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All worts performed meets or exceeds federal and State requirements. Sincerely, o Conor McInerney ConserVision Energy ° __ cn 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVrODAY.COM i ' CP 11/14/14 Thomas Perry, CBO Town of Barnstable Building Division 200 Main St Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed for insulation work at 52 Harbor Hills Rd (application#201204704)has been inspected by a certified Building Performance Institute(BPI) Inspector. All work performed meets or exceeds federal and State requirements. Sincerely, w t � u ® co c Conor McInerney n ConserVision Energy rn 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 W W W.CONSE RVTODAY.COM I a e� � P. 1 f' Communication ResuIt -R.eport ( Aug, 9. 2012 11 :47AM ) 2) Date/Time: Aug, 9, 2012 11 :46AM File Page No. Mode Destination Pg (s) Result Not Sent 9956 Memory TX 915088338384 P. 2 OK Reason for error - - E. 1) Hang up or line fail E. 2) B.usy E. 3) No answer E. 4) No facsimile connection E. 5) Exceed.ed max. E—mai1 size Town of Barnstable zao rannsum . Ta 5neaez.We - - For SOMNOW ` - 7a CanorMalnvney - n— Debi By a - PsoR 50&0 MEW Pon-liYpnduenro cow page) - - Pharr Dot. 819M2 no -62 Hvbar M Rd,Cenffi cc - O urgent O For Rook— O Meaae Comannt o Ptease rsepy ❑Please Reet'ele.. - Hi,Co"you maerved two penmis fm 62 HwbwHill;,Rd CufftMile App IMM4403 issued- WM26AppS2012047041ssued077112 Please wripIte Ore"form enrcbsed and fax back Orne.'Iwll � reindrur:e youS65.00 fv01e 8/7M2 pamd. - - - - Thank.. Debt - - - Building Division 200 Main Street Hyannis,MA 02601 Town of Bamstable Tel: 508-862-4038 Fax:508-790-6230 Fax To: Conor Mclnernay From: Debi Barrows ' Fax: 508-833-8384 Pages:° (including cover page) Phone Date: 8/9/201 Z Re: 52 Harbor Hills Rd., Center CC: ❑ Urgent ❑ For Review. ❑ Please Comment ❑Please Reply ❑Please Recycle Hi, Conor you received two permits for 52 Harbor Hills, Rd. Centerville App#201204403 issued 8/2/12&App#201204704 issued 8/7/12. Please complete the w-9 form enclosed and fax back to me. I will reimburse you$85.00 for the 8/7/12 permit. Thanks Debi Fcrm 1111-19 Rectusi t._for..Taxpayer Give form to the (Rev..March t the - Identification Number and.Certification requester. Do NOT Department of the 7reawry send t0 the IRS. Intemal Revemie Servioe Name(If joint names,list first and circle the.name of the person or entity whose number you enter in Part I below.See inswcdons on papa 2 It your name has changed.) Business name(Sole proprietors see instructions on page 2) p c o Please check appropriate boz 0 IndividuaVSofe proprietor Corporation Partnership [] Other ► ______________________ __ y. Address(number,street and apt or suite no.) Requester's name and address(optional) m a City,state,and Z1P code Tax a er Identification Number IN List account number(s)here(optional) Enter your TIN in the appropriate-box. For Individuals, this is your social security number (SSN). For sole proprietors,see the instructions on page 2. For other entities,it is your employer identification number(EIN). If you do not have a OR For Payees Exempt From Backup number, see How To Get a TIN below. Withholding(See Part If Note:If the account is in more than one name, Employer kl°"tifi`ati0^mxnbw instructions an page 2) see the chart on page 2 for guidelines on whose number to enter. . Mralm Certification Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer Identification number(or 1 am waiting for a number to be issued to me),and . 2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I-have not been notified by the Internal Revenue Service that 1 am subject to backup.withholding as a result of a failure to report all Interest or dividends,or(c)the IRS has notified me that I am.no longer subject to backup withholding. Certification Instructions.