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I , ,", "­�,;-�,,,-,,,,,,�": , �,"`,',�. ...........- - , � , , , , 4 ,,�_ � ,� 1, �.�,,� � '11.�,_: 1,_� &��- , , �-,�-,���, ",, ,, -.��, ., '_,-,,�,��,_'.j_ ��,,%i � ,,�,-­,,, ,,�,� 'A'A'.,,4"",�,, , �-_,.�-�-,,, g,- 1,44��J����....... ,� ��,,,1,�',' ! ,,,�,.,,,,,.,f '11�1 ...... , __ , ,_�L,,�:,,��,, ,� � ��" , � _ , �r ,�, ,,,�, - _�, , , - _�j ,j _ �,,�,, ,.", ��, , ��',,�,��.�:�,.�,-,,,,,�,,�,,,,,��,,,�, _'11',i��L�11_11"__-,__,� ,­'�,,,,�z,� '­'��,,,'�,,�','�-,�,,,;,'�',��""".,�'��,,�t�,-,���i,��".,.���,,�"A",,,-,,, , , ",.�c,_,�,'�!" �:­ ,.',� " i,,,,�,,�,�;,,,-,'-�_-,-,%';;� . ,"111f­`L�:.1:f-. _11:;,vd - " � , -, - "ej,.'z,,L�,�, - � ,�,"� TOWN OF BARNSTABLE BUILDING PERMIT APPLIC7ATION Map Parcel r``e� Application # 7 Health Division - � � Date Issued Conservation Division ` .C, `` Application %FL2(_ Planning Dept. � Permit Fee Date Definitive Plan Approved by Planning Board X(11>�' Historic - OKH _ Preservation/ Hyannis / �. Project Street Address Village Owner Ak C5( kC\ Address �AAG Telephone Permit Request �LC-Mg-� 6Xk%)WG %C6T P-Q& RgVcc• W,,' %C-CT Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zo nin g'District _K Flood Plain Groundwater Overlay '=�'Prpject Valuation a 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 t^ o✓ On Old King's Highway: ❑Yes ❑�d'o Basement Type: ❑ Full U,6rawl ❑Walkout ❑ Other Basement Finished Area (sq.ft) C'J Basement Unfinished Area(sq.ft) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing —new Total Room Count (noIs ding baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes Q_Ko 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 l lac �N tea �c�1PC - Telephone Number �5��� SkAi cM( c Address �`�Q�c9Tv�G License # Home Improvement Contractor# Email �1���1�® Z CyIL00 K. COM Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 17M Camratam. vea u,fMaFsadi=etas p Departs gent a'r'rrdustrid Accide7a 4 _ -Orwe v.fIrCSez69aiia=rs. - r' r ' 600 Washargton meet . 4 Baston,,IA aZ.UI: k6'MP TItasm9orldiQ Warke& tiompensaiian.L=—mce Affidavit:Builder-dCantmcturs/EectriciausJFhm hers Am1kantItiiw3,ating please prim f egi T� Nam Address CZ0 Arne ypu an.employer?.Checkthe appropriate bay Type of project(require s L 9 I am a employer wiffi 4- ❑I arts a general confrsctor and I ❑New oonstiut fort employees(fall mWor par Time * liave hired:the sub-con&acfoss 2.❑ I am a sale propdetmr arparfner- listed outhe arched sheet. . 7. [remodeling These sub-congractors have sip and have no employees. 3_ El Demolition wod7.ng for me in any capacity- employees workers' 9: ❑Building addition r jNo wodoe.rs'comp.�tizfancii .' Comp-i.,�xn�#- required-] I ❑ We are a corpozatton and its ti 16-❑Electrical repairs,or additions officers have exacised their , 3_❑ I am a}>QmeovEer dairrg all tiFord 1L 0 Plumbing repairs ar$dc€ti�s my-self[No vvo�'gip- tight of em n pfion per M(M i 12-0 Bnafrepairs. ins=nce rea d]i, c.152,§1t�andwe have no employees,[Nowudoe& 13.0'f}tfier cone_insurance reTired-] ��Y aPF��ffiat chedsTwa rl�nst alza ffiwEthe sectFoabeiowsliatoag iLe¢s�orkeis'mmp�•mfir.,.peycpiafo�sac� . �r��a,n,nen who sabot dais s�davi8 ia�cztiag$�v_y sagdaing alFtra�c sad then I�aartside crn�ciotsnmst snfrmit a newsr�dzeit indiesdr.�sacs: .- ZCaabsctastffist chec8iiffs bax mast sttarh sa xAdidnaal shad sbnuiagthenaneof the suh� snd stafewhe ier arnotthase edifleshave empda}ees.Iftise aahadas eMrigyees 1he}'=x'rgsa'i&&'&trarkes'tamp.PQHCYaaaabrr- I ant an empLa t7tr�is pran g tvarkers'cotcrperrsrdzrrtt utsrtrarres or enrlrIQ} es I£eIoav is i7tepaficy ate}eb side ISSumse sampan*i+Iaffie: Paficy or pelf-ins Lio_ LS LG V�' G c 9 kA0 W 6 hatiaaDate: yob ite Address` 3 G kVN�C C t,4C 7 city'stafel ip: C(S t ��x AE#2ch a copy of the workers°compensationpolicy declaration Me(showing the policy number and espiratioa date). Failure to secures coverage as required under Secti(m 25A o€MQ.r-157 can lead to the imposition of commal pennitaes of a fine up to$L50D AQ andfor one--vearimp€Isor-ent,as wL:Il as civil penalties is$ie fans of a STOP WGRIK ORDERand a fine ' of up to$2510.0 a dap affainst the violator..Be adi ised ilxat a copy of this zbaement maybe£ormded fn.the Office of Imrestcgations ofi ie DIA for insmz,re coverage Luca ion_ I d'o Freraliy eard)j,rtud�tfiap�ar' and�lpmawa pm.' a* ra is byre rrrirl arrrect. . Phone i �� S G QuEdd aw wtfy. Do!wt write in ffds area,€a be crrupi od by ck artojm ajcuat City or Town: N�mnse# r ,' Isst>ing AmAority(drde one) L Board of Real& I Bua mg Deparunenu 3.atpirow i Qerls 4L nectrical Inspector S.Plumbing bspector " 6.Other Canbct Person: Phone#: Information and Instructions ' to mmpmsafion for fbeg MPl =- 7��c�rl,,,c�ts G-etneaal Laws cha =.I52 req�es aII employers Pie - Pmsaantto this sf ,an.