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0105 HILLSIDE DRIVE
. f . _ : _{ _ _ L o, ., _ � . s �, .. , , a �� w a F, �. ,.- ,; .. .._ 9 � , r -.� .. �. .. ,. � 4 � _ .. �. ., - u -. � �� .9 .' ,. a r . . �� 2 S - _- ,. � .. .' � .� a a. v o - � .. .� r - i �. ,. C r. �. .. .. l�� �. Q Town of Barnstable Building ;��'"�:' Post This Cad So That it�s Visible:From.tfieStreet Approued'Plans Must;be,Reta�nedonsJoband;this'Card Must be.Ke t vMASS. Posted UBARNSTAUM t F nal l"ns ection Has Been Made g .' F x ��:P Permit i634- ? ... BS,,. ; �;�.. P3�, ` " ..�` „ ,: c u.� i .. 5 •'" . :`�` ° Where a�,ert�ficate of Occupancy'is Requiredsuch Building shall Not;be Occupied until a Final Irispection has been made Permit No. B-18-272 Applicant Name: FALCONER,SHIRLEY A& BARRINGTON Approvals Date Issued: '01/31/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 07/31/2018 Foundation: Location: 105 HILLSIDE DRIVE,CENTERVILLE Map/Lot 193-014 Zoning District: RC Sheathing: Owner on Record: FALCONER,SHIRLEY A&BARRINGTON � N _ Contractor�Name: Framing: 1 Address: 105 HILLSIDE DRIVE ' Contractor License 2 " > CENTERVILLE, MA 02632 Est Pro ect Cost: $6,000.00 Chimney: Description: re-roof stripping old shingles-dumpster Permit Fee: $35.00 Insulation: i f Fee Paid $35.00 Project Review Req: Date 1/31/2018 Final: _. Plumbing/Gas um mg/G as ` Rough Plumbing: 1 Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within si" nonths after issuance. Rough Gas All work authorized by this permit shall conform to the approved application and the approved construction documents forwhich this permit has been granted. All construction,alterations and changes of use of any building and strktures shall be in compliance with the local zoning by laws;and codes. Final Gas: This permit shall be displayed in a location clearly visible from access streetor road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. .% Electrical R The Certificate of Occupancy will not be issued until all applicable signatures Bdb ing and,Fire Off iciaNjare provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work ; w i 1.Foundation or Footing s � ,. Rough: V1. 2.Sheathing Inspection ..' .. 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT y Town of Barnstable Building i _ PostThis�Card-So That rt is /isible Frorn the�Street,„-Approved Plans Must,beRetairied on Job andsthis Card�Must�be Kept��;� 8"r.ffFABm • ,jj'. �ix��s"' ,�',.xy `r1 't k s. `' `a t �' Permit NAB&1639. Posted Until4Final Inspection Has BeenMade ; j ° Where aCerificate of Occupancy is Required;such 8u�ldngshall Not beFOccupied until a FiVnal Inspect�onhas�been made Permit No. B-18-272 Applicant Name: FALCONER,SHIRLEY A& BARRINGTON Approvals Date Issued: 01/31/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 07/31/2018 Foundation: Pe YP g Location: 105 HILLSIDE DRIVE,CENTERVILLE Map/Lot: 193-014 Zoning District: RC Sheathing: Owner on Record: FALCONER SHIRLEY A&BARRINGTON A' Contractor'Name Framing: 1 ContractorzLicense 105 HILLSIDE DRIVE 2 Address ., CENTERVILLE, MA 02632 .' Est Project Cost: $6,000.00 Chimney: Permit Fee: Description: re-roof stripping old shingles-dumpster $35.00• <.' at o n I i n: I su Fee.Paid:` $35.00 Project Review Req: 1312018 Final: D ate / / f. �� � • - Plumbing/Gas Rough Plumbing: F Building Official Final Plumbing: .. a This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afterissuance. Rough Gas: All work-authorized by this permit shall conform to the approved appl id6tion and t�helapproved construction documents for wh h this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by lawsarid codes. final Gas: This permit shall be displayed in a location clearly visible from access street 0rgg6cl and shall be maintained open for publ c inspection for the entire duration of the work until the completion of the same. p }s Electrical The Certificate of Occupancy will not be issued until all applicable signatures by iheBdildihg atfd'�'Fi"rL-"Offi"c"i'�'il's,a'i'r4.proviaed on thisxpermit. Service: Minimum of Five Call Inspections Required for All Construction Work z p q Rough: 1.Foundation or Footing 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ,d Town of Barnstable *Permit# - 1 - a?C Building Department Services Expire"moVeefromissae e RAMSTMIXBrian Florence,CVA P+'�er-�' MAM ' Building Commissioner prfp Mp'l 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us JAN 2 9 Office: 508-862-4038 T®!!"!7 ry N R IU 51 A q,: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address d Il iJ 16 residential Value of Work$ 00 d Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address SV111 1 5_4 + roedti✓��� `"{�� ►-��.( Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor p'I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ['Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. ,A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNAT Q:IWPFILESTORNIMbuilding permit forms\EXPRESS.doc 08/16/17 1 -Uw Comnornveal&ajfMaswdrusetts DV rklreut rr, rn hu id.4ccMTe7z& - Oc�a,�'.Tm�estigt�axrrs 600 Wasfgtm i�treet Bast on,AIA 0211.E mmumass gm1dia Waders' Ctmpensa{i=InmEmuce Affidavit:Bmlder-dCbntractarsMectn mns fibers AppEcant Infanmation Please Print Le�lly �T � P Dame(Hushegs�x6ion&&idhaor � �'Ql Go r%e� Address: f�� -t'f1 t`S��� 2)r Cityfsta: �� ►� Da63� Pham� `J �S �'©f ���� Are you an employer?Checktheappropriatebom ' T of reject r L❑ I am a 1 u� 4 ❑I am a general.confrsctor•and I Y� e 1 ( ��d}= employees(all arEdfor part lime* lave hired the sub-coatracfos 6. ❑I�e�v eonstzo�iag 2.0 I am a sale proprietor orpartuer- Tilted on the attached sheet . ?. El Remodeling ship and have no employees Theme sub-confxactors have ,❑Demolifioa -waling a na fare is any capacity. employees mdbave woAmss' 9. ❑Budding addition - [NO Nags' comp_inc tta•n ce comp.mare n $ requiied_] 5. ❑ We are a corporafien and its 10 ElEPF-tdcal repairs,cr adds 3_ am a bomeo�er doing aid wtrrlr officers have exercised their Ito phteNagrepaim or additi=l. myself[No urafla;rs'gip_ light of exemption per M L L[�Roafrepairs reTo red]1 c.152,§l(4 6 andwe have no employees.