl= 3)0(, Historic-OKH Preservation/Hyannis Project Street Address 4 aaa ck- Z 0a Village�ctr �,,L/JC Owner VQ ,7&- 4 Address es® Telephone L Permit Request 40 ognEen odC ..r iQ%i% " Square feet: 1 st floor:existing -"` proposed 2nd floor:existing proposed Total new Zoning District - - Flood Plain Groundwater Overlay Project VaIuatior -- Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes X ' Basement Type: null ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) �- Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing — new First Floor Room Count - Heat Type and Fuel:-_YGas ❑Oil ❑Electric ❑Other Central Air: ❑Yes 2.9 No Fireplaces: Existing ''- New ""` Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:0 existing ❑new size Attached garage:❑existing ❑new size Shed:0 existing ❑new size Other: i Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ P c rp DO Commercial .❑Yes ❑ No = If yes;site plan-review# - - - Current Use Proposed Use UILDER INFORMATION �T / Name zF Telephone Number ��� o -L U 00 7 Address iv►C_ t 5.1 6?n, r License# O/O 1-4 alZ22.5's Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 0 SIGNATURE DATE--' � a FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER l ' DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. . Town of Barnstable P °-^ Regulatory Services BAMSMBLEv ' Thomas F.Geiler,Director BuRding Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-403 8 Fax: 508-790-6230 Permit no. f Date AFMAVrr HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERIVIIT 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: '�)/J� � '� C / Estimated Cost k0a Address of Work: 141 elm) v'A­ /Z- L'�� Owner's Name: VIA a, �� /7>? Date of Application I hereby certify that: Registration is not required for the following reason(s): FlWork excluded by law ❑Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTMS OF PERJURY I hereby apply for a permit as the agent of the owner: J_—1), 64 A r4,'A— Z 4Ta 5— Date Contractor Name Registration No. OR , Date Owner's Name QArmhomeaffidav Town of Barnstable sReguiatory ice ThOMM F.Gaffi Wed" Tom PeMo su co nix 200 MAn Ste, Ifyoub,MA 0260 WWWAQWu-bwWftbJO,uMW Offi": 50 62.4038 50$-7,, .6230 Prop Owwr Must CompleW and Sign'TI Section If Us'Mg A Buil&r r� c w work wdmiwd bytes bmift pg , appi d �for. . 01 vw=--- Psi The Commonwealth ofMassaehusetts Department oflndustrzal Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/lElectricians/Pluaaabers Ainflicant Information Please Print Le ibl Name(Business/or, nizationadividuaD: Address: f 2"17 G_ f e/ 4 ' City/State/Zip: , Phone#: Are you an employer? Check the-appropriate boa: Type of project(regaired): 1,I I am a employer with a _ 4. ❑ I am a general contractor and I 6. ❑ New construction employees(fall and/or part-time).* have lured the sub-contractors 2.❑ I am a sole proprietor or p=er- listed on the attached sheet 1 7. Remodeling ship and have no employees These sub-contractors have & ❑ Demolition working for me in any capacity. workers' comp.insurance. . g, ❑ Biding addition [No workers'GomP.insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs oT additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t , employees.[No workers' 13.❑ Other . comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policyinfonnation; t Homeowners who submit this affidavit indicating they are doing all work.and then hire outside co�actars must submit a new affidavit indicating such %contractors that check this box must attacbed an additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance CompanyName: ,4 /. /Ord r Policy#or Self-ins.Lie#: /G�� ` '�®-� Expiration Date: Job Site Address: City/State/Zip: /'f &�i 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$1,504.00 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. 1 do hereby c;=srnalties ofperjury that the information provided above is true and correct; Si atire: Date: _a6 ' 94 Phone#: 2 Off cid 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/.T owa Clerk a.