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0036 HOLLY POINT ROAD
� Hol-o Po/ N—(t qc T��F I - Towne of Barnstable *Permit# l Expires 6 montko 5 S date °7 'Regulatory Services Fee ,;- • MAM i t ,ThomasE, � F,Gelier,Director s, f 8 I I z 3 hL/ a Building Division �. Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA'02601` ✓T/�"V( ;. . iAwwAown.bamstable.ma.us.` .' r Office: 508-862-4038 Fax: 508-79076230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red K-Press Imprint Map/parcel Number o 3;3 o Property Address L XR.esidential Value of Work$ Q Minimum fee of$35.00 for work under$6000.00 /Ovmer's Name&Address Contractor's Name 3= Telephone Number �� Home Improvement Contractor License#(if applicable) /73 Email: Construction Supervisor's LicensX PRESS? e# (if applicable) 76 7 EMIT Workman's Compensation Insurance JAN�.2 , Check one: 2014' f ❑ I am a sole proprietor ❑ I am the Homeowner - r TOWN ®F - �I have Worker's Compensation Insurance �QiRNSTABLE Insurance Company Name (/A)A aS , Workman's Comp.Policy# _�a 7 R/!ea 9, - Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) r. Lj Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed not stripping. Going over existmi layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value 1!11 (maximurrL35)#of windov�i #of doors: ❑ Smoke/Carbon Monoxide detector's 4 floor plans marked with red S and inspectigns 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,cto. . ." ***Note:' -Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is = aired. 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CS-095707 BRIAN D DENMSON , rr 7 LAMBS po1vD Eater ` Charlton MA 01507 r Expiration Commissioner 09/08/2614 &foie �pna�r�u�rts ,lz ��1�Office of Consumer Affairs Business egu atlon 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Ev"ation• 9119,2014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 Update Addreu and return card.Mark neaten for change sun o 0 Address ❑Renewal E.Ooyment Lost Card !--, Rue of Conmmer Al6irs&Boslnen Regulation License or registration valid for fodividol use only E IMPROVEMENT CONTRACTOR before the eepiratioo date.If found return to: _ X! ofrwe of Coosumer Again and Busiuest Regulation i3tr800n: 173245 Type; 10 Park Plarn-Sarte5170 Expiration: 9nS=14 supplement::ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL By ANDERSON SRN 1137 PARK 1137 PARK EAST DRIVE � WOONSOCKET,RI 02895 Underserremry Not valid without signature I Qk The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF `600 Washington Street Boston,AL4 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARiplicant Information Please Print Legibly Name(Business/Organization/Individual): Address: &Z10k) �b City/State/Zip: t1 Nvolpi dl Z-'rPhone#: D! Areru an employer?Check the�appropria,-box: 1.LJ 1 am a employer with L C/ 4• 1 am a general contractor and I Tie of protect(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner listed on the attached sheet. ', ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.'* 9. ❑Building addition required.) 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp, right of exemption per MGL 12. Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.ZOther W1IV comp.insurance required.]' *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infAnation. f 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 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 thepo/icy and job site information, Insurance Company Name: )a6tJWM_f_ 4aA Policy#or Self-ins.Lic.#:�j�9Z 7f I?a 2 39 y Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby er the pains and penalties of pc.jury that the information provided above* true a d correct Signature: Date: t Z Phone#: �— Official use only. Do not write in Mils area,to be completed by city or town o,(j'iciad City or Town. PermittLicense# Issuing Authority(circle one): 1.Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Client#:30124 SOUTNEW V ACORD,. CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YY" 8/06/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Anita Little Willis of New Jersey,Inc. A o Fit:856 914.4660 a� No): 856-914-1881 1015 Briggs Road,PO Box 5005 E-MAIL ADDRESS: anita.little@willis.com PO Box 5005 Mount Laurel,NJ 08054 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen INSURER c: INSURER D 26 Albion Road Lincoln,RI 02865 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY S202945900 0811012013 08/16/2014 EACH OCCURRENCE $1 000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ERENTED n. $100 000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'LAGGREGATELIMIT APPLIES PER: PRODUCTS-COMP/OPAGG '$3,000,000 POLICY JECa LOC $ A AUTOMOBILE LIABILITY S202945900 8/10/2013 08/10/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident A X UMBRELLA LIAB OCCUR S202945900 8/10/2013 08/10/2014 EACH OCCURRENCE $5,000 000 EXCESS LIAR HCLAIMS-MADE AGGREGATE s5,000,000 DED RETENTION$ - $ C WORKERS COMPENSATION 0000068028-RI 8/21/2013 08/21/201 X WC STAT IT OTH- AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN AIC927818352394 8/21/2013 08/21/201 E.L.EACH ACCIDENT $1 00O 000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 00O 000 B yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 „ AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1"of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088 AXL 10 Town of Barnstabje *Permit# Expires 6 months from Regulatory:Services Fee awWasresr& yXLMThomas F.Geiler;Director rFD MP't Building Division Tom Perry,CBO, Building Commissioner. 200 Main Street,Hyannis,MA 02601 m ww,.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERmrr APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 7i 3. Property.Address ❑ Residential Value of Work � `It 61 - 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ",xel- b r-5 iyl� Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) k-PRESSM IT Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor TOWN OF BARNSTABLE ® 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) z of(hurricane nailed (stripping old shingles) All construction debris will be taken to�("Jit/S ® Re-roof(h )(. P ❑Re-roof(hurricane nailed)(not stripping. Going over. existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows. Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and.inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department"regulations,i.e.Historic,.Conservation,etc ***Note: Property Owner must sign Property Owner Letter.of Permission. ; A.copy of the Home Improvement Contractors License&Construction Supervisors License is /r-eequired. SIGNATilRE /J The Commonwealth afMassachusetts Deprrrtntent of Indusb irrt A ccidenft , Dike o,f investigations b(tU 'asteu4.gtwn Street Boslon,.MA #2111 WKW.M goV1'din. Worken' Compensation Insurance Affid2vit:Builders/Contractors/Elec ric ans/Ph tubers: Applicant Information Pease Print Le ibly None dual): A.d&ess: Ak Cit rf tatefZip_ . "/�2- Phone# �.70 3 6 1--3 7/5— Are you an employer?Check the aplrroprdate boz: Type of project(required): 1.❑ I am a employer with . ❑ I am a gmeral contractor and I ' * have.hired the sub-oonhwtms 6- ❑New construction employees(Ain andlorpart-time). 2.El I am a sole proptie�toi or partner- listed.an the attached sheet` -?: ❑.Remodeling ship and have no employees These sub-contractors have -8_ ❑Demolition ' . R`orkiag forme in any capacity. employees and have warkers 9. ❑BudIdYng addition comp rneimanne.$ {NO workers' Cot27p.ins arr:rocg required:] 5..❑.We are a corporation-and its 10.❑Electrical repairs or additions- II am a homeowner doing all work. 'ffi"n have exercised dwir 11.❑Plumbing repairs or additions right of exemption per IVIGL myself.'[No workers"comp. 12.❑Rflof repairs insurance required.]F c. 152, i{4),and we have no employees.