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HomeMy WebLinkAbout0050 OXNER ROAD � � .� . a .� . . Q ,� � w4 , a . _.: _ �� � �� x � . � s ; . . 4 „,� � e c 0 ��. Y •t ', .. .. ,. � .. � � - f i. ' o .o 9, �. • � I ,. i \; � � � .. ,..,: .ems.,.. ... ° .. .. c ,� �� � � ,, f 1 I �� , . ._ � :. . . . n e �� � — e . f, J- _. p. �. .o .0 � ,� ., ., � '� u ar i O ., .. I c. Q q- I -1 k dbljsw n� ovvn of Barnstable *Permit# 0 Expires 6 months from issue date Rq�jub lator Services XFe 6 Richap�v_Scali,Director i3q. 10 iz' k Building Division ONO Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ExP"SS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Jq3 //(a Property Address 0 0,�(ei e—r Rd �/ti�✓l��� YResidential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address"R"A ,rd l4a-Cr,k"L-4e r C�n'tec✓i Ile. HA 02W,32— Contractor's Name 'n vt„J rr, 159/7 Telephone Number ��(O l 0(� Home Improvement Contractor License#(if applicable) 73 Z q 5 Email: _ Construction Supervisor's License#(if applicable) Ooq 5 7 c7 7 Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ m the Homeowner I have Worker's Compensation Insurance Insurance Company Name (20Y7 f'OLI%j I Ales e/'n lah ( e) Workman's Comp. Policy# Wled6 313126 f 1 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 • 30 (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 kowner must Sign Property Owner Letter of Permission. A copy cft the Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: D—L.; C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outtook\2PIOl DHR\EXPRESS.doc Revised 040215 f Rlbieeme s3607, Renewal RENEWAL. BY AvDERSEN rIkense4W345 �' bAndersen. sense#c7Gs4s3 WINDOW sa►uetaeNr en�d.,teco®►., 26 Albion Road • Lincoln,RI 02865 text Firm A123 Phone 8%563.2235•Fax 401.633.6602 taunt Tee ro 046-a7666 I l Southern New England Windows,LLC d/b/a Renewal by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyers)Nurse: � � Date otAjraemene Buyers)Sam Address.City Sate,and Zip Code I P.O..I .,.,r ...(,L..._,,.. l.l_....... 1 E•MulAddren �L�) I"�_l "lJ11L('! Ho�mETeleplana Number:ll/- (t [zg work Telephone Number: Buyer(s)hereby jointly and severally agrees to purchase the products and/or senices of Southern New England Windows,LLC d/b/a Remew-al by Andersen of Southern Net,•England("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheets)(collectively,this"Agreement"). 0 Historic 0 Condo ❑ HOA7 TotalJobAmountsr�,-3 Estimated Starting Date: Method/payment Q Check ash O Financed Deposit Received(33%):,1YZCb- Credit Cards are accepted for deposit only-maximum I/3 of the Baluxe at Start of Job(33X):1 f-�i project cost.(Please see Credit Cord Payment Form)By signing this Estimated Completion Date: Agreement,you acknowledge that the Balance at Start of yob and the Balance on Substantial c — � Balance on Substantial Completion of Job cannot be made by credit Completion of Job(33%):J a y card and must be made by personal check,bank check,or ash. Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing any of the terms of this Agreement. Buyer(s) 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 and(2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES, (Rhode Island Sales Only)Notice to Buyer:(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it.(3)You may at any time pay off'the fall unpaid balance due under this Agreement,and in so doing you may be entitled to receive a partial rebate of the finance and insurance charges.