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#; ini®rrnaia®n ana tnszructiuns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express orimplied,.aial 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 trastee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three aparttaents 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 binding appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)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,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work untd acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es) and phone numbers)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 sure.to sign and date the affidavit. The-affidavit should be returned to the city or town that the application for the permit or license is being requested;not the Department of . Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies shout eater•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 to fill out in the event the Office of Investigations has to contact you regarding the applicant = Please be sure to fill in the permit1l icense 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 th.at•a valid affidavit is on file for future permit or licenses. Anew 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 affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Departrnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. fi 617-727-4900 ent 406 os 1-877-NIASSAFE Revised 5-26-05 Fax # 617-727-7749 ww—w.mass.gov/tea NOTICE NOTICE TO Y v TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC 6010142012005 12/08/2005 - 12/08/2006 POLICY NUMBER EFFECTIVE DATES Rogers&Gray Insurance Agency 640 Route 132 Inc Hyannis, MA 02601 (508)775-0011 NAME OF INSURANCE AGENT ADDRESS PHONE John A Leboeuf 35 Princess Pine Rd Hyannis, MA 02601 EMPLOYER ADDRESS 11/17/2005 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ` ADDRESS TO BE POSTED BY EMPLOYER rc, ie �irinzovuuectfali ^%y4/ � - . BSjard of Bui,sung fte ulations afid`SEH�§ arcs .ti �FO!V;E fM�OVEA11EtJT�ONTF'�aC'i'OR Regist Tsr1` Ij7,372 r X MEN5r? /12,20 , � Yp �� ititiduai JOHN A.LEBCEb}F _sz} ,1bHtV LEBOEUFr ' • 35�'RFNCESS F'tNE'#2p-,�'' :�� - .��.' HYANNIS, MA-02601 ✓le -Po�.vazoou,.ea/.�i o�✓f/laaaaclzuae� ��,� BOARD OF BUILDI REGULATION'S �? License:.CONSTRUCTION SUPERVISOR ' Numbef GCS 010161 BirtMdate 9/30/1960 3 zpires` 09/30/2007 Tr;no: 7030.0 f`% • t , } f.v., t 6 e Restricted0 JOHN A LEBOEOP 35 PRINCESS PINE R3 r i i 0�4 HYANNIS, MA 026n �"'" Commissioner '-�I of Town of Barnstable *Permit# G Expires 6 months from issue date ' IARNSPM : Regulatory Services Fee"AMASS 7 gib 1639. ,0� Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 X-P p CRG PERMIT Office: 508-862-4038 OA Fax: 508-790-6230 SEP 0 4 2003 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �( Not Valid without Red X-Press Imprint TOWN OF BARNSTABLE Map/parcel Number 2— Property Address LA 6,04 0 C-0,u.9 L. esidential Value of Work . &"d� LU tt) Owner's NanM&Aditress ___2 tv cn Contractor's_Named y- Telephone Number Home Impro77mentontract�License#(if applicable) Constructioxupeor's Li nse#(if applicable) o � o3g ❑Workman's Compensation'Insurance Checkmate: EEK am a sole proprietor ❑ I am the Homeowner ' ¢' ❑ I have Worker's Compensation Insurance - Insurance Company Name Workman's Comp.Policy# Permit 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) l MIA- e-side ❑ Replacement Windows. U-Value (maximum.44) ti *Where required: Issuance of this permit does-not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner ust sign Property Owner Letter of Permission. Home ovement tractors Li ense is required. - F Signature Q:Forms:expmtrg Revise053003 °Ft►E Tq Town of Barnstable Regulatory Services 9B"RN `'8�'�," Thomas F.Geiler,Director �prfD Mai A,0 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section \ If Using A Builder I I, A414c- T 7" F, G L yNA , as Owner of the subject property hereby authorize 7- A`CdInM to act on ray behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) ignature of Owner I5ate Print Name Q:FORM&OWNERPERMISSION ` , � ✓fie V�omynzo�ziaea� o�✓�aaac�uaerta !1111 Board of Building Regulatioons and Standards i < HOME IMPROVEMENT CONTRACTOR d Registrat oN 139398 Eptrafion 7/14/2005 _ Pe l dridual PATRICK LANCASk�� 1 i PATRICK iANQST€F�f I 11 COACH LANE BARNSTABLE,MA 02"5'� `'J Administrator