[No workers' 13,❑Other insurance required:] 'Any applicant that checks box Al:ninst also fill out the section belowshavring their woake&cnmpensatm policy infornmatiaa 7 HomteoWUM who submit this af5dsvit indicating fty ue doing all wa t and Shen like outside caarttactors'mast submit a new affidavit indicaitiug such ICantractors that check this box must attached an additiorM sheet sh,owmg the nine of the sub-comdtacton and state uhelb"or not those entities have ' emp"es. If the sab-cnnmiaurs have emp1ayee%they mim ptavide their warkers'camp.policy number. I ain art employer that is prmlidtng workers'compffl srddon in=rance for MY employem Below is the policy and job site. inforiviatlam Insurance Company Name: Policy#or.Seff iris.Lit. FoTiration Date: . Job Site Address: City/State/zip.Attach a copy of theworkers':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 iehd to the imposition of criminal peulties of a fine up to$1,500-00 n0or 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 Iuvmstigaticrosof the DIA for`iusrran^e coverage verifrcatic I dui hereby certify pnder thir pain s a ndpmahiss orfpetyu.tgy that A info rnxatton provided abavti/a is true and correct "Fate `Ph,ome# 3 — 5 7< �5 O,tid use only. Do not write 2n this ared,to be coatpletetd by cio or term tafciad City or Town PermitlUcense It Issuing Authority(circle one): 1.-Board.of Health 2.Building Department 3.City/Town Clerk d.Electrical Fnsperter S.P'lumbi ng Inspector^ 6.Other Town of Barnstable Regulatory Services. BARNSTABLE, # Thomas.F..Geiler,Director 9�A i6 renH►ota Building Division" Tom Perry,Building Commissioner, 200 Main Street, Hyannis,MA-02601. www.town.barnstable.ma.us Office:. 508-8624038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION ` !.. Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone#. work phone# - CURRENT MAILING ADDRESS: 36 /l A,80 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 Persons)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 j 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.requiirrements 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 perfoirning_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 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, of IKEtoy, P� ti BARNsTABLE + 9� "� ,� Town of Barnstable Arfp Mp'l A Regulatory Services Thomas F. Geiler,Director` Building Division Thomas Perry,CBO. 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 as.Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on,the reverse side. n'\wpFii.FS\FORMS\hnilriinv nermit fnr -APYPRF4S rinc �oFrKiro� T'ow' xi of Barnstable *Permit ` .RegulatoryServ7ees EFeees6,r�oirtlisfronrisStrerlafe 'r BAItYSTABLE, � - $�r�b �A��� Thomas F. Geiler,'Director �^ 'e'2ZI�� v Building Division, X-PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 OC,)' d 2010 www.town.barnstable.ma.us p RR Office: 548 862-4038 TOWN] C�F1�xA���yU"6� EXPRESS PERMIT APPLICATION.- RESIDENTIAL.ONLY No!Valid without Re`d X-Press linprin! Map/parcel Number 7Residential rty Address ! PCi1 Value of Work 75 T�=a inimum fee,of$35.00 for work under$6000.00 Owner's Name & Address Contractor's Narne� /�� ��.�1�1�e� AuCyV Telephone Number_16( Home Improvement Contractor License#(if applicable) Con uction Supervisor's License#(if applicable) Workman's Compensation Insurance Check one: ❑ .I am a sole proprietor �m the Homeowner , I have Worker's Compensation Insurance Insurance Company Name el}CO/t/ = � ��✓ 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 Y ❑ Re-roof(hurricane nailed)(not stripping._.Going over existing layers of roof) ;�R'eplacement # of doors Windows/doors/sliders. U-Value 0.% .-� (maximum .35)#.ofwindows *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-lmprovement,Contractors License& Construction Supervisors License is required, SIGNATURE: QIWPFILESTORMS\building permit forms\EXPRESS.doc ' Revised 072110 The Ccvninoirwer7hh of Afassachitsefts Deparfinerif ooflndustr al Accidents a dice af'Investib adorn I� 600-Washingian Street Bosfon, JV4 02111 ianniunass gavldirr AForkers' Ce>!mpensation Insurance Affida'vit: Builders/+Can:tractor-s/Electi is ans/Plumbers Applicant Information AA Please Print Le 'bly Name, (BusinemrOrgaiw_BE Ondiv-dtiai): Al( : Address: 3 / 5 Cxty t�tte/ xp:. Od�� kE Pli•one #: �_"�2 `_� j f Are Qu a-it employer?Cheick the appreprinte boa.. Type of t{i equ Lied); 1. I am a employer_vi#h _ 4. 