(4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(5)You may cancel this Agreement if it has not be d at the main been signed e office or a branch office of the a seller,provided you notify the seller at has or her main office or branch office shown in the Agreement by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement,excluding Sunday and any holiday on which regular mail deliveries are not made.See the accompanying notice of cancellation form for an explanation of buyer's rights. Buyer(s)received r education materials r r() ed the consume p o tded by the Rhode Island Contractors Registration Board. (Buyn's irtidalrJ Renewal b Andersen of Southern New England BuyersC4; Buyer(s) B). • Ignature of P oduct iVfanager Si ��- �/9,SSI ,�//S/ A�J�G✓�rsignature Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. NOTICED CATION - - - - - - � - - - - -x NOTICE OF CANCC€Left Date of Transaction - You may cancel 1 Date of Transaction this transaction,without any pen ty or obligation,within this transaction,without an •You may cancel three business days from the above date.If you cancel,any I three business days from the above ate.If yor outcancel,tany property traded in,any payments made by you under the I property traded in,any payments made by you under the Contract or Sale,and any negotiable instrument executed I Contract or Sale,and any negotiable instrument executed by you will be returned within ten business days following I by you will be returned within ten business days following receipt by the Seller of your cancellation notice,and any receipt by the Seller of your cancellation notice, and any security interest arising orust make at of the vailabletransaction o the Seller I security interest arising out of the transaction will be canceled.If you cancel'you as canceled.If you cancel,you must make available to the Seller re your reside oods delivere in d substantially you under this Contract or I received any in substantially as good condition as when received,any g with the y goods deliveredSale to you under this Contract or the Seller regaou rding the the return shipment of the instructions ds he I the Seller you if.you wish,comply with the.instructions of, y g girding the return shipment of the goods at the Seller's expense and risk.If you do mak the goods available i Seller's ex Pence and risk.If you hi make the goods available to the Seller and the Seller does not pick them u within to the Seller and the Seller does not pick them up within twenty days of the date of cancellation,you may retain or 1 twenty days ofgthe date of cancellation you may retain or dispose of the goods without any further obligation.If you i dispose of the oods without any further obligation.If you fail to make the goods available to the Seller,or if you agree 1 fail to make the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,then oat to return the goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the 1 remain liable for performance of all obligations under the Contract-To cancel this transaction,mail or deliver a signed Contract.To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice or any other I and dated co of this cancellation notice or any other written notice,or send a telegram to Renewal b Andersen of I written notice,or send a tole gg am to Renewal by Andersen of Southern New England at 2tS Albion Road, ncojn RI 0 5 1 Southern New England at 26 Albion Road,Lincoln,RI 02865, NOT LATER THAN MIDNIGHT OF . I NOT LATER THAN MIDNIGHT OF (Date) 1 1 HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. t!rlot Name Date auyer�e SiSnatun ee, ,_u_ _ _ - _ Southern New England windows d.b.a Renewal by Andersen of