�IO3'�is definmd aspp¢son m$ze service of aot3rudx any comract ofbIIry express or implied,oral or wznen-" c a�cociafion,coipor�ion or other Iegal eoiify,at any two or more �Tay�is defined as"nit mdxvidaaI,P � I er,or the of�foregoing m a joint eamprise,and inclndmg the Iegal Fepresen faiNes of a deceased emp oy asociahm or otb=legal emrty,employing mploy - HoweY�the receivmr or trastee of an mdivfdnal,part ship' artraeuts znd�vho resides therein,or the occapaat ofthe- owner'of a.dwmTmng horse having not more than three dw Ei g house of ano`hcr who m3ploys persons to do maw ce,causLm"t'on or 1epai wo&on such dwelling house or on the grounds or bmkTmg aPP�� thereto shannotbecanse of such m1ploy�be demmedto be an employe" I�M chap § C(� state or local Ticeasmg agency shaII wrChTiold the iss'aance or ter 152, 25 also stem that everp ermit to operate a business or to mnshn�bmZdings is the commonwealth for any renewal of a$cease or p aPPTrc=f who has notprodnced acceptable evidm m of cdmpliance with thin insurance.coverage regoired- Additionally,M ff-chapter 152,§25CM sb±es-Teif =tfie coE=caQealib.nor'Ly ofits Political snbdivimcros shall FM inti any contra at for the performance ofpublic win k n�1 acceptable evMm=of compliance with thD mscnance.. req�ems of ibis chapter have been prese�d in the oo—„fr��,a a�iiozity." - Applicants Please fiII oil the worms'compensation affidavit camplminly,by g t .e bo=thataPPly to y�situation and,if snb-contadmr(s)nangs), addresses)and Phonenvmbes(s).along with their ceai�cate(s)of necessary:sr�ply s or p W&no to ees other the the insurance. Lmmitrd Liability,Liability,Co=ames(LLC)or LfimtrdLiah�ityP sbiF ) Y members is,are not rimed to carry WMka[s' co�ensafzon mseaan� If an LLC t nt does have enzpToyees,apoliCy is requited. $e advisedihatthis of idaYltmaybe smbmi rd to the Department of Iudnstnal Accidents for continuation of�ce coverage: Also be sure to sign and dafe-fete affidavit The affidavit should be rmt mii-,d to I.e city or town tip the application for the pemct or license is being request,not the Department of ; h dzrsiiial A�ciri�f� n0uldyou hate any quess ins regarrmg the law or ifyon.are reed in obtain a workers' =�mnpolicy,Please call theDeparfineotatthenumberlistrdbelow Self-fimamdcompaniesshouldeartheir self-n+surance>Hcemse Ir=ber on the apprapaai- Ime- tlty or Town dfEICLOS f Please be scam that the afddavt is co and andprioh:d.Iegibly. The DeparEmenf has provided a space at.ti�boii�n of the a$davitfor youto fill outin.ihe eventthe Office oflnvestigati has to co C�you g e applicant Please be s=to MI m tho pe<mnit/Iice❑se Dumber vhi-chwill be used as a mfmmce number- In addition,an applicant that must submt 3aUI4Ie p CMitllice<nse applications is any given year,need only sobmzt are affidae indicaim '�g ere t olicy i,r = atian.[if necessmy)and under"Job Sue Q ddressa the applicant shoLld -all locatims n (�'or p town)_"A copy of the-affidavit that has beta officially stamped or mat3o:d bythe city az town may be provided to the - 71 applicant as proof that a vflid affidavit is on file for fotnre.penits or Hcenses. A ncFY affidavit must be filled OiXt ear- year.�Tliere a home owner or citizen-citizen-is obtaining a.Hcen se or permit not related in any bvsinrss or commercial (ie. a dog li=mr,or pe<:mit to bum leaves e#�.)said person is NOTart�lete this affidavit Thm office of rmycsf;gsffinas would like to thank you k advance for your'coQpera Lion and sbonlci you havm any questions, please do not hesiiaiz is&m ns a ca1L The Depar[mmfs address,telephone and fax nx�be� - dj&ssach- Depaifmmt of YkimtdBl A=dents� 4 �nSx Tf,-L.:E 61-1-72749W eEft 4-06 cat 14 MA&�A� Ram x.evismd 4-24-07 gPgVdi& cl AWC Guide to Wood Construction in High Wind Areas:I10 mph.Wind Zone Y . Massachusetts Checklist for Compliance(7s0 CMR 5301.2.1.1)t C Chwk 1.1 SCOPE Y - Compliance Wind Speed(3-sec.gust).. - 110 mph _ Wind Exposure Category..._.... ... ......... ....................... ... ...............................................................B 1.2 APPLICABILITY Number of Stories - '..........., .......•. �9 2).................... ...... stones. 5 2 stones- • _ RoofPitch ..........................................................................(Fig 2)............................................ 512a2 Mean Roof Height (Fig 2)_'...:.......:...::_:... < — ......._.. ft 33 Bwlding:wdth,W ......................:(Fig 3)...... < :.. ft s 80, Building Length,1: '...........:...... ................................(Fig 3).....:................................................ ft s 80' _ Building Aspect Ratio(L/W) ........ .... (Fig 4).::... 5 3:1 _ Nominal Height of Tallest Opening2 ...............................(Fig 4)...... 5 6'8' 1.3 FRAMING CONNECTIONS General compliance with framing connections:...................(Table 2).:............................:.................................. 2.1 FOUNDATION Foundation Walls meeting requirements of 780 CMR 5404.1 Concrete.................... ........... .... .... .....................:.. ........ ..... ....... ..... . Concrete=Masonry — ...... ..... ............................................................................................... _ 2.2 ANCHORAGE TO FOUNDATION1'3 , `5/8"Anchor Bolts imbedded or 5/8"Proprietary,Mechanical Anchors as an alternative in concrete on) _ Y BoltSpacing—general _......................................:...(Table 4).:..................:..,.................,..... `'m. BoltSpacing from end/jolnt of plate ............................