Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0033 HARBOR HILLS ROAD
G B o �*, ttNe r� w 0 �dflw �rrr Panted On 10/29I2019 ° o Comptlaint CaI Repaq"nh w wnwwEwa w 7 � k ptdmgi "� 3 +� s 5 HAYES� RO o►M4E,NNTER /ILLE "rfOMP+° Case# C-19-800 Case#: C-19-800 Address: 5 HAYES ROAD, Date: 10/29/2019 CENTERVILLE Owner Info: Property Info: FITZGERALD, MARIA SULEIDE & MBL: SILVA, 33 HARBOR HILLS ROAD 210-091 CENTERVILLE MA 02632 Owner Notified?: Complaint Details: Type of Complaint Classification of Complaint Method of Complaint Illegal Dwelling unit,Zoning, Building Medium Priority Phone Code, Complaint Summary: Caller indicates he re[presents 20 neighbors. Says there is an illegal apartment in the basement. Many Cauzeault workers reside here as evidenced by number of their trucks/vans on site.Also washing and repairing those MV on week-ends. Action History: Action Taken Date Description Fee Inspector Inspector Assigned to Complaint: lauzonj Filed by. andersor Comments: Comment Date Commenter Comment 10/29/2019 andersor Property owner applied on multiple occasions for more bedrooms than septic capacity allowed. Owner recently submitted an application for a large enclosed 486 sf ft porch. 10/29/2019 andersor Referring to Health as well. Date: 10/29/2019 Town of Barnstable Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Pre-application for Business Certificate Date !; I o IL Map Parcel D Applicant Information Applicants Name Iv Al A A/ 1) �� C Z 1'� �.L -�J Applicants Address H H ILL� �l�r e Al G M A Email Address /V R N 0 L Telephone Number Listed ❑ Unlisted ❑ Business Information New Business? ----------------- ------------------------ Yes No Business is a registered corporation? _______________________'_. )�,e No If yes Name of Corporation &V L r( e p A) Does business operate under the registered corporate name? , s No Is the business a sole proprietorship or home occupation? _---_____ No If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business Business Address Type of Business b Building Cominissionef Office Use Only Conditions d Building Commissione ^' Date Clerk Office Use Only - V YOU WISH TO OPEN A BUSINESS? For Your Information.--,, Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1,st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill ilease;. APPLICANT'S YOUR NAME S: �iC'Sclt% �//�� 1, / I W r t Up? BUSINESS YOUR HOME ADDRESS: 3 C t Z6 2 TELEPHONE # Home Telephone Number NAME OF CORPORATICQN; NAME:OF.NEW BUSINESS 1"Or� l 'P P ti try TYPE OF BUSINESS: P E IS THIS A HOMEOCCUPIXTION _ YES. NO ADDRESS,OF BUSINESS:- H> o�: MAP/PARCEL NUMBER, �" (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town; 1. BUILDING CO ISSIO R'S.OFF E WITI'I( E-k [� This individ al e irr. d f n 'per it re uirements that pertain to thMU$Tc Q elsX. * RULES ANI REGULATIONS. FAILUR TO< u riz Vig a r COMPLY MAY RStJLT iN FINrES. . O ENT o c OM ee:j 2. BOARD OF ALTH This individual has een ifarr�e�l,gf�the permit requirements that pertain to this type of business.. MUST COM yvMAM {��,hl'V b V 9 �' HAZARDOUS MATERIALS REMATl O Authorized Signature** _ COMMENTS: 3. CONSUMER AFFAIRS[ C NSING AUT ORITY] This individual has ee informed -- he licensing requirements that pertain to this type of business. uthorized Signature* COMMENTS: Town of Barnstable Regulatory Services Richard V. Scali,Director Building Division BAMSTABIA M'AQQ $ Tom Perry,Building Commissioner 16gq. 'OrEp ° 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: . Name: G J1� Phone#: C D Address: I L L —Village:g Aqnn d 'V1 , n , Name of Business:_M91- 0 LT?ce1 Type of Business: Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions-of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; . and no increase in air or groundwater pollution: After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external.alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the.production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. . • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same.lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. , - • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: A P Date• a 0 I Homeoc.doc Rev.103113 . . :. Date: SIC�l TOWN OF BARNSTABLE TOXIGAND HAZARDOUS MATERIAL NAME OF BUSINESS: r�,1� P ; , l (� { y (a R 1' L