—You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage Interest paid,the acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement (IRA),and generally payments other than interest and dividends,you are not required to sign the Certification,but you must provide yona.correct TIN.(Also.see Part III Instructions on page 2.) Sign Hare. Signature ► Date,'► Section references are to the Internal payments under certain conditions.This is interest and dividend accounts opened Revenue Code. called"backup withholding."Payments after 1983 only), or that could be subject to backup Purpose of Form.—A person who is 5.You do not certify your TIN.See the required to file an information return with withholding include interest,dividends, p�III instructions for exceptions. the IRS must get your correct TIN to report broker and barter exchange transactions, Income paid to you,real estate rents, royalties,.nonemployee pay, and Certain payees.and payments are transactions, mortgage interest you paid, certain payments from fishing boat exempt from backup withholding and the acquisition or abandonment of secured operators. Real estate transactions are not Information reporting. See the Part II property,cancellation of debt,or subject to backup withholding. Instructions and the separate Instructions contributions you made to an IRA. Use If you give the requester your correct far the Requester of Forto�W-9. Form W-9 to give your-conect TIN to the TIN,make the proper certifications,and How To Get a TIN.—If you do not have a requester(the person requesting your TIN) report all your taxable interest and TIN,apply for one immediately.To apply, and,when applicable,(1)to certify the TIN -_dividends on your tax return,your get Form SS-5,Application for a Social you are giving is correct(or you are waiting payments will not be subject to backup Security Number Card(for.individuals), for a number to be issued), (2)to certify withholding. Payments you receive will be from your local office of the Social Security. you are not subject to backup withholding, subject to backup withholding if: Administration, or Form SS-4,Application or(3)to claim exemption from backup. for Employer Identification Number(for withholding if you are an exempt payee. 1.You do not tarnish your T1N to the businesses and all other entities),from Giving your correct TIN and making the requester, or your local IRS office. appropriate certifications will prevent 2.The IRS tells the requester that you If you do not have a.TIN,write"Applied certain payments from being subject to furnished an incorrect TIN, or For"In the space for the TIN in Part 1, sign backup withholding. 3.The IRS tells you that you are subject. and date the form,and give it to the Note:I/a{equester gives you a form other. to backup withholding because you did not requester. Generally,you will then have 60 than a W-9 to request your TIN,you must report all your interest and dividends on days to get a TIN and,give it to the use the requester's form if it is substantially your tax return(for reportable interest and requester. If the requester does not receive • similar to this Form W-9. dividends only), or your TIN within 60 days,backup What Is Backup Withholding?—Persons 4. You do not certify to the requester withholding, If applicable, will begin and j continue until you furnish your TIN. making certain payments to you must . that you are not subject to backup withhold and pay to the IRS 31% of such withholding under 3 above(for reportable 17 Form W-9 (Rev.3-94) TOWN OF BARNSTABLE,BUILDING PERMIT_APPLICATION . Map Parcel Hilp", tion # Health Division Date Issued 1 Conservation Division_ Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board pk $1711 Z Historic- OKH __ Preservation/ Hyannis Project Street Address Village C P-c\-'ce c J A\-e- Owner�ac\r-.'N6 Address R As Telephone _ Permit Request �� (�\°1 •-ko O� G ���. 