(Fig 5)....................................:. in.s An. Bolt Bolt Embedment—concrete....:..::.......... . (Fig 5 >_( 9 ).:.:.. ...................... `._in._7" t - Bolt Embedment-masonry.........................................(Fig 5)............................................ in.z 15" Plate Washer....................................:.......:.................(Fig 5)....................................... ......z 3"x 3"x'/," 3.1 FLOORS.. Floor framing member spans checked ............................. (per 780,CMR Chapter 55)............................:...... . Maximum Floor Opening Dimension..:................................(Fig 6)............................. L ft s 12'or L12 or W/2 _ Full Height Wall Studs at Floor Openings less than 2'.from Exterior,Wali(Fig 6)...............................I.......... Maximum Floor Joist Setbacks — Supporting Loadbearing Walls or Shearwall.:........... .(Fig 7)................................... .......__ft 5 d Maximum Cantilevered Floor.Joists — Supporting Loadbearing Walls orShearwall................(Fig 8) ft 5 d Floor Bracing at Endwalls......................... ........ ...........(Fig 9)...... ..... .......... .............. Floor Sheathing Type . '(per 780 CMR Chapter 55)..................................... Floor Sheathing Thickness .....(per,780 CMR Chapter 55)........ ` in. _ Floor Sheathing Fastening..................................................(Table 2).._d nails at—in edge/=in field. 4.1 •WALLS Wall Height 4 ........(Fig 10 and Table 5) ft_ Loadbearing walls.......: .......:............... s 10' Non-Loadbearing wails ......... ......... ...............I(Fig 10 and Table 5)..........................._ft 5 20' Wall Stud Spacing . .....,.:......... ... .........(Fig 10 and Table 5).................. in.s 24"o.c. Wall Story Offsets ..(Figs 7 8 8) — 42 EXTERIOR WALLS' ' Wood Studs' w Load bearing walls....:..................... ................................(Table 5)'..............................Zx ft in. ' Non-Loadbearing walls.................................................(Table 5)' -—ft—in. — — i :...................2x ft in. Gable End Wall Bracing — Full Height Endwail Studs ................:. (Fig g 10) .... ...... ............. WSPAttic Floor Length................................................(Fig 11) :....,....:........:...:. ft?W — Gypsum Ceiling Length(if WSP not used)....................(Fig 11) ........ ................a......._ft z 0.9W 2 x 4 Continuous Lateral Brace @ 6 ft o.c...(Fig 11) .. ....I....., Double Top Plate — Splice LengthI......... ...........................(Fig 13 and Table 6)_. ..._.................. ....... ft Splice Connection(no.of 16d common nails)..............(Table 6)...................................................... AWC Guide to Wood Construction in High Wind Areas:110 mph Wind Zone 1. Massachusetts Checklist•for Compliance(7so CIMR 5301.2.1.1)t Loadbearing Wall Connections Lateral(no.of endnalled 16d common nails)..............(Table 7).............._......................................... Non-Loadbearing Wall Connections — Lateral(no.ofendnaffed 16d common nails).._...........(Table 8)............................I...................... ..._. Load Bearing Wall Openings(record largest opening but check all openings for compliance to Table 9) Header Spans ....................................................... (Table 9).................................. ft_in.511' SillPlate Spans ........................................................(Table 9).................................._ft_in.s 11, — Full Height Studs(no.of studs)...................................(Table 9)........................................................ _ Non-Load Bearing Wall Openings(record largest opening but check all openings for compliance to Table 9) Header Spans.................. able 9 _ _ Sill Plate Spans.._"" (Table 9).................... _ft_in.5 Y 12 _ Full Height Studs(no.of studs)....................................(Table 9)........................................................ Exterior Wall Sheathing to Resist Uplift and Shear Simultaneously4 — Minimum Building Dimension,W Nominal Height of Tallest OpeningZ. .................................................................:.............._5 BY SheathingType..............................................(note 4)...................................................... Edge Nail Spacing.........................................(fable 10 or note 4 if less)........................—in. Field Nall Spacing..........................................(Table 10)...........................................:..... in. — Shear Connection(no.Hof 16d common nails)(Table 10)........................................................ _ Percent Full-Height Sheathing.......................(Table 10).................................................... % _ 5%Additional Sheathing for Wall with Opening>6'8"(Design Concepts).............. ... Maximum Building Dimension,L — Nominal Height of Tallest Opening2......................................................................... 5 SheathingType..............................................