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0175 HARBOR HILLS ROAD
l��— �rb�r- 1�-� ul�, .�: � . �� . . - � x : . f afS 3 �� Town of Barnstable =Permit9 Rybw 6montlisfmrrr issue date i Regulator Selr�ees Fee � t � a BARNSPABLF. a �$ 1634,- Richard V.Scali,Interim Director e Building Division Tom Perry,CBO,Building CommiSS1O er IT M 200 Main Street Hyannis, A 02601 l N"irw-town.barnstable.ma.us OCT 3 O 2015 Office: 508-862-s038 Fax:508-790-6230 MRESS PERNR'I'APPLICATION - RES .� 9 ENO 1 0W Map/parcel Number�2 QG} L� -7 ' Not Valid without Red-X-Press Lnorint Prope Address jV C yj'L /LIL�(�I�! I [Residential Value of Work S 7,�179 _ Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address_ - Rn/I/M C'enfies^liale �� oz/� 3 y Contractor's Name n a1 L 1J;ncn,, s�/ 9L;5,•, Telephone NumberM,i' X 2-,'-q k ZC Home Improvement Contractor License.--'.'(if applicable) /7 3 2 q_S Email: Construction Supervisor's License_(if applicable) p 5 7 p-7 01Workrhan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I:=the Homeowner I have Worker's Compensation Insurance Insurance Company Name A rel,,o cwt .lnsucg Yt ce Workman-s Comp.Policy1 truC q�8p $3 57 2 3 y 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) ❑ Pe-side ( Replacement Windows/doors/sliders.U Value 3 0 (maximum 335)_of windows 3 of doors. - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Eled&ical&Fire Permits required. s'Where required- Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. �`'AIote: Property,Pivner must sign Property Owner Letter of Permission. A copy o1 the Home Improvement Contractors License&Construction Supervisors License is required. J SIGNATURE: Vl Q INTFILESTOR1 Mbuilding,permit fomts0TRESS.doc Revised 061313 Renewal tt tlmuc r36078 REN*A Mr ANbERSEN �' MAhiameMtrs245 Andersen. �o �l 31•►n Cr UQCM 40634555 noes evuwrruh meee.+saeom, 26 Albion Road • Lincoln,RI 02865 leadrimf,h23r Phone 866.563.2235•Fax 401.633.6602 recant rain rtreNWosses3o Sotidmie n New Ei&nd Windows,LLC d/b/a Renewal by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT (�N �D a+wUls��aa�oasaoe.maIIVCoe.,va.eo� -- . c tt,n ++.taty_. 1� VWrliTel�licne tJumfiv BuV0)hereby}oMi-*and severally agrees to purchase the pivducts and/or urAces of Southern Neiv Edgtannd Windows,LLG d/b/a ReriiivW by Andersen of Southern New England("Contractor'),in accordance with the terms.a id conditions described on.the front and the reverse of this agreeigent and on the.attached speci&cation,sheet(s)(collectively,this"Agreeeiterit'7:. ❑Al&Ac: Q:Casdo O liOA? Tonal ob Amount 7 Eaonpud Stud iNethod of Phtyment, O Check, O Cuh. riincei! J ,y�9 Deposit"R«Nved(3�x)�_`_'` Credo Gods are aoixpted for tli Oik only—mai lmum`1. d the,, Balince at Start of)ob(339 C): - EsWnated:Comph C Project cost{PGeuse sa Crcdt Card Femme Fam)Br si�htf tM r Agreetthem;you aduwwte�e that the allu"at Start of Job and the: Balance on Subsuntia! .�l �/ $' Bakiice on 5ubsuiitlsl Compledat of Job dnnoi be made by weft mp Cakttion of joti(33, � aid and must be malt by Personas clieclt,binli check:stash: Buyers)",ageees;a"understands that thin Agreement wastitutes the entire understanding betsreea the psutti es,a";that there art sivestial aadastaadings ammgiog nay of the terms ofahis Agreement.Bayer(s)acknowledges dial Boyer(s), (I)bus read this Agreement,andersttmds the teems,of situ Agreement and'h"received a"campletet3,sited,and dated copy of this ABeeementi'inttad8og the two attached Notices of Cancellation.on dse date Arst written above t►nd.(2),tvas orally informed of Bt>tyer's right to eaacei this Agreement:DO NOT SIGN THIS"CONTRAC 'IF THERE ARE ANY BLANK SFACSS: (R4odtGland Sera Osely)Notice to Bryn a(1)Do not=stirs this Agreement if airy of*6"space:mteoded for tic greed:terms. to the extent of then available information are left Mani::(2)-Yon are;endded to a copy this Agreement at the time you sign its.(S)Ycis essay if lay time pay off,the fall anpald balance due tinder this Agreement,sad is w doing you may becataded to receive a partial rebate of the litaance and iasniaritue charge:,(d)The:seller tins ao eight to aolavyiitlly en ur your prises or commit any breach of the peace to repossess goods purchased under this Agreement (S)Yon"may.eancei tbisAgreement g{ft hub:not beeasigaed at the main ogee or s brands office of tke seller,Pro tridetl yoo notify°the relies at hu.or her males• office oe branch oA$ shdsva in theAgreegment by tr�d or txrtt&ed mail:vrhicb shill be'pottted riot4ter t3an midnight of theibird calendar day si ter the day onwhiirh t>ie buyer sigma the Agreement,excluding Smdry aad,aay holiday oa svhicb regWat'tnail dellt+eriesrenot tsstide:See:the icoompanyingaolux of eaneeUadoa fo+mforaaepbsaatioa of buyer's azgfits. Buyes(s)'received the co 16,"cr educatioi materials prd ided by the Rhode Island Contractors,Regiatrauot Board:: (Ai 's Taitiaitf Itenewalby era England Bu y e r(s ) Buyer(!), By, of Product_ ' ignam ^ Signature' =. AintName_of Puodua+ Set PrtnrNarne_ Peat:ame;+ YOU,THE.BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT &,THE THIRD- BUSIIVESS DAY AFTffit THE DATE OF THiS_T.t 1.