Al BUSINESS LOCATION: 1-i ,� 0, P I Li,` R 1) 0 F ni"rrIVILLL INVENTORY MAILING ADDRESS: 7, I-i_r� n , 12 �) �� F. �� `7 (, / _j_t TOTAL AMOUNT: TELEPHONE NUMBER: '� q CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER. MSDS ON SITE? TYPE OF BUSINESS: F i /l i s INFORMATION/RECOMMENDATIONS: Fire:District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW 0 USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW 0 USED (insecticides, herbicides, rodenticides) Gasoline;Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products:grease; Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED. Degreasers for engines and metal Printing ink 9 9 9 Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt.&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners _ (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with"poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous.Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil&stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash I ) 4 WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature �� Staff Initials �. V f. YOU WISH TO OPEN A BUSINESS? r For Your.Information: Business certificates (cost$40.00 for 4 ears). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to p a e. You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: 'APPLICANT'S YOUR NAME/S:_A At2aZu I- f•,Opp t BUSINESS YOUR HOME ADDRESS: �� FJA2�30�'t HILLS CL�1 C ,tJt�r2VtLLs�. MA a� +� - TELEPHONE # Home Telephone Number - © 13 : [ IS NAME OF;CORP.ORATION � II' NAME OFNEW BUSINESS 1=:LI I' �J►rSl ( 1N S O G " 7 T1F :E OF BUSINESS IS THIS/ ,HOME!OCCUPATION� 'YENO ADDRESS OF BUSINESS�3 ::M/�l2tQi0T� I LC 527 �N2✓t,C.0 M"/} MAP/PARCEL NUMBS [Assessing] 6. When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSIO ER'ScE UST COMPLY WITH HOME OCCUPATION This individ al h n i fn o m d f an pe mit requir ments that pertain to this type of busines RULES AND REGULATIONS: FAILURE TO A horize i natu ** COMPLY MAY RESULT IN FINES, O ENT its "V 2. BOAR OF OEALTH _0 7 D� This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRSZILICEN AING AUTHORITY) This individual hqs i rm d of the licensing require ents that pertain to this type of business. Auto ' ed i nature* COMMENTS: I Tow of Barnstable Regulatory Services Thomas F.Geiler,Director t RARINCI'ARf.F.� s Building Division . v M F`®g Tom Perry,Building Commissioner t 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us U• Office: 508-862-4038 Fax:. 508-790-6230 Approved: Permit#: HOME OCCUPATION REGISTRATION Date: rl Z2(a ho V�s Name: A/)D2Z f✓. �OPZ S Phone#: 60S 73 1/9 Address: 3 village: C,,;.e) 2 Vi C c e- Name of Business: L 1-1 7�Z FRI N i i A.) 1?5 SO EI i Type of Business: r#1 Au t.Ai cy Map/L.ot — v INTENT: It is the intent of this section to allow die residents of the Town of Barnstable to operate a home occupation «zthin single family dwellings,subject to the provisions of Section 4-1.4 of dle Zoning ordinance,proNided that the acthity shall not be discernible from outside due dwelling.. there shall be no increase in noise or odor;no visual alteration to the premises which would suggest.anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the follmiri g conditions: • The acthrity is earned on by the permanent resident of a single family residential dwelling unit, located vrithin that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwellirng which are not customary in residential buildings, and there is no outside evidence of such use. e No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,Nabration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of. normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation, and not ciathin the required front yard, • There is no exterior storage or display.of materials or.equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in lerngth uid mot to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating due Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business, die street address shall not be included. • No person shall be employed in the Customary Home Occupation N•vlio is not a permanent resident of the I dwelling unit. I I, the undersigned,have read and e%ith the above restrictions for my home occupation I am registerung. � I Applicant: - Date: I i Homeoc.doc