(note 4)...................................................... Edge Nall Spacing............................ (Table 11 or note 4 if less).......... . ....—in. —_ Feld Nail Spacing.......:..................................(Table 11)................................................. in. _ Shear Connection(no.of 16d common nails)(Table 11)........................................................ _ Percent Full-Height Sheathing.......................(Table 11).................................................... % Wall Cladding _ 5%Additional Sheathing for Wall with Opening>6'8"(Design Concepts)..................... - Ratedfor Wind Speed?.....................:........................................ ................................................................ 5.1 ROOFS Roof framing member spans checked?.......................(For Rafters use AWC Span Tool,see BBRS Website) _ Roof Overhang .............:.............:.......................(Figure 19).............. ft s smaller of 2'or L13 Truss or Rafter Connections'at Loadbearing Walls — Proprietary Connectors Uplift................................................(Table 12)............................ ......:.:._._...U= plf — Lateral .. able 12 ...............L= plf _ Shear...............................................(Table 12).............:..............................S= pli, _ Ridge Strap Connections,If collar ties not used per page 21.....(Table 13)..............................T= pif _ Gable.Rake Outlooker.........................................(Figure 20) -ft 5 smaller of 2'or L/2 .................. .............. Truss or Rafter Connections at Non-Loadbearing Walls Proprietary Connectors Uplift...............................................(Table 14)............................................U= lb. _ Lateral(no.of 16d common nails)...(Table 14)............................... ..L=_lb. _ Roof Sheathing Type...................................................(per 780 CMR Chapters 58 and 59).................. Roof Sheathing Thickness.............................................................:.........................._in.a 7/16"WSP — Roof Sheathing Fastening...........................................(Table 2)........._..,................_....................'.... Notes: — — 1. This checklist must be met in its entirety,excluding the specific exception noted in 2,to comply with the requirements of 780 CMR 5301.2.1.1 Item 1.If the checklist Is met in its entirety then the following metal straps and hold downs are not required per the WFCM 110 mph Guide: a. Steel Straps per Figure 5 b. 20 Gage Straps per Figure 11 c. Uplift Straps per Figure 14 d. All Straps per Figure 17 e. Comer Stud Hold Downs per Figure 18a. 2. Exception:Opening heights of up to 8 ft.shall be permitted when 5%is added to the percent full-height sheathing requirements shown in Tables 10 and 11. 3. The bottom sill plate in exterior walls shall be a minimum 2.in.nominal thickness.pressure treated#2-grade. AFFC Guide to iYO-od Corasr5•aadoa hi Jl Tr RurrzdArazz 119 Dr prr:.ff�r-adzarze . Massachusetts Chec t far Ca p i.ance(no Ct��Rs�ot�:r)I 4_ a: Form Tables ID and 1.1 and loca5m*cif wan sheaf fng and SUUrr g Aspad RaSo,determine Perter3t Fuld-Height• Sheathing and lA Spacing.regUirem=►fs . b. WDod Sbucturaf Panels sW be minimum fhidmass.of 7116`and be installed as fDBDwk - Panels shall be bnsEaIled r strength ass paraIlel fo shrd� -- ii_ All horimrW joints shall o=r over and be;nailed is frmssing. 'uL On single stnfy mnstruc oN Panels shall be atiacbed to bof m plates and fnp.inember of fhe double -:--- — top -----_----._._--_-. ..�r�Dnfuro.stnry_canstrslcfionr.t�PP PaisshafLhs f-adied.toAit*me=barof ffie-upper doublefnp-- --- plal:a and tD band joist at bDftam Df panel.Upper affachmanf of lower panel shall be made to band joist -and 1Dwer2ffachmri1 madebn Jawest PlafB at first:tfrjorfrarrsing. ' v. HDrrmnt d nal spacing of dpubla fDp plates,band joists,and girders shall be a double row of ad . staggered at 3 inchEs Dn tang per figures below:Verircal and Hodmntal Masi mp for Panel Affachment S. Glaring profactiorr a)Tsew hDusa or horimnfat addMon-required if pplectl;i riule or ciosertD shore(generally,south of Rh_ZB ornorm of Rfa.6) b)Viral addffian-not tequlred u-ilass theta is egg ranm-ADn io the fast1cor ' _ c)rePlar.�nentwaidows-needs energy rrans�on cornprcance only(chap 93) . E Wood Frame Construction Manual(1►►rFCM)for 110 MPH, 1=xpos111-a B may be obfainedfrom the Arnerin Wood Council _ (AWb)websiie. - . �stsnat - • - tr>5s=�aur� t[ tl o tt 11 LE • F tb 11 0 [ i CEId 19 [ It a L [ FIS�'A?ilF7lilTi= 'I tE .J . - IY pp a "S Jr Fit �trIsc c rlt - -.rt - t f,�kS—`�kGkv1 AL4Lpl42Tglkl PANEL ' � �-` ' Fr�13Y•►'!;' -- •L nQ1IEEEb44lLl�GESPACL4G.DIAL ', _ See.l3a1Q rl Nwd Pagr< - lretfical and Hai'vmrrW WarTrng L�efarl . Vary end Ifariz nial hlaiCrrsg _ for Park l Attachment fDF Passel Af mhrr a if . I i ' I m o I —————— — -- --- I� RN, lvl� - In x - \ A I 3 I G, Z \7 � 1 p - A Z v D r I 3 o z m m A L.r Q1 r� ✓� __ 1 n O E m A A I o � > v/Ix 3 x � z ' • I m r GAi _ _ z , I m o • I � y o I N I • I - I I ` I I I , I i vistration valid for individul use only License or reg Regulation before the exp iration date. If found return to: office of Consumeitekffairs 5170 and Business 10 Puck P1VIA 021,16 Boston, L � of valid�witho' ' nature ',, vW IRA, WK- Ow r 1 Massachusetts Department of Public.Safety: Board of Building f e9bl 1O and Standards a License: CS-066099 Construction Supervisor ` ;IF.S o . ` Fes' EDVAN A MONTEW06 169,MARAVISTA EAST FALMOUT}I+ �t ! ....k Expiration: xpi8 w 10/ 12017 Commissioner z DATE(MM/DD/YYYY) ,ac Ro® CERTIFICATE OF LIABILITY INSURANCE r 1 10/26/2016 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: LOTS Ferreira - PAUL PETERS AGENCY INC. Pn cCNo Ext: (508)548-2500 ac No): E-MAIL ADDRESS: IOIS@paulpetersagency.com 6 FALMOUTH HEIGHTS RD. r - INSURERS AFFORDING COVERAGE NAIC# FALMOUTH MA`02541 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED • INSURER B: MONTEIRO EDWIN A DBA MODERN DESIGN HOMES INSURERC: - `. INSURERD:- 169 MARAVISTA AVE wsuRERE: E FALMOUTH MA 02536 INSURER F: COVERAGES CERTIFICATE NUMBER: 97260 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. ` I R TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DDY EFF POLICY D EXP/LT LIMITS LTR COMMERCIAL GENERAL LIABILITY a - . - EACH OCCURRENCE $-1 DAMAGE TO RENTED CLAIMS-MADE OCCUR r PREMISES Ea occurrence) $ MED EXP(Any one person) $ �N/A - PERSONAL&ADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- ❑LOC - *` - PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - $ Ea accident ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS 'AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED - - PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per accident - UMBRELLALIAB OCCUR - " . EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A - - AGGREGATE $ - DED RETENTION$ - $ WORKERS COMPENSATION = OT AND EMPLOYERS'LIABILITY X 'STATUTE ERH Y 1 N ANYPROPRIE'rOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? NIA N/A NIA 6S60UB0459MO6116 10/13/2016 10/13/2017 (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 - N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ` Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage: CERTIFICATE HOLDER CANCELLATION ' a SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE ,THEREOF, NOTICE WILL BE DELIVERED IN - Town Of Falmouth Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 59 Town Hall Square - AUTHORIZED REPRESENTATIVE Falmouth MA 02540 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(201410,1) The ACORD name and logo are registered marks of ACORD - Town of Barnstable Regulatory Services . 4 . Richard V.Scali,Director Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601, www.town.barustable.ma.us Office: 508-862-4038 Fax: 508-790-6230, Owner Must Property Complete and Sign This Section If Using A Builder . I M\QA NA ��G V� ,as Owner of the subject property hereby authorize` V�4%.W .- to act on'my behalf, in all matters relative to work authorized by.this building pertnit application for: 33 V�) Gcvz. ; (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspecti ns e pe ormed and accepted. Signatute of e of AppliygrZ Print Name Print Name to • Q:FORMS:OWNERPERMISSIONPOQLS ` Town of Barnstable Regulatory Services foF Richard V.Scali, Director Building Division n'R"'°'• Paul Roma,Building Commissioner aAse. �163 � 200 Main Street, Hyannis,MA 02601 Ep� www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print , DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityttown state zip code .The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or,farm structures. A person who constructs more than one home in a two-year period shall not be,considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or.larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required . shall be exempt from the-provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. C51zj_7/rf0, Town of Barnstable *Permit# a b 16,0 �a�g Expire73� ths from issues date Regulatory Services Fee �o� snaxsrna�, vMAW 1639. Richard V.Scali,Director p1� Building Division �� Tom Perry,CBO,Building Commission ss 200 Main Street,Hyannis,MA 02601 DEC 012015 www.town.bamstable.ma.us -�p'� Office: 508-862-4038 o F BWWOAb6230 EXPRESS PERMIT APPLICATION - RESIDE 1 ONLY �� Not Valid without Red X-Press Imprint Map/parcel Number� �� 1 i o\ Property Address 3 3 G N C; Ff� T C'a y desidential. Value of Work$ 5, :50 r-) Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C4 a-L. S Contractor's Name c G VJ 0'N K.. M o N:N:C n 1oo Telephone Number Home Improvement Contractor License#(if applicable) 1255 31 Email: e ,I�A<=- Construction Supervisor's License#(if applicable) 'arkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ Lam the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ st(check box) . LZ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 9C.