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HomeMy WebLinkAbout0127 MAIN STREET (CENT.) a z � � � � i ... - :t v 6 ,. A e © .. .. -.� _ .. .� �. .a . ,. � _ .. Y .. ,. i .. :, ;.. ., � :.tr . .,u., .� �. e q � '.. ... .. .. a �. .. e - ,. �_ ..� o ,. n 0 3• � ... Vr Town of Barnstable Building s WON, ue* �P �a F P-.ost T.his,GardSo That rt.IsVis�ble:From_the Street-A "roved PlansM Stbe Retained on Jobn�dthis,Card„Must be Ke t F tAR1V�3'[Xi31JE. IRPz f ,s ?{ryx 'a Permit ' Posted Until` nal lspecton Has Been Made ' rh ,� Where a Certificate bf Occu anc is Re u redy-such Buldmshalb IVot be Occur ieduntll a Final lnspect�on has been made Permit No. B-18-15 Applicant Name: PAUL J. CAZEAULT&SONS, INC. Approvals Date Issued: 01/05/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 07/05/2018 Foundation: Location: 127 MAIN STREET(CENT.),CENTERVILLE Map/Lot 208 093 Zoning District: SPLIT Sheathing: Owner on Record: CHESTER,WILLIAM G JR& LYNN Contractor Name ' PAUL J. CAZEAULT&SONS; INC. framing: 1 Corit actor,Llcense;a,103714 Address: 45 BRIDGE STREET 2 BROADALBIN, NY 12025 Est .Project Cost: $7,000.00 Chimney: V Description: re-roof stripping old shingles-yarmouth Permit Fee: $35.70 i $ Insulation: Project Review Req: Fee Paid $35.70 i�_ Date 1/5/2018 Final: $ _ Plumbing/Gas IL � �•, Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six monthsafter issuance. Rough Gas: All work authorized by this permit shall conform to the approved application aiid he approved construction documents fog wh�cF 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 zonmgJby laws and codes. This permit shall be displayed in a location clearly visible from access sYreetoroad and shall be maintained open for publicnspection for the entire duration of the work until the completion of the same. _ s - r Electrical ° Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided.on this permit. Minimum of Five Call Inspections Required for All Construction Work.. z `' 1.Foundation or Footing : Rough' 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. 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 Town n of Barnstable *Permit#-S& Expires 6 months torn issue date ®� Regulatory Services � Fee + BARNSTABLE, ' mb 9. �� Richard V.Scali,Director y . -Building � Divisi0 � .�.,�� Tom Perry,CBO,Building Co mrrii�si � i �/ J 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 FaY 68-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number O ci Not Valid without Red X-Press Lnprirzt �4 � 3 Property Address 12-7 ti-CA,N 57 "residential Value of Work$ 'I, 6-ZS-Z) Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address b0 I L-�1. PrYv-) G L-i S UZ Contractor's Name .-P A V 1r J. CA Z�A U -j-- Telephone Number Home Improvement Contractor License#(if applicable) Q 3"� (4 Email: 0-t C-e Construction Supervisor's License#(if applicable) C S 108 ( S f�-- ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner �ve Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# k/G — / 3 - 3,25 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request heck box) e-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: ❑ 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 required. SIGNATURE: C:\Users\DecollikUppData\Local\Vlicrosoft\Windows\Temporary Internet Files\Content.Outlook\-)PIOIDHR\EXPRESS.doc Revised 040215 f i Property Owner Dust Complete & Sign This Fora If Using a Roofer I Builder. i I (print) as Owner / Agent of the subject property hereby authorizes Paul J. Cazeault & Sons Roofing Inc. to act on my behalf, in all matters relative to work authorized by this building permit application for. Address of Job/a `� �� r�� ��������� ✓��'� � r, Signature of Owner Mailing Address of Owner �• �oX �� o A cl.914>Y Al" Telephone # ` `� Y �0 Date Please return this form to Paul J. Cazeault Roofing along with your signed contract. It is needed for us to obtain the building permit required by your town to complete your roofing project fax#508-420-4555 ? office@cazeault.com o® I p� Pau! J Cazeault& Sons, o www.cazeault.corn 1031 Main Street. oflce@eazeault.com Osterville,MA 02655 Phone(508)428mI177 Fax(508)420-4555 BILL TO Proposal Mr William Chester DATE Proposal No. PO Box 574 Broadalbin,Ny 12025 10/31/Z017 I�14226 Estimated by. Mike Customer Email wgchestex(�gmail.00m Description of work to be.performed Total At 127 Main Street,Centerville Remove existing shingle roof on all sections of the roof not already complete. Re-uail any loose boardixig. lastall.032 aluminum