SIVE -- %lassachusetts Department of Public Safety Boatel of Building Regulations and Standards License: CS-095707 �# ' BRQAN D DENNSSON 7 LAMBS POND CIR� CHARLTON MA 01607 CA, expiration: Commissioner 09f0812018 Office of Consumer Affairs end Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement;Contractor Registration F Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWI'S LL Expl'adOf1 9119/2018 DENNISON BRIAN 26 ALBION RD LINCOLN,R102865 Updace Address and return card.Mark reason for ebange. �i{o��nenw+waaa/D+o��aaw.oE.reAl12 . ce er Coasamer Af min&Baslaess Regutadon License or registration valid for individui use only E IMIPROYEk1EffT CONTRACTOR before the expiration date(f foand return to.- Office of Cousumer Affairs and Business Regulation ngbtrauon: 173245 Type 10 Park Plaza-Sake 5170 Expiration:t 11'94 016 SupplemeM..Ord Boston,MA 02116 SOUTHERN NEW ii GG-6 tdD.WNDOWS LLC. RENEWAL BY AhtDms6W.r DENNISON BRUW 26 ALBION RD a LINCOLN,RI 02W Uaderseertgry of valid without signature c The Coninionfvealth of iWassachusetts Depar-tment of Indrrstrial Accidents I Congress Street,Suite l00 K Boston, MA 02114-2017 Y , www inass gov/dia ' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERt111TTI``G AUTHORITY. Applicant Information t Please Print Legibly Name (Business<Organization/Individual): (A, d" DV U) E066& QQ � A` Address: 1!p o o City/State/Zip: 01 al5s Phone 4: C) Are you an emplover''Check the appropriate box: Type of project(required): !. f am a employer,with '2c)temployees(full and/or part-time).-' 7. New construction 2.17 1 am a sole proprietor or partnership and have no employees working fnr me in 8. 17 Remodeling anv capacity.[No workers'camp.uuunnce required.]. - � 9. ❑Demolition 3.❑1 am a honhcowner doing all work myself.[No workers'comp.insurance required.)' ` 10 0 Building addition 4.17 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I l. _� Electrical repairs or additions proprietor.,with no employees. 12.Fl Plumbing repairs or additions 5.17 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. l3.(�Reof repairs These sub-contractors have employees and have workers'comp.insurance.*• L�Vl/ r 6.�we are a corporation and its officers have exercised their right of exemption per�IGL c. 1 . Other 153, lO,and we have agemoloyees.(No corkers'comp.insurance required.] CR M'en-t— 'Any applicant that checks box K 1 must also till out the section belwr-showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. Contractors hat 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 ant air employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. + ) Insurance Company Name: C6kT1-1 L— Policy 4 or Self-ins.Lic.K: CA J 13&0 $/ Expiration Date: Job Site Address: 5-0 Ox✓1 e r 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 aeainst the violator.A copy of this statement may be forwarded to the Office of Investigations'of the DI.A for insurance coverage verification. 1 do hereby cer ' hider the p 'is and penalties of peijury that the infori ration provided above is true and //correct. Signature: Date: '' b Phone n � Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.;Plumbing Inspector 6: Other Contact Person: Phone#: t i SOUTNEW-01 CZOLLINGER DATE.