$ACTION.SRE THE ATi'ACHED NOTICE OF, FOR AN EXPLANATION OF'THIS RIGHT.` ac NORICE Ohm CANCELLATION NC TICE'OF CANCELLATION 2c Date ofTramaetkh _-.,,You may=Acef i Date f,7Fmhsict#on. - You may cancel'. this trantocdon,`wtthout:mry penalty or oWigatiar,within: this vansaction.witiltout any peirhaJly or obbgadon,within three;business d._,_ firom,die atiove date.H you tleiicel.arty ) three'bttstness d from ehr,above date H you.cauhcel,anjr �opn �traded in,any pslremnts`tnatb bji yet udder tfie"+ I property traded-pj any payer►ents er►adti by you under the:. Con�u.or Sale;and aryl. k instrument eaeatted: I Contract or Sala.and arty rhegot#abIe instrument executed by you"will be returhhed: n;tanbusines3 days`following: i by you will be'rethtrned withiri'een business dajn following' receipt by the Slier of:yotr�caneellaliosi notice,aitd:.any i receipt lty etii Seller'ot your cancellation tiottce,and any" t seeu ft interest arising_out of the transaction ,will_be seeetrity t lntoerist writing out of the;'ermhsaedon' will. be e sneered.if you cancel,yyoou must rinse available to the Seikr'.; I t�elet if you cancel;yyoou m�int make available:to the Se11ir sc your eetldtyhca in subttathdaily IN good condidonas when i atyour riWcknt e,in wbstantially.as good comltlon as si f tbceived.aryr goods deth+ersd to you uncle_r,dtis Contract or, I, A celved,any,good:delivered to you under this;Cbntraet or Sale;or you may,Hyou wtah,comply with the instntetfons of I Ssl�,o.you may.H you wish.imply with the instructions of the Sena regarding the return shipment.of the goods at the, dhe,Seller regarding the r"Umlihipment of the goods at the Sellerli expense anti risk.if you do:make the gg000ds available Sellers expense and risk If you'do make the s rinds avaihifle to the Seller and the Seller does.not pick them up withld to die Seller,and die'Seller does not pick t�iem up lthin twenty,days of the date of t nke-Ration;you may,retain or; i twetit)►days of the date of cancelh�oe,yoo mq re h or dispose of the goods without any further obligation.If you rl disport of d►e goods vinthout arty further obfigat#on If you. tell eo bialm the gnash writ aWe to.dre Seiler or tf ou htil to makeafte avetlahtti to die Seller,oe if you agree to rethien die goods to the Seller-rid hn to do sordhen you j -to return the go t:the Seller and fail to do so,then'you. remain liable for performance,of all obligations under the I remain liable for performance of all obligations order the Contraet.To COMA this amhmcdot!.mail or deliver a signed ContrakLU cancel this transaction;mail or deliver a'signed and dihtetf copy-of"this caeKelistiori noeite or.any other I and dated copy" of this cancellation notice or any other, writ. nodc.e�or send a telegram too Renewal byAn&rsen of I *H i- ttotice,or send a tel etiRenewai bjrArtdersen of E Southern New and att 226Aibfon Road,Lincoln,N CM5, I Southern New England at Albion Road,Lincoln,RI 0296S, ((NppOT LATER 'MIDNIGHT OF I ((NOT LATER THAN, MIDNIGHT OF Da (H�Y CANCELTHISTRANSACTION. I i HEREBY CANCELTHISTRANSACTION. Sum{ Pon NVI Mu try: ! Prots RA." Gets IibA Copr White Buyer Cope Yellow Buyer Copr.Pink 3 Southern. New England Windows d.b.a Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License:CS49§M a• ��s� r' BRIAN D DENN5_0N 7 LAMBS POND li'IIt s Charlton MA 01 r - I x, tc+'a Expiration Commissioner 09/08►2016 o ,�:,:�-.��.-vim.= �. .. ,�-�A �.,t.��._ .�.<,�- - -u.,.��- � ��. ,��- -:�, •. _ Office of Consumer Affairs d Business Regulation 10 Paris Plaza-Suite 5170 Boston,Massachusetts 02116. Home Tmprovenient�Contractor Registration r _ Regisiraftn: 173245 r t Type: Supplement Card Ex0aft: 9/1912016 SOUTHERN NEW ENGLAND WINDOWS DENNISON BRIAN i a 26.ALBION RD LINCOLN,RI 02865 _ `Update Address and return card Mark reason for change. scn,®2M605M Address [j—Renewal a Employment Q Lost Card s�/ro�oo'.aroxoul��B't/.awolb�eele2 Riee of Cooaemer,Affivs&Business Regulation License or registration valid for indrvidui use only a ' E WROVENIENT CONTRACTOR before the expiration data If found return to: Office of Consumer Affairs and Business Regulation s eg on 1?3?AS Tom-. to ParkPiero-Suite St70 Expiration 9I Vni-6 Supplement and Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON 4 DENNISON BRIAN 26 ALBION RD LINCOLN,RI 02865 Undersecrenry Not valid without signature 7 sr.w�..w� - -:�.•<w.: �.rw•..W. �..:-.tea_�_a, -- "e-s,>-a.-�:,.:. _. s`��..�:.�;.z.,r __....•.a:..-: ,.4s�.-:m=z�,�:.r•� The Commonwealth of Massachusetts ➢epartment of IndustrialAccidents Office of Investigations p a I Congress Street, Suite 100 r Boston,MA 02H 4 2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/S,tate/Zip:Lincoln, RI 02865 Phone#:401-228-9800 Are you,an employer?Check the appropriate box: Type of project(required): 20+ 4. am a general contractor and I t.