heavy duty drip edge. Install WeatlierWatch or StoMguard ice and water sbield on bottom edge,in valleys,and around penetrations. Install GAF Deck Amour premium roof deck protection. Install CTAF Timberline HD lifetime arcWtectural style asphalt sbingles. All shingles to be storm nailed. Vent pipes to receive new flashing. Cut open and install Cobra ridge vent_ All roofing related rubbish to be removed from premises. Paul J Cazeault&Sons to obtains building/roofing pm-nit. .Provide GAF System Plus Warraxxty that Covers both labor and material. COST 7,000.00 1/3 due with signed coiatract,1/3 due when job is half done,1/3 due upon completion ry- 1 otal $7,000.00 Z�` �� of 9 Customer Sigaotwte The above prices,spedflcagops,and wnditions are sadsfa"and hereby. accepted.You are authorized to do the work as spedfied.Paymentlo be made as outlined above, Dote of A cceptance In addition to the above,if Customer fails io make payment set forth above,then Customer agrees to pay Pauli Cazeautt&Sons Inc,all reasonable costs and fees,indudhg but not limibd to Attorneys fees,inouned in collecting payment from Customer, Price Is good for 30 days unless othamisa noted. L f' is )1�.•' _„ ,3'f%•L. ` .:� end E•r'�'�(, �:�%C`,-'i��:-�._` '9:GL Z� r.- % Vt .:1ivv�'LC% .�::�;lf, =� Office of.Conswnei Affairs �iad Business• �• Regulation , r� 10 Pa:i k Plaza - Suite, 5170 Boston, Massachusetts 02116 Dome haap ovement Contractor Regist ation Registration: 103714 Type: Supplement Card PAUL J. CAZEAULT & SONS, II\IC. Expiration: 7/9/2018 RUSSELL CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02658 Update Address and return card.Marls reason for change. I. r. Address Renewal Employment 0 Lost Card sCA i :,. Zorn-osri 1 [. I. �r t('v.•�ir;nr+rrnc'a�C�r�•C_��r.;.rrrr�a.It(Li --,Office of Consumer Affairs Ke Business Regulation License or registration valid for individual use only ` E" before the expiration ation date, If found return to: - I�POME IMPROVEMENT CONTRACTOR P l:VOW i - Office of Consumer Affairs and Business Regulation i•'Registration. 1b3714- Type; 10 Park Plaza-Suite 5170 Expiration; :7/gj2013'- Supplement Card Boston,MA 02116 PAUL J.CAZEAULT&-SONS,INC, s� l RUSSELL CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02658 Undersecretary Notyalid without adnature FMassachusetts -Department Of PLiblic Safety I + Board of Budding Regulations and Standards Construction Supervisor 4: I License: CS-108157 — 127JSSELL CA.ZEA,tJI T-_:.,` m ' 2071 IYWN=RLET, ';'_ Brewster IYIA 02631 - ,r. Commissioner 11/23/2016 .' • l _ f + A CCOR" a [__'DATE(MM/DD/YYYY) 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: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PWC.HONIJ E t: (508)775-1620 a No: ADDRESS: Sullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: LM INS CORP 33600 INSURED INSURER B: PAUL J CAZEAULT& SONS INC INSURERC: INSURER D 1031 MAIN ST INSURER E: OSTERVILLE MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: 181752 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ _R POLICY❑JEC LOC PRODUCTS-COMP/OPAGG $ OTHER: I I I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ 1$ WORKERS COMPENSATION X STATUTE �RH AND EMPLOYERS'LIABILITY Y/N — ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA NIA N/A WC531S386670027 08/10/2017 08/10/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1.000.000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Paul Cazeauit ACCORDANCE WITH THE POLICY PROVISIONS. 1031 Main Street AUTHORIZED REPRESENTATIVE Osterville MA 02655 Daniel M.Crotvey,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 6 �� �3 eY@7Ep �P 1� ®& 6' rin ablk . ' 'Fermi$# )Expires 6 months from issue date flee ,U 20-117Y.SCrVIlCeS Fee 7 sARNszASLE. �$ MASS Thomas F Geiler,Director �p i639' Bulfldl: DiVisI® KNIT Tom Perry;CBO, Building Commissioner }` 200 Main Street,41yannis,MA 02601 >, OCT 22 2014 - - . . ; www.town.ba Office: 508-862-4038 TOWN OF BAR TAR -6230 EXPRESS PERMIT APPLICATION ,-,RESIDENTIAL ONLY © Not Valid_without Red X-Press Imprint Map/parcel Number Property Address Z ..1( A-j IN 5, 7 t C:E ti tea V l,LA_ E sidential Value-of Work$ Minimum'fee of$35.00 for work under$6000.00. Owner's Name-&Address Contractor'sName �iAvZ Zr=-�yt— fi S�t"S Telephone Number `I Z-do ]'� -7-� Home Improvement Contractor License#(if applicable), 0..