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Home My WebLink About0279 GLENEAGLE DRIVE 79 &/a h e � e 1, n m ��wsp Town ®f Barnstable Permit Expires 6 manthsfronr issue date Regulatory Services .Fee t Bnarrsrnars, 1639. `� Richard V.Scali,Interim Director r , Building Division . Tom Perry,CBO,Building Commissioner ' 200 Main Street,Hyannis.MA 02601 www_town.barnstabl e.ma.us Office: 508-862-4038 Fax: 508-730-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY l a a t o Nor Vafid ivithout Red X-Press Imprint Map/parcel Number .- Property Address GL ®Residential Value of Work S-_ Q Minimum fee of$35.00 for work-under$6000.00 Owner's Name&Address��CLrneg -1 `fie+_ 'YYl l �. CJ2 MRA 4-)t I La !'h n- C-3!R l D-;kzk Contractor'sNamec)OU��X n We Wind ;1. )Aj `n=. Telephone Number 4` b i t�f.1141uVil . Home Improvement Contractor License t(if applicable) 1- 9,4 57 Email: Construction Supervisor's License#(if applicable) &Vorkanan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner- OCT ®9 2014 Na I have Worker's Compensation Insurance 1 n'n' n Insurance Company Name TOWN OF BARNSTABLE Workman's Comp.Policy# h q 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`strippirig. Going over existing layers of roof) ❑ Re-side s Replacement VJindows/doors/sliders_U Value 30 (maximum 35)#of windows d #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. Separate Electrical&Fire Permits required. °Where required: Issuance of this permit does not exempt compliance with oilier town department rep lations,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 SIGNATURE: TAKEVN MBuildi ESS PEPMITlEXPRESS.doc Revised 061313 The Commonwealth of Massachusetts r7: - Depa tment of lndustriaI44ccidents y Office of Investigations 1 Congress Street,quite 100 w�a Boston, 114 2017 www.mass.govldia Workers'Compensation Insurance Affidavit:.Builders/Contractors/Flectricians/Plumbers Applicant Information Please Print LegibIv Name (Business/organization/jndiidual): SOUTHERN NEW ENGLAND WINDOWS LLC Address: 26 ALBION ROAD City/State/Zjp: LINCOLN, RI 02865 Phone#: 401-228-9800 Are you an employer?Check the appropriate bog: L 0 I am a employer with 20 4. ❑ I am a general contractor and I Type of project(required): 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.* 9. ❑Building addition required.] 5. ❑ We are a corporation and its I0.❑Electrical repairs or additions J.❑ I am a homeowner doing all work officers have exercised their 11. Plumbing re myself. ❑ g pairs or additions Y [No�rorkers' comp. right of exemption per MGL insurance required.] t C. 1527 §1(4).and we have no 12.❑Roof repairs employees. 13.0 Other WINDOW REPLACEMENT [No workers comp.insurance required.] *Any applicantthat checks boxi ' must also fill out the section belovsshonnng their porkers'compensation policy information. Homeowners vho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a neiv affidavit indicating such. Contractors that check this box must attached an additional sheet shoving 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. T 1 am an employer that is providing workers I compensation insurance for my employees. Below is the policy and job site infonnation. Insurance Company Name; ARGONAUT INSURANCE COMPANY Policy fi or Self-ins. Lie. !#: WC927938352394 08l21/2075 D Expiration Date: Job Site Address: 7 • ` City/State/Zip: Qha /(,Z !'Y)l4 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 Iead 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 In forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby rtify under tlae pains and penaRks'of perjury that the information provided above is true and correct. Si at Phone 9: 401-228-9800 0ffictal use only. Do not write in this area,to be completed by city or town offciaZ, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3-City/TOwn Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• f ,. . . . .4co d' CERTIFICATE OF LIABILITY INSURANCE F°"'�"�°°""""'' 08/12/2014 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(hes)must be endorsed. H 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 8eu of such endorsement(s). PRODUCER Willis of New Jersey, Inc. CT c/o 26 Century Blvd PHONE AMJftJjk 1- 77- 5-7378 FAX P.O. Boat 305192 A/C No:1-888- 67- 378 Nashville, TN 372305191 USA ADDRESS:cartificatesewillis.cam INSURER(S)AFFORDING COVERAGE NAIC 0 INSURERA:Selective Insurance of 8s 39926 INSUREDSouthern New Ragland Windows LLC INSURERB:The Beacon Mutual insurance 24027 D/e/A Renewal by 26 Albion Andersen INSURER C onaut insurance 19001 Road Lincoln, RX 02865 INSURER D INSURER E: INSURER F- COVERAGES CERTIFICATE NUMBER:N529160 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. DR LT TYPE OF INSURANCE DL SURRI POLICY NUMBER POLICY EFF POLICY EXP UNITS X Ce1W9tGALGENERAI LIABRRY ❑ EACH OCCURRENCE $ 2,000,000 X DAMAGE A CLAIMS-MADE PREMISES O ooanrenae $ 100,000 MEDEXP Any—persqAGG $ 10,000 8 2029459 08/10/2014 08/10/2015 PERSONAL aA0vINJU 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 3,000,000 POLICY � �LOC PRODUCTS-COUP/OP 3,000,000 OTHER. $ AUTOMOBILE LIABILITY EBINED SINGLE LIMIT sd $ 1,000,000 as' X ANY AUTO BODILY INJURY(Per person) $ ALL A AUTOS �OOSS LED 8 2029459 08/10/2024 00/20/2015 BODILY INJURY(Per acddent) $ X HIRED AUTOS X AAUTOSSWNED PROPERTY DAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESSLIAB CLAIMS-MADE S 2029459 08/10/2014 00/10/2015 AGGREGATE $ 5,000,000 DED RETEMItNI WORMERS COMPENSATION AND EMPLOYERS'LIABILITY' YIN X IER $ATUTE ER B ANY PROPRIETORIPARTNERIEXECIJTIVE OFFICERIMEMBER EXCLUDED? a NIA 00000680 E L.EACH ACCIDENT $ 1,000,000 28 OB/21/2014 OB/21/2015 inIq N K describe under EL DISEASE-EAEMPLO $ 2,000,000 yes, DESCRIPTION OF OPERATIONS blow EJ_DISEASE-POUCYLIMIT $ 1,000,000 C Work Camp/SL Covg: NC927938352394 08/21/2014 08/21/2025 .L Ra. Accident - $1,000,000 Statutory Limits - NC L. Disease Policy Lmt - $1,000,000 L Disease Ba. Rmployse - $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sdoduls,may be stladurd H mom space b nqulred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southern NR LLC AUTHORIZED REPRESENTATIVE 26 Albion Road A r oln, RI 02065-0000 e �taa 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD SR ID:6629625 BATCBsBatch N: 79627 May.27.2013 08:59 P.AUL CObBOY RENEWAL ANDER,781 545 1293 PAGE., 6/ 6 ls��uirx asaa*o' t`�ndemn �, RFNE,IYAI BY DERSEN �e wing" aaacadr b� 26 AiWirot iWad • liaauLc KI IyY iS r�vvl,a n eos:r Pleuotr,8064(.4 2M•Fux 40 L.63S.W4 rat r�i u1 4�aresiwo _ u 8ovth,eea New Ergiand W'mdo.