Rev.01/3/08 CAPE COD T116111 OF BARN9ABLr- INSULATION �lyG ®7 All At t ; rq!l Ql M StA Li$S SPf AT MIA SYS""D _ 'ns 1-800-696-6611 DI Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601' Date: 7Ia711 �--� Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in.accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village a �� �- t 1 des 33/ r�OD✓����s � v � y , Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings (x) Slopes ! ( ) ( ) ( ) ( ) ( ) Floors . (x ) ( ) ; (30) ( ) (110 Walls ( ) ( ) ( ) ( ) ( ) �1IY-readioil. • Sincerely HeP idy r, President Ca sulation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel . Ic a ion # .A Health Division Date Issued Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 1Y � Village !: 82 , 2"k-01-11 Owner r"A Address Telephone Permit Request . ,� �� 404A� ( JZ005;��2' ra Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type/ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family a' Two Family ❑ Multi-Family (# units) Age of 4xist�rR Structure Historic House: ❑Yes-tf-No On Old King's Highway: ❑Yes -L3-No Basement Type: ❑ Full 0 Crawl ❑ Walkout ❑ Other er a Baserr�ent Finished Ar a(sq.ft.) Basement Unfinished Area (sq.ft) c0 I K._M Numb§r of Baths: FuII:Y 6Xisting new Half: existing new Numbftof BedroomsA,_t existing —new Total FRm (count (not r hiding baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New _ Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size-_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone NumberJIJ Address 65-' , mod License ## Home Improvement Contractor Worker's Compensation # ltjG!0 Z) ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 4_j✓ 0 ale SIGNATURE_ DATE FOR OFFICIAL USE ONLY r 'APPLICATION# -,t MAP/PARCEL NO. ADDRESS VILLAGE OWNER r DATE OF INSPECTION: •FOUNDATION FRAME INSULATION. FIREPLACE I ' ELECTRICAL: ROUGH FINAL t. PLUMBING: ROUGH FINAL t G. w L,, - ROUGH a FINAL r i f_ ..-FINAL BUILDING A__DATE CLOSED OUT ASSOCIATION PLAN NO. k. 4; OWNER AUTHORIZATION, FORM '. r ( wner's Name) owner of the property'located at , (Property Address) �2h t' . }2 ,632 D (Property Address) hereby authorize CO CO'1n S v I�l V f r0` (Subco 4r ctor) an authorized subcontractor.for RISE Engineering, to act on my behalf to obtain a'building permit.and to perform work on my property: , . _ mow. f + _ Q.. .. + f. .. • . •. Owner's. ignature - Date. APR `20 2012 . 10 Park Plaza - Suite 5170 , Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC %, rf HENRY CASSIDY 455 YARMOUTH RD. E . HYANNIS, MA 02601 <4 } - � -- $ �' / ;Update Address and return card.Mark reason for change. 1� Address ' Renewal Employment ❑ Lost Card DPS-CA1 0 50M-04/04-G101216 Officed o mer Affairs Bus ne Regul pion License or registration valid for is uiv"tur use o^!, HOME INfP � 3 °� It� fR" before the expiration date. If found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 OD INSULATION, INC HENRY CASSIDY' y 455 YARMOUTHV. RD HYANNIS, MA 0260i1t Undersecretary k Atalidd ith t si tune ' M -tcliusetts-::Dcpailnient of Public SafetN Board of Building Regulations and Standards' ®, Construction Supervisor License License: CS.' 100988 -4 HENRY CASSIDY 8 SHED ROW tr WEST YARMOUTH,.MA 02673 Expiration: 11/11/2013 ('ounuissi,nc�' Tr#: 7620 k • t �, f The Commonwealth of Massachusetts Department of Industrial Accidents' W Office of Investigations W 600•Washington Street wa Boston; MA 62111 9"0~ www.mass.g9v1dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers f Applicant Information Please Print Legibly Name(Business/Organization/Individual): e C el G, Address: City/State/Zip: Yl;Y1�1d� Phone#: •ac 25 L-;Z�IL/ Are you an employer? Check the appropriate box: Type of project(required): y .' . , . 1. LIN I am a employer with , Q 4• Q I am„a general contractor andl have 6. J_j New construction employees(full and/or part-time).* hired the sub-contractors listed on 7. '❑ Remodeling the attached sheet.$` „ • ' 2. ❑ I am a sole proprietor or partnership These.sub-contractors have 8 ❑ Demolition and have no employees working for, employees and have workers' comp:4 9. Building addition me in any capacity'. [No workers' insurance.$ 10. Electrical repairs or additions comp insurance required.] 5.