-if-P-14S ❑ roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#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 required. SIGNATURE: C:\Users\Decollik\App a ocal\Microsoft\Windows\Tempo tercet Files\Content.Outlook\2PIOI DHR\EXPRESS.doc Revised 040215 I ` i The Cornntonivealt it o,f Massadiusetts _-- Departtiteirt of Industrial Accidents Office of Investigations 600 Washington.Street -- Boston,AIA 02111 t4wvtv.mas&gav/ilia Workers' Compensation Insurance Affidavit:Builders(C-ontr actors/Electticaansfp"lumbers Applicant Information Please Print Legibly Name(Bu=eworgu=tLon4mclivaattall: C �..� A- o ty�GURc o a�RV� 1�GS�GVe) �d\I A Address: 0V ,j S6- _ CitylStaterZip: Phone#. ��'' J SO K if , Are you an employer"Check the approp 4 Type of project(required): 1_El a employer with �a general contractor and I loyees(fall andlor part-time).* �Ve hued the sub-contractors 6. ❑mew construction, 2. Ism a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling strip:and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition fNo workers' comp.insurance comp.insuranoe.t 10_❑Electrical repairs or additions required-] 5- ❑ due are a corporation and i� � 3_❑ I am a homeowner doing all work officers have exercised their 11_❑P g repairs or additions self o workers' right.of exemption per MGL myself � �mP- 1'2. of repairs insurance required.]T c. 152, §1(4),and we have no employees.[To workers' 13_ thou St G5 t� comp-insurance required.] *Any applicant that checks bon#1 must also fill out the section below showing their cers'compensation policy inbimatiaa Homeovinirs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afidavit indicamg su€h. =Contractors that check this box must attached an additiond sheet showing the name of the sub-contrK#rrs and state whether or mot those entities bwe employees. If the sub-contrsctots have employees,they must provide ftit workers'comp.policy number_ I am all etatpioyer that is prot+iditrg workers'cotaapensation insurance fotr arty euVo yetis Below is the policy; and job,site information. Insurance Company Name: Policy#or Self-ins-Iac..#: Expiration Date: La 13 \ tM Job Site Address: 33 GkN G6u �,. Citylstatedzipc C 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 2.5A of MGL c, 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andlor 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 he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerfift ander the pains and penatfies of pedury that the art orattahonprttrtid'ed ab ire is t w and correct Si tune: C Bate: Phone##: o 0 0 O cial rtse onty. Do not mite in this area,to be completed by city or town afficiat City or Town: PermitlUcense Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 74 snntvs ABM ,� Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 i Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) l o, �-� Si azure of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Fi1es\Contcnt.0ut1ook\2P10I DWEXPRESS.doc Revised 040215. Rightfax N2-1 10/14/2015 6:07:09 AM PAGE Z/002 Pax Server DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE T. IFICATE 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. D THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME: PAUL PETERS AGENCY INC PHONE FAX 6 FALMOUTH HEIGHTS RD (A/C,No,Ext): (A/C,No): EMAIL FALMOUTH,MA 02541 ADDRESS: 25TSR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY MONTEIRO,EDWIN A DBA MODERN DESIGN HOMES INSURER B: INSURER C: INSURER D: 169 MARAVISTA AVE INSURER E: E FALMOUTH,MA 02536 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN&SUED 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 CERTFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEAMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY j PAIL)CLAIMS, 6NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MmmyYYY) (MLMM\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY a PROJECT❑LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNEDAUrOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X ,WC STATUTORY I OTHER EMPLOYER'S LIABILITY Y/N UB-0459MO61-15 10/13/2015 10/13J2016 iLIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N!A E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? (MandatorylnNH) E.L.DISEASE-EA EMPLOYEE $ 100,000 It yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR MONTEIRO,EDWIN A. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 367 MAIN ST IN ACCORDANCE WITH THE POLICY PROVISIO 0 , AUTHORIZED REPRESENTATIVE HYANNIS,MA 02601 ` ?. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPW1 is reserved. I �� :- ,• �fieo'nyrr�ariweaC�i" • k '.dlahon: + ... ` &'Business Reg "' ffice of Consumer Affairs ; ME`IMPROVEMENT CONTRACTO, istrat►on .125531',: Type: r 9. dividual s-1 j_15/2016 I n. xpiration j ' ED 'IN A.MONTEIROI EDWIN MONTEIRO ! 169;MARAVISTA E.FALMOUTH,'MA02536 Undersecretary " - rA� +r`, �. s '"�a'�' a•^ n.-,rxf,E,�,`ks�,a w-."