(MMIDMYYYY) 1 CERTIFICATE OF LIABILITY INSURANCE 612912016 j THIS CERTIFICATE IS: ISSUED AS A !NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER.THE COVERAGE: AFFORDED BY THE POLICIES 3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT. CONSnT TUTS A CONTRACT SETflIEEN'THE ISSUING INSURER(S),AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE.HOLDER: ! j IMP)RTANT:. If then certificate holder Is,an.ADDITIONAL INSURED;the policy(les}must be endorsed, if,SUBROGATION IS WANED,subject to the terms and conditions of the policy,:certain policies.may require'an and 1rsement A statement on this certificate'does not confer rights to the certificate•holder in.lieu,of such andorsement(s)'. COk ACT ' ?RODUCER NAME �CoBiz Insurance,Inc. -CO i PHONE. AIC No Ext:(.3Q3):588-0446 aixc..No): (303)988-0804. a21 L7th St _-MAIL CaBizlnsuranc cobizinsurance.com Denver,CO.30202 ADDRESS INSURERS.AFFORDINGCOVERAGE NAIC 4 j INSURER'A:Continental:Westem lhsumnce Company 110804 I !NSURED ! INSURER'S: Southem Now-England Windows LLC ! INSURER C DIBIA Renewal:by Andersen INSURER'.D`: ! 26 Albion.Road 1 Lincoln,RI02866 INsuRER,E.: I iNSURMF: COVERAGES CERTIFICATE NUMBER:. REVISION NUMBER:. THIS IS TO CERTIFY THAT THE. POLICIES OF INSURANCE LISTED BELOW HAVEBEEN�ISSUEDTO'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 TMIS 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: NSR. MD POI ICY NUMBER' LICY EFF ,: POLICY ! LIMITS 1_TR, TYPE OF INSURANCE. IVSD MMIDD MMID . COMMERCIAL GENERAL UABILITY i i t. EACH OCCURRENCE S 1,000,000 �La!Ms MACE i X JCCUR ICPA3136080 ! 1 OT109/201v(07.1011.201T . §. 1.00 00 1 PREMISES Eaoaurrence I VIED EXP(Any one person) I S 10+00 F i ' 1,000;000, PERSONALEV RY i 2066,00 i GEN'L AGGREGATE LIMIT APPLIES PER:. I GENERAL ; 3 t, X! ?OLiCY I PRO> j OC j PRODUCT AGG I.b 2�000',000 JECT EMPLOF1 S 2,000,000 i OTHER: OMBINEIT AUTOMOBILE LIABIUTY' I Ea accide I A �,,aN�Auro CPA3136080, 07(01/2016 OTI01/201'T• BODILY INJURY(Peroerson)„ 5_ 1 J ALLOWNED SCHEDULED ' BODILY INJURY(Per accident) $ AUTOS — 0SNO-OWNED 3 I� !?R OPERTY D AMAGE HIRED AUTOS AUTOS I eaccident ' II$ j X } I I Ei1CH'OCCURRENCE b U00�000 i i UMBRELLA LWB X OCCUR I I A =1(CESSCfPB CLAIMS-MADE ' iCPA3136080' 10710112016 i 07101/201i7, AGGREGATE i $ 0 I iAggFogate s 5,000,000 j 1 i DIED X ' RETENTION S. I 'STATUTE I 1 ERH WORKERS COMPENSATION IAND*EMPLOYERS L1A IUTY YIN! k VI/CA3136081 07/0112016 0710112011, E.L EACH ACCIDENT a 1,000,000 A I.ANY PROPRIETOR/PARTNERIEXECUTIVE I I Nl A I I I�I I 1.000,OOQ ' !(Mandatory In NH) NH)EXCLUDED'' I 1 � E,L.DISEASE-EA EMPLOYE 5 !If yyes,.describe under i {. I ! E.L.DISEASE-POLICY LIMIT b 1,000,000 OESCRIPTION OF OPERATIONS below 1 j DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space.is mqulred) , I CANCELLATION 4 CERTIFICATE HOLDER I ! SHOULD'ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE: EXPIRATION', DATE: (THEREOF, NOTICE.WILT. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AU1*0RM REPRESENTATIVE ®1E88 ACORD'CORPORATION., Alt rights reserved. ACORD 2S(2014101) The ACORD name and logo are registered marKt#bf'ACORD r79S65 Town of Barnstable *Permit# �FISE TpK, Expires 6 mouths from issue date " Regulatory Services Fee 0 sAxxsreBrE� Mass. Thomas F.Geiler,Director v� sbg9, ��plf 639 + Building Division Tom Perry', Building Commissioner 200 Main Street, Hyannis,MA 02601 B18ViSNHV13 JO NMOl Office: 508-862-4038 Fax: 508-7g0-6230 OZ 9 1 Nnr EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Ll d 3 d®X Nap/parcel Number ' Property Address � °1 �°� Value of Work []Residential Owner's Name&Address �'e Pjff Telephone Number Contractor's Name 1 S��cP�c Home Improvement Contractor License#(if applic le) / 3,6 y 7 Construction Supervisor's License#(if applicable) []Workman's Compensation Insurance Check one: I am a sole proprietor [] I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name