+es ILG d!b/a . Renewal by Andersen of&m&ern Niw 6agland CUU01M ViMO'W,Arm DOOR REMODELING AGRRSIdENT 9 Som Gb.3mea v�d 2ir Co�E 1 P.0.8m '" 6.7 crrra C . io 0163i�?." 6nSd�tdsw Nt¢yT eyP6.d�rr vn,rp7papaoANuaMr'. Iiuyes{;eJ ftcirt'hy jiniedfy uiul nrsif:mlly agR�c t,n�„(rhsw ohr piiducix and/or x:rriuocd'Scn�tlxrn Atc�v Fa�,imi�Yt�+mx I.I.C'tFibla Rciuctitil Iv}'At�deraon of Suulhcru New FSiejiutd(Gutip�cc wr ),in tiuuw+lorice wah doe rernos 7lt .0 ilfrvu:caxnbed,xn fhc fetn.L and fhr rewcrx Of this agnt—i ocat mod wo the utiad►nc0 fpacdi�:uerii�shnci{rj(c slkcG ;-thu':�giccmcid'.'}: ❑IUsbarlc' ❑Cnsdn ®fEOAY TotalJobAmount/4 6 ® t msidit"Pf� Mr edofPoymerat 'OCMeck UICtsA+ Sar►aed n c Necdv d( aJ` C"t Cir&are.awWA for dapack a dr-maximiann 1(3 of ft fmhnoru Smart d)ah(33 ) Eernnme c° Damwaloer mff a nee ceeda two ) � Otis"Otis"'a AS--- .y-admo,.wio dvr eho eaf we ze Sterc.f"m,e tM ag nm as S Mgt eompletea of job a be mMe by eP6ah C imn r6lob( y'J Ord on mdt be eM&by MrsafW&M&bVik dvDck or wn: Buyear(s)apum and vale *u this Agmoa wnt cangdMies the v.169 odd r b sing 64wee.the 1 'and that bra am no verbal any of..abe terms ot.{Ids Aginamant..B.yzr(s) adkmigwvledges tksi Beicl(s) (I)has Bead dds Agmerasit,wWWftlw&ft tha mane a.thin Apwement,Aid has recwi.ed:a oomplrcedr a4otdt a"dead cagy of tideAg;w$M*d,lach, tinetiegibedrladeeaef.canoeuadon,onrfaadare first writ6eonb*w*wed(x)wasorally ingorned of IS�yois : aaaael tlaigAsceamaat.DO NOT UGN T IM CONTRACT IF THERE AM ANY BIJIN, -eft Btli. OUJO s Island SakV OXf Vj NVtWF W s,y6s(1)Ifo'•ot'a guam eft It=y d dw gmoM sated m ie.:peed o to the casse�t of dma civaoil*W hdai ukdom arse left blauh.(2)You an Sanded tw A'eopy of tEm Aweeroeni nar die. 1bs d.+..i""o sage yt.{3)Yaa mey itt any time pay off dos fill maid bob ace dine,a AlsAgrwaLanA and in so doing jvw only bo oatw&A to" receive,a partial rebate of tbo Em9bieo nmA iaa amec (4)The"lisp fives"right to unlawfw*enter your pacmiaee err eosnml.t�3'biseeh ad tbs pwa90 tw rapors�ac gn°de pterabased wades thin pgrooa..ut:(S)Yo.may ianeel pia df fr bag nwt 5esa afVmd st due nairi off ar a 6raaab ofBee of tfce seller,prowidadYa":nnfafy the seller at has or ber main ofBCce or bramda cfSce 't6owa.fn ffie'Agntby d+eg�teired of ceitlAed many which alall be posted sotlaier than ms+bod�tt of'the tUr+d cabtadotr day aftwr the dayoat tr>bk the buyer fdgnetlm Agr.'amwot,`eac6rdmg Sonday and any 4oliday gas wbdch marl aatit+a9aa are aa1 made.Bee do wcoinpanying nodes of;ai adm firm for an" ef buyer's cigbt& Bulcefi)nr_'cfiml fhc - (�r3'Iara�J ' Renewal by .of Now XV91"d air p sn ` Br: ram`~• �6Gi s iytawt Si etuto �J/Gen r GtcSCrj" l'rintrtmiueodFroditctlulstet� P'rloaPfante P,iniNamc , YOII►THIB BUYSR(S), MAY cANCBi.THIS TRANBl1CTi0AI A?.A TIM6 FRIOR-TO MIDNIGlff OF TM THM BUNM%6DAYAFiSJ1=DATEOFTHmTRANgAL"1'i0li,=THEAT151CHEDIY0r=Ol?OANCE "TIONFORMS FOR AN EMANATION OF.THIS RIGHT, ce of Dale.d TranrKtiea— — —'LAT1014 satfa�l �s UW cwm d dh tmns=11ia4 vAfiout wary peaialtDr or watkin tbhareitsaeilo w[�M!seY peasMy or ahlgaBe*vA" tbrww batlests ftemt the mibmm dats6 tfyaa—el,awl, I tfhee baminea ft+wri the abpve Saba.N yea.need a4, �aa��ppww��rr ti'aded 4.MY tatiti enda by you under 1&a � P�Pe*{Y.""E 1%omf Peat;nmda'byi you niche,line fvo a�or gal%and any "�61�Iwskrwrrnat;.exemafcd I. COSRI9MDE or So*and a*n Itlttf sksculed bw-pow vela be NWA Od i�tC2 tMl AbSovAng I,*rw!vde be estaawed-vAlWn."eml°eta Ianwmns by lbw Sin*of aaseeXEjjoA tmda `"a My I` tb.$olkr.e1 yo�frrt i pyCaNallnn- sad A" eaettriq/ fuldeg Oat of dw will be � nterimA wWni w =of &e"traraaatloa will be eaftc".flyvuc 0_4' n,maormlbea.Nib&6,6d;eSeflff I. eance"Iffp°eanQa� �dt�meeosbe.Soer at)Pair reddeooa its ss>Qoo4 QonfigaA.#s wine I_ ne ym tuside=n o . as coedltls°= wre n r.a:eiared:aw gaodie dAv.sped tie you tredw d&Centrack or, I eecwr*d,a l'So°ds Ael6tnerel m yea ands,ehAs Caenatraet oN ary.oe�ffyamvnatyao vamthe irr j-Sekneryl"?M44d#p.__jw1b; bvditteel om6f Mylr_11nadenett". neatcftbegeno atNte tiosS�re�r�the return�trientofee attM Salves sae and rW f yow do,nw"fits�pe�s evdLble � Sb :e�Mw and*A6It yen be Make Oe wMis bfc to tits l end the Sir 40"Met pickMa1et:up-vA&tn is for S�and the Shcwr.d6m:"t ptek,bem up vAd t tywny albe die ergaa6eWtlaa,y"0* maln,vewn ear I tweeey of e6e'dato of aaaeensdoi.yea NNW retain or ditpens ra/ goods i nay der e"�ee,;B You I''dlw— moods!eittioaat any der a 1t�u bIl to madew tits gvoi'a to tfw SmAm;ar Ngvn tree: I rill to avloe the joasd!awdlifble.te lab Scheyer if you s$Mo to retum tlte.0eiodS*$V the 144ar OM fall ea ii►,aei,-tlue I to retgre nisi gp*&-m,the Sebw and�m do.�ttrAn 1a aaeaals teem�far peeaaea.of an obpfaome anadw I you rv>maw same-for pulierauaae or aIn'owpowlis undaa t1c,Cmttiraclk- a.eovxd'tiels taata»edoty',mil or deiror the -]b_.aced"dda trunsw lhwe coin or da9vw 1t"tli and chid capr,dl tbfs' neAiea or smyr �' ia.>swed nod;dated copy of two oauoetb>!loti.molloe or'am ot6. w.iwfica air send atallWfte:4n Ran.