✓" +' d_r,.E'f:��, y Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-066099 Construction Supervisor }•�' EDWIN A MONTEIR 169 MARAVISTAAVE EAST FALMOUTrI M` '0 5 6 = )I lit Expiration: ' Commissioner 10/19/2 017 p ` C l fze TP �'" y � �;;�C�vEccaa�acl uaeC� �� � aryunaprypwea ff ce:of Cons6uier Affairs&Business Regplahon ME IMPROVEMENT CONTRACTOR ! b. gistration 12553'f. Type: Individual xpirationla 'EDWIN A.MONTEIRO°G r fDWIN MONTEIRO -,169 MARAUISTA.AUE , E FALMOUTH„'MA 0253t Undersecretary ; s Massachusetts Department of Public Safety Board of Building'Regulations and Standards License: CS-066099 t a Construction Supervisor EDWIN A MONTEIRb �'" * 'i: 169 MARAVISTA?aVE / EAST FALMOUTJi M 25 4 � r "'"� l_✓�_ _ Expiration: ' Commissioner 10/19/2017 n t i'u r j! , License or,reg�strafion valid for mdmdul use only before the exp�rat�on date •If found return to Office of.Consumer-Affaj`rs;and Busmess Regulation ,.. AWY l0 Park Plaza Surte 51.70; Boston,MA 02116 '_ out s► nature '� ;,Not vale g 5 i ..License o`rregistration valid for indmdul use only before,the ex gyration date °If found return to P x ar G Office of.Consuine Affairs and Business Regulation 10,ParkPlaza Sdte5170 4 Boston,-MA 02116 F V • Not t vah hoyt signaure„ � .�. Y� '� •'� �.$n.;�+iF-, mkt t�ws .:.�a�".,�;...,,�T.::`r*', �eo-;:.a,- ��'"t• n�v 9 A{% III ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel `� Application# �� v�� Health Division Conservation Division Permit# Tax Collector Date Issued 1 Treasurer Application Fee Planning Dept. Permit Fee / Date Definitive Plan Approved by Planning Board GI 5/I►1a7 Historic-OKH Preservation/Hyannis Project Street Address e tb\i�m Village C—c—mm. \,A&v7 . A Owner m A 1% Ff; y S Address Telephone CG - Permit Request as c 6 Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuationit�S 0 Q- 0-,(30 Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing a 29w Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor RooRt'-vount w Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal tove: LJYes P]No pp M Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑exis ng ❑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 BUILDER INFORMATION Name(z'lawk4.) A: Vt �` � Telephone Number Address ikl�Acwgs ck, License# ��� rtk . TM o)\5 Home Improvement Contractor Worker's Compensation# " ` ' Ci �aj ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO C' �i� SIGNATURE DATE �° FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED r' ` MAP/PARCEL NO. ADDRESS VILLAGE OWNER r ` DATE OF INSPECTION: , FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL " PLUMBING: ROUGH FINAL GAS: ROUGH FINAL . . FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations ' ! d 600 Washington Street Boston,MA 02111• wY*.mass.govldia ' Workers' Compensation Insurance.Adfidavit: Builders/Coiitractors/Electricians/Plumbers Applicant Information ( .Please Print Le gib Name(Business/Org ' atioC dividual): .�CI�J\v.� Mo_YksALo o6'm �J,d•N�6"S � . •Address: � t cavJ. ,... •— �At� CRC � � • 1 City/State/Zip: 1�: Phone.#: Are you an employer?Check the appropriate b 1, am a employer with . ; 4 am a general contractor and I :Type of pioject(required):• ❑ I 'employees (full and/or part-time),* • have hired the stub-contractors 6. ❑New construction . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑R modeling ship and have no employees These sub-contractors have g• molition working for me in any capacity. employees and have workers' comp,insurance.$' 9. ❑Building addition [No workers comp,insurancear 10.❑Electrical rep airs or additions required.] 5• ❑ Vile are a corporation and its q ] officers have exercised their '3.❑ I am a homeowner doing ill-work . 11.❑Plumbing repairs or additions . mysel f, o workers comp. right of exemption per MGL Y � ' P 12.0 Roof repairs insurance.required.]t c. 152, §1(4), and we have no CN employees, o workers' 13.❑ Other_ . • comp,insurance required.] *Any applicant that checks boi#1 must also fill out the section below showing their workers'compensation policy irfarmatien. f Homeowuers,wbo 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'camp,policy number. I am an employer that is providing workers"comp ensation insurance for my employees. Below is.the'policy and jab site, information. ��� . Insurance Company Name: QQ� Policy#or Self-ins.Lic.#: U D 221 9 Vs 5(A Expiration Date; �0 \ �' Job Site Address: 33 a�)Ccf�c �_W �C'"1�tiZ�"`e'C City/state/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure.to secure coverage as required under,Section 25A of MGL c. 152 can lead to the imposition of crarinal penaires of a fine up to$1,500.00 and/or one-year imprisonment,as weL as civil penalties in the form of a STOP WORK,ORDER and a une of up to$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the.Office of Lvestisations of the EIA for insurance coverage verification, I do hereby certify under the pains�dp ' o er' ry that the in orrnation provided ab vg ' true and correct. E Pture: Date: ------------- 1j OfZcial use only. Do not write in this area; to.be completed by,cry or town offuicl City or Town: ' Tern-_'t/License Issuing Authority(circle one): .'1.Board of Health 2,Building Department 3. Ci��own Clerk 4.Electrical inspector 5.Plt:tnbing T sDector 6, Other Contact Person: Phone#: I ' tormanon ana in mr cuu u s Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to t statute, an employee is defied as".,.every person in the service of another under any contract of bL e, 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 t1,e foregoing engaged in a joint enterprise, and including the legal representatives of a-deceased