Worlunan's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) old shingles) All construction debris will be taken to Dum✓'`'�'� Re-roof(stripping I Re-roof(not stripping. Going over existing layers of roof) [] Re-side Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with ofner town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. r Signature Q:Forms:expmtg Revise053003 n f . There will be no refund for special-order windows, doors or any other non-stocked materials after three days from approved proposal. All warranties will be null and void if account is not current and paid in full. Owner to move all personal objects, furniture, etc., from work areas. All items against walls should be considered for removal during any exterior siding jobs, additions, etc. to guard against damage. In the case of any roofing and ridge venting, dust and debris should be expected and any items in the attic should be removed. McSweeney & Son Home Improvement is not responsible for any damages if said items remain in place. Curtains, drapes and window and door treatments may need proper reinstallation or replacement by customer due to sizing on any window or door replacements and is not included in jobs contracted with McSweeney& Son Hoare Impovement. McSweeney & Son Home Improvement is not responsible for any damages that may occur during construction to landscaping or any finish ground work, plantings, asphalt or stone driveway, etc. Flowers and shrubs against house may need to be repaired or replaced by �017Wood 0*11 . all x. Roar ` d°fR°ilding R F/OME e AMR gulatioos `2 � Re CVEMENT. nd Standards 9�str'a i n Co*k4 ` ffaf�gtl 1130 TCR < 311;p/20p DAN/E� ! r Al:. pANIEL C CS,* f f nd�vidual 66 Bp McSwBIVF- yM`S1 _. - MAS G RIVER BED\ r "PEE, MA p264g . Ad ator _. . 06/24/2004 09:08 5085396882 TJAIJPJV': PAGE 02 na:o A CMRL�� .. .....................,. .,:,.:,e;;!xa�Yv....'.iY''•,.�.„L'Nss,. ,:�>:<q:,..;.': s!s:s�: .�:.,, > _ •4:. ,,. ' �' '� 0 3 26 0 4 �9v>s PRODUCERy THIS CERTIFICATE IS ISSUED AS BA{MATTER OF INFORMATION X ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE RIDER RISK SPECIALISTS ALTER THE"CO ERAQE IS AFFORDETE ED UY THE POUS NOT CIEE BELLOW. INSURANCE AGENCY, INC. COMPANIES AFFORDING COVERAGE P.0.�30 115 COMPANY CATAUMET, MA 02534-0115 A UNDERWRITERS AT LLOY'DS INSURED COMPANY MCSWEENEY & SON 8AIM MUTUAL INSURANCE COMPANY DANIEL MCSWEENEY D/B/A COMPANY — 66 BOG RIVER BEND C MASHPEE, MA 02649 I C)OMPANY P .. ..s;s::;FR'y�y?y si�`t�e(!u•:fE o:.n:a;a .. x.Y•{:<' i <e::xex.r:.: •aZ:I:oz:9wcY' s,vs�i y#''F:i 6s, a1Aa 8a4 3E l , ;., �' ;�. ,Y,; � - {i#'�y�jR:;iey x� #s8i#£. �i8@8i �.,>..6,�6�`s: F, M.,c12 .Ye.SSes> ' a:3h4: }.1 x-x»•Ai ,?M P .: I«f :3sst` YrS°THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTER®FLOW HAV BEEN ISSUED TO THE ENSURED 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 8E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLtGE'$DESCRIBED HEREIN I$SUBJECT TO ALL THI;TERMS, EXCLUSLONS AND CONDITIONS OF SUCH POLICIIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, _ LT�R TYPE of INSURANCE POLICY(NUMBER POLICY EFFEC 1YE POLICY EXPIRATION �.•.,- DATE OAMIOOPM DATT(UMM O" LIMITS GENERAL LIABILITY GENERAL AGGREGATE 4F?QO O00 X COMMERCIAL GENERAL UA[iIUTY PRODUCTS-COMP/OP AOG $3 O O O O O CLAIMS MADE OCCUR PERSONAL 6 ADV INJUC) ®30 O 0O 0 A OWNERS&CONTPAaroRrPROTi LCL034450 3/7/04 3/7/05 EACH OCCURRENCE $300 .000 ��DAAIAaE fA�v ono fret $5 0 000 MED EXP fAn one pe.) $5 0 0 0 _AUTaIto011E LIABILITY ANV AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS i BODILY INJURY SCHEDULED AUTOS i (PA,person) $ NIREDAUTOS --... ...._... NON-OWNED AUTO$ BODLY INJURY $ (}*or aocidenq PROPIATY DAMAGE $ GARAGE LIABILITY AUTO ONLY•EAACOIDENT $ ANY AUTO OTHER THAN AUTO ONLY I EACH AGGIDGNT 5 A00RELiATE $ EXCESS IJABIUTY UMBRELLA FORM EACH OCCURRENCE EACH E OCCURRENCE 6 -- I OTHER THAN UMOMEL LA FORM $ "` WORKERS COMPE14ATION AND X TAT , M ?;a:•t„:,,, «s#;::>;:;:<:.