[Nowo&ess' 13_❑other camp_inset nce regrured.I 'Amy WB a tCut cbec sbas R amst also ffic lthe secHoabPSowst>mdag die¢workers'c=peasafianpaHryiafatmsuaa i EU meoaraerswlm submit ibis affidarg is they arr£<rlain�s1Fc�aaic soil tbenlgre autade r amst.solrmit a memaffida2tt mdicanno suet ICa�actost'bstchecici3usbmcmustatte�e�ffiaddi6analshQetshauagtLensmeofthesnb-camdmc�o-ss�dsF�ewleeihecarnattbnseenhifiesha�e employees.Iftbesob-taat actumbave emplcyeZs,their I pmv-idett&wadm 'pomp.palm ammbet I am tux elnrpl�xr dint;it pr Mk.workers'compewdian i=jrmw4fbr my enFLcIves: $elo�v is$�epaticy arrd jQb Site iR�arllrlt�iOtL ' Tn€�trance Conzpauyi'�ame: • Policy l,*'or Self-ins.Lic-4 lxpm aIIDate: Job Site address: CitylStM.tp: Afbtch a copy of the workers'coanpensa lion policy"dec-laration page(showing the policy,number and expiation date). Failure to secure coverage as required unde r Section 25A of MGL r 15°f can lead to the imposition of criminal penalties of a fine up to$UOD OD anWor one-year imprisoameak as w&as civil penalties im fe fb=of a STOP WORK ORDER and a,frIIe of up to MOO a day against the violator_ Be adiised gmt a copy of this statement.maybe forwarded to the Office of Isryestsgatians ofthe DL4 for insrsr ce coverage,mrifrcation. -Ida hers c uder Ste pains andperaaItiss afpee-jicrp th&tfie aef braua€va pn it£ed abates is hats and correct Siffiatu Date: , ®t Phone ik QjWi L use w9y. Da not write in t ds area;hr be catrspl'eted by tafp or town nj9aerat City or Town: PermitUcense:9 Dsuing Authority(cir&one): L Board of HeA fi BuR ing Department 3.City/rown Clerk 4.Electrical inspector S.Plumbing hupecter 6.Other Contact Person: Phone#: information and lastructions Massachnse s Gf-D�Laws chapter I52 regaaes all employers to provide wozke&=33Pensaffon for ffitir employees. employees. •this ,an=17Ioy,=is defined as.¢:eveaypmson.m..ffie sCMCr of anoffiW Under nay colftact ofiae; empress or implied,'oral or " Aa anp&yer is defined as"an in i4idn 1,paring,assoaati�n,�P On or oti�er Legal entity,or any two or more of the foregoing CMP9ID&in a Joint eoterptzse,andinclndmg the legal=2res=tafies of a deceased employer,or file receiver or trustee of an incfxvidnal,pa t=Mhip,association or o$ierIegg entity,employing employ- However the owner of a dw'ellmg Douse hWb2g7 not more than three arLmen�and who resides therein,or the occ¢pant oftbe- dweIIing horse of another who emplus pmsams to do ,CongkaCtjon or repair Wow an such dweIImg house or on the grounds or burldmg ag urfE -'ttherein shonotbecanse of surh employmentbe d=Medto be an employer." MGL chapter 152,§25CC6)also sues that¢every state or loe Hcensmg agencyshZ.WhhhDId•die issaance or renewal of a Hcen a or permit to operate a business or to construct bm7db3V in the comrnunwealth for any appliamtwho has notprodnced acceptable evidence of campTianm VWi the insnrance.coveMgereq� - Addi ionalb,MGL chapter I52,§2.5CM stairs=Naft m the nor iay ofits political subc lions shaIl enter into any coat ad fi r the pesfm:nM7-L of_publio wade matI ac u ptable evidence of compliancevrhh$ie msmmacd._ req�e�s of this chapteahavebeen.prese±rdto ibe g.auibority." AppHcan-b Please fM oil the waj=,compeasaiion aidavit completely,by chug&o boxes�apply to your On.-Eon and,if ne y, Ply sab_cont mzt M(S)name s), add=sCes)and pbnne nnmber(s)along withtheit ceriffi s)of „=f n ce. L=iti--d Liab ity CoinP=es(LLC)or Limit I bbf7ityParfneshzps(LI P)`Yz&no cIDPIoyees othm ffim ibis members or par[a=;are not reed to cagy wor3=s'cmnpensafron insu cc, If an LLC or F LP does have employees,apolicy is requir t Be advisedthAthis affitdaykmaybe snbmitc;dta thr.Depar(ment of ludusthl Accidents for coma of insurance coveaap. ATso be sine to sign and dateire of davit The affidavit should be•retomed to•he city ortowntbat the applicEdon for the permit or license is being requested,not the Deparfinenf of TTri„et,-r aI�g_ccid�s_ SbM&Yuu bays any guest L s regarding tiie law or ifyou are rcq=ed to obtam a workers, =npmsationpohcLpimsecaIItbeDepmfraedatthenrmberliste belovt Self-insi companies should cater1hr-ir s elf-i sa aace Homse mmmber on fhe appropriafa line. City or Town Officials . r Ple asp be sure that tits afbdav�is complete and prided Legibly. The:Depazfineat has provided a space at the bottom of the affidavit for you to fM out k the event the Office oflnvesfigationS has to confactyo'nreg•Sdmg the applies PLeasebesuretofillinthepen�ifilIitensenrnabeswhichvMbeusedasa=&=ccnumber In addition,an applicant tl�must submit multiple p=3tIUC use applibions in any given year.need only submit are affi fiGn indicating current p ohcy information.Cif necessary)and under°Lob�e Address"the applicc�should write asII locations in (�or town)."A copy of ffie affitdavitibat has be=offichIlY Stamped