4`.0 Sc oT yCpA Square feet: 1 st floor: existing proposed _ 2nd floor: existing proposed Total new Zoning District Flood Plain _Groundwater Overlay Project Valuation 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup porting,.documantation. ; fy Dwelling Type: Single Family .❑ Two Family ❑ Multi-Family (# units] r� Age of Existing Structure Historic House: O Yes ❑ No On Old King's Highway ❑Yesi .❑ No UJ Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) _ Basement Unfinished Area(sq.- Number of Baths: Full: existing- new __ Half: existing _ anew- Number of Bedrooms: _ existing new Total Room Count (not including baths): existing new_ First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other___ Central Air: [� Yes ❑ No Fireplaces: Existing New __ Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size ._Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded ❑ Commercial ❑Yes ❑.No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C C)S)OC CT-(\e,C = Telephone Number ^:jn37; Address _ (� ._ \3Q �U� ,C, License# �C)A!JT 9 Home Improvement Contractor# 1� s1 _ Worker's Compensation # VAC,�°` S(0s� ALL.CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE � ! _ DATE TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map y� Parcel` �' V plication # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH _Preservation/Hyannis Project Street Address J�a \Ao `gyp` )�:,\\5 Village C-ea�c v'•\\�e, Owner CQ\C\S�OAe- Address Telephone — Permit Request �,\O\ Le-\\u\\0 e—C\ 0.'cN< ANC. 0\1:W\L c�c� �ooSe��i Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District __ Flood Plain Groundwater Overlay Project Valuation N!CEO Construction Type _ Lot Size Grandfathered:. ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. .❑ Two Family ❑ Multi-Family (# units) _ Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.)_ — _ Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ _ new _ Half: existing new Number of Bedrooms: — existing —new Total Room Count (not including baths):existing view _First Floor Room Count tom . ^a Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes. ❑ No Fireplaces: Existing New _ Existing wood/coal stove --❑Ye,�:,❑ No Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑new :'size_ Attached garage: 0 existing ❑ new. size _Shed: ❑ existing ❑ new size — Other: - Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes U No If yes, site plan review # _ Current Use _ __._ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name _ �1cS�__(� Lc�e ne � ���� $3�� Telephone Number i Address . 96, .90�Qa? \21O C License # \QW15:3 !, �nAOi�( ,,d1� 0 ,5b� Howie Improvement Contractor# Worker's Compensation # W 6.5 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 1 _ DATE �3 � 0 S �L f i .�,.� - � t..� t � ��� � 1 } ,ff i I �. _._ _4..__._ ..._. _ .._ ,. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map l� Parcel` ppli tion # Health Division Date Issued 1 Conservation Division_ ;',Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic- OKH _ Preservation/ Hyannis Project Street Address _ 9—ok Y\�C t a C -A`\N\5 (Z(-�C .A Village C.ecy)ce.cy'\\\n0, Owner V Ca,car_' C_. �cAt�n � Address Telephone _ Permit Request c�—� ��. :f Se aA o� tN� d� b0\S2m\kA Square feet: 1 st floor: existing proposed _ 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation r 0 _Construction Type _ Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting,.docu entation. ZE Dwelling Type: Single Family" ❑ Two Family ❑ Multi-Family(# units).— Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway`:°'❑Yes" ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other _ Basement Finished Area(sq.ft:) _ Basement Unfinished Area (sq.ft) --� I Eu Number of Baths: Full: existing_ new Half: existing : new- rn Number of Bedrooms: _ existing ___new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other _ Central Air: ❑Yes ❑ No Fireplaces: Existing, New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing D riew 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) A 1111 Name L zo �N_ t e Telephone Number 50g _ Address _ �Q _ � 5�.