� .1 C{ -Email. Construction Supervisor's License#(if applicable,) GS ` .G2G 3 )—S"- ❑Workiman's Compensation Insurance . Check one: �,a ❑ I am a sole proprietor ❑ I arp the Homeowner I have Worker's Compensation Insurance Insurance Company Name' Lti1 ( h►S '�D52( ;' Workman's Comp.Policy#. VV � Copy of Insurance.Compliance"Certificate must.accompany each permit Permit Reques deck box) Re-roof(hurricane^nailed).(stripping old shingles) All construction'*bras will be'taken to Re-roof(hurricane nailed)(not stripping Going over. existing layers of roof) ❑ Re-side ❑'.Replacement Windows/doors/sliders.'U Value ,.. (maximum'.35)#of windows of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and`inspections'required., Separate Electricals&Fire Permits required.' *Where required:Issuance of this permit does not exempt compliance with other town departmerifregulations,i.e.Historic,Conservation,etc. rxxNote: Property Owner'must sign Property Owner Letter of Permission. A copy,of the Hom'eImprovement Contractors Licerise.&s.Construction Supervisors License is required. ' SIGNATURE: C:\Users\decollik\AppData4calNier6s6ft\Windows\temporary Internef Fifes\Content.0ut1ook\8R76BDVA\EXPRES&doc - Revised 061313 6/14 4:25 PM Page Property Owner Must Complete & Sign This Form If Using a Roofer / Builder. 1 (print) J Owner �% Agent of the subject property hereby authorizes Paul J, Cazeault & Sons Roofing Inc. to act on my behalf, in all matters relative to work authorized by this building permit application for.- Address of Job 1,2 1- 10 - j o - r Signature of Owner Mailing Address of Owner n _t r ►q-p ALl3 A, f Telephone Date 62 Please return this form to Paul J. Cazeault Roofing along with your signed contract. It is needed for us to obtain the building permit required by your town to complete your roofing project. fax#508-420-4555 office@cazeault.com �I r 1 ^ ® � A6� Z CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDlYYYY) 8/7/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER DOWLING &O'NEIL INSURANCE AGENCY INC NAME:CONTACT 973 IYANNOUGH RD PHONE FAX PO BOX 1990 e MAIL Ext: AIC No HYANNIS, MA 02601 ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: PAUL J CAZEAULT&SONS ROOFING INC 1031 MAIN STREET INSURER C: OSTERVILLE MA 02655 -INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 21146142 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR TYPE OF INSURANCE WVD POLICY NUMBER YYY MM POLICY EFF POLICY EXP LTR IDDIY MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ —1 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea ocw ence $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY jE 7 LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-386670-013 8/10/2013 8/10/2014 STATUTE OERH AND EMPLOYERS'LIABILITY Y/N WC5-31 S-386670-024 8/10/2014 8/10/2015 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑N NIA A E.L.EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LM Insurance Corporation lJ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 21146142 CLIENT CODE: 1614182 Lucy Garfield 8/7/2014 2:44:49 PM (EDT) Page 1 of 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen•isor - License: CS-026325 PAUL J CAZI7 1031 MAIN ST n fs OSTERVILLE MA 0265521 ] +; 1\ )I N7\1 Expiration Commissioner '1 0120/2 0 1 5 iE _ Office of Consumer Affairs and Business Regulation 5� 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 103714 Type: Private Corporation Expiration: 7/9/2016 Tr# 254237 PAUL J. CAZEAULT & SONS, INC. Paul Cazeault 1031 MAIN ST OSTERVILLE, MA 02658 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card 3CA 1 L: 20M-05/11 (7J vim~ Office of Consumer Affairs&Busines's Regulation License or registration valid for individul use only �KOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: a istration: Office of Consumer Affairs and Business Regulation g 103714 Type: g E_expiration: 7/9/2016 Private Corporation 10 Park Plaza-Suite 5170 a Boston,MA 02116 AUL J.CAZEAULT&SONS,INC. %ul Cazeault f i 31 MAIN ST g �. �� f TERVILLE,MA 02658 Undersecretary / Not valid withou gnature The Commonwea[th of Massachusetts __ ,Dept�r s tment oflndUEtrialAccident IM .._ ... off ce of Invesagadons 600 Rfashir gton S&eet . .Boston, ALA 02111 www.mass.gov/dia Workers' Compensation lasnrance Affidavit: Buiiders/Contractors/Electricians/Fiumbers Applicant Information Please Print LeObiv Name(Business/Organization/hdividual): OA UL- ZL-_A-u y' i_ f- Sc s✓V� Address: O �� �(4.A."IV City/State/Zip: Phone T: 5D Are you an employer? Check the appropriate bog: Type of project(required): 1.[/I am a employer with r U,7/i� • ❑ I am general contractor and I 6 ❑New construction empart-time). ployees(full and/or = have hired the subcontractors 2.