❑ We area corporation and its ' 11. Plumbing repairs or additions officers have exercised�their right`of ❑ 3. ❑ I am a homeowner doing all work exemption per MGL c. 152§(4),and 12. Roof repairs _myself. [No workers' comp. we have no employees. [No workers' 13. Other 'f`"e(`�Z � .insurance required.] t 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 new affidavit indicating such. $Contractors that check this box must attach an additional sheet showing the mime of the sub-contractors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'con1p.policy number. p I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: �1 t. � �' l) Policy#or Self-ins.Lic.#: �Zr d0!1 � / Expiration Date: 6AL2 al, Job'Site Address 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 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 ma e forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here c i under the ins and penalties of peg jury that the iriforination provide 1 abo a is true and correct. Signature: Date: Phone#: F 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 ,..t 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ' f Date: 4/19/2012 Time: 10:13 AM To: Cape Cod Insulation, Inc @ 1508-778-5735 Rogers & Gray Ins. 'Page: 002 Client#:4597 4 ;CCINSUL t ACORD.M CERTIFICATE OF. LIABILITY INSURANCE D TE(MMo;2YYY) 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 ofthe 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: Margaret Young. Rogers&Gray Ins.-So.Dennis PHONE 508-760-4602 = FAX AIc No Ext: Alc,Not. 508-258-2102 434 Route 134 ADDREss: youngma@rogersgray.com P.0.BOX 1601 PR DU ER #; South Dennis, MA 02660-1601 CUSTOMER ID- • INSURER(S)AFFORDING COVERAGE NAIC# INSURED - - INSURER A:Peerless Insurance 18333 , Cape Cod Insulation Inc INSURER B:Ohio Casualty Insurance Company 455 Yarmouth Road INSURER c:Atlantic Charter Insurance Hyannis,MA 02601 INSURER D:Commerce Insurance Company 34754 INSURER E:. INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N R DDL UBR - POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER. MMIDDIYYYYI (MMIDDIYYYYJ LIMITS A GENERAL LIABILITY CBP8263063 01/2011 0410112012 EACH OCCURRENCE $1 000 000 . X COMMERCIAL GENERAL LIABILITY - DAMA E T RENTED PREMISES Ea occurrence $1 OO OOO CLAIMS-MADE DR]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 PRO- LOC - - $ - D AUTOMOBILE LIABILITY _ ' 11MMBCKVMK /01/2011 04101/2012 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ,$1 OOO OOO BODILY INJURY(Per person) $ ALL OWNED AUTOS .BODILY INJURY(Per acadent) $ X SCHEDULED AUTOS t - .PROPERTY DAMAGE r X HIRED AUTOS (Per accident) . $ X NON-OWNED AUTOS - - $ $ • B UMBRELLA LIAB X OCCUR , 0001254514645. 04/01/2011 04/0112012 EACH OCCURRENCE $1 OOO OOO EXCESS LIAR CLAIMS-MADE AGGREGATE $1 OOO,OOO DEDUCTIBLE $ X RETENTION 10000 $ ' C WORKERS COMPENSATION WCA00525902 0613012011 06/30/201 X r WC STATU- oTH- AND EMPLOYERS'LIABILITY YIN IT ANY PROPRIETOR/PARTNER/EXECUTIVE _ OFFICER/MEMBER EXCLUDED? 7 NIA E.L.EACH ACCIDENT $500 OOO - - (Mandatory lnNH) E.L--DISEASE-EAEMPLOYEE s500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,if more space is required) Workers Comp Information Included Officers or Proprietors + 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. AUTHORIZED REPRESENTATIVE ` 01988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The'ACORD name and logo are registered marks of ACORD #S80552/M68179 MEE OFIME ros 'Town of Barnstable *Permit Expires 6 month m srfe date �. Regulatory Services Fee ■ ■ Y ■ BARNSTABLE, " MASS. Thomas F.Epp Geiler, Director 1639• , -IZ7J13�J ATfD MP't A Building Division Tom Perry, CBO, Building Commissioner. 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us 01'ficc: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number_; U(70V Property Address ._ _3 wlllle3e,� W( ❑ Residential Value of Wort. SC', 0 0 Minimum fee of$25.00 for work under$6000.00 Owner's.Name &Address il -CZY-A7 l,/ is.' jF Contractor's Name l%�� ,4tf z!l���/ Telephone Number 0 80 I lame Improvement Contractor License 4 (if applicable) Construction Supervisor's License# (if applicable) S ❑Workman's Compensation Insurance Ch k one: F[ , am a sole proprietor `°r ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance MAY 2 6 2009 Insurance Company Name TOW! . I- AABLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request (check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side dReplacement Windows/doors/sliders. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,_i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner-Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATU11E: ✓�f�i: / � `� l L l `4� �!.'V 1'I II.I:S1Pt7RMS\huilding permit forms\EXPRESS.doc Revised 100608 P.1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): ; 11 Address: ?6 City/State/Zip G 2EG' Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 2: I am a soleprpprietor or partner-' listed on the attached sheet 7. .❑Remodeling ship and have no employees These sub-contractors have 8.'❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'•compAnsurance comp.insurance.$ required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.ElI am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself.[No workers' comp_ right 6f exemption per MGL 12❑R of repairs insurance required] t a 152, §1(4),and we have no employees. [No workers' 13. Other 52 f1 1 -�� 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contactors have mployccs,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure io secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a finp 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 may be forwarded to the Office of _ investigations of the WA for insurance coverage verification. 1 do hereby cer*under dthe pains•andpenalties ofperjury that the information provided above is true and correct Si e: : G_ Z«c Date: Phone# rG A YO ' 2' S 2 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 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 7. f the foregoing rn a jomE-en rpnse ru�u�ng lie leg represen�atiYes 6f deceasezi'empi - o a=•_--.-- = receiver or trustee of an individual,partnership,association or other legal entity,employing employees.'However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the • dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an e "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 compliance with the iDs-unan,Ce 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-contiactor(s)name(s),-address(es)and.phone number(s) along with their certificate(s)of umn-ance. 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 permittlicense 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"A-locations in (city or tAwn),".A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that'a valid affidavit is on file for future perm s or licenses. A ne�v 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 (Le.a dog license or permit to biim 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 MassachusetEs Department of Industrial Accidents 4fftee of IaVestigadons 600 Washington Street Boston,MA 02111 Tel # 617-727-49-00 ext-406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gav/dia d� TKEri Town of Barn-stable of Regulatory Services r $, Thomas F.Geller,Director 16 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 4as Owner of the subjectproperty�►'Yj� � 0c, I�� � J hereby authorize I ✓ to act on my behalf, in all matters relative to work authorized by this binding permit application for: -33 '(Address of Job) e-- ' Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption ForYn on the reverse side. ! Town of Barnstable .rt N'TP�o4 it•+e r�y� Regulatory Services RI RNCT`LR -� Thomas F. Geiler,Director r L� , MA-9& �+ Building Division TED Tom Perry,Building Commissioner Rwvv.town.b arnstab le-ma.us Office: 508-862-4038 Fax: 509-790-6230 HOI 4MOWNER LICENSE EXEMPTION Please Print DATE.- JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: eityhown 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. DEF irnON OF HOMEOWWT11 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 siructures accessory to such use and/or farce structur6s. 