or mmiced by the city or town may be provided to the ' applicant as prooff hat a valid affidavit is on file for 5:d= 'pmmits mm or Hc= 6 A new affidav>trst be flied Diat each year.Where a home owner or citizen is obtaining a limmse or permit not related in any business or commercial v H (ie. a dog lj=wc orpennit to bmn leaves eb.)said person is X0T req�d to eomple this affidavit Ibe Office Ofj-MVCSflg3fi=WDuldll MtntiaMkyoninadvance for your coopex-4=and sho-old youany4ucsti=• please do noth Gate to give us a CA The Departm mf's address,telephone and fax m=bcr Tbb CO.IIDMMW21t f Of Massachnscttg Depadment t&�A.GGtdf via • �4� �an Sty �as1�E1��11 T(z-L 4 617-' -4 =t4Q6 or 14 MA R� Fax#Q7`27 7M revised4-24-07 gldhL WE Town of Barnstable Building Department Services ` MAB& ` Brian Florence,CBO 5 Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma,ns Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section - If UsinfA Builder as Owner of the subject property hereby authorize to act on my beb4 in all matters relative to work authorized by this building pertnit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rer.08/16/17 Town of Barnstable Building Department Services Brian Florence,CBO R Building Commissioner ' 200 Main Street, Hyannis,MA 02601 KASS. www.town.barnstable.ma.us 639 F� Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: I �`` ,/� JOB LOCATION: I �(1 S I'U � (� M►7 3 numbs pp G village 5,"HOMEOWNER% 1(r� �cc n e-1 4-5) O ct o( ! l q•05 name I home phone# work phone# CURRENT MAILING ADDRESS: I b \Sl �r cityhown 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. DEFINMON 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 buildingpermit. (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 Pro e s requirements and that he/she will comply with said procedures and requirements. I Si store of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q.\WPFILES\FOFIVL%uilding permit forms\EXPRESS.doc 08/16/17 J �$tL aF Town of a �� � Permit"# Expires 6 inwifirs from issue date Regulatory Services Fee anxNs'raa[.a 3 9$At 1 &,0�a Richard V.Scali,Director'Building Division FD MA'S , Tom Perry,CBO,Building Commissioner 00 Main Street,Hyannis,MA 02601DEC www_town_bamstable.ma.us �� �6 l Office: 508-862-4038 �:�f ax: 5 8-790-6230 EXPRESS PEIZIVIT APPLICATION - RESEDENTLAI OP / ,5-. Not valid without Red X-Press Imptitrt bfap/parcel Number 9 ' Property Address` C�(� i'liLL,91,6E YResidential Value of Work SZ/1 Q7! ;Minimum fee of�$35.00 for work under$6000.00 Owner's Name&Address >;..V6/1 OA f-- VA-R-r �o� • /sue �X-i � �v,'�lP, 4 v3 z- Contractor's Name 127,1 (>j/jr jpl( Telephone Number Home Improvement Contractor License#(if applicable) 47 Email: Construction Supervisor's License#(if applicable)_ (-)q 57 O 7 T TWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor m the Homeowner I have Worker's Compensation Insurance Insurance Company Name E r ezMe- rl,-� -Ep!zU Eh1a e Workman's Comp_Policy# C A 31 8 7 2— 2.o Copy of Insurance Compliance Certificate must accompany each permit_ s Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to , ❑Re-roof(hurricane nailed)(not stripping: Going over existing layers of roof} ❑ Re-side Replacement Windowsldoors/sliders. 0-Value . 2 (maximum.32)#of windows of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical& Fire Permits required. *Where required: Issuance.of this permit does not exempt compliance with other town department regulations,i_e.Historic.Conservation,etc. ***Note: Property caner must sign Property Owner Letter of Permission. e - - - - A copy the Home Improvement Contractors License&Construction Supervisors License is j require r SIGNATURE: C:\Users\Decollik\AppData\LocaiNMicrosoft\Windows\Temporary Internet FileslContent.Outlook\2P10I DHR\EXPRESS.doc Revised 040215 Renewal Agreement Document and Payment Terms*. - Andersen. dba:Renewal B Andersen of Southern New England yShirley &Barrington Falconer Legal Name:Southern New England Windows,LLC 105 Hillside Dr. RI #36079,MA"#173245,CT#0634555, Lead Firm#1237 Centerville,MA 02632. w:xoow RE ono..... 10 Reservoir Rd I Smithfield,RI 02917 H:(508)901-1985 . Phone:866-563-22351 Fax:401-633-6602 1 sales@renewalsne.com C:(508)332-0668 Buyer(s)Name: Shirley & Barrington Falconer . Contract Date: 1.1/25/17 Buyer(s)Street Address: 105 Hillside Dr., Centerville, MA 02632 Primary Telephone Number: )901=1985 Secondary Telephone Number: (508)332-0668 (508, Primary Email: faleonerearr@gmail.eom Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the patties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount. $21,979 By signing this Agreement,you acknowledge that the Balance Due,and,the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $10,989 Balance Due: $10,990 : ..Estimated Start - . - Estimated Completion: 6-10 weeks 6-10 weeks Amount Financed: $20,000 Method of Payment: Cash/Check We schedule installations based on the date of the signed contract and secondarily on . :Financing. ..the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date..Rain and extreme weather are the most common causes for delay. Notes: 10989.00 deposit-GREEN SKY; 9011.00 balance-GREEN SKY,1979.00 balance-CHK;. Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyers)hereby acknowledges that Buyer(s) 1)has.read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and2)was orally informed of Buyer's right to cancel this Agreement. - NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the.contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 11/29/20117 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER:SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,.LLC. dba:Renewal By Andersen of Southern New England Buyer(s). Signature of Sales Person Signature. Signature Chris Hutson Shirley-Falconer Barrington Falconer , Print Name of Sales Person Print Name : Print Name UPDATED: 11/25/17 Page 2 / 13 L I Massachusetts Department of Public Safety Or Board of Building Regulations and Standards License: CS-095707 a. Construction Supervisor BRIAN D DENNISON 7 LAMBS POND CIRCLES N 'r CHARLTON MA 0150T� = l„� Expiration: Commissioner 09/00018 ` � ��ie �t�i�a2����c�,cz tYC>�a�i a�t� • Office of Consumer Affairs 6nd Business Regulation k or- , 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home improvement Contractor Registration _ Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 SOUTHERN NEW ENGLAND WINDOW_SLL- �, BRIAN DENNISON 1-x 26 ALBION RD LINCO_N,RI 02865 ;3t ' 'Update Address and return card.mark reason for.change. Address [i Renewal .Employment G Lost Card SCA, a 2oMosm �'--� fUce of Gonsamer Affairs&Business Regulation Registration valid for individual use only before the expiration:dam Iffoondreturn1o: vOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Registration-17.�.iS Type: 10 park plain.Suite5170 Expi2Uon9f13/2018': :Supplement-CaitlBostou,MA 02116 SOUTHERN NEW ENGLAND VYINQOWS'LLC.. RENEW AL BY ANDERSON BRIAN DENNISON ULIAIBION RD NCOW,'RI.02865 �l.jiade�rsecre try- Not valid without signature 1 . I The Commonwealth of Massachusetts t Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-201 i www.mass.gov/dia >� Workers` Compensafion Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTLNG AUTHORITY. Applicant Information Please Print Le 'bly Name (BusinesslOrganiiation'individual): KWERAJ e U3 E OW"S Address: ,Z& ALtwo Cit,/Siaier`Zip: IJ Phone 4: Are you an employer?Cbeck the appropriate box: "hype Of project(required): 1.1 am 5 employerv6tl !O fempioyees(full and/orpar-time).' i. New construction 2.7 I am a sole proprietor or partnership and have no employees working for me it, S. Remodeling any capacity.(No workers'comp.insurance required.] o �Demolition O i am a homeowner doing ail work mvse--krNo workers-comp.insurance required.] 10 []Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work or MV properrv. 1 will ensure that all contactors either have workers'compensation insurance or are sole l 1_Q Electrical repairs or additions nrop:ietors with tic emplovees. � 12_ Plumbing repairs or addition: L.❑I am a general contractor and I have hired the sub-contractors listed or.the attached sheet 1-,_❑Roof repairs Tnese sub-contractors nave employees and have workers'comp-insurance.= II (,(> 14. �Other ty/ E.❑We are a corpgratior,and it olfficea have exercised their righr of exemptior.per MGL C. I 1(c).and we have ne employees.[No workers'comp.insurance required.: 'Any applicam that checks box 1,l must also fill outa section 1 h their rkers compensanor policy irfarma or.. Homeowners whc submit this affidavit indicating they are doing all wort,and then hire outside contractor`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. Lithe sub-contractor`have employees;they must provide their workers comp.polio•number. I am an employer that isproviding work-ers'compensation insurance for my empiovees. Below is thepolio and joh site information. Insurance Company Name: lrf Ine ns I Policy#or Self-ins.Lic.#: C v6�<7 Z — �- Expiration Date- /DPI �c . Job Site Address: City/State.%Zip: t Attach a copy ofthe workers' compensation policy declaration page(showing the police her and expiration date). Failure to secure coverage as required under MGL c. 152,F25A is a criminal violatior punishable bti a fine up to$1500.0C 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_A copy of this statement ma}v be.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd under ih sins and penalties of perjure°that the information provid7b;Ua and correct Date: Si atom Phone : Official use only. Do not write in this area,to be completed by ciV.or town offteiaL City or Town: Permit/License# issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cit-V/70wn Clerk 4.Electrical Inspector 5_Plumbing Inspector 6.Other Phone#- Contact Person: ESLERCO-01 SANDERSO DATE(MMIDDIYYM CERTIFICATE OF LIABILITY INSURANCE 0610712017 ER THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI ON L EXTEND Y AND OOR EA TER THE COVERAGE AFFORDED BY THS NO RIGHTS UPON THE CERTIFICATE EPOLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 suchendR.A rsement(s). CONTArPRODUCER W6 FAX No):(303)98"804 Biz Insurance,Inc.