� ,C, License #- t �cC At,J\ (03 _ Home Improvement Contractor# Worker's Compensation # woolli S�,O 5-5- ` ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE _ GATE_ / FOR OFFICIAL USE ONLY APPLICATION# ..DATE ISSUED -:.MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: : ,,'FOUNDATION' FRAME :�JINSULATION' : ` FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS:_^ w-w ROUGH _ FINAL ° :IFINAL BUILDING` •If _ - ` { R t ' } DATE CLOSED OUT t4 ASSOCIATION PLAN NO. r Piit EpttTit ;� • � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations .1 Congress Street, Suite,100 Boston, MA 02114-2017 www,mass.go vldia Workers' Compensation Insurance Affidavit: Builders/ ntr p Co actors/Electricians/Plumbers Applicant Information - I Please Print Legibly Name(Business/Organization/lndividual):CONSERVE ENERGY INC. d.b.a CONSERVISION ENERGY Address: 376 ROUTE 130, SUITE C City/State/Zip:SANDWICH, MA 02563 Phone #: 508-833-8384 Are you an employer? Check-the appropriate box: ] Type of project(required): 1. 'I.am a employer with 6 4. ❑ 1 am a general contractor and I employees(full and/or part-time.):* have hired the sub-contractors I 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet, 7. ❑ Remodeling These sub-contractors have ship and have no employees $. ❑ Demolition working for me in any capacity. employees and have workers' g (❑ Building addition [No workers' comp. insurance comp, insurance.' required.] S. [] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ 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 employees. [No workers' 13.© OtherWEATHERI2AT10N comp. insurance required.] 'Any applicant that checks box#i must also till 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 stew affidavit indicating such. tconttactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I anti an employer that is providing workers'compensation insurance for my employees. Below is tite policy and joh site information. Insurance Company Name: SELECTIVE INSURANCE COMPANY OF THE SOUTH Policy#or Self-ins.Lic.#:WC7956539 Expiration Date:3/15/13 Job Site Address:_ S2 +4NIW 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.MG L c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties,in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA-for insurance coverage verification. I do hereby certi under the ains and enalties o er'ury that the in ormation provided above its true and correct Si atur, Date: 7 Phone#'. 508-.833-8384 i Official use only. Do not write in this area,to be completer/by city or town off vial I City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityPrown Clerk d.Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: Phone#: Client#:68880 CONSER ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) _ 03/15/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ._ ...... ...._._ ._....._ IMPORTANT:If the certificate holder is an ADDITIONAL INSURED the pollcy(ies)must be endorsed.If SUBROGATION IS-WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Rogers$Gray Insurance Agency,Inc. __. �a_c°No Ex, tr 508 398 7980 FAX nod. 434 Route 134 !EMAIL 'ADDRESS: South Dennis,MA 02660 -- SOS 39H-79HO .,r_........_�. INSURERS AFFORDING COVERAGE t NAIC.S .(� _ -_ ._ .INSURER A:Selective Ins.Co.of the South INSURED `INSURER B - { Con-Serve Energy,Inc. _-. . j INSURER C: 376 Route 130.STE C -- — Sandwich,MA 02563 IN URER D. PINSURERE INSURER 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, L" TYPE OF INSURANCE ,ADDLSUBR — POCICYEFF '; POLICYE%P '�'—"—'-- __._.. ,.. J.-SR 1 D POLICY NUMBER .�1MMlDOlYYYYi i Mf MIDDIYYVSf.) - LIMITS A GENERAL LIABILITY X ; S2011299 3I1412012 03I1412013 EACH OCCURRENCE $1 00O 000 I I M �,,ETORENTED� _--X COMMERCIAL GENERAL LIABILITY DAA 1 } P� REMISES LEa occurrence, i$100,000 i{ CLAIMS-MADE I OCCUR MED,EXP iAny one per,?21 $1�0 - I III! PERSONAL&ADV INJURY,_{S 1,000 OOO GENERAL AGGREGATE }$3,000 000 GEN'L AGGREGATE LIMIT APPLIES PER ! +t 'PRODUCTS_:COMPiOP AGG ;$3,000,000 _.._._ !