-In by.L,vfho w11E00%itoei4 or,Slid'a ttlfipoMl to ltanre+tal-by `'Attdffm 01 Shins`...Nsw• me 1 III rarb Etdt Dts, I AMdt+een.of Sou&t New at d 137 Panic Eat4 Oa, Nsncdtsb f99i.KQT LARRTNAN f�pfAlt�ffr tiF I^ NOT LATIIItY{AN Ml1p1116}IT OF i N®ICdY CA1'IClL eta. 1 I$UMBY CAP&MT MTRMSACT10Nr eaer✓s al�r.eanr Pe1rt M.nw`y oaaa awin"t4uua+ snot r , i1tA COPY Y►gtMe ..0 Copy Yew "r Captr Pink Southern Ne w.Eng1arid 'W1n*d.o' s d.b.a Renewal by Andersen of SNE !A! Massachusetts-Department of Public:Safety Board of Building Regulations and Standards Construction Supervisor license:CS-095707. B1tIAN 6bRNNISbN 7 I A W POND CHt s Charlton MA 6A7 Expiration Coffunisiioner 09/0W/ 016 o��e�i�aaac�uae� � • . Office of Consumer Affairs end Businesas Regulation sc 10 Park Plan-Suite 5170 Boston;Massachusetts 02116 Home Improvement Contractor Registration i E Reglstration: .173245 n' Type: Supplement Card Expiration: 9119/2016 SOUTHERN NEW ENGLAND WINDOWS LL;t DENNISON BRIAN • 26 ALBION RD LINCOLN,RI 02865. Update Address and return card.Mark reason for change. SCA,0 zmwvn O Address 0 Renewal 0 Employment E)Lost Card �x-,non�i.�ea(!/s o`Cl�amacbuac!!d •. : glee of Consumer AlTain&Badness It - License or registration valid for 14widul use only. ME IMPROVEMENT CONTRACTOR '•- - before the expiration data If found return to:' Office of Consumer Affairs and Business Regulation eglatratlon: 1732,5 TYpe• 10 Park Plaza-Suite 3170 f Ezpiratlon: 9/, M,6 Supplement•.;ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC.,' . . RENEWAL BY ANDERSON's DENNISON BRIAN 26 ALBION RD I'I LINCOLN,R102865 VWersecrcury Not valid without signature i 1 Town of Barnstable *Permit# �Y� "'�1•� Expires 6 months from issue date g Re ulato Services Fee o , �MAS& Thomas F.Geiler,Director 059. & � Ep MA't Building Division 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 (� 0 Not Valid without Red X-Press Imprint Map/parcel Number _`ProPerty Address ' '� cyz/" Residential Value of Work r Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ' Contractor's Name G V U N rldu0 -P t5ax) Telephone Number Home Improvement Contractor License#(if applicable) / 3 Construction Supervisor's License#(if applicable) lJ� � -PRESS PKEVINpDam ( Workman's Compensation Insurance �UN 6 Check one: 2013 ❑ I am a sole proprietor ❑ I have the Homeowner TOWN OF BARNSTABLE [l�I have Worker's Compensation Insurance ,, Insurance Company Names_ Workman's Comp.Policy# 16 2g 3 ��3 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 #of doors (�Replacement Windows/doors/sliders.U-Value °!7 c 3 (maximum.35)#of window ❑ 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. \ ��1 SIGNATURE:�1 QAWHILESTORMS\building permit fomis\FMRESS.doC Revised 053012. i Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-095707 BRIAN D DENNISON ' 7 LAM POND EIRCLE' BS Charlton MA 01507 Expiration Commissioner 09/08/2014 _L�, C�� u�•ri�a.a��cu�alll a (�/l/�<.��acc�;/z�c�elri Office of Consumer Affairs en Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Repistnation: 173245 Type: SUPpI-mmd Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9119)2014 DENNISON BRIAN — - 1137 PARK EAST DRIVE - -------- WOONSOCKET,R102895 Updulr Address and return card Mark ream for change. scA1 0 raics^, 11 Address O Renewal Ci Employment Lmt Card - -.Otfi.of Comm...AM.&Badaru Reaalstba Mont or regirtrudon wlid for Iodividul ase only Me NPRIMMENr CONTRACTOR before the apirallon daw.If found return to: �'1^TiSgrte yes" Office ofConsomer AAalrs ad Business Reg"atinm 173245 yp To: Regulaiioo y� )0 Park Ptaa-Saite S170 Expiration:gn=014 St"W-nt:;and Boston,MA 02114 SOUTHERN NEW ENMAND WINDOWS tLC. _ RENEWAL BY ANOERSON DENNIS SWAN f') 1137 PARK EAST DRIVE WOONSOCKET.RI 9299E Undersecretary Not"lid wUboot signature Y Client#:30124 SOUTNEW . ACORD. CERTIFICATE OF'LIABILITY INSURANCE DATE(MMIDD/YYYY) 5/08/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the 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 NAMNE CT Anita Little - Willis of New Jersey,inc. (AIICONN Et):856 914-4660 a No: 856 914-1881 1015 Briggs Road nogeess: Anita.Little@willis.coin PO Box 5005 w INSURER(S)AFFORDING COVERAGE NAIC Y Mount Laurel,NJ 08054 INSURER A:Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER C:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen 26 Albion Road INSURER o Lincoln,RI 02865 ENSURER 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 CONTRACTOR 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. LTRR ADDLSUBR TYPE OF INSURANCE NSR WVD POLICY NUMBER POLICY EFF MMfDQ EXP LIMITS A GENERAL LIABILITY S202945900 8/10/2012 08/10/2013 EACH OCCURRENCE $1 OOO OOO X COMMERCIAL GENERAL LIABILITY PREMISES &ELATED ce $50,000 CLAIMS-MADE rx]OCCUR + MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1 000,000 GENERAL AGGREGATE' $2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY F PRO- ECT LOC $ J A AUTOMOBILE LIABILITY S202945900 8/10/2012 08/10/201 COMBINED SINGLE LIMIT Ea acdden{ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS accident)Per BODILY INJURY( ) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident - A X UMBRELLA LIAB OCCUR S202945900 8/10/2012 08/1012013 EACH OCCURRENCE $S 000 000 EXCESS LIAB CLAIMS-MADE a AGGREGATE s5,000,000 DED RETENTION$ $ B WORKERS COMPENSATION AIC927698352394 8/21/2012 08/21/201 wCS LIMIj oTH- AND EMPLOYERS'LIABILITY C ANY PROPRIETORIPARTNERIEXECUTIVE YIN 68028 8/2V2012 08121/2013 E.L.EACH ACCIDENT $1 000 000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 if DEe%describe under SCRIPT ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,006 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks.Schedule,H mom apace Is required) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road' ° ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION,All rights reserved. ACORD 25(2010/05) 1'of 1 The ACORD name and logo are registered marks of ACORD #S214638/M214631 AXL The Commonwealth of Massachusetts Print Form _ - _ 7 Department of Industrial Accidents + Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, Applicant Information Please Print Legibly Name (Business/Organization/Individual):_S&y4k0'/✓ AJ*u ii N'9&AldL W je�� e;LG Address: 4Ml�� City/State/Zip: e-/NGcGIN ases Phone#: l�C�l a�� e cj 00dro Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with o� 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 8. ❑ 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.