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 Budding Official on a form acceptable to the Building Official,thathe/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) 713,e undersigned"bomcowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and reguMons. The undersigned."homeowner"certifies that.he/she understands the Tpwn of J3armstable,Sui j.wg Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signatirrz of Homeowner Approval of Budding Official Note: Thrce-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMMOwNER'S EXEMPTION The Code states that Any bomnwwncr performing work for which abuilding permit is rcquircd shall be rxcmpt from the provisions of this section(Section 1 D9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a pe'san(s)for hire to do such work,that such Homeowner shall ad as supervisor." Many homeowners who use this exemption are unaware that they arc assurrong the responatbJ1itics of a supervisor(sex Appendix Q, Rules&Rcgulations'for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homcown er hirrs unlicensed parsons: In this case,our Board cannot pmcesd against the unlicensed pa-pon'as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To en are sure that the bomreowner is fully aw of his/her respmmWitics,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 eumently used by several towns. You may care t amend and adopt such a fmTnhertification.for use in your community. Q:forms:homccxcmrpt _-_�--, c: ...__ . �M��z o�✓j/lir'.t'"`T,�auaeCl� . , 6j�-&Www Regulation and Standards } Board of Building- eNisor License Construction Sup. ---- f U�e e. ras CS 9975 girtfidate 811311942 T .2096 Exp�rapon 811312009 i { I � t � ,Rre__striction. 00Jt BILLY'E CAUTHEN �- �� + I 86 Commissioner i IS,MA 026.01 r HYANN "'— Board OfBuildo�� ug ud gtaHOME IMPROVEMNards RegulatiSa Registt TCO Nra o TRACT ORa ; ' a1 1 . EXPuatt 11660g ; ... t86 N</ 62 9/2010. nidBILLY Tr# 26804 AUTII ua 3 BIL -j AUHENgEYTH LANE HYANNI S, MA 02601 Administrators t • i } _ f . Llcehs..: efore t en h registr g °ard o f Qrm at�0h 8 heAshbBhi/dih ratio dat),all, forl� OstOh,4a rtw.Oh p aReg4/atiOlf fOhh�ividul uretuS. Q Rhi 1To an d Standar t0 only ds �r d'a t Pa/id wlth0ut sgh attire 'Engineering Dept. (3rd floor) Map Parcel Permit# g..,.Y House# Date Issued 5 - _ Fee- 9�, 6 Planning Dept. (1st floor/School Admin. Bldg.) e tive Plan Approved by Planning Board 19 RNSTABIX;MAM 0 TOWN OF•BARNSTABLE Building Permit Applicatio Project Stre t Address 3 4j I�,L 5 Village Owner -:5OiHN 5PAPAiZ0 Address ' A 3©5 519NDPIPIFf- be- Telephone Permit Request Ralf- (7,0 016 1Z CDC l s r 1 U6 a l LIP First Floor square feet Second Floor MM square feet Construction Type Estimated Project Cost $ 61 3 Z Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 25 Historic House ❑Yes (ANo On Old King's Highway ❑Yes [�`NNo Basement Type: of ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing Y New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes YNo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) MIA ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name I e`✓w 51-livy8F124 Telephone Number 76'0 1513 Address 19' R47 License# ® 7-z-g Home Improvement Contractor# /0 5% 216 Worker's Compensation# bYC C �001 Z 350 -,/ NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE, —o't --94 BUILDING PERMIT DENIED FOR THE FOLL ING REASON(S) FOR OFFICIAL USE ONLY �. PERMIT N - DATE ISSUED ` MAP/-,PARCEL NO. ' F ADDRESS.- VILLAGE y OWNER DATE,OF 04SPECTION: FOUNDATION F FRAME INSULATION _ FIREPLACE ELECTRICAL: ROUGH FINAL t - PLUMBING: ROUGH' FINAL + ; GAS: ROUGH FINAL i w f FINAL BUILDING -!-'DATE CLOSED OUT , � 1 'Al . ASSOCIATION PLAN NO. , ! t . _.x ., • °FWE A - 'The 'Town of Barnstable • aaaxsr�ats, 9e ,0�' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only f ! Permit no. Date 1 1 i AFFIDAVIT ! HOME IMPROVEMENT CONTRACTOWLAW" SUPPLEMENT TO PERMIT APPLICATION I MGL;c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. P g 9 Type of Work Est.Cost ;1 C� 3 Z 00 Address of Work: 2, -2, NUM '0 1 U-5 C-e y ff e y vLL l /Owner's Name ::1041 SPADIPM0 Date of Permit Application: DEC -Z I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the age fit oft owner: 1056-7-4 Date Co ractor Name Registration No. OR Date Owner's Name The Commonwealth of Afassachusctts •t:l :�_`=�.: Department of Industrial Accidents t • . ` k\ '•�{ct �I1%CEDII/IYeSt/yat/OdS 610 if oshi»i;tt)t Street Bustotr, Man. 02I11 •' Workers' Compensation Insurance Affidavit Aalic-t—n nforntation - / Ple:►se i'RINT'le�ibly 93 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity am an employer providing workers' compensation for my employees working on this job. compin n. e• �ddr s ��J• =' Phone0. insurance r ce2 0d I am a sole proprietor, general contractor, o homeowner(circle one) and have hired the contractors listed below whc the following workers' compensation polices: om an• name* addres • city phone 0- e insurinc co. nniicv 0 _ r1V:•''•��.0•.