<:<..::: ElIPLOYFRs't.lAB1UTY KMHACCIDENT $100 000 B THE PROPRIETOR/ INCL AWC 701559101 3!/7/ /04 7 0`5 EL DISEASE-POLICY LIMIT 0500,000 P.ARTNERSIEXECUTIVE OFFICERS ARE: $ 'EIOGL EL DISEASE-FA EMPLOYEE $100 0 00 OTHER DESCRIPTION OF OPERATIONSROCATIONSMMtCLVASPECIAL•I1I:03 �F81Iw' idi£ip s 4�F�yw",rig ..A•'S,, '�#�:Z,'�:. •;: "iL',s^•.�. <;i.: .:v • ... SHOULD AMY OF THE ABOVE 063M6ED POUCIEb BE CANCELLEO B&FORE THE ` ATTN: L I NDS E Y EXPIRATION BATE) REOF, THE *SUING COMPANY WILL ENDEAVOR TO MAIL 10 OAV51 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE{EFT, p ,I L BUT FAIL TO M L SUCH NO CC 5"Lk IMPOSE NO OBLIGATION 00 LABILITY 508 420-2164 ,` OF KIND Pon E avARv, 1T9 AGENTS OR REPREMNTATIVEB. AUTH gD RE mow— ' "r'41•nax�:aar;saq_�?i:, "�F�AS. .��.., aw«•< .:.•,< .:�u,..,.a•.an.: ;�s.�S i•;s»pT•;le• ,��;, x:�.- s;s:s§��:#. #: s < <asi ii _NATOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ��J Parcel N Perm# s- q0 " Sk- Health Division I k Q3 fl� BD12M Date Issued Conservation Division f 16,12,co Application Fee Tax Collector �t� (7 k N L 1 I b l�� Permit Fe Treasurer 03 SEPTIC SYSTEM MUST EE Planning Dept. INSTALLED IN COMPLIANC; WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE ANIL Historic-OKH Preservation/Hyannis TO MI RECULAT1C'"' Project Street Address �D �oal_ Village l� 2 CJ�►�`� Owner 5 te\4 e 7 1 C me n S II Address `r— Q Telephone Permit Request Ao S�D�►-���n s� �a f I s ® a Square feet: 1st floor: existing proposed 2nd floor: existing proposed TotZnew Zoning District Flood Plain Groundwater Overlay -�. CO Project Valuation 16m —Construction Type C)j 33• z � Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting do umenta8gn. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) rn Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new v 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 Cl No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size O ; 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 ' ��! kcw_)C Telephone Number JD 7 -7 T- (a°�� i 1 ���` s Address � ���� � License# (`S �bJ 9 1 M A Home Improvement Contractor# 06 Worker's ComP ensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ( - � � i FOR OFFICIAL USE ONLY - • _r PERMIT NO. DATE ISSUED - �- MAP/PARCEL NO. ADDRESS- `-# VILLAGE ; OWNER - } 7-1 DATE OF INSPECTION: - FOUNDATION " - FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL, , 4 PLUMBING: ROUGH . . FINAL GAS ROUGH i FINAL FINAL BUILDING ©Ket 2-23-oa lam. DATE CLOSED OUT ASSOCIATION PLAN NO. P`oFIHe►oyti The Town of Barnstable ` N BARM MASS IN. .a by Department of Health Safety and Environmental Services , TEo Mpr Building Division 367 Main Street;Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: S T�vk' .S / C rz,l Map/Parcel: q f l r: Project Address: <0 Builder: L ov G6rsa The following items were noted on reviewing: 1 IxA7 U S % 1w 7-9 1-z 7 / C AA. e-' I-"v sy //iC/.5i/1`'T `In& 5 T S uPf'c. v c y//;r���,gd , f 4 1'fd rr �� f f� r Reviewed by: F. Date: q:building:forms:review r °FIKEr°,,, :: Town of Barnstable. Regulatory Services Ba MASS,�. ' Thomas F.Geiler,Director y Mass. � .. `bA i639. Building Division g . Tom Perry,Building Commissioner 200 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. 