+. X'POLCY' PRa I LOC t i r AUTOMOBILE LIABILITY I I j ---� COMBINED SINGIEGMI7 I �(Ea accident} , 'S ANY AUTO I l BODILY INJURY(Per person} $ H ALL OWNED 7 SCHEDULED j --- — _-- AUTOS '.AUTOS ? ' I BODILY INJURY(Per acaoen[} HIRED AUTOS � AU0T08WN£D ! i . i �PROPERTYDAMAG ----- 1 - tS I(Per acc,oent, is A ueaBR£J LA Llae X OCCUR E X j S2011299 3114/2012 03/14/2013 EACH OCCURRENCEs1,000,000 I 1 X EXCESS LIAR CLAIMS-MADE I AGGREGATE f$3 OOO OOO OEO_ X I RETENTION$0 J $ A WORKERS COMPENSATION s WC7956539 (Mandatory to NH) X 'wCSTATu- }- :ERH-I AND EMPLOYERS'LIABILITY .Y 1 N '` 12.031141201 I MRY ANY PROPRIETORMARTNEWEXECUTIVE I - f I E.L.EACH ACCIDENT }$100 OOO OFFICER/MEMBER EXCLUDED? N J A i �— 1 I - _ Il E L.DISEASEE--EA EMPLOYEEI$O OOO Byes,desaibe under DESCRIPTION OF OPERATIONS below }E.L.DISEASE-POLICY LIMIT $500,000 —.1...,,...-_ .___......_. ___._..._.__..........,__ i DESCRIPTION OF OPERATIONS Ilocxnokis I VEHICLES(Attach ACORD 1ti1;Additional Remarks Schedule,if more space is required) Excluded officers under workers'crimp-Conor.and Courtney McInerney. Blanket additonal insured coverage applies under CGL. CERTIFICATE HOLDER CANCELLATION Thielsch Engineering;Inc, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave. ACCORDANCE WITH THE POLICY PROVISIONS, Cranston,RI 02910 AUTHORIZED REPRESENTATIVE o 198 -2010 ACORD CORPORATION.All rights reserved.. PA(CORD25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #tS788991M78898 DO R "r Office nsuiiie'ifiprs� fus ne �igu(;i`�tn i' x�+~~ L icense or registration valid for inciividui use only HOME IMPROVEMENT CONTRACTOR before the expiration(late. If found return to: P Registration: .;171251 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/1/2014 Partnership 10'Park Plaza-Suite 5170 ERVE ENERGY Boston,R•IA 02116 CnN=S CONOR MCINERNEY 376 ROUTE 130 SUITE C SANDWICH,MA 02563 Undersecretary i of valid without signature w . a . r4t'lnts:ac3tu5i.tts=i)eI)aiCrncnrof uhltt S;tftts Bolartl of 113uildino Rc.,-tultttia)ns A nil Stwjii,14t tld Constructtori Supervisor Specialty License 0cense: CS Sl 102778 Rik-tr iCted to: 1G 4$ €. DONOR MCINERNEY o t 39 SIASGONSET DRIVE L q SAGAMORE BEACH; MA 02562 .. i ff ✓- -- —s '' Expiration: 8/19/2012 <sv1§i�tu +ii,ros° Tr4: 102778 OWNER AUTHORIZATION FORM . (Owner's Name) owner of the property located at (Property Address) (Property Address) hereby authorize P r cyY7 ` 'p— (Subcontractor) an authorized,subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work,on my property. Owner's Signature Date JUL 2 2012 x t„ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION , 4 63Map Parcel' 61, �Plliloat # Health Division Date Issued AplicatinFeeConservation Division Planning Dept. Permit Fee _F Date Definitive Plan Approved by Planning Board 0�,�, $I?j(Z Historic - OKH _ Preservation / Hyannis Project Street Address J,0N Y\01 b ` Village��e c y'.\\2, Owner Address Telephone Permit Request )X d Le_\\v.\oSc? Av oc*ec\ 01�:W\— c�c� Square feet: 1 st floor: existing proposed _2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation \!�o 00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. ..❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.)_ _ Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ _ new Half: existing new Number of Bedroorns: existing _new Total Room Count (not including baths): existing new _First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ 01:1 ❑ Electric ❑ Other Central Air: ❑Yes ❑ No . Fireplaces: Existing New Existing wood/coal stove Ll Yes ❑ No Detached garage: ❑existing ❑ new size.—Pool: ❑ existing ❑ new size _ Barn: ❑ existing U.new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size ` Other: X HNa 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 C_0c\ac _�C:1 C Telephone Number ��b' �5���� '� Address 3fl(l RDU�e, \' a v.