-CO ,E,d:( 1401 Lawrence St,Ste.1200 CoMaii@coWinsurance.com Denver,CO 80202 SS: AFFORDING COVERAGE NAILR A:Ance Com an 31395R e:France Com an of WA D.C. 21784 r INSURED 10725 Southern New England Windows,LLC.dba Renewal by R c:LUS Insurance Andersen of Southern New England RD:26 Albion Road,Suite 1Lincoln,RI 02865RE:ER 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 I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS SURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE IN EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REPOLICY DUCED BY PAID CLAIMS. i LIMITS ADDL SUBR POLICY NUMBER MMIDD �F NIN ID POI CY E7CP INSR I TYPE OF INSURANCE INSO WVD 1,000,0001 A X COMMERCIAL GENERAL LIABILrrY EACH OCCURRENCE 5 01/0112017 01/01/2018 rrre DAMAGE TO RENTED 300,0001 CLAIMS-MADE �X OCCUR CPA3158728 PREMI E Ea ocnnoe 5,000I MED EXF An,one erson S PERSONAL S ADV INJURY s 1,000,000� 2,000,000 GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 X �I PRODUCTS-COMP/OF AGG 'S POLICY F %Ref ❑LOC I EBL AGGREGATE 2,000;000 s OTHER: COMBINED SINGLE LIMIT S 1,000,000i FA I AUTOMOBILE LIABILITY Ea amtlent BODILY INJURY(Per person)CPA3158728 0110112017 t''SS1/2018 ANY AUTO I BODIL INJUR�SCHEDULED d OWNED L�AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED Per accitlenl = AUTOS ONLY AUTOS ONLY I 5 I 1,000,0001 I UMBRELLA LIAB X OCCUR EACH OCCURRENCE A X CLAIMS-MADE 112017 01/0 I CPA3158728 I01101/2018 AGGREGATE s ExcEss L1AB I Aggregate I s 1,000,000 DED X RETENTIONS 0 OTH- j X STATUTE ER B wORxERSCOMPENSATION 01101/2017 01101/2018 1,000,000, AND EMPLOYERS'LIABILITY YIN CA3158729-20 E.L.EA ACCIDENT ANY PROPRIETORIPARTNERIEXECUTIVE r 1 1,000,0001 N I A OFFICERIMEMBER EXCLUDED? EL DISEASE-EA EMPLO i 5 1,000,000 (Mandatory m NH) It yes,describe under E.L DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below WCA3158730-20 01/01/2017 01/0112018 B Worker's Compensatio 01/0112017 01/01/2018 1,000,000 117 I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) I17-18 Workers Compesnation Includes-All states except ND,OH,WA,WV,WY I � I I I CERTIFICATE HOLDER CANCELLATION � ELLED SHOULD NOTICEIES BE WILLCBECDE:LIVERED RIN I ACCORDANCE WITH THE PaL.IE'1'PROVISIONS. I AUTHORED REPRESENTATIVE I i F R Informatignal PurpQ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Town of Barnstable Building .' + n«ro"�'" e "` ,. .. .^ <,,'1r. rti.s,.,^'y t- +g1r, yy. •! ,y»t ..,y ,:.yrr- '4'+t^t""..r,,.. ,y ., .,v ..y w,�*a^. • PostfThis Card So That it is:Visible From the Street Approved P1ans.Must be Retaine..d on Job and`this Card Must be Kept . a�ttxsrweu ,. "'"� Posted Until Final Inspection:Has.BeenMade H, ': t Permit s639 �� f ,�. .,.su11 x :y a «•. 1 erlll�l ,�x�° Where a Certificate`"of Occupancy is`Required,such Building shalI j of be Occupied until'a Final Inspection has been made :.,. h .x. .�.� mow._ �.M« .. Permit No. B-17-4226 Applicant Name: SOUTHERN NEW ENGLAND WINDOWS LLC. Approvals Date Issued: 12/11/2017 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 06/11/2018 Foundation: Location: 105 HILLSIDE DRIVE,CENTERVILLE Map/Lot: 193-014 Zoning District: RC Sheathing: Owner on Record: FALCONER,SHIRLEY A&BARRINGTON Contractor,Name-`'^;,SOUTHERN NEW ENGLAND Framing: 1 WINDOWS LLC. Address: 105 HILLSIDE DRIVE 2 CENTERVILLE, MA 02632 "Contractor,License 173245 Chimney: Description: Replacement windows(12) Est Project Cost: $21,979.00 Uvalue.29 �Permit Fee: $ 112.09 Insulation: Project Review Req: Fee Paid:r $112.09 Final: Date:' 12/11/2017 t Plumbing/Gas v ���,�c �/p Rough Plumbing: tea_ Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open forpublic inspection for the entire duration of the Electrical work until the completion of the same. s x Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided'o6'this permit. g Minimum of Five Call Inspections Required for All Construction Work:„._ . Rou h: 1.Foundation or Footing Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TQWN( F BARNSTABLE BUILDING PERMIT APPLICATION IqS c� Map Parcel®� Application 9>41c)�v Health Division Date Issued I /S� Conservation Division Application Fee Planning Dept. Permit Fee,5&5 - rJ Date Definitive Plan Approved by Planning Board I y1�5 .7 Historic - OKH _ Preservation / Hyannis Project Street Address '10S ►k, Village CCr�+cr� 'f'Ir Owner f oa,c V Address -%-Lr-c Telephone ¢2s •Sal-19hy� Permit Request 1Mc��►�<r►z .� IZ lc��flox cJ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Or, _Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 2/ Two Family ❑ Multi-Family (# units) -= w Age of Existing Structure Historic House: ❑Yes ❑ No On Old King';s Highway. 0 Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other f z Basement Finished Area (sq.ft.) Basement Unfinished Area (sglft) Number of Baths: Full: existing new Half: existing new L33 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 Mike McCarthy Construction Telephone Number PO Box 52 Address west Dennis, MA 02670 License # Cell (508) 280-6964 CS,-5 3-3 HI C''-169393 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 'e �`+Pi^• Jar SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. .ADDRESS VILLAGE ti OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL CAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. j � v Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-058633 MICHAEL J MCC}�R PO BOX 52 s W DENNIS MA 8267 Expiration Commissioner 04/10/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massac}�psetts 02116 Home Improvement C`6ndactor Registration Registration: 169393 r f, Type. Individual - _ Expiration: 7/1 , 0117 Tr# 264961 MICHAEL MCCARTHY {1 _ MICHAEL MCCARTHY _~ P.O. BOX 52 1 WEST DENNIS, MA 02670 Update Address and return card.Mark reason for change. Address Renewal (=j Employment Lost Card 20M-05111 l- The Commonwealth of Massachusetts Department of IndttstrialAccitlents r I Congress Street,Suite 100 Boston,ATA 021I4-2017 °y wwlumass.gov/din.. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Phimbers. TO BE FILED WITH TiiE Pi RMITTING AUTHORITY. ' Applicant information Please Print Le ibl Name (Business/Organization/Individual): a o6—p_08Z (Rog) 1123 Address: OL9ZO VW `Sluua(l ;saw City/State/Zip: not Are yoi an employer?Check the a propriate box: Type of project(required): l. m a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp:insurance required.]t 9. ❑Demolition 4.n 1 am a homeowner and will be hiring contractors to conduct all work 10 E Building addition on my property. (will ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.F1 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.igsurance.t 6.n We are a corporation and its officers have exercised their right of exemption per M_GL c. 14.dOther 152,§1(4),end we have no employees.[No workers'comp.-insurance required.] Any applicant.that checks box#I 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. tContractors that check this box must attached hn additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. lam an employer that is providing lvorkers'compensation insurance for my employees. Below Is the policy and Job site information: Insurance Company Name:_ ATM M,4,( Try), 1Mi2!r,i Policy#or Self-ins.Lie.#: 706'�a1`( � Expiration Date: k- )IN Job Site Address: �G� I'�.,Q� 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 MGL c. 152,§25A is a criminal violation punishable by 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.A Copy of this statement may be forwarded to the Office of investigations of the DiA for insurance coverage verification. I do hereby certify an tl ai snail nitles rjtrry that the-information provider/above is trite and correct. Signature: Date: Phone#: 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i s WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMAfi=PA.GE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 800 876-2765 NCCI NO 26158 . POLICY NO. VWC-100-6017656-2014B PRIOR NO. I VWC-100-6017656-2014A ` ITEM 1. The Insured: Michael McCarthy Construction Inc DBA: Mailing address: P 0 Box 52 FEIN:**-***3862 West Dennis, MA 02670 Legal Entity Type: Corporation Other workplaces riot shown above: See Location. 2. The policy period is from 12/15/2014 to 12/15/2015 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000:each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information,required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTEA 0712979 INTER SEE CLASS CODE SCHEDU-E Minimum Premium $550 Total Estimated Annual Premium $29,332 GOV GOV Deposit Premium $7,748 STATE CLASS MA 5479 State Assessments/Surcharges $28,601.00 x 5.8000% $1,659 This policy, including all endorsements,is hereby countersigned by 12/15/2014 Authorized Signature Date Service Office: B den&Sullivan Ins A c of Dennis Inc PO Box 1497 Burlington MA 01803 54 Third Avenue ry g y ffff So Dennis, MA 02660 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, \ v� ` used with Its permission. V Imo- -- 1 2� r Town ofBarnstable Regulatory Services MASS Richard V.Scali,Director o , Building Division Tom Perry,Building Commissioner 200 Main Stieet,TIyaruus;_�ZA 02601 tivww.town.ba rnstable_ma.us Offic4: 508-862-4038 pax: 505-790-6230 Property Owner MUMS t. . Complete and Sign: This Section.. If Using A.Builder as Chxmer, or Elie subject prnpci,1;v bereby authorise C I� �l io act on m, -behalf, in all.matters r-,a14vc•to work autho . y-this bLdc in-permit application for: (Address of Job). ' "fool fences and alarms are the responsibility of.t:h%-apphcau. Pools are not to be filled or utilized before fence is inst.alled ,.wd all 11c l inspections are performed and accepted. S onamre of Chi ner. Si-nature of.A ppli alit 4 t Print Na'rne Print.Name X � 13i� Date _ j QTORA1Sa0?'i FRPr,:?1�t15S10A'PUOi.S I} i 0pIKEt Town. of Barnstable 'Permit# Expires 6 months from issue date n� srAB Regulatory Services I{ee v�p 36& a1� Thomas F. Geiler, Director m - rf°�,pg Building ]division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-�1038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONi,'St' Not Valid without Red X-Press Imprint Map/parcel Number Prope Address Residential Value of Work zy) 1 00 Minimum fee of$2S.00 for work under$6000.00 Owner's Name&Address CIh1 , � 0,5-� s - Contractor's Name !t Q N L��I�Ii�1; ^ Telephone Numberd Home Improvement Contractor License #(if applicable) 1.11?1? Q Construction Supervisor's License#(if applicable) 2 �1140 01 X-P E S ❑Workman's Compensation Insurance Check one: AUG t 4 809 ❑ I am a sole proprietor ❑ I/erffi the Homeowner TOWN OF BARNSTABLE I have Worker's Compensation Insurance Insurance Company Name--- Workman's Comp. Policy It Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) e-roof(stripping old shingles) All construction debris.will be taken to ❑ Re-roof(not stripping. Going over existing layers of room ❑ Re-side ❑ Replacement Windows. 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, Home Improvement Contractors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\Express\EXPRESSPERMIT.DOC n�.,�,•„n�ndnn s t The Cotnmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 �,•� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elee'tricians/Plumbers Applicant Information Please Print Legibl Name(Business/Organization/Individual): Z11114,7 0/q--5�7 Address: Zc9 &Ili 3®h City/State/Zip: lv��I,Lf /Li Phone.#: y Are you a mployer? Check the appropriate box: Type of project(required): 1. am a Y emP to er with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sttb-contractors .2.