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL- 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13 er PtO Gt,C.Pa^J�_ employees. [No workers' 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. ;Contractors 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. lam 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.#:_ r✓ ��76�g� 02 3 �7 Expiration Date: 11.3 Job Site Address: �t / _l � City/State/Zip: 3__X Attach a copy of the workers'compen tion policy declaration page(showing the policy number and expiry ion 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb cad er the a*ns and enaldes o e 'u that the in ormation provided above is true and correct Si afar .. Date Phone#: . d I a < ,pov Official use only. Do not write in this area,to be completed by city or town official ',. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other , Contact Person: Phone#: 1 RMaay.27.20013 08:59 PAUL CONBOY RENEWAL ANDER 781 545. 1293 PAGE. 6/ 6 - ' ll lli N2 mne a "°tl1 #1744',ENFWAL BY DERSENbyA, uerseL 26 6 cr I.i ��r+ocy<sas PUerNrNT .n Arvlu.enuispr, Alhinn Road • Lincoln,RI 028(i5 wrnoow er Levi iron if I tan Phunt:$f G,563.2235•Fm 401.633.G602 ndcrll 7'JN ui#46-00,6ua:.ut Southern New England Windows,LLC d/b/a Renotvstl by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(i)Nuns Date of ent AlneS d-�c,nc1 6 Buyer(.)$no Addren.Or/.Stare,end Zip Code/P.O.Box c�79 Ci eoea k_ 0o263Q. e-Mall Addrar HomoTelephene Number Work7olephmeNumbee ^Gcr I t acmcGs slit —],So a-771 Buyers)hereby jtlindy and 4r16rxally agrc:ts to purchuse the ptuducts and/or serviLes of Southern New England Wtndtiws,Td..p d/b/a Renewal by Anderson of Southern New Enowsd("Contractor"),in;uxordance with the terms and cxtndilions described on the front and the reverse of. this agrtrmcnt and on the attached specification sheet(s)(collectively,this"Agrccmcnl"). ❑Historic ❑Condo ❑HOA7 Tottl)obAmount://�Q Estimated Searting Date: Method of Payment I]Check U Cash k�F'�r`nanced Deposit Received A; 'ca Credit Cards are accepted for deposit only-maximum 113 of the job 33%):_..___....___ proles cosL(fie see Ciedh Caro rayment form.)By signing this Balance at Start of 1 ( Estimated Canpleu�'Date: Agreement you acknowledge that the Balance at Start of job and the Balance on Substapyldu� Balance on Substantial Completion of job cannot be made by credit Completion of job( l6).... _.-F.. __., card and must be made by personal check bank check or cash. Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing any of the terms of this Agreement.Buyer(s) acknowledges that Buyer(s) (1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and(2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Salve Only)Notice to Buyers(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it.(3)You may at any time pay off the"unpaid balance due under this Agreement,and in so doing you may be entitled to receive a partial rebate of the finance and insurance charges.(4)The seller has no right to unlawfully,enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(5)You may cancel this Agreement if it has not been signed at the main office or a branch office of the sellet;provided you notify the seller at his or her main office or branch office shown in the Agreement by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement,excluding Sunday and any holiday on which regular mail deliveries are not made.See the accompanying notice of cancellation form for an explanation of buyer's rights. Buyers)received she tmcr r. (Btryer's hititsk) Renewal by Of 4114s,New Ettglathd Buyer(s) Buyer s) By: cureff t ager Signal a / Si stun ��/ c aarr+e s7l Cep rl orree7` I�yl ii Print Name of Product Manager Print Name Print Namc YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. Et- - - - - - ^� - - - - - - - v�- - - - - - - - - - - - - - -� .OF CANER LATION - - - - - y NOTIC6�ESe9dSe TION Date of T.saaction S-r� �3 You may cancel : Date of ThuteaeHon y .You may rpnc�d this transaeden.without any penally or obggadon,within this transaction,without any penaky or obligation,within three business days from the above date.N you cancel,any I three business days from the above date.N you cancel,any Property traded In,any payments made by you under the l property traded in,any paymts en made by you under the Coursed or Sale,and any negotiable instrument executed I Contract or Sale,end any negodande Instrument extorted by you will be returned within ten business days following by you wig be returned within ten business days following receipt by the Seller of your cancellation notice,and any receipt by the Seller of your cancellation notice,and any security interest wilting out of the transaction will be atxurity interest arising out of the transaction wig be catmeled.Kyoucatrcal, umustmakeavaihrbletetheSeller I carwled.Ifyoucanctskyou must makenvai4tbletotheSeller at your residences,in substantially as good condition as when I at your residence,In srbstandaly as good Condition as when received,any goods delivered to you under this Contrast or I received,cry goods degvered to you under this Contract or Sole;or you may,if you kish,Compy with the Imtrtndfons of I Salgor•yous nw/0If ye:a wcis,Comply will:the lstet"V. dons eif the Seller regardingthe