0 I am a general contractor and I enTloyees(full and/or part-time)-: * have hired the sub contractors 6- Q..N construction 2- I.am a sole proprietor orpartner- listed on the attached sheet. 7- ' em dehng shipand-hmre no 1 Tees These sub-contiatrtors have .° . 8. .I)tiuolition urorking :far me in any capacity.' employees and have.workers' coin tnsurance:7 9. Q.BIIaldin9 addition jNo ttforkers' comp.insurance p- 5. We are a co, oration.and its 10•El Electrical repairs or additions retlitired:] ❑ rp af3scers have exercised their. 3.❑ 1.a sn a.homeoticaxer doing ail Work 11.0.Plumbing repairs or additions Myself [No workers'cotiip. right of exemption per i1VfGL 12.0 Roof repairs insurance required.]T c- 152, §1(4),and Nve have no` employees.[No workers' 13.0 Other cemp.msuranrce required, •Any appticamt that chech box#1.mnst also fill out the se€doa below,showing.their Yrmlters'compeasati.on policy infannfeau Y Homeowners who.submit this aftidmi in&cating they are doing in wmt and then here outsid-econmctors mast submit a 3mw o idat it indicating sadL tcontracinrs that check this:box must attacbed an sdditional:sheet Showing the nine of flue strb-coirtractors and state whether or not those emit-ses bni e employees. If the sub-contsactars:have empioYtes,they.nmst Provide their workers'comp.,policy number. faint an emiployer flint is providing itwr leers .conijortsah'on insfir fin,ce for rety'.;sirrpLayeai. Beloit,is the policy rand join situ - inforrmrcticrrt y� Insurance Company Name: C 'r// Policy*,or Self-ins.U.C. k C Expiration Date:_ :lob Site Address: � b fic j,1,V Attach a copy of the workers'compeirsation policy declaration page(showing the policy number and espi-ation date). Failure to secure coverage as required under Section 25A of IwfGI c. 152 can lead to the imposition of crinunal penalties of a fine up to$1,500.00 and/or one-year imprisonment,its.well as rivil penalties in the form of a STOP AtORP°ORDER and a fine of up to$250-DO a day, against the violator. Be advised that a copy of this statement may be forwarded.to the Once of InNT.stigations of'the D.IA for insurance coverage verification. I do hetvby certify andor thepains and penahies nfperjitry that 619 ir!forrnaH,rn prmrid,-d above is true and corrrecck Date: �J�cial.iise vnr v. Do not write in fliis area,to be cosiplyied by city or town official City or Tort: Permit/License IssuingAuthonty(r ixte fine): 1.Board of Health 2.Building Department 3.City/Foiim Clerk 4.Electrical Inspector 5.Plumbi7�kJnspector 6. Other Contact Person: Phone# 6 4 Bodo y i� 14 7 PAM JAS MOON DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE °-MOONA 1 10/05/10 PRODUCER THIS CERTIFICATE.IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC9 INSURED Moon Associates Inc. INSURER A: National Grange insurance Co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI INSURERB: Beacon Mutual DBA Gutter Helmet Roofing* DBA Moon Works INSURER C: 1137 Park East Drive INSURERD: Woonsocket RI 02895 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 INSRE TYPE OF INSURANCE POLICY NUMBER - DATE(MMIDD/YY1'Y) DATE(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 10 0 0 0 0 0 A X1 COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREM�ISES'([aoccurence) $500000 CLAIMS MADE X❑OCCUR - - MED EXP(Any one person) $ 10 0 0 0 PERSONAL&ADV INJURY $ 10 0 0 0 0 0 . - - GENERAL AGGREGATE - $2 0 0 0 0 0 0 - GEN'L AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMP/OP AGG $ 2 0 0 0 0 0 0 POLICY JEa LOC AUTOMOBILE LIABILITY " - COMBINED SINGLE LIMIT $'1000000 A X ANY AUTO BIS26619 09/16/10 09/16/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS " BODILY INJURY $ - NON-OWNED AUTOS - (Per accident) _. PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - - AUTO ONLY-EA ACCIDENT - $ ANY AUTO OTHER THAN EA ACC $ . AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY - EACH OCCURRENCE $ 1000000" A X OCCUR CLAIMS MADE. CUS 2 6 619 0 9/16/10 09116111 AGGREGATE - $ Fx DEDUCTIBLE $ RETENTION $10 0 0 0 $ WORKERS COMPENSATION - - - X-TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N B ANY PROPRIETOWPARTNEWEXECUTIVE 28586" 10/01/10 10/01/11 E.L.EACH ACCIDENT $500000" OFFICERIMEMBER EXCLUDED? a (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500000 If yes;describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $5 0 0 0 0 0 OTHER - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION -- .. MOONASs DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I �g-)j5,A13 Nnde ����� Customerr names: � Renewal by Andersen of RI,CT,&Cape C U �� �-Ycar Builx: =QeSales A reementAdd Customer IDp: 1137 Park East Drive la City,State,Zip: Order Number: Woonsocket,RI 02895 WINDOW REPLACa metae r GL4 phone-Home:_ '2=52 i5052 Phone-Work: pa 7y license p RI-30839 RI-12259 MA- Email: page, of L Dare: ^� _ J 119535 CT-562725 UNITS 7edWcal Measure 04 n191aos GRILLES EET h-1- k a a 9� t : e - sr, ill 9 j$ fh Description6 S �t a a 'gill fit Aa 8 ,ske� { 6 II gg ggs _ g� nI SPAKES � k .fig�y �h Ci V W W 1fs'3 / .x• x IF l S • w w _ � P U M of the ahmt na,,,W„n,,vat Jono ro prtny or r amoaro sstel in cha rccmeat.'Ihe iSCell�rKuy,S Credits Or EX nset Sub foul Naas rl '� rccnain.afid frr 3n c6ya and ro au an a 4Y C.usuuacr rnJ XetLrod by gnlerscn Mari r u (Stairu Wro I ,Re r promo!! � . _�Ckbri'� n& P, py. on,etc.) P3 nt Method �� Dewaip&r,C Notn $Price S Subtotal won,,,.I I� Rmm l by Anderson S Rc e.,n El Sub Total too hares / cbe CuetOlaerACCepptanc�Yin an•hcrfn aurhoN ur rumA w"- a dur�c �y aXrcemmc Cur n'Aidt fhc umknipred arpeaa m pay Me atarunr arar this NwMd m complete rh h Mite.Crtdlts w ExpBtlyiS s1{1►M.. l� Entm CMd aytcoement oral acwnling ro Nrc tetras yer�,C. ✓See Revetge Side forTerme and Gondidong of Sale.You,the buyer,may cancel thisansaction at arty brae�r"lot to midnight of the third btrsiaesa day niter Total ❑ NrrB9 the dace of thin transaction.Tease Dee attar notice of caacetlation for an explanatio of this right. /n� SafesTw �r Acnpnd a �f J n Total Miscellaneous CxMits or Fxpensa llah r.usn,mcs Appn,val%gpratute ,^v—�+�•` a fcury wet torn ro mu'.c.cdlr I-pnx columnar.fghd Waft PBRIdI Cost / bddMiawl QAv robuAtgtlwd IPkraat ehda aA Nat 6ppyl Acapnvl Special Order Notes Total AlnouM Di Agreement , brio poor umm Door 1)nrr Nwc wal by Andecncn Manager jypntyn k earn ruary am AMMyPtma smbargar Deposit Required arNtteprrlra+smd,may do nol Ua Madndow cp�fp a„ PlanaA dwmale unableMbW an rtpaitbp �� be nitded knot nr al Pl ys umeen d7au9a.aar�aetd tn�x agar®ceen uaeu main�pnrw inns tlK�cu�° �of �r ��n9�faraation��jl�tanpk4`�"aBc BaIaMQ Due an CoRlpietiprl r� naba arehMaaed. mha�wharmted, en4cA�9rswfmdietWa"vsuaonyturapproaal. Prkeiaeludealabor.matVisla,imuWNon, At theandof the tab all tnnocyryrn deb b WNI be Customer n� .� Custotmn Tj�t )� adwtai e and we w n c4an raw raw wmum s am white-Rerreoel �� J Irthids: (J / me hNAn nsURation Pink.Hamemrlar rrvw.al,and disposal oFpnoducY.replaced. W+rrJMa,,.4,vr'.m1.n.WmrdMa.L,�.4y,....,.W.,.pn.1'�Jm.{4,vr6t�p�t$�iN Mdr,aa C�Iaruu as az'R-d.r aP.VIVA l t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION t Map Parcel A3303"? Permit# 4 —1 Health Division Z$ 0) Date Issued �Z�l Conservation Division i�� / 0/ _ Fee U Tax Collector SEPTIC SYSTEM 10 � t� Treasurer ` INSTALLED IN COMPLIANCE Planning Dept. A + WITH TITLE 5 "4' EN ONMENTAL CODE AND Date Definitive Plan Approved by Planning Board �e�R_. ®WN REGULATIONS Historic-OKH Preservation/Hyannis i y Project Street Address Village Owner f4, Address dam-g Telephone Permit Request `k 16 4jCf7_ZP 0 01-41✓ ®1G oi.o sAeal&4e_ is > loo gam L*e Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation Zoning District RQ— I Flood Plain Groundwater Overlay Construction Types 4cQ 3©'i 0 Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑ No ,Basement Type: ❑ Full ❑Crawl 0 Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing 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 Cl 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 BUILDER INFORMATION Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO s /IGNATURE FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED ° - MAP/PARCEL NO.