•- - =..t... � _r-rabr .1t'•'}T tom+ S. •_�" -- - �` - . ru mot-�. nm nn• name- •addre c- city phone 0: incur�nce co noiic�•d :Attach additional sheet if tieees�� ��w'-�'� +�^'�r`f--"��:a;:w:.: r+:'-� "'r" ''"�" '+- •� ' n 3 = "='"'`_:. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 an one I cars'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand tt copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. 1 do herehr cerrift'under dte pains att penalties of pe4urt•Mat the information provided aboyis true and comet. Signature Date P ' t name C � 51=11ii�C phone /^ ` 113 official use univ do not write in this area to be completed by city or town officiai pet mit/license# r1Buiiding Department eit} or town: Licensing Board C3scico check if immediate response is required alleal t Department Office �ticalth Dcpartmcn[ contact person: phone if• rJOther .'Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provideset ice of another underfo` . employces. As quoted irom the -law-.an emplimee is defined as ever), person in the contract of hire, express or implied. oral or written. An entplrn•er is defined as an individual, partnership. association. corporation or other legal entity. or any two or rr the the fore-going, in a joint enterprise, and including the legal representatives of a deceased cmpioyeHo ever receiver or trustee of an individual , partnership, association or other legal entity, employing employees owner of a dAvelling house having not more than three apartments and who resides therein, or the occupant of the dwelling_ house of another who employs persons to do maintenance , construction or repair wort: on such dwcflin�_ or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empic MGL chaPtcr 15'_ scaion 25 also states that evcry state or local licensing agc^cy sh211 the withhold%s tile issuance or renewal of a license or permit to operate a business or to construct buildings in applicant m-ho lias not produced acceptable evidence of compliance with t1><e insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence ofcompiiance with flue insurance requirements of this crap: been presented to :he contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking theb x Witted that pliesto Depar to yoursit ttiof on z supplying company names. address and phone numbers as all affidavits may b industrial ,accidents for confirmation of insurance coverage. Also be sure to sgn and tistile beinclrequeste1e affidavit should be returned to the city or town that the application for the permit or license not the Deparnnent of Industrial Accidents. Should you have any questions regarding, the "law" or if you are -ep to obtain a workers coinpeitsatioit policy'. pie--se call the Department at the number listed belo\t•. _.. _ .._.. ... . _.. _ ::s..: City or ,roivns Please be sure that the affidavit is complete and printed legibly. The Department has provided aspace the t tile i ec ntc the affidavit for you to fill out in the event the Office of Investigations has to contact you repar O P be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retur. the Department by mail or FAX unless other arran`ements have been ma thank you in advance for you cooperation and should you have any que The Office of Investigations would like to please do not hesitate to Give us a call. ,�+ap..-,'..-�,». �..._.....-........-• ....�..��-.�.....r-a-.�.�.-y-ram:-. �—�" - ,:.'.:�::.- .. _ .. _- _ ��_ The Department's address. telephone and fax number: - ,. .. The Commonwealth Of Massachusetts r . . .. Department of Industrial Accidents Office of 1nvestig2tiOnS 600 Washington Street Boston, Ma. 02111 f . ..... . .....: SR HS .. _... DATE(M M ID DN Y)ITYINSUNLac® Dr A OF LIABI AG E R 10/09/96 _..... . . .FC .;: PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Drake, Swan & Crocker HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lot's Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 COMPANIES AFFORDING COVERAGE Peter G Walther COMPANY Phone No. 508-255-3212 Fax No. A American States Insurance Co INSURED _ COMPANY B American Policyholders Michael Shamberg COMPANY DBA M S Construction C 23 Lane Rd COMPANY Dennisport MA 02639 p COVERAGES '< _. 