return shipment of the goods at the the Sailer regarding the return shipment of the floods at the . Stilln+s expense and risk.N you do stake tits grwds wAdiablp � Seller's expense an a d risk.If you do make the goods vailable to the Seller and the Seller does not p1le them up within I to the Seller and the Sailor does not pick them up within twenty days of the date of cancellation,you may'retsin or i twenty days of the date of cal Imio■.you may retain or dispose of the goods without any further oblgation,if you I dispose of the goods without any farther obligation.N you fail to make the goods s ral6,ble to the Salim;or if you agree I fail to make the goods w1aliable to the Sailer,or if you agree to return the goods to the Seller and fall to do a%then I to return the goods to the Seller and fail to do so,then you remain gable for performance of all obligadons under you remain iable•for performance of all obligations under, the Contract.To cancel this trattsaetionn,, mail or deliver I the Contract.To cancel this trranowdon, mail or dogver a signed and dated copy of this caneellatlen notice or any I a signed and dated Copy of this cancelladon Irotk:e or any other written notice,or send a telegram to Renewal by I other written notice,or send a telegram to Renewal by Andersen of Southern New England at Ill31 Park East Dr., I Andersen of Southern New England at 1137 Park East Dr., Wo o t 2$9$,NOT LAT'ERTHAN MBDHIGHT OF I W n 02895,NOT LATERTMAN MIDNIGHT OF 1 HEREBY CANCELTHIIS�T�RANSACTION. 1 HEREBY ELTHDIST�RANSACTION. Buyer's Signature Print Name Data arryr's slgnature Print Name Date RbA Copy:White Buyer Copy:Yellow Buyer Copy:Pink .1 Town of Barnstable F1ME Tp�� Regulatory Services Thomas F.Geiler,Director 9'"RNMASSB`Eg� Building Division Tom Perry,Building Commissioner ; XV µ f 200 Main Street, Hyannis,MA 02601 _ www.town.barnstable.ma.us cii rN a Office: 508-862-4038 Fax:: 508 Z90-6230 �- , a PERMIT#PZO( aO( FEE: rr, SHED REGISTRATION 120 square feet or less Location of shed(address) Village Property owner's name Telephone number le2x 1a L(o Size of Shed Map/Parcel# yea a Siena r Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? � Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU BF WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A n PLOT PLAN c.� Q-forms-shedreg REV:042506 F i i 1 u /Mo irx�c TM i !�t ?tI PC, 2r� v J i �-' C L -76 r. 1 G%SY�'y Vic, su Lc i x T E. �. / C�J�/�.�..Y —�^�!ll/ •.-y`"� `i � � �� . -..:{..J^1 C��.c �' i 1.,::�'�F'a �.l �.,r`L�� f��'� -1 « TOWN OF BARNSTABLE BUILDING PERMIT,APPLICATION,,, Map U Parcel "-Application #en2(ld��d=7Sd Health Division Date Issued Conservation Division Application Fee 770 Planning Dept; 'Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Stre t Address IE4 ea le P Village LIPA11y, HA 6 Owner ym_e S 91 e X( Address _`_2� Telephone, Q� Permit Request e&5O e a,We- Square feet: 1 sit floor: existing Maproposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 00�00D•cI�Construction Type GU Lot Size d 3' Grandfathered: ❑Yes ®'I<lo If yes, attach supporting documentation. Dwelling Type: Single Family :V' Two Family ❑ Multi-Family(# units) Age of Existing Structure c Historic House: ❑Yes a- o On Old King's Highway: ❑Yes W o Basement Type: LirFull ❑ Crawl ❑Walkout ❑ Other q Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) /C66 Number of Baths: Full: existing new _l Half: existing / i neg� f� Number of Bedrooms: existing 0 new 21 Y Total Room Count (not including baths): existing new First Floor Roa 1 Count'". en, _ � " Heat Type and Fuel: 2 Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑'No Fireplaces: Existing New Existing wood/c al stov& ❑p s ❑ No Detached garage: ❑1existing 0 new size—Pool: ❑existing ❑ new size _ Barn: ❑e isting nevi size_ Attached garage: ®'existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes C�"No If yes, site plan review # Current Use Proposed Use �Sau.A-k APPLICANT INFORMATION (BUILDER OR HOMEOWNER)__ Name p� Uf 2Y( 36-6 'j a ^e �co-o � �riz �.7U. �� /��• Telephone Number � T Address License # CS �33�!2�Q kl�ead .Sinai. Home Improvement Contractor# 0,u-,kgP.A)7U I MR 09-68de� Worker's Compensation # Co1_ q3_ f 6S1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6_56MOL SIGNATURE DATE 2)6 �� La FOR OFFICIAL USE ONLY - APPLICATION# DATEISSUED / MAP/PARCEL NO. ! ADDRESS VILLAGE OWNER - f DATE OF INSPECTION: FOUNDATION FRAME( INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL , GAS: ROUGH FINAL r FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please +Print Legibly Name(Business/Organization/Individual): '_D 14U\0_ -e_ zcx t �Oe`exs IN C. Address: F_b-cvi City/State/Zip: �eln��s�i"R�e Phone.#: Are an employer? Check the appropriate box: Type of project(required): 1. I am a employer with_ 4. 0 I am a general contractor and I employees(full and/or part-tim.e). * have hired the sub-contractors6. ❑N w construction .2.❑ I 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. employees and have workers' [No workers' comp. insurance comp. insurance. # 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 PIumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof 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. XContractors.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. lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: M,(�`e St Policy#or Self-ins. Lic.#: ('�� j— l�� Expiration Date: l Job Site Address: 1 ! �1�v\-eCzC� C. City/State/Zip: Le— ita 02-�h�j�— 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 tip 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 maybe forwarded to the Office of Investigations of the DIA for insurance cgverage verification. I do hereby ertify u er t ai ad [ties of perjury that the information provided above is true and correct: Si ature: 2 Date: a Phone#: 1 r7 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#: Information and Instructions n •. 