� I al a employer with � I g 6. New construction employees (full and/or part-time).* have hired the sub-contractors, . 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_ F1 Demolition working for me in any capacity. employees and have workers' 9 F1 Building addition [No workers' comp. insurance comp. insurance 1 required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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. Other G�i)cld�✓ comp. insurance required.] Ife 10/4 r,eM en f *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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policv and job site information. Insurance Company Name:ARGONAUT INS. CO. _ Policy#or Self-ins. Lie.#:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: 1, Z 75- 4 /.U'4,,9 r City/State/Zip: /111 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---uf-NTGL 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 ' urance coverage verification. I do hereby certi under the and penalties ofperjury that the information provided above is true and correct. c signafore: Date: Phone#• 4012289800 Official use only. Do not write in this area,to be completed by city or town ojfleial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Eleeftiical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SOUTNEW-01 SHETTYSHT ACORU' CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) 8/19/219/2015 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 CONTANAME:CT Willis Certificate Center Willis of New Jersey,Inc. PHONE FAX c/o 26 Century Blvd- A/c No Ext:(877)945-7378 ac No):(888)467-2378 P.O.Box 305191 ADDRESS: Nashville,TN 37230-5191 ADDREss:certificates@willis.com INSURERS)AFFORDING COVERAGE NAIC M INSURER A:Selective Insurance Company of Southeast 39926 INSURED INSURER B:OneBeacon Insurance Company 21970 Southern New England Windows LLC INSURER C:Argonaut Insurance Company 19801 . D/B/A Renewal by Andersen INSURER D 26 Albion Road Lincoln,RI 02865 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. INSR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DDY/YYYY MM/POLICY EFF LTR /1MYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE N OCCUR S 2029459 08/10/2015 08/10/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - " GENERAL AGGREGATE $ 3,000,000 POLICY JEST N LOC PRODUCTS-COMP/OP AGG $ 3,000,000 FX]OTHER: $ AUTOMOBILE LIABILITY EOa aBINED SINGLE LIMIT $ 1,000,000 ( ccidenA X ANY AUTO S 2029459 08/10/2015 08/10/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED i P BODILY INJURY(Per accident) $ AUTOS AUTOS ( ) X HIRED AUTOS NX NON-OWNED _ PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE S 2029459 08/10/2015 08/10/2016 AGGREGATE $ 5,000,000 DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I JER B ANY OFFICEOPRIET ER EXCLUDED?ECUTIVE NIA 0000068028 0812112015 08/21/2016 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Workers Compensation WC928058352394 08/21/2015 08/21/2016 See Attached DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 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 Evidence of Insurance r�D ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD S THE Town.of Barnstable �*Permit# Expires 6 mont is Jrom issue date Regulatory Services Fee snuvseABIA MASS. Richard V.Scali,Director 039. 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 Not Valid without Red X-Press Imprint Map/parcel Number Property Address [Residential Value of Work$ �`� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 0 VA n �:N. �Cd� Contractor's Name _�� ►��� Telephone Number " Home Improvement Contractor License#(if applicable) \��\�-��� Email: S k�`,-�s-��' Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor cbs ❑ I am the Homeowner DEC 15 2014 D4 I have Worker's`Compensation Insurance 1A �1 D fl' p Insurance Company Name \' U \p �� ��VyN OF ~n'uSTADLE Workman's Comp. Policy# ',. le N U k,,.S-a iE 40 9 8-1 - Lk - Copy of Insurance Compliance Certificate must accompany each permit. Permit Re uest(check box) c) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to�� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of th o e I �provement Contractors License&Construction Supervisors License is required SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS. Revised 061313 e� �Ctifrrmrrrcririfc�rrt't�o��assael�rts _ , Depaninmt of rzzdrvsf6d Accidents - to rs}Eritzgr�t[arrs 600 Waskrxgton Sreet Baston,MA Q-2111F wn.w.xnasmga-Vdia Workers' campensatian Insurance Affidavit:$_iFilders/C.antractors/E ectriciansMumbers `c-ant Infarmation Please Print Legibly Names(&h8�s31dFganiio�_dividmal)_ C J - T CIty/S ate-/ZIp: Q e i, \\ P7.oIle&,k- � Are you an employer?Check thjv.�appropriate box.: T . of •ect C �-_ Feral confractor and'I ?