� License # ` C I� S Hot Improvement Contractor# Worker's Compensation # 53�1 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE _ ' DATA FOR OFFICIAL USE ONLY g APPLICATION# DATE ISSUED MAP/PARCEL NO. x ADDRESS VILLAGE r OWNER ' + DATE OF INSPECTION: ,.DLFOUNDATION rY FRAME INSULATION. "' FIREPLACE ELECTRICAL: ROUGH FINAL-- PLUMBING: ROUGH FINAL 1 ;GAS: ,: ROUGH a.r_ �.. s FINAL p _ FINAL BUILDING:; gg' -DATE CLOSED OUT z ASSOCIATION PLAN NO. a - F The Commonwealth of'Massachusetts Print otttt §r Department of'Industrial Accidents office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApplicantInformation Please Print Legibly Name(Business/Organization/lndividual):CONSERVE ENERGY INC. d.b.a CONSERVISION ENERGY Address: 376 ROUTE 130, SUITE C City/State/Zip;SANDWICH, MA 02563 Phone #: 508-833-8384 Are you an employer?Check the appropriate box: Type of project(required): 1.ZI 1 am a employer with 6 4: ❑ 1 am a general contractor and I employees(full and/or part-time.): have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have & ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. corporation We are a oration and its 10.7 Electrical repairs or additions ❑ P 3.El officers have exercised their I am a homeowner doing all work i I.❑ Plumbing repairs or additions myself. No workers comp. right of exemption per MGL y [ p• � 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13X® OtherWEATHERIZATION comp, insurance required.] I *Any applicant that checks box#-I must also fill out die section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work unit then hire outside contractors must submit a new affidavit indicating such. Tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for ray employees. Below is the policy and job site information. Insurance Company Name: SELECTIVE INSURANCE COMPANY OF THE SOUTH Policy#or Self-ins.Lic.#:WC7956539 Expiration Date:3/15/13 Job Site Address: 22. ffinlg&K 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 MG L 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 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 veriftcation. I do hereby certi under the eains and eenalties o er'ur that the in ormation provided above is true and correct.Si afore: .Date:... 3 YZ Phone#: 508-833=8384 Official use only. Do not write in this area,to be c-ompleted by city or town official. City or Town: Permit/License# Issuing Authority(circle one): i.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:68880 CONSER ACORD,. CERTIFICATE OF LIABILITY INSURANCE F ATE(MMIDDAYYY) 03115/2012 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 INSURERS),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 NAMEACT __...— Rogers 8r Cray insurance,Agency,Inc. PHONE, 508 398-7980 — FAXCEA fto '(AIC,No):434'Route 134 1_ADDRESS,_ ..._...._......_ ....-..____.._ -South Dennis,MA 02660 508 398-7980 INSURERS)AFFORDING COVERAGE NAId 0 INSURER A:Selective ins.Co.of the South INSURED ._ ---- INSURER S.: Conserve Energy,Inc, I— -- I INSURER C: t 376 Route 130.STE C r_ ,: Sandwich,MA 02563 INSURER D: -_ ;INSURER E; -�- INSURER F COVERAGES CERTIFICATE NUMBER- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN issum 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. LT R - ADDLSUBR POLICY EFF t POLICY EXP '--_..,,,....__.:..___..:..._..._. . TYPE_OF INSURANCE _ �IN,AR, D POLICY NUMBER _ MM1D_°lYYY1�'(MM@DffnN LIMITS A GENERAL LIABILITY I X 152011299 3/14/2012'03114/2013�EACH OCCURRENCE 151,000,000 X COMMERCIAL GENERAL LIABILITY + I. I OAMA TO RENTED n _PREMISFEStEaoccuvenrs) +S1O0,000 CLAIMS-MADE .J OCCUR #.... ..._......... .. s} � }MED ExP 1Anyone persons ;$10,000 _ i t I 'PERSONAL&ADV INJURY S 1 00O 000 GENERAL AGGREGATE s3 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOP AGG $3 000 00.0 t X:POLICY PRO LOC I ,$ AUTOMo01LE LIABILITY 1 1 C MO BINED SINGLE LIMIT _ -- 1 ,jEaacutlentl $ ; I (Per person) 5� --- t ANY AUTO ' }BODILY INJURY ALL OWNED SCHEDULED AU AUT05 ( T,OS I a I BODILY INJURY(Per acmeml j$ I NON-pWNE¢ I (-PRUF'ERTvDAMAGE HIRED AUTOS ( AUTOS (Per accident)" t7 S A UMBRELLA LIAS X OCCUR I X � S2011299 �3/14/2012103/1,4/2013,EACHOCCURRENCE !