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 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 enance, construction or repair work on such dwelling house dwelling house of another who employs persons to do maint or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an 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 of public work until acceptable evidence of complizrice 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-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be 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 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 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 ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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 Department of Industrial Accidents Office of lnvestigatians, 600 Washington'Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 61 T-727=774 Revised 11-22-06 www.mass.gQv/dia DATE(MMIDDIYYYY) ACORD� CERTIFICATE OF LIABILITY INSURANCE 08/OS/2008 PRODUCER (508)997-6061 FAX (S08)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Roycroft & Kuehne Builders Inc INSURER A.- Arbella Protection Insurance 6S Eben Smith Road INSURERB: Merchants Insurance Group Centerville, MA 02632 INSURER C: INSURER D: INSURER E: GRANITE STATE INSURANCE CO COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY 8S00022738 08/01/2008 08/01/2009 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPRFMISF.O.(Fa n 're $ 100,000 CLAIMS MADE �OCCUR MED EXP(Any one Person) $ S,OOO A PERSONAL&ADV INJURY $ 1,000,000 s GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: a, PRODUCTS•COMP/OP AGG $ 2,000 a 000, POLICY PRO- LOC JECT AUTOMOBILE LIABILITY 7AM027701409S 10/18/2007 10/18/2008 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 r ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) B X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS' (Per accident) $ PROPERTY DAMAGE 0 (Per accident) $ GARAGE LIABILITY +- AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBREL_LA LIABILITY EACH OCCURRENCE $ OCCUR F CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC 990610 09/06/2008 08/06/2009 X I WC STATU- OTH- EMPLOYERS'LIABILITY i E.L.EACH ACCIDENT $ 100,000 E ANY PROPRIETORIPARTNERIEXECUTNE gP OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ S00,000 If yes,describe under SPECIAL PROVISIONS below . E.L.DISEASE-POLICY LIMIT $ 100,0OO OTHER n DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS , CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL TOWN OF BARNSTABLE 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ATTN BUILDING DEPARTMENT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 200 MAIN STREET OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. HYANNIS, MA 02601 AUTHORIZED REPRESENTATIVE JJoanne Bretton ACORD 25'(2001/08) FAX: (SO8)420-1947 ©ACORD CORPORATION 1988 �, .JllG"ir'O/t67/lailflJfC7��O`l./r1tTd�C'CtGfC��.'. #,s Board of Building Regulations and Standards aat Construction Supervisor License = °u License: CS 83280 r Birthdate: 11/29/1964 Expiration: 11/29/2010 Trf# 5313 Restriction: 00 to omv/rw�afae a a . ` Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR SEAN J ROYCROFT ug 65 EBEN SMITH RD Registration: 141225 CENTERVILLE,MA 02632 Commissioner a Expiration: 1/22/2010 Tr#. 262207 Type: Private Corporation ROYCROFT&KUEHNE BUILDERS,INC. Sean Roycroft 65 Eben Smith Road Centerville,MA 02632 A inistrator E • Taff Town of Barnstable Regulatory Services . t =ARNbTABLE, • MAM g, Thomas F.Geiler,Director 'TEDrAf�A`� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder C"I" k , as Owner of the subject property hereby authorize Eel-v� �o CT-0 to act on my behalf, in all matters relative to work authorized by this building permit application for: -0 ( dress of Job) f if Signature of Owper Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION Town of Barnstable Regulatory Services BAms'rABM : Thomas F.Geiler,Director MAIM Building Division jOjfD µA'1 A Tom Perry,Building Commissioner 200 Main-Street,-Hyannis,MA_02601.., . ... ._ ._.. .-- . __.. wvm.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# - work phone# CURRENT MAILING ADDRESS: city/town 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. ,. k . 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 buildinIa 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_be/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 uttimatclyresponsible. 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 hdshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fonn/certifi cation for use in your community. Q:forms:homeeaempt REScheck Software Version 4.2.0 Compliance Certificate Energy Code: 20061ECC - Location: Barnstable,Massachusetts Construction Type: Single Family Conditioned Floor Area: 160 M Glazing Area Percentage: 30% Heating Degree Days: 6137 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: 279 Gleneagle.Drive James&Janet Micari Steven Cook Centerville,MA 02632 279 Gleneagle Drive Cotuit bay Design;LLC Centerville,,MA 02632 43 Brewster Road Mashpee,MA 02649 508-274-,1166 steve@cotuitbaydesign.com Compliance:4.3%Better Than Code Maximum UA:46 Your UA:44 LC Ceiling 1:Flat Ceiling or Scissor Truss 160 30.0 0.0 6 Wall 1:Wood Frame,16"o.c. 208 13.0 0.0 10 Window 1:Vinyl Frame:Double Pane with Low-E 22 0.320 7 SHGC:0.35 Door 1:Solid 18 0.140 3 Door 2:Glass 40 .0.320 13 SHGC:0.35 Floor 1:All-Wood Joist/Truss-Over Outside Air 160 28.0 0.0 5 Compliance Statement: The proposed building design described here is consis ent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has a designed to 4et the 20 IECC requirements in REScheck Version 4.2.0 and to comply with the mandatory requirements list i the RESche ns ctio hecklist. Name-Title Signat Date d Project Title: Report date: 01/12/09 Data filename:C:\Program Files\Check\REScheck\micari.rck Page 1 of 3 REScheck Software Version 4.2.0 Inspection Checklist Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-30.0 cavity insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame,16"o.c.,R-13.0 cavity insulation Comments: Windows: ❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.320 For windows without labeled U-factors,describe features: #Panes—Frame Type Thermal Break?