� �'o I tr���- 1,6 I am a�.ployes witlf_ _ I am a❑ g. 6- ❑New construction employees(full andtorpart-#ime).* havehire4the sub contracts. Listed on the attached shl of 7- ❑I�ode-liug 2_❑ I am a sole proprietor orpartner- � Zltese sub-c�tcactors ' skip aiul have no employees have 8_ ❑Demolition w --,Cyr me in an• ci r employees and.have workers' otlan Y capa. t5 1 p_ El Building addition ' [MonAt0±-kP1S' comp..rn�sanre comp-II1SLtia4�i�_ [P,p„r f 5-❑ We area corporatioaaad its I{l_❑Mectrical repairs or additions o f" h" ave exerciseer IZ_. airs or additions 3.❑ I am a homeowner doing all tivorl; d their ❑Plumbin g� . f [No workers'romp- right.of empfianper2vfCiL I—❑R of repass il,c: jcereTlired_]t c_152, §1(4} aadwehaveno . employet� [No worknrs' 1 _❑other comp_msurance raquited.j *Axrp Epplicrat'+Nat checks boa W l ermst slso fill our tle section below sho,ring dwir workers'compessa�oa Fp F m oa 9 i om�cwn s Valo subm t mis stE x M.Ey sse+ioing s?T rrm3c and then YCE Mta6e eogtraerors]¢mat 5UbMit a nL:ai;davit —rh =Cenmrmrs fast cb?ck this bmc mist Yffached as s3ditinnaI Slit t sbvccmg fli nxme of lie sir ors and stRZg uMA.Ier oclao:those Mites have e}mlayers_ Yth--sob-co-aractuzs h.-se employees,they must gmvide tt-=r worker'romg_poIacg number_ I am an empZayer thatisprmicUffg tt orkzrs'corrrpgrurtivn ucsrtr=cs,f`or rtty employees, He.Zatr is the policy anal ob srtg irzformalzoz ,T-1 In_stn$nce Gompasz_t'I�Iame: `l"��V�\�.r5 Po or Self-ins_Lim 'S _�`� —\4�Expiration Date: ` — t Job Site Address \t S �� � ���` �1��\ city"Statelzip: ��eaa eU'�till� Ak oa6,34 fittxclx a.copy of the workers'comp eusativii policy declaration page(shawl the policy number and expa-atien date). Failure to sec=e coy sage:as regrired Nader Section 25±L of MGL c. 152 can lead to the impositioa ofcriminal penalties of a Run up to S 1,50G.OD andlor one-year imprisonment,as well as civil peaalti.es in the form of a STOP WORK ORDER and a Env- of up.to$250.00 a.day against the violator_ Be advised that a copy of this statement maybe farwarded to tine Oti"ice-of Investigations of the DIA fax iusa mce coverage cation_ I dd hcrreby 7mder penaL66s afpedary f#rrtthe iafbrmaz n prmide-d abase rs b-ua and Correct Simattme: Bate.: Phone 0: 0f zcizrL use an£y. Da nat write in this area,to bs utmpreted by cil j ar town 0�4czaL City-or Town: Pm-mitfUcense# j Esui.ng t' Nth 6rlty(t7rde orie): 1.Board of Health 2.Budding Department CibaT,G n Cleric 4.Electrical Inspec-tor S.Plumbing fmpector 6.C�4her Contact Pecan: Phone#_ 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 insides 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 employer." MGL chapter 152, §25C(6)also sta-fi-s that"every state or Iocal Licensing agency shall withhold the issuance or renewal of a 1iee)ase or permit to operate a business or construct buildings in the commonwealth for an.y applicaut who has not produced acceptable evidence of compliance-vith the zasurance.coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the com-moavealth nor any of its political si.ubdivisicns shall enter into any contract for the performance of public work u.uatil acceptable evidence of compliance vih the insurance nc.e requirements of this chapter have been presented to the contracting authority_" Applicants — Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)andphone n�=_,ber(s)along with their certlucait(s)of insurance. Limited.Liability Companies(LLC) or Limited Liability Pa1-t:ie„hips(I-LP)veit7no tinploye-,s other than ibe members or partners,are not requuir�d to carry workers' compensation iDDr-ante- if an LLC or LLP does have employees, a policy is required. fie advised hat this affidavit may be s:bn iited m the Depa-t-ment of indusirial Accidents for Also be sure to sign an.d date the affida, t Die affidavit should be returned to the city or town ltsat he applicaii-on for the permit or license is being requested, not the DepariMent of Industrial Accidents_ Should you have any questions regarding the lava or if you are required to obL�n a;;corkers' compensation policy,please ca..11 the DeparSnent at the number listed below. Self-insured companies should enter heir self-insurrance license number on ti.e arproprizte at, Cityor Town Officials Please be sure that the affidavit is complete and printed legibly, The Department has pro`ided a space at the bottom of the affidavit for you to ill out in he event the Office of investigations has to contact you regarding the applicant- Please be sure to fill in the peraiitlLcease number which wuU be used as a reference number. In addition- an a?pLcant that must submit multiple penZit/hutrase applications in any given year..need only.submif one a de-avit indicaruing current policy information (if necessary)and under"Job Site Address"the applicaut should write"all locations in ___(city or town)."A copy of the affidavit