employer, or the receiver or trustee-of an individual,pa�ership,association or other legal entity,employing employees. However the owner of a dweLing house wing not mare than three apartments and who resides therein,or the occupant of the dwelling house of antler who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant taereto shall not because of such employment b e deemed to be an employer." MI CTL chapter 152, §25C(6)also states that"every state or local licensing anency 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 of public•work untii acceptable evidence.af-cozsplar;ce 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-conti:actor(s)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 sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers.' compensation policy,please call the Department at the number listed below: Self-insured companies should enter their self-insurance license number on the appropriateiine. 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 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 fo 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 C0.MMaWV1-W of Mass huWtts Departmect of ladusWal A.cald=ts ' Qfflee of Investlga ons R Washingtog S•tred Bostonx.MA 02111 TO.#61 7-72'-000 ext 406 or 1-877 MASSAFE Fax#6.17-727- 749 Revised 11-22-06 V .Ma=&ENV/din r - 05/07/07 12:45 FAX 617 426 2835 STCLL & LEE INC 1 001 05/07/2007 12:51 5085489481 MONTETRO REAL ESTATE PAGE 01 Town of Barnstable.. Regulatory Services. . �; BuIldiag Division ®an��xrT, �uildta�resnmieai®xxer - ` 200 tvi.StmA Umals,Asa 02601 �rvv`r�.t®�.baraxat�.ble.'�a.as Of5ce; 568-862-4038 F,�x: 508,7904230 Property Oner Must Coniplete and Sign This Section. If USml g A.Builder as Oaer ache s�bJ'ece roe . . P p . � hereby authorize - ``� A , V0 ���= °�:1 to 04ct on,my behalf in all ark Uers rclatiyc tp,ivork authorized byc6 biad q Peru spp9 cwaon for: cc (kd&t i 01 J® ) ` S,�urt�r�C?wnor Da - i r �FO�S:UWAiER?�TS�I01� .. • No U�IUV o T uw 860-277-0111 5/7/2007 4: 38:07 PM PAGE 003/003 Fax Server ACOR®. CERTIFICATE OF INSURANCE ' . DATE(MMZD%YY) 05-0 -u;- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION! ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAi E PAUL PETERS AGENCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 6 FALMOUNTH HEIGHTS ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 669 COMPANIES AFFORDING COVERAGE FALM0I.JTHj/.A 0 541 ' COMPANY 25TSR A.HARTFORD GR0I1-11? INSURED COMPANY B MONTEIRG EDWIN A DBA DBA MODERN DESIGN HOMES* COMPANY 169 MARAVISTA AVE C E FALMOUTH,MA. (7?i36 COMPANY h D COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED TO THE iNS!JR£D NAME ABOVE FOR THE POLICY PEROD INDICATED,NOTW!THSTANDING' ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER.DOCUMENT WITH RESPECT TO WHICH THIS CERTIPICAT'E MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRISED HEREIN IS SUSJECTTO ALLTHE TERMS;EXCLUSIONS AND CONDITIONS OF$LICH POLICIES.LIMITS SHOAIV N;A`r HAVE BEEN REDUCED BY PAID CLANS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE jMM1DDWY) DATE(MMODWY) LIiVIITS GENERAL LIABILITY GENERALA0GF.EGA7E } COMMERCIAL GENERAL LIABILITY PRODUCT S-COMPIOP AGO. $ CLAIMS MADE OCCUR. �, PERSONAL&&ADV.INJURY S OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE 3 FIRE DAMAGE(Anyone fire) $ III MEO.EXPENSE(Anyone person) S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT' $ ' ALL OYV NEE ALIT CS PODILYIN'JURY;PerPerscn) $ SCHEDULE AUTOS BGDIL'(INJURY IPerAccident) $ HIRED AUTOS V, PROPERTY DAMAGE $ NON-OWNED.AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN.AUTO ONLY: EACH ACCIDENT 5 AGREGATE S EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSAif7ON AND A EMPOLYER'S LIABILITY UL-OC73E795-06 10-13-06 -10-13-07 STATUTORY L IMi"S.. X THE PROPRIETOR/ EACH ACCIDENT $• 100,000 PARTNERS/EXECUTIVE % INCL DISEASE•POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE•EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVENICLJESJRE iTRICTIONSA^)PECIAL ITEMS ''HIS REPLACES ANY PRIOR CERTIF<CATE ISSUED TO THE CERTI.F'ICATE HOLDER NFFEC`TING WORKERS COMP COVERAGE. THE NVORKERS COMPENSAIION POLICY DOES NOi PROVIDE COVERAGE FOR MONTEIRO EDWIN A. CERTIFICATE HOLDER CANCELLATION SHCLL.D 4NY OF-HE ASOVE 0ESCRI3EC PCL(CiES 3E C*,(,LlLED EEFORE THE TOWN OF BARNST'ABLE EXPRATION DATE T'iEP.EO- T-1E ICSUING COMPANY'Is ILL ENDEAVOR TO MAT-10 - DAYS WRITTSV NTj7%.E-O T!-E OERTI-'(:ATE 10Cu:R NA',i ED-C TIE LEFT,SJT r' BLDG DEPT 7ALURE TOMAIL SUCH NOT'CE SHAL L TIPOSE NOOBL!GATION ORLI,aILITf OF ANY 167 MAIN S 1 KIND JPON THE?Oh1>wnY,ITS AGE'cTS OR R_.`RESENT.TrVES HYANNIS,NIA 0 601 AUTHORIZED REPRESENTATIVE Ran-lini fiver ACORD 25.5(3193) " Results Page 1 of 1 e Licensed Contractor Look Up Select the search method: I License j Maximum number of matches: 25 1 Enter Search terms separated by spaces. 66099 Select Search type: AND r ORSeach Search Results City/Town Name Type Lic. # Restriction Expiration Street State Zip MONTEIRO, 169 E FALMOUTH EDWIN A CS 66Q99 00 1Q/19/2007 MARAVISTA MA 02536 AVE Total of 1 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.ma.usibbrs/contract.pl 5/11/2007