_Yes No Comments: Note:Up to 15 sq.ft.of glazed fenestration per dwelling is exempt from U-factor and.SHGC requirements. Doors: ❑ Door 1:Solid;U-factor:0.140 Comments: ❑ Door 2:Glass,U-factor:0.320 Comments- Floors: ❑ Floor 1:All-Wood Joist(Truss:Over Outside Air,R-28.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints,penetrations,and all other such openings in the building envelope that are sources of air leakage are sealed.t ❑ Recessed lights are either 1)Type IC rated with enclosures sealed/gasketed against leaks to the ceiling,or 2)Type IC rated and ASTM E283 labeled,or 3)installed inside an air-tight assembly with a 0.5"clearance from combustible materials and a 3"clearance from insulation. Sunrooms: ❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U-factor of 0.50 and the maximum skylight U-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Vapor Retarder: ❑ Vapor retarder is installed on the wane-in-winter side of all non-vented framed ceilings,walls,and floors;or it has been determined that moisture or its freezing will not damage the materials;or other approved means to avoid condensation are provided. Comments: Materials Identification: ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R-values and glazing U-factors are clearly marked on the building plans or specifications. ❑ Insulation is installed according to manufacturer's instructions,in substantial contact with the surface being insulated,and in a manner that achieves the rated R-value without compressing the insulation. Duct Insulation: Project Title: Report date: 01/12/09 Data filename:C:\Program Files\Check\REScheck\micari.rck Page 2 of 3 i ' Li Ducts in unconditioned spaces or outside the building are insulated to at least R-8. Ducts in floor trusses above unconditioned spaces or above the outdoors are insulated to at least R-8. Duct Construction: Air handlers,filter boxes,and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and mechanically fastened. Lj All joints,seams,and connections are made substantially airtight with tapes,gasketing,mastics(adhesives)or other approved closure systems.Tapes and mastics are rated UL 181A or UL 181 B. Ll Building framing cavities are not used as supply ducts. Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. r Lj Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the International Mechanical Code. Temperature Controls: Thermostats exist for each separate HVAC system.A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor is provided. Certificate: ❑ A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values;window U-factors;type and efficiency of space-conditioning and water heating equipment. NOTES TO FIELD:(Building Department Use Only) Project Title: Report date: 01/12/09 Data filename:C:\Program Files\Check\REScheck\micari.rck Page 3 of 3 2006 IECC Energy Efficiency Certificate Ceiling/Roof 30.00 Wall 13.00 Floor/Foundation 28.00 Ductwork(unconditioned spaces): Window 0.32 0.35 Door 0.32 0.35 Water Heater: Name: Date: Comments: it Assessors map. and lot number .67i" . .. .. ..... .�....L...NO ' � �� _ v�, S MUST 13 EPTIC SYSTEM E INSTALLED IN COMPLIANCE. Selvage';Permit number ...............................`�.. ................... r WITH ARTICLE 11 STATE *THE TOWN -' OF BA R l � '_TowN . 1. Z BdHHSTOBLZ� i Gy MARL 1039. BUILDING, " INSPECTOR R c.sGrt �� CATIONS FOR z PERMIT TO . �D-,� . . ...... ....... r YPE OF CONSTRUCTION .. "..�•!V'...t'll. .. :.... ......... .............................................................................. ................................................19........ L 2TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit ccorcling to fhe following information: Location ...... .. ...... q. ,.. . . ..... 1.. .a/.. ......tip. ... ................� ProposedUse ... .... ... . ... ................ .................................. ...... .. .... .. .. Zoning District �. ........................................................................Fire District �-` ........ . Name of Owner, ... . vVs. ....Address'� ..Y.. �! !F. : . .. ....... .. .... .. Name of Builder ..... ... ... .Address; : ..� r ... ., ..Name of Architect/�� .... ....Address ...................................... ............... .............................. Number of ooms ,�/V`-e... � .. .......... ....................Foundation .fll.... ... ............. .. .. Exterior .. . . .. ... . ...� .. ...*.... ........ ...............Roofing .. ................ . .............. Floors .... A ..........................Interior ... ... ..' .. ::.fir,�.:5�......�.... .. . ..... ....................Plumbin ... ..t..V..a.(.)......#...Heating' L}.:L4�?l....... . ....� . . g .. . ./. .......�..'.................... ,� Fireplace ..... .......Approximate Cost` v .................... Definitive Plan Approved by Planning Board --------------------------------1-9--------. Area ....... . ...... ... ... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH Lo0/3 00 NSA K"T 3� L e-e. #1 hereby agree'to conform rto all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name `` .