That has been officially stamped or marked by the`city or gown may be.provided to the applicant as proof that a valid affidavit is on file for future persits or licenses_ A new affidavit mutest be filled out each year_W here a home owner or citizen i s obtaining a license or permit not related to any business or co;-nmercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidav t The Office of Investigations wouhld like to thank you- advance for yourr cooperation and should you have any questions, please do not hesitate to give us a tail_ The Department's address,telephone and tax number: Th�Commmwtatffi of Massach>osoi . tpaz`,ment afhidustrkalAcci:dents afee ofkyestigatimi 6QG Washmgtoa St1-� Ttl,, 6I7-127 49-Q0 ext4Qf or I� 7-7-'_11vLkS AFE Revised 4-24-07 Fr' .m gov Loa Town of Barnstable' Regulatory Services MAS&iE� Richard V.Scali,.Director 9. 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 114 ;I r►{ as Owner of the subject property hereby authorize eiA.) le-4 to act on my behalf, . in all matters relative to work authorized by this building permit application for: a (Address of Job) ,M Pool fences and alarms are.the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed'and accepted. t Signature of Owner , _Signature of Applicant o J P ljv jl �e Print Name Print Name Date QTORMS:O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services s ��oF rOty,� Richard V.Scali,Director Building Division 4 K • mass Tom Perry,Building Commissioner Y � 1639. 200 Main Street Hyannis,MA 0260 3 A` t, }' 1 'OT Y EO N►A www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: 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. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official .Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a persons)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,RuIes &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require;as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRFSS.doc Revised 061313 I DATE CERTIFICATE OF LIABILITY INSURANCE �..� 11/26/2014 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. I 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 a`lo endorsement. A statement on this certificate_does not confer rights to the certificate holder in lieu of such endorsements. I PRODUCER CONTACT , NAME: NORTHWOOD ESHBAUGH INS PHONE FAX 540 MAIN STREET AfC,No.Ext): AIC,No: E-MAIL ADDRESS: HYANNIS MA 02601 1 27JDD 1 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED INSII RER B: DEAN F STANLEY BUILDING INSURERC: CONTRACTOR INC ; 359 CAPT LIJAHS ROAD INSURERD: CENTERVILLE MA 02632 INSURERE: INS i RER F: COVERAGES CERTIFICATE NUMBER: 1 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. 1 INSR ADDL SUBR I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED i PREMISES Ea occurrence S k CLAIMS-MADE F-IOCCUR MED EXP(Any oneperson) 5 EPERSONAL&ADV INJURY S GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG POLICY PROJECT LOC S AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT " Ea accident S _ ANY AUTO JtVffiULED BODILY INJURY Per oersonl S ALL OWNED NON-OWNED ( BODILY INJURY er accident S AUTOS PROPERTY DAMAGE HIRED AUTOS Per accident S 5 UMBRELLA LIAR OCCUR C EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDI IRETENTION . S S A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY (7PJUB-2E49857-5-14) . 10-08-14 10-08-15 X TORS LIMITSI JER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? YIN E.L.EACH ACCIDENT Is 100,000 MandatoryinNH) Y NIA If yes,describe under ELDISEASE—EAEMPLOYE S 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMITS 500,000 I j DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES(Attach ACORD 101,Additional Rerriarks Schedule,if more space is required) i r I CERTIFICATE HOLDER ( CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I EXPIRATION DATE THEREFO,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE I POLICY PROVISIONS. Tn,.,•, nr n•n•,rr•n, r - ��ie tpon�n�eancrsea�Cl a��/lccaaac�care� License or registration valid for individul use only Office of Consumer Affairs&Business Regulation (#TOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:. ��2egistration 132149 Type Office of Consumer Affairs and Business Regulation �Y 1_ 10 Park Plaza-Suite 5170 Expiration 11/28l2016 Individual ' Boston,MA 02116 DEAN F. STANLEYy I DEAN STANLEY 359 CAPT.LIJAH RD J CENTERVILLE, MA 02632'-'"' Undersecretary of valid withou signatul u -Department of Public Safety Massachusetts d Standards i1w Board of Building Regulations an Construction Supervisor tk License: CS-035037��; . .1 lei DEAN F STANLE)� 359 CAPTAIN LI4AH - Centerville MA 0632 Expiration 0111912016 Commissioner 3 '. NO- INIV ot It CoV61 1_kw_ w . w� A 1176 A 6 . v A4 ,` v. mL 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 175 Harbor Hills Rd (application#201407048) has been inspected by a certified-Building Performance Institute (BPI) Inspector. All work performed meets�or-exceeds Federal and State requirements. Sincerely, O Conor McInerney -. ConserVision Energy ` s � 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVTODAY.COM TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z.i. Parcel 0006 Application # l Health Division Date Issued 1 11(o!y q Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner Address \,%s Telephone a o's - 3 V'� b'� Z.a c.