❑ �I am a s ole proprietor or partner- listed on the attached sheee 7. Remodeling ship and have no employees These sub-contractors have g. []Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.in uranceJ required.] 5. ❑ We are a corporation and its 10.E Electrical repairs or additions 3.❑ I am a homeowner doing all work oMcers 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' 1 ther ,�, L 0Fi0 comp.insurance required_] 'Any applicant that checks box#1 must also fill out the section.below showing their workers'compensation policy infomiattion. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor must submit submit a new affidavit indicting such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractor and state whether or not those entities have employees. ff the sub-contractor have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Betora is the poZicy and job site information. Insurance Company Nam6: Z_M //N ems. L Polk or SeIE ins.Lic.t: 8�C6-` 3 I S- 7( 02_`� B-xpiration Date: �1 C� I y Job Site Address: l M A(N Sr 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 tb 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. lie advised that a copy of�ihis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the sins and penalties of perjury that the my orma ion provided above is true and correct Signature: Date: !C7�2 Phone r Off cigj use only. Do not write in this area, to he completed by city or town offaciaL City or love PermitUcense Issuing Authority(circle one): 1.Board of Health 2.BuildingDepartirtent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone T - Assessor's map and lot, number .: .�.°.. 01.�.... .."� �. Sewage Permit number :.................. j p fT"ET°�� '4 TOWN OF BARNSTABLE i AHHSTADLE, • j w 9 "3` � BUILDING '. INSPECTOR " �9 i639•'�90 "i ' 'FO NPY a. c i , tliL�APPLICATION FOR PERMIT TO .............................. .....:......................................:.....:. TYPE OF CONSTRUCTION ...:.... °................ 'L .......... .............•... t ......® ...................19.1:�ry j.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a orra permit according �t- V!�. to the following/formation: Location ................... .1 �.....1!!.111 .v.Y................C:'.W.-I. .4.4.. .......... ....... . .............................................. e. ProposedUse SU �u .� .......................................................................:.. ZoningDistrict ....... .. ..Y .:. .................................................Fire District ........ .........................................................:'...... S Name of Owner T.....O:Xd N...................:. ............Address .............................. ' ame of Builder ✓W7 L. 5... .I �. '..................Address .�:v.�!�.Q..��..Jfl.�1...[.�.j.. ..�.... �1 Nameof A"rchitect ..................................................................Address ...................................:................................................ Numberof Rooms .....................................:....................:.......Foundation :............................................................................ Exierior ....................................................................................Roofing .................................................................................... Floors .........Interior ............... Heating .......'........................................:.................................Plumbing .................................................................................. 0 Fireplace ..................................................................................Approximate Cost ......... ...C............................................. I �//l ------19--------. Area ....� .. ...U.... Definitive Plan Approved by Planning Board ---------------------_-__ v U �.�.............. � ' O Diagram of Lot and Building with Dimensions, Fee .. ..... .................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH • r , r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable, regarding the above construction. Name .... ........�........ ......... ................................ Chester, Olive_& L. J. Dixon 18707 deck No.................. Permit for ............................. . ........................I.:%.............. ...................................... Location ........;.12.7..Ma in....S.tr.e.et...................... Centerville ............................................................................... Owner ..........Olive...Chester...