�% •1 ��: Trudell, Raymond W. 18602 1 1/2 m tory, �_ < No ........:.......:�Permit for .................................... -- ",single family ,dwelling Locat fi� %!,n gle Road........................... Centerville ..................... .................................. + • _:t �'� Owner Raymond W. Trudell Type of Construction ............frame ........... \ i ....... ..................................................................... "Plot ............................ Lot ...............#2.6.......... 1 ! u - Permit�G August 1ranted ...............�........... ....::,19 76 Date of Inspection . .. . . ""'� f :Date Completed ......19 PERMIT REFUSED' r' •# i .r +. 7r ................................... ......... .... 119 .:•J ' .. .... f/............................................................ .. -V . ............................'.�.................... w / i +t t- t t.......................... ...! -�7....... -' 4 r^ 1,' Apprs>ved -= ......................... .... 19 {4> e ' t ......................................................... ............. •► ............... ......................................................... ` j , Assessor's map and lot number ..i.. ....................... ; �� :� - 71 Sewage Permit number `......................................:..................... ; r %THEr 1 TOWNIE OFJ ,BARNSTABLE I►� Z BABBSTAB ,.i ro QNYLEa`�m� J^11 5! - lUI:LDIN � INSRECTOR � O sb39- r `APPLICATION: FOR PERMIT TO°'•.. ..'..�..:.': j I '� . , Y .... ..'R. ... . ' .... 1 �'♦TYPE .OF CON • � . . ��...�; . ..�.. .,r . ;�, • . STRUCTION .. j ........... ......... ...... ........... yn �.-..., ."•1 r '� y �;'' ' '� y�.. ... ... ........ 19 TO•+THE INSPECTOR. OF BUILDINGS: , a ,;• _ . 9 y PP P ,,g it, �Y i for.. a permit accordin #o then_ u w _ The undersi ned hereby a `I'es following information:.�� ` 3+ .. •� � 7 a ..^...°{ ° �t[ 'rX ' 4� � r 'f. ° f II ` f-�,. .s�. sM1l 4.._ r J Location .. ..... t 'j. A .... .... ..... ................... I . h , Proposed'Use�`........ !........��....... ...: .....t#........................ ............:......................................... ....................................... Zoning Distr c FIDE, D4 , �r c, 4 f vt tf ....... .............. . istrict .l... ...... ..lL .. r .. .... ►,Z Name of Owner. .L -11/ ..... ... .' '' .....Address• # (/4... Name of Builder `.:?.:. k'........ .:..... �:t M-' �;,: Ir .1s C► ...... Address ......................... Name of Architect, ...................:. ... . ,.............Address ........................'...................'..................... :.. r R . ....... .. . Number of Rooms /.c.�� k..: �-^ ............ //� It r�,� +� Foy ndation ........................1.............:.�t/c ..t/j................ ior ..............`r1 r ; .I�.......f.. .........+.............Roofing .. ': ..-.�4.. jL:t.....f ...... ... ....................................Exte . . ..: /Ie"7 Floors ".:i.........`..............:..::. ..........................Interior .... ...................:.... .............................................. Heating r { .. ,1 "�.,.....................Plumbing ................................... . ....................... FW T. . ' J+r ✓�r� rT tl Fireplace ...........::...:......:.: ......................................................Approximate Cost .......:...::...........'.'...r..............................?`� Definitive Plan Approved by Planning Board -----------_-__---------------19--------. Area �Z9... S-, ...... ............... Diagram of Lot and Building with Dimensions Fee ' ............ f 1 SUBJECT TO APPROVAL OF ,BOARD OF HEALTH ', 44 • < "� ..�w'r F} r ;, W - fit. !'F f9 ,, ' _ �, "f' ,iJ' � +�,'{Sh `4 fi,i �,' fir, ;"¢f" '" � � -a�� r`s �jf"f •.e..R,�%7E7 }lt�'' '4 �,',„ �1�'rt•",' "4?h�.'.. � "� ♦,.� 'ti\. '` ��" �"� � �� ,:kf-�'I '177� y { r,- � � :fir. t'•w-� t '+'"�[' .}t•. '"^"M�'3i..^� 1��°" � r��'" I !•\ 7n, .!7i"7. i �1� ,...,. ... � .' � fit; . ry4, ° +.� +,: •i,,,. .,�,� �A+ .� - ♦ 3lr' �' ,.. ' y ��, „• .. ter, +.� � t•:t }} !� .y 'f•_ �"�n i,. F7:' y se r 1 r :. 1 �`',a k� .� �,� C.,.� - r.a _ � N'. «�N� r � �'�� „•1°�c �,u:,�i, .x ..� .�+' •� - `y r , . .+� �'•.... y n• *�., , �.'� ` ,M .. / " � .� '�` } ,L:.'1 ��Y 4 t,r�,p R- .i _ - is ` I _ i+4. i n w F hereby,agree to conform to all the Rules and Regu lationsljf of the Town of Barnstable,'regarding the above construction: Z.1 ' Name ............................................................. .................. Trudell, Ra,;mond W. A=1 4.0 Yj7 18602 1 1/2 story, No ................. Permit for .................................... . ...........single family.dwelling. ........................................................ Location2.......leneag.l.e..Ro.a-d..............*.. ..................... . .. .... . .. Centerville ............................................................. .... .. Owner ...........Ra.ymond..W.....Tru.d.el.I................... ........... .. . ...... . .... . Type of Construction ...frame....................................... ..................................... . ........ Plot ..............................—L��t #2 6........ ........ August 1�9 76 Permit Granted ..........................P..............19 Date of Inspection ................./...............19 Date Completed .............../ e .............. 9. PERMIT REFUSED ................ ............................................... 19 .............. ................................................................ .................... ...? .............. ............... ... ............ ... ........I.........7 ....................... .. ....... .. .... ....... ... .... ............. .. ... ...... .......... ..... . Approv .... .............. . ...................... 19 ............. . ............ ..................... .......... ...... 4.49 14A CAL 71LILI - 1� CL R-T P� Erg PLOT PLNN t aF LOCA "-VION CENTEstl4%U r= "Rs�, 1 fCA. 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