�•-�d Z�. �. , �+.A b L<e3Z. Permit Request \o Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 'Project Valuation 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 tc% 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 Z. new Half: existing new Number of Bedrooms: 3 existing —new i Total Room Count(not including baths): existing (a 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: Wfl?Tj 7 lirl Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use - - . - - Proposed Use - -- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) , Name Telephone Number 50+► , Address _' �s �e�i�. % 3o License # s�.%3zs", .�..,A, , •�..� b z.s c�,'� Home Improvement Contractor# k A c Ls Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE __1., L�� DATE j�lS ` FOR OFFICIAL USE ONLY ,+ APPLICATION# D TEISSUED ' MAP/PARCEL NO. ADDRESS VILLAGE OWNER • a s DATE OF INSPECTION: yr FOUNDATION;uo -i - FRAME -.. INSULATION;?.w _.,ia.a • : N FIREPLACE ELECTRICAL: ROUGH FINAL. PLUMBING: ROUGH FINAL GAS: ROUGH FINAL: FINAL BUILDING. DATE CLOSED OUT ` t ASSOCIATION PLAN NO. opt MRWAUNG PER Il° A T i TI N 21 owner of the roe located at: j P ,p rty. (Owners Name,.p nted) (Prb. rty'StreetAddressj: (City/town); hereby authorize the Mass Save Horne Energy Services Program assigned Participating Contiactor listed':belou+i to:act on,my behalf and obtain a,building"perms to:perfocrn insulation and/or rweather nation Work on iN property. Owner's Signature Date FOR CSG OFFICE USE ONLY Conservation Service$Group ha§:assigned the following,Mass Save Home Energy Services Par#cipating Contractor to the above referenced project;;. Participating Contractor Date s. Rev..12132011 ` The Commonwealth of Massachusetts Department ojlndustrial.Accidents Office of Investigations 600 Washington Street .Boston, MA 02L11 ►vww.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): ConserVision Energy Address: 376 Route 130 Suite C City/State/Zip Sandwich, MA 02563 phone.4: 508-833-8384 Are you an employer?Check the appropriate box: Type of project(required): 1.[3 1 am a employer with. 8 4. ❑ lam it general contractor and] 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. + ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10:❑ Electrical repairs of additions 3.❑ T,am a.homeowner dating all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152. §1(4),and we have no 12.❑ Roof re-pairs insurance required.] + employees. [No workers' l3:[3Other Weatherization comp. insurance requires.] Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation pulicy information, t Homeowners who submit this affidavit indicating they are doint,all work and then hire outside contractnrc must submit a new affidavit indicating such. lCnntractors that check this box musi attached an additional Sheet shuwine the name of tite sub-contractors and their workers'comp..policy information, t ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: CS&S/WORKCOMPONE Policy If or Self-ins. Lic.#: 6011316349 Expiration Date: 03/11/2015 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 lV1GL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 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 foe insurance coverage verification. 7 do hereb tify t der th,pc 'ns nd penalties of perjury that the information provided above is trite and correct. Si�nalure: Date: N Phone#: Official use only. Dar not write in this area, to he 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 i 'ACCORD� CERTIFICATE OF LIABILITY INSURANCE °AT31`17°0`14 03/1712014 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: CSSS[WORKCOMPONE PHONE FA" PO BOX 946580 I.C.No, Ettt 11C.Not: MAITLAND,FL 32794-6580 ADDRL DDRESS:.- Phone-877-724.2669 INSURER(S)AFFORDING COVERAGE NAIC q Fax-877-763-5122 INSURER A,Continental Casualty Company 20443 INSURED .INSURERB: - CONSERVISION ENERGY INSURER C: 376 ROUTE 130 Continental Casualty Company 20443 SUITE C INSURER O: _ .- SANDWICH,MA 02563 INSURER :Continental Casualty Company 20443 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE:INSURED NSUAEO 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. NSR1O UNITS LTR TYPE OF INSURANCES INSR WVD POLICY NUMBER - MMIOD NNIOD/YYY GENERAL LIABILITY EACH OCCURRENCE $1,000,OOO COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300,000 PREMISES(Ea oocunence) CLAIMS-MADE ®OCCUR MED EXP(An one person) 10,000 A Y N 6011316335 03/11/2014 03/1112015 PERSGNAL s nOV INJURY $1,000,000 GENERAL AGGREGATE -$2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS.COMPIOP AGG $2,000,000 POLICY JEt LOC COMBINED SINGLE LIMIT $1,000,000 AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Pet person) ANY AUTO - A AALL UTOS NED SCHEDULED N N 6011316335 03111/2014 03/11/2015 BODILY INJURY(Per acddem) MIRED AUTOS AUTOS NON-VWNeu PROPERTY DAMAGE AUTOS cident} UMBRELLA LIAR OCCUR CCURRENCE. 