❑ I am a sole proprietor or parttler-: listed on the attached sheet. T. ❑Remodeling ship and have no employees These sub-contractors have g, '❑Demolition working for me in an capacity. employees and have workers' g Y P ty. 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their I I- Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g p myself. [No workers' comp. right of exemption per MGL 12 (Roof repairs insurance required.] t c. 152, §1(4), and we.have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant.that checks box#I 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 17 Insurance Company Name:• �d�l� Policy#or Self-ins.Lic. #: Expiration Date: lob 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 cri_mirial penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the MA for insurance coverage verification I do hereby certify under the pains /and penalties of perjury that the information provided above is true and correct Si ature: y Date: d Phone#' ( ld .7.gj, 49 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 S.Plumbing Inspector 6. Other ai Information and Instructiolis Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in.the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the 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 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«zth the uisurance 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)and.phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/liernse number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address" I.he applicant should write"all locations is__(city or town),".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or license's A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. ue Office ofTavestigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts- ' Dc-partm(mt of Industrial Accidents Office of Irtvesdgatians 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777749 Revised 11-22-06 www.mass..gov/dia 08/14/2009 12:50 FAX 508 775 3821 OLDE CAPE COD INS AGENCY lJ 002 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID EV DATE(MM/DDMW) VILLA-1 08 13 09 Olde PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cape Cod 'insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Martha Findlay HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2 a nis MA 02601Street . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone:508-771-3300 . Fax:508-775-3821 INSURERS AFFORDINGCOVERAGE NAIC# INSURED INSURER A: acanito Bt►tg Ineusanca Co_ INSURER B; Villani Construction Inc INSURER C: P.O. BOX 692 INSURER O; West Hyannisport MA 02672 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MM UDm LIMITS GENERAL LIABILITY EACH OCCURRENCE _ $ COMMERCIAL GENERAL LIABILITY _ PREMISES Eo N I E:V ce $ CLAIMS MADE ❑ OCCUR - - MED EXP(Any one person) $ PERSONAL&ADV INJURY S GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIIT APPLIES PER PRODUCTS-COMPIOP AGG $ POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Eo accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS $ NON OWNED AUTOS BODILY INJURY(Per emident) PROPERTY DAMAGE S (Per accident) GARAGE LIABIUTY AUTO ONLY-EA ACCIDENT $ ANY AUTO - - OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ 9 DEDUCTIBLE $ RE-rENTION — $ WORKERS COMPENSATION AND DRY LIMITS ER- A ANY PROPRIETORETORILITY/PARTN6R/EXECUTIVE WC007=42-7055 04/01/0 04/0 /10 E.L. CH ACCIDENT $100000 A �. OFFICERJMEMBER EXCLUDED? E,0 ISEASE-EA EMPLOYEE $ 100000 If you.describe under SPECIAL PROVISIONSbetow 141 oisEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Barnstable IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 230 South Street REPRESENTATIVES. Hyannis MA 02601 AUTHORIZED REPRESENTATIVE Ju Sullivan ACORD 25(2001/08) ®ACORD CORPORATION 1988 f Building dsBoard oifs an License or registration valid for individul use only HOME IMPROVEMENT.CONTRACTOR before the expiration date. If found return to: % Registration:_ 128560 Board of Building Regulations and Standards Expiration.;:4/21/2011 Tr# 283931 One Ashburton Place Rm 1301 Type: Individual Boston,Ma.02108 RICHARD VILLANI RICHARD VILLANI y j 109 WAGON LANE"•-' HYANNIS,MA 02601 Administrator Not valid without signature 1 - Miissaehusetts'- Departinent of Public SafetN Board of Buildin- Rcoulations and Standards Construction Supervisor License. ,:License: CS 74360 Restricted to 00 RICHARD IUILLAN;I PO BOX 692 W HYANNISPORf, MA 02672 Expiration: 6/23/2010 . Commissioner Tr#: 27991 II i VILLANI CONSTRUCTION INC. Roofing& Siding Specialists PO Box 692 West Hyannis Port,MA 02672 508-778-2495 1-888-766-3043 Member of the Better Business Bureau—Insured—Licensed—Free Estimate Donald Reeves August 8,2009 105 Hillside Dr. 508-362-5009 Barnstable Ma. DESCRIPTION Furnish and install the following, labor and materials to re-roof building at 105 Hiilside Dr. Ma. as follows: 1. Remove and dispose of existing roof shingles.Nort end gable only. 2. Check all boarding and nail where necessary. 3. Remove existing drip edge and soil pipe flashings. 4. Install new aluminum drip edge. 5. Install new aluminum and neoprene soil pipe flashing. 6. Install 15#felt paper. 7. Install ice&water barrier to eves,valley and penetration. 8. Install 30yr architectural roof shingles. 