-' y ADDRESS VILLAGE - r OWNER r AA, DATE OF INSPECTION, ; FOUNDATION F FRAME _ ry INSULATION �. FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH` -- -, FINAL GAS: ROUGH - r `: FINAL r FINAL BUILDING DATE CLOSED OUT = ASSOCIATION PLAN NO. i ti The Town of Barnstable • anxtvsrna�e. - 9g,A i'�: ��� Regulatory Services rEo►�+A Thomas F. Geiler, Director Building Division Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax! '' 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION N MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not.more_than.four dwelling units or to structures which are adjacent to _ _------..,--o.such.r-esidence,.or building.be-done-by-registered contractors,with certain exceptions,along with other requirements. 4 Type of Work: Estimated Cost 11 . Address of Work: 36 1do �u OO��r,' , r0_vr7e_rVj, Ile Dga6 a Owner's Name: Date of Application: I hereby certify that: .:;-Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 []Building not owner-occupied Acaner pulling own permit Notice is hereby given that: --OWNERS_PULLING-_THEIR.,OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav The Cofnmonwealth of Massachusetts Department of Industrial Accidents �.�:-�"_ '==�� 0lfice ofla�esti9auoos �' - 600 Washington Street Boston,Mass. 02111 z���. - Workers' Com insation Insurance davit ;�}E1DiiG:IIE'iTi{t} ��/. R@! � � !t ..........��`; ^'' name locatie*t -- city hone# �602 Flo/ 9 I am a homeowner performing all work myself. I am a sole proprietor and Have no one working in any achy ME I am an employer providing workers' compensation for my employees working on this job.. ;:;;.. :.:.:... :....;.;.. ... . ... comonnv name: - - ' - — address:—=—=- -- ::. hone#� city /// // [� I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below v,nc have the follo«ing workers' compensation polices: ;.. ... comoanv na me- . address: .. : .::.'....j: :• .. . cttv: .......... . ....::. ....... insurance co. ::.::.::.::...::::................... ;. camnanv name- :....:.. :;:;:;::::;;.:..::.:.::. ::::;:•::::.:.:•.. address- . ... "lione#' ctt4. ............ . ;<>:: Failure to secure coverage as required under Section 25A of MGL 152 ties lad to the imposition of critninsi penalties of a Hue up to understand that or one vears'imprisonment m wig as�pities to the form of a STOP WORK ORDER and a Me of S100.00 a day against me. I understand that a coov of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herenv certify under the pains and enalties ojpei jury that the information provided above is tra.-and coned Date 2- 0 simature — - Phone Print:.ame „i'acW use only do not write in this area to be completed by city or town ofttchd s permit/license# ❑Building Department tits or town: ❑Licensing Board ❑selectmen's Office citecic if immediate response is required ❑Health Department phone k; ❑Other contact person: r: .1 Information and Instructions Massachusetts General Laws chapter 152 section.25 requires all employers to provide workers' compensation for their is defined as every person in the service of another under any coos-- employees. As quoted from.the`law",an employee 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 ei the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver, association or other legal entity, employing employees. However the owner of a dwell,,of as individual partnership, apartments and who resides therein, or the occupant of the dwelling house of dwelling house having not more than three another who employs persons to do maintenance, construction or repair worm oa such dwelling house or on the grounds t building appurtenant thereto shall not because of such employment be deemed to be an employer. state or local licensing agency shall withhold the issuance or rene4 MGL chapter 152 section 25 also states that every ^_A __ of a license or permit to operate a business onto:construet_biuldings m the commonwealth for any-applicant who h: not produced acceptable evidence of compliance with.the in ... commonwealth nor any of its political subdivisions shall'enter into_anY c rtract,for the performance of publiFwo- = acceptable evidence of compliance withthe of this.chapter have been presented to the cO=ZcdTC authority. Applicants checkuug the box that applies to your situation and ` Please fill in the workers' P�atiort affidavit comPhY, be by --._._ • _.. rnrmbers-along with a.cemf cote of wurance as:all affidavits may supply company address = iso be:sure to sign_and • ofinsaraace.coverage +? s6bmitted to the Department-of.