1,000,000 0 EXCESS LIAR CLAIMS-MADE N N 6011316352 03/11/2014 :0:3/:11/2:01t5AG-GREGATE 1,000,000 OED RETENTIONS 10,000 1 GSTATU+ OTH-WORKERSCOMPENSATION RY LIMITS ER AND EMPLOYERS'LIABILITY $100,000 ANY PROPRIETORMARTNERIEXECUTIVE YIN N. N 6011316349 03I11/2014 03I11I2015 E.L.EACH ACCIDENT E OFFICERIMEMBER EXCLUDED? ❑ $100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE It yes,descnbu undo $500,000 DESCRIPTION OF OPERATIONS beta* E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/,LOCATIONS I VEHICLES(Attad+ACORD 101.AddAninal Rema*s Sd+edule,it more space is required) C Certificate Holder is added as an additional'insured as provided in the blanket additional insured endorsement. CERTIFICATE HOLDER CANCELLATION iSe ng neertng SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE 1341 Elmwood Ave THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Cranston,RI 02910 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD taca&45 i Massachusetts -Department of Public Safety / Board of Building Regulations and Standards Con truction S►peniiu.r Specialo License: CSSL-102778 CONOR D MCINE"RNEY '^ 39 SIASCONSET-DRM1 m SAGAMORE BEACH 1 kf'OB62 r Expiration Commissioner 08/19/2016 r•,�� UrJit il7r:Nlnr+iir'/il i�i�!fr/;;itl`�d3r•//J: .. _ . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration: 171251 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/1/2016 Partnership 10 Park Plaza-Suite 5170 Boston,MA 02116 CON-SERVE ENERGY CONOR MCINERNEY 376 ROUTE 130 SUITE C SANDWICH,MA 02563 Undersecretary Not valid without signature y�f THE T0� e�P TOWN OF BARNSTABLE BABB9TOBLE4 i �FaY a' G INSPECTOR am039. BUILDIN Dom" , APPLICATION FOR PERMIT TO ........ .....✓. e.................... .................................. ........................................ ..... .. .... TYPEOF CONSTRUCTION .............................................. .. . ..... ........................................................................ ....................197:3 TO THE INSPECTOR OF BUILDINGS: The undersigned here y applies for a permit accordin to the following information- Location ...... .........(Jr,.1............../ ... � .).e ...h.? . �......... ProposedUse .. ................................................................................................................................. ZoningDistrictN r ...................................Fire District........... ............................................................... Name of Owner �Q ..(.o. .. Address . .� ........ .. .. Nameof Builder ...... ........... ...................... .................. . ddress ....................... ................................. Nameof Architect ........... ......................................................Address ............. ..................................................................... Numberof Rooms .. ...... ...............................................jounclation ................... .... ... ....................................... Exierior .. .... .. .. ..........,� /. 1 'oofing ...... ... .. ...................................................... Floors ......................... .......................................Interior Heating ` .:... . ..... .. ./.. ....... .e ... ...................Plumbing ..... ......................... ....... U Fireplace ......../ .......................................................Approximate Cost .......��. 0-0 ....�.�:. �� ...... ........ Definitive Plan Approved by Planning Board ---------------____-----------19________. Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH Lj V P(p E J,.91 � . � ri" . REGO I herebyagree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above g g g g o e construction. Name ~ Them Construction ' / ^ ' No - .. Perniit for ...... ......... ' ---�L?jgA..f;)Ia.3:)�J[. ..................... � �O5~ �J[ls']�^~d Loco�on�.(��—°*^��p� l----...-`^=...-----' ` ----''— ���o Owner ----.----.�..--.---_---.—. / Type of Construction ........�����-------- —'—`-^—^---'------'^^----^~^~--- � Plot ............................ Lot ___ ................ Feb Permruary it lA ` \�PermitGronhw6 —.--.��.��.��—��---]g '~�g vl� Date of Inspection ...... l9 �—~w ~..^ Completed A.. ^ | | < PERMIT REFUSED ........................ 19 ` --.--.-.—..—.---,....----~—.-----. \ . ^—_--.,_------..------,...------.— ) � ~`'~^~---~^^—'---'~'^''`~'~^^'—^—~—`—'--' ! ' � '----``^^--'--'-'~^^--'—^~'~^^'----~~ Y � Approved ................................................ lA ^ -------.------.—_..----..----- . � - ` -------.----.-------..---.—...' � / | | ' Assessor's pffice(1st Floor): 1. -� a g. Assessor's map and lot num FA,91 a_7 SEPTIC SYSTE6UST BE Conservation(4th Floor INSTALLED IN CORAPLIANC Board of Health(3rd floIT� TITLE Sewage Permit number rt ssai�raata EB9I6'Tt®MMi1T6.�;,G �+Cf'a .',. 1 r6 Engineering Department(3rd floor): ''i? b. House number i 9u s` oe�r Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 AU'and 1:00-2-00 P.M.only { .TOWN 5 OF BARNSTABLE 4 °BUILDIING INSPECTOR APPLICATION FOR PERMIT' 3 Ll TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Proposed Use Zoning District Fire District I / � �Lj�y7r��j o4 `T' Name of Owner h Address / �/id9 � 2LI L n S ��" ) Name of Builder L L 11 g7r/r S 1�L�L'�Z�5 Address L �� �2l O � ��r� Cle )LLB Name of Architect / Address Number of Rooms / Foundation ��� Gl?,e7 � Exterior 51_ n Roofing .b L Floors ��°�' � Interior n Heating �l/d Plumbing ✓y Fireplace �'V d Approximate Cost 82, �y Area G O ��-- Diagram of Lot and Building with Dimensions Fee y p&.k OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Si ipervisoes License O S K 3`10 K.ENNEDY, BONMI No 3 Permit For BUILD ' ADDITION Location 175 Harbor Hills Rd. West Hyannisport Owner Bonmi Kennedy Type of Construction Plot r `"P Lot " August ust 15 :g 4'ermit Granted 19,� - Date of Inspection: r - Frame 19 Insulation 19 (Fireplace 19 t - Date Cbmpleted � �►�'� 19 i } P. COMMONTWEALTH OF MASSACHUSETTS, DF ?� � OF I?�TDUSTRIAL ACCIDENT'S �— /� 600 WASHTNGTON STRE °BOSTON, MASSACHUSL:hIS 02111 fames Ga`oDe, �c^�"ss one WORIaRS' COMPENSATION 1T'SURANC.E AFFIDAVIT I, (l icc nscc/permi rice) with a principal place of business/residence at: PA 7-9)'o (City/ tatdZip) do hereby certify, under the pains and penalties of perjury, that: [ J ] am an employer providing the following workers' compcnsation coverage for my employees working on this job. Insurance Company Policy Numbcr I am a sole proprietor and have no one working for me. ( J or homeowner (circle one) and have hired the contractors listed bclo,- I am z sole proprietor, gcnerzl contractor -,vho have the following workers' compensation insurance policies: Name of Contractor Insurance Company/Policy Numbcr ?game of Contractor Insurance Company/Policy Number Name of Contraaor Insurance Company/Policy Numbcr D I am a homeowner performing all the work myself. NOTE: Plcasc be : +•are that while bomeowners who employ persons to do maintenance,construction or repair work on : dwelling of not more than three units in wbieh the bomcowncr also resides or on the grounds appurtenant thereto arc not gcncrall)- considcrcd to be employers under thcWorkcrs' Compcosation.Act(GL C. 152,sect. 1(5)), application by a bomcowncr fora license or permit may evidence the legal sutt:s of an employer undo the Workers'compcnsation Act 1 understand that a copy of this statcmcnt will be forwarded to the Department of Industrial Accidents'Ofi'icc of Insurance for covcra=c verification and that fa.ilurc to secure eovcrngc as rcouired under Scedon 25A of MGL 152 ern lead to the imposition of-mrninal pen2ltics eonsisong of a fine of up to S1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and fine of MOM a day against mc. Signed this day of Licensce/Permittee Liccnsor/Permitter 58 09. 43 ► � r � N Zc� ;- ,qOD/T/Dit/ ti N '-� _ • 9 DEC K U� LoT 57 � { /o, 06 9 t S.F W 1N OFM4SS ROf�ALD 2 JAMES u> PLOT PAl FOR o At ,C�0NM'l WENMED IV ��� Jut tv lzi (?94 5o�c,- zo -, R.J. CR4014 L AC , )'L S BOX 258 W )"ARMOUTip/, Mr9 ------------ ---- -- --- _. t _ _ ___ c to E O F fl, 7� .. f 2 O J 17 _ __----- - ---- ----.__._..:..r._ 20 � `7 ' __. L. i r i - -- ------- - { _ PIC 1y e73 ' 7� G _ G,sG,oEQ . , �,/ I .............. .. - ... - .-. . �A9 r 1.cv/v r/0-4) __ I I pG ' �.� 3 ROOF- VEN7 12. sKk LrUNr Propel Ucrj -30 �NsL• 2X�i i�"oc- �� � .� ro T,/-4 c4o L- \�� \\ Nt EO DRIP Eoci& z,� Ti s � � ve �j2 �g Y WCAI)CR s Z pR,-f gg 2�ti , s-f(40 Ivs L. . �.8 Ip5L 31° r$ PLC,wWD 2- Z'c o� 2 I aTRI^ I2 y n 13 E.Lac.., R a l)E ZC9Z0 yW ?11I N" l 0I dl vd aO1valsumwov 211'1H0S NbI11IM 00 0NIO1IO2 '7'�ujS I'll l o uoT;e!rdx? b80 - a Q! u E•yOZi'r ,Ipr,PI�SI$ �b01 J.„yL�10J iN3W?nnu. IT 2 �:,db, 3W0H ooMMONYyEALTM , DEPART'M&,fT of t ! OF j 1010 COM �JC CNUSETTS ! ( SAFETY MASSA ' BOSTON,M02215 AVE. r EXPIRATION DATE { CONSTR�= EHSE :I 07/31/19 UPERV� 11 RESTRICTIONS 9; ISO R J NOpE EFFECTIVE DATE' ATE UC NO. r,8/01/1991 0363�0 F 4 , f > j ga WILLIAll L. StHULZE � '► PATRIOTa MAY - RHOTO(BLASTING OPR ONLY) FEE: IC�`MTERVILLE " MA 02632 0.00 z HEIGHT: NOT MAID UNTIL j �.. DOS: STAMPED O SgNAD BY LICENSEE AND OFFICIA Y SgNATURE OF THE COMMA E 0/29/19Si TH6 DOCUMENT MLISTC.ARIED ON I( OTHERS RgNT THUMB HE HOLDER TH PERSON p3 L _ ( PRINT EO IN HEN ENGAG� oo.'", t.. THIS OCCUPAtpj. `�� eE OF LICENSEE ' 20QM-2-87.8t42g '�r^ mart MISSgNER I f' .