&. Dixon ........ . .... . . ...... ... .. . ... frame Type of Construction ................. ................ ....................... ................................... Plot ..................... Lot .................... .................... October;12 76 Permit Granted ........................................19 . Dateof-lnspection ......... ..........................19 Completed Date ...........19 'OF 'PERMIT REFUSED ................................................................ 19 ............................................................................... ............................................................................... ............................................................................... ............................................................................... Approved ................................................. 19 .................................................................. ........... . .................. ........... 1• r- • - �_ -- , Assessor's map and lot number ...,.......�... ...................... y 7 ,s C—wl�� ? l'T -- --� _ �bhL�crx/- Sewage Permit number ....................................................... .. O o*TNETo TOWN OF BARNSTABLE r � i AMU ABLE, i r �9 "AG& i6 BUILDING INSPECTOR p J 40 39• \00 o m G• c J U rU ` �. \ APPLICATION FOR PERMIT TO dult ...........................•....•....:....................................................... TYPE OF CONSTRUCTION ........W�..° . A ....................19 . l TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies foe a permit according to the following j reformation: Location ..................c. . .....dl!�. " ..�?!............... t�( ....................................................................... Proposed Use .............Sv.�.!.: ....................... ........................................................................... ..... Zoning District .... .......Fire District r �N � Name of Owner ....... \r...... Xv� ................................................Address ........................................:.....:.p ............................... ,Name of Builder .................Address ..............!. Name of Architect ................Address ...:.............................................. .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exierior ....................................................................................Roofing .................................................................................... I Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost ...........l,.A„0............................................. 2i- Definitive Plan Approved by Planning Board --------------------------__ ..................19______--. Area f wo, Y....................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH N r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable, regarding the above construction. 0 �", Name .................................. ........................................... •y -7- Chester, Olive & L. J. Dixon A=208-93' 18707 -)Aeck No ................. Permit for ............:. ......... ........... ............................................ ... ............... 127 Main Street Location ..............0 ...................... ............................ Centerville ............................................................................... Olive Chester &-L. J. Dixon Owner ......................................... ......................... me* Type of Construction .............f.... ...r1 k. I . ..................... ................................................ ........................... Plot ............................ Lot ................................ go Permit Granted ....... . .....ber...—12- 19 76 .......... Date of Inspection ........................... ........19 Date Completed .......................... ...........19 PERMIT REFUSED .......................................... ..... 19 ... ..................................... .... ... ....... ... . . . ... .. ..................... ................................................. ............................ ............................................................................... Approved ................................................ 19 ............................................................................... ...............................................................................