-Industnai Acade s _ A date the affidavit. The affidavit should be-rcmmedto the city or town that the apphcat an for the pe*atzt or`Lce se efytdustnalAccidents you have any z. nbeb being requested,not the Department x_ the" elow: ._ the _ w or yc- _ . r. are required to obtain a workers' call the Department / City or Towns that the affidavit is complete and printed legibly. has provided a ace at the bottom of t bl The Department p space Please be sure . . - the hcant.�ple!se ons:has-.to.contact you regarding aPp affidavit for you to fill curt in the event the Office of iavettigatt =- _ be sure to fill is the pei i tfflccnse number which will be used as a reference number.. The affdavits may be zetumed to the Department by main or FAX unless other==g= have been made. The Office of Investigations would I&c to thank you is advm=for you cooperation and should you have any questions. please do not hesitate to give us a ca.L The Departme.at s address,telephone and fax ar The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imtesduadons 600 Washington street _ Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 l The Town o arns a e Department of Health Safety and Environmental Services Building Division * saxtrsTnsre. ' 367 Main Street,Hyannis MA 02601 Mass. t a ED MA'i Office: 508-862-4038 Ralph Crosser Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE-EXEMPTION Please Print DATE: i --11 I i JOB LOCATION: 3� l�o�/u r�T ���►' r✓r` //Q 0216-9 R number n /T street village /'� "HOMEOWNER": r�t�C r�2' / 4rse- name home phone# work phone# CURRENT MAILING ADDRESS: S4r» 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, rop vided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Perstin(s)-who owns`a parcel"ofIand-on v hich fie/she resides orintends 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 submittotTicBuildir�g-0ffrcial'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. c 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.I-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 of this issue is a form currently used by several towns. You may care to amend and adopt such a fomi/certification for use in your community. Q:FORM S:EXEMPTN STANDARD LEGEND NOTE:not all symbols will appear on a map GOLF COURSE FAIRWAY ^- EDGE OF DECIDUOUS TREES ^/ EDGE OF BRUSH (w/1 ORCHARD OR NURSERY . !O f y-V-D-V EDGE OF CONIFEROUS TREES MARSH AREA EDGE OF WATER DIRT ROAD DRIVEWAY �. IE— PARKING LOT 233. -----_- PAVED ROAD DRAINAGE DITCH 1 PATH/TRAIL PARCEL LINE Inur Ito-5E— MAP# P ^^^ 21 E PARCEL NUMBER L 3 3 #leeo E -HOUSE NUMBER a \ 2 FOOT CONTOUR LINE \\\ - 10 FOOT CONTOUR LINE 3 Elevation based on NGVD29 i/4.9 SPOT ELEVATION STONE WALL \ \\ MAP "3 X—X- FENCE \ RETAINING WALL RAIL ROAD TRACK j \ ` STONE JETTY \` \ 0 1 P'oo SWIMMING POOL • \ \��\\ ��� PORCH/DECK \ �] 0 BUILDING/STRUCTURE ` IL'U DOCK/PIER HYDRANT e VANE O MANHOLE o POST OF FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C 1 N r'F O R M A T 1 O N S Y S T E M S U N 1 T a SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE:This mop is an enlargemeIthis' NOTE:The parcel lines are only graphic representations DATASOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The James1"=100'scalemapandmayNOTof property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD UTILITY POLE M TOWER we National Ma Accura Standardso� 2� 40 p rydo not represent actual relationships to physical objects Corporotion. Planimetria,topography,and vegetation were mapped to meet National Map Accuracy Standards p LIGHT POLE O ELECTRIC BOX : 1 INCH=40 FEET* enlarged scale. on the map. at a scale of 1"=100'. Parcel lines were digitized from 2000 Town of Barnstable Assessors tax maps. \Barn\sitemaps\Pub1ic\m233.dgn 09/25/2000 02:491:26 PM