$1,000,000 X EXCESS Lu+B CLAIMS-MADE I ( AGGREGATE s3,000,000 'DED- X 1 RETENTIONO. A WORKERSCOMPENsnnoN AND EMPLOYERS'LIABILITY WC7956539 3/1412012 03/14l2013 X gyTATU i 1OTfi- YIN ---ANY PROPRIETORIPARTNER)EXECUTIVE NIA I I E.L.EACH ACCIDENT $109,000 OFFICERIMEMKR EXCLUDE¢? - -- -- ;— IMandatory in NH) E-L_.DISEASE-EA EMPLOYEE$1 O0 OOO if ppaess;desui6e uhder ' 1 ii I ' DES.CRIPTIONOFOPERATIONStlslow 1 ) I °E.L.DISEASE-POLICY LIMIT $500,000T I � , DESCRIPTION OF OPERATIONS ROGATIONS i"VEHICLES(An{ach ACORD 101,Additional Remarks Schedule,if more space is required) Excluded officers under workers`comp Conor and Courtney McInerney. Blanket additonai insured coverage appiies.under CGL. CERTIFICATE HOLDER CANCELLATION ' Thielsch Engineering;Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis Ave: ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,RI 02910, AUTHORIZED REPRESENTATIVE tC�I gali.2010 ACORD CORPORATION.Ali rights reserved. ACORD 25(2010105) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S78899/M78898 DOR 1 w ,,. r.',f�n C�urrr�n +�,el/ c�.. ll�,•treJe G+etda Uffice oft~onsumer �rrs 'Business�ula`�ion License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Registration: ,,171251 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/1/2014 Partnership 10 Park Plaza-Suite 5.170 ' Boston,MA 0211.6 C1SN=SERVE ENERGY CONOR MCINERNEY 376 ROUTE 130 SUITE C k/ �4< SANDWICH,MA 02663 Undersecretary Not valid without signature^ -81a s achu-setts- D'opartinent cal'Public S;tj,0.% Bvartl of Bui-ldin_�- Rc:4oulations a"d-Stand=trds Construe"Jon Supervisor Sper:iaQy License License: CS SL 102778 Re41rrcted to: IC i. GONOR MCINERNEY` ` 39 SIASCONSET DRIVE r d SAGAMORE BEACH, MA 02562 6-' -- -- �•+ Expiration: 8/19/2012 j. t`•�rurutiairii=r Tr#a 1-02778 3 ✓ j OWNER AUTHORIZATION FORA (Owner's Name) owner of the property located at J Z /(a,- ar v`1S rd/. 1 (Property Address) G>°� (Property Address) hereby authorizeorw"SP:CV < 5 P OY) �")q (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature 7 - Date D [ECEadr JUL z 2 112 GEORGE J. KHOURI & ASSOCIATES Development 6- Construction Advisory Services AFFIDAVIT ARCHITECTURAL DESIGN AND INSPECTION To: Building Inspector Town of Barnstable Re: Alteration to Home 3.51 Huckins Neck Rd Centerville MA July 12, 2012 In conformance with the Massachusetts State Building Code Eighth Edition, I certify that to the best of my knowledge, information and belief, the plans and computations for the captioned building were designed in accordance with the requirements of the Massachusetts State Building Code and all other pertinent,laws and ordinances. I also certify that I have, and will continue to inspect the work during construction. This will include the inspection and review responsibilities outlined in Section 116.2.2. I was responsible for the entire scope of work and performed those tasks prescribed in the MSBC which pertain directly to my construction documents. All registered professional engineers and any design-build/installation by a licensed tradesperson or legally recognized professional, for a system under their licensed jurisdiction involved in this project shall be responsible for their individual scope of work, required drawings and affidavits. I have inspected the foundation and the additional concrete and find that it is in conformance with the requirements of the Massachusetts State Building Code Eighth Edition. Geor,�e.T'�Khouri E�ngner r- �yg.No. 22660 JOHN KHOU No.U& p fSTE� \� , 37 Taurus Drive Q Mashpee, MA 02649 Tel: 508-419-1410 * Fax: 508-419-1536 O Email: gkhouri@comcast.net