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. CO TYPE OF INSURANCE POLICY NUMBER :�JDATE(MMIDDNY) LICY EFFECTIVE POLICY EXPIRATION LIMITS TR DATE(MM/DDIYY) GENERAL LIABILITY GENERAL AGGREGATE $ 600000 A X COMMERCIAL GENERAL LIABILITY 01CC86352260 08/29/96 08/29/97 PRODUCTS-COMP/OPAGG $ 600000 CLAIMS MADE rX]OCCUR PERSONAL&ADV INJURY $ 300000 OWNER'S&CONTRACTOR'SPROT EACH OCCURRENCE $ 300000 FIRE DAMAGE(Any one fire) $ 50000 MED EXP(Any one person) $ 10000 AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT $ ANY AUTO - ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY t NON-OWNED AUTOS - (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ _............................. ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ I UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WC STATU- OTH WORKERS COMPENSATION AND TORY LIMITSI ER EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 100000 THE PROPRIETOR/ g I wcL WCC2092350195 12/03/95 12/03/96 EL DISEASE-POLICY LIMIT $ 500000 PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 100000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/SPECIAL ITEMS Carpentry CERTIFICATE HOLDER CANCELLATION JOHNSPl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE.CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY John Spadro 6305 Sandpiper Drive OF ANY KIND ON T E COMPANY,ITS AGENTS OR YPRESENTATIVES. Lakeland FL 33809 AUTHORIZEj ATIVE ACORD;25-S(119.5) OACORfl CORPORATION M ;;; s.�,T, :man. ro�uuea V °`r cuae . 4- 7- HOME IMP.RO.VREHEW NTRA'CTC7RS ':,REGISTRATION 8p6`r d of Elva, ding ReCoLt l .t a o'ns� r d Standards I ::� ,uiv One Ashburton. Pack foam 4t e t 2168 E "HOME?" •ZMPROV MENT CQSVTR�CTOR C r' - -J" Soyr��SZ2.l_�6f�rj/�. eols rat en 10562 x.piraton 07,/,2A`96 ` E `�De e s.; HOME SMPROVEMENT CONIAACT R r r r. E R 5 6 Registration 10 62 9 `CONSTRUCTION Type - 06A , M chae.l. D. Shamberg E Expiration 07J20/99 23 Lane Rd Dennisport MA 02639 ! M. S. CONSTRI!CTI9N ! Michael 0. Shambere E We Rd I ADPANSTRA� 0ennisport MA 02639 t �3c"PAE;i'�Ers,l'T f P�J L l 56§5 Y n w CVIa ASHELEi';�N PLACE', Ru 136�': ( ri( . . MAC 11996 CONST ucTION SUPERVISOR 1_ICENSE Fr• Exp.res pix-tt,,iate: �° b CS 0,'44229 0510;iI99S 0510E�;15 : � I?est:icted To- flfl � k�.f� �+c M:C}Ihw; � t!�A'fL'•°pr. 4 ` fig vw �w -��tar:. � .x.4. . , . �.. .. .. .. .-r- _ _ ..... ._.. ... s7ENN:10PORT, MA 4 rn�.+�.—•.=.`".;r;,����:-,...`r �..���---- �asrH>�nu.�a� r�..�fafatr�/rerr®!!e C r J J fO5$�RUCSI014 Su`?SRV'rFUR r a O 1 G :�' :: cs OyazF9 a5r?a;:s9a ;,fa,,q.a :rz�,,q a we: .� estt.6jg,t6c 00 Fa :c:e to p�;Sea a cu_rec; °ii.iGl c. ��e j` R aSaC'75et s £!a'.e RCLL:: !c4 code MM MTC1i L D :N6lf6kRf, s caese fo: revoclf.p'r �: *t"ie iieense. - �,,,,,�,.� tid 23 LANE ROAD i; DFNNiBFORt, 1tA 226?y T O d 3 I NN3 (1 S I s3. 4 S T tr T " OW 96 — Z — Z T rMmplete items 1,2,and 3. 7B -,q., ture nt your name and address on the reverse —----- dent that we can return the card to you. � u ❑Add seeach this card.to the back of the mailpiece, id by(Printed_,Name) C epfhiv on'=1e front if space permits. 1. Article kddressed to: D. Is delivery address different from item 1? Y / If YES,enter delivery address below: ❑No ILI 3cA II I�III�I IDI �I I II II(I I(( IIII I I� I I III ICI 13❑AdulltSgn Signature Restricted Delivery ❑Registered Mail Resice Type 0 Priority Mail tricted *Ccertified Mail® Delivery 9590 9402 1933 6123 1792 14 ❑certified Mail Restricted Delivery *Return Receipt for ❑Collect on Delivery Merchandise 2. Article Number_(transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationT i "red Mail ❑Restricted Delivery Signature t on 7 017 10 0 0 0 0 0` 6 7`5 9 =6 2 4 5 oo� Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt , USPS TRACKING# - - --- -ll - - First-Class Mail N Postage&Fees Paid USPS �• Permit No.G-10 9590 9402 1cf33.7`6123 1792 14 United States •Sender:Please print your name,address,and ZIP+4®in this box• Postal Service TDWN OF BARNST,ABLE I BUILDING DIVISION 200 MAIN ST. HYANNIS, MA 02601 I iS hkg.c kd c xM lSyi.•r ii}� E• ii '� at#I Ir }2f !!! • � !►�;� ,if. Ilat l', 1 ill il.li �� fi i If f I,:f t 11i� 11 �•~.