9. Install ridge vent. 10. Remove debris from job site. -Dump fees for removal are included in this quote. Villani Construction guarantees labor for 10 years. We propose hereby to furnish labor&materials complete in accordance with above specification for the sum of- ONE THOUSAND SEVEN DOLLARS: $1,700.00 Payments to be made as follows: DUE ON COMPLETION All materials are guaranteed by manufacturer. All work to be completed in a substantial workmanlike manner according to specifications submitted,per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon verbal request and will become an extra charge over and above the estimate. All agreements contingent upon weather, accidents, or delays beyond our control. Owners to carry fire, tornado, and other necessary insurance. This proposal maybe withdrawn if not accepted within 30 days. ACCEPTANCE OF PROPOSAL--- The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized IQ do the work as specified. Payments will be made as outlined above. Signatur Signature C1,Q Date J i Assessor's map and lot 'n'umber ......r/..c ".... Bpi THE T0� , N 81 �PT'C SYSTEM Eris �Q o._ tlST �E ' Sewage Permit number ..........................� ............. INSTALLED IN C �� :. IV:P A BAHHSTA� Z MP, i House number ..:...... . ....... .. ... ...................:............... . WITH TITLE 5 ro aea "�'iRC3i0if'� ENT'd� Mb39•a`00� C. r G YAY TOWN ;OF BARNSTABLE BUI.LDIHG NS,PECTOR APPLICATION:FOR PERMIT TO > .: .. �? 1`li! IA ................................... .. ..... TYPEOF CONSTRUCTION / (� ......... .................................................................................... ............ .....................19... TO THE 'INSPECTOR-OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...... .0..�.........��....:... . ..... ... ........P�............. • .. ... �.......................... ................................... IM - ProposedUse ..... ....... ....... .......... ................,(........................................................................................................... ZoningDistrict .................................... ....... ...........................Fire District ............................................................................ /�/�JJ �- "c. .i.Cfl✓V t P Nameof Owned,..... .......................... �...................... ......:..Address la.-3........ .. .......... ................................. ..... Name of Builder .. . .. ........ .......... ..:......... ........................Address .31.......... ........................ p�S. Nameof Archite ............... .......................................Address .........(.......................................................................... Number of Rooms .. -�..................................Foundation ..�? � .........'................................... Aj Exlerior ...�........ ...� Z?........'�............................................Roofing .����:`.'."'"'.'t........A4-1416-tl..................................................... . .................... .... ... . .............................Interior ............ ... ...�..........A................................................. Heating ... .. .. ...... .............. ................... ...... ...O....!.��'... ..Plumbing ........................ ...................................................... Fireplace ........ . . ................................................Approximate Cost ....... ®® Definitive Plan Approved by Planning Board -----------____---------------19_______. Area . or. ......... . ..................... Diagram of Lot and Building with Dimensions Fee .................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH a V '410 � pro c ifirc N� rs*t 57 I �' 46 it. i IT/ram 4� '`d �tIS We r ka 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 Supervisor's License ....0a[[�� 2 QQ /... .. ..4�.. JOHNSTONE, ROBERT No ..28019... Permit for ...ADJAMOR,:............ Single Family Dwelling :;.............105 Hillside Drive.. .................. Location ..................................... ....................... _ Centerville J;`: ......................................................... .............. Robert Johnstone Owner ............. :.. .......................... ... ............... �,, G, � � # �, - � "'�'• -e 4_ . Vol T `pe of Construction ..Frame :....... .................... ..... v i................ ............... ............... "„' ..�r YeS 3•f•1.-: Plot .................. .:. Lot ...... .........: Y'Y Jr r , Permit`Granted Ju17�..13, ... y19 85.. p Date of Inspection ... ...7 �1:19 Date Completed ...... ........ 19��D OF e J T.OWN OF BARNSTAULE BUILDING INSPECTOR AP g4 ...................4.3.....................19...F.r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Exterior ... 6......<a,�......................................Roofing ......... ................................ ...... ............. ........ k" 16 a t i n g=47�! Plumbing ....... ...................... .............................. ............. ........) SUBJECT TO APPROVAL OF BOARD OF HEALTH /000 /009 - ' � � . . , \2 } ' � ` . | | ` \ ~ - ` / � . OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS | hereby agree to conform to all the Rules and Regulations of the Town of 8omnsto6|e regarding the above construction. Name —. (j/6(/,Vy1& .....-.'.--................ ............................ ' y Construction Supervisor's License .... Single Family Dwelling Owner .. Robert Johnstonev � Plot ............................ Lot ................................ � JuneI3 85 Permit Granted ------..�------.lA ' /Dotaof |nxpechon ------------lq ' Date Completed ------------..lq � � ^ / ` ` ' ^ � � � � � � ` . � . . .