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 such residence or building be done by registered contractors,with certain exceptions, along with other requirements. Type.of Work: Estimated Cost Address of Work: JU r ��✓` L Owner's Name: i Y,� � �`lev� J,em�`lt^ Date of Application: I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 Building not owner-occupied ❑Owner 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 owner: o Date Contractor Name Registration No. S�L� Dale twner's Name Q:forms:homeaffidav The Commonwealth of Massachusetts — � Department of Industrial Accidents °°_-� — Ol�ce of/osestigatioas _ 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance AMdavit ej location. city l LV phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one ii,orking mi capacity �%0/00�/%/G///�%/%/ er rovidin workers' co ensation for my employees working I am an em 1 g .........mP...... ........:.::.�:::::: .......,.:..:..:...........................:.:......:........ .:........ ....................... " an :name....... .. ..... ......:::::: ire .................................. .. ....... ..::....:::::::.,.::::r:.:. �h n •Qty ❑ I am a sole proprietor, general contractor, or homeowner(circle on and have hired the contractors listed below who have ens' co ensation olices: ::::::•::::::::::::{<::::.::::..:.::::•::.:::::::.::::::::::•:h.:.:::;;;.;>:::;>.:<>A..,:�;±::>:r> :} :u;:;;::::. followln work mP ......................................... the ...............� ...............................:::.:::::::•:::.�::::.:;:;;.:::::::.�::::;...:.::..:::::.::::::.::.:::::.:::.:::::.:.:::::::•::::.�::::::.:... ,;....:. �{�C> C�`:�?� i< ;; ' >�?zi: :ii:i �:>%%i't�i`' �::i; >i.:;:%2?Yci; ^;is:: :i;^s;%q3i-?: ?'?"`>:.r"`"":: ';'`''::' ;: :' :::`` `:::°'<:`':.:;:' :::;`;::;:';. :;'.:,o�•,r� .................:::::.}�::;•}:4:{J:•i}}}}}i:•}:•}•.........:�::::::::v:::;:.�.v:•w:" w:•.�::.v::•;.,:}:;•i}i}:n...::•: .....::::•}:;{........:..................i::i•±}:x x:{:•}i w:•:::::i.v:::::•:rn{S.};.;t}}:iii};•}:v':::: :%?:.},}}:^:•:rh}:;;?;Y:vn:{•}:•:v:•:•n:. .. :\:. ....'!• .r:.:::::...............:::•.......,....,. :.::•i:•.:.....r:........... r..,......,.......... ......... .........x. ...........:..........w:::::::::.v•........w:::::::....................:.}:.}:;{W};;;•::::v.......... :........;•,v•:)v;}::}:::.vS:.v:x^'F...--••:rr.:.:.U.,v..v. }..:.:.::}:nK?,•...,..,}vn�• .... .............. ............... .................. .............. ...::.�::v.::v�nv:::::v.:v{{•}}v;{•}}}}}:{4::v:x:.. .. rv....r., .:.. .}v;r.�...:::}:r\v.L•.,;.-.;.. .......... ...r..... ...... .......... ............... .....r................:v..v:::...• ::::::::.v..•:•::v:::•:•v::::.v:::::i:{:i�+:?::�:::±nv}:?r...v.,::}:•:Sr.,v;i nb}4:J:;Jw.K?:};ii:;:}:?:;: n�nF83tCei'CQ:?:::::x;.%:•;±±;;%{{,•::;{r•}}:<.::,.:?.::.:.:..:.-•:::...:�".....:. ............ .. ......... .:. }:k3;•,••::{i:+::.'!:`i:v:i{ii}%:�!{ii;;:;i::;+i::'ii::;:Y;'{:;: :i?<L:?iii:ii';CS%::v::;}iii:;:ii:Ci'r'i::'i{:<:v3iii'riiii{ti•}:•i:;i•}:•}:{.:ti4:{•.;.v::.v::::.;.•:::{:.};}..................... ...::..:.v::::::4:v}:•::;•.;4:•}:v;•.:.:�:.;:":::}:•i:::i: NO %;%:}i ii:i:t:�:i;?:i:%:!:iiii::iiY:i:;:•,>:;%ii}:i%i::i;}{:i::!!i;?i:i i::{!•:;Li}}'.:.:,:;ii:ii ':iiiti;:;:^{;:is}iv :•i:;±:-} ............ .......................;.....;;...::::::::::::.:�p':.v:v;........................,..::�::":::::::::T:ti(is':•:j::jJn';niii:?:ii::iiii:i: ••••ess ::}i :j....., iii;}is?ii:j}iY:�f:•::i:�:;:j�i:;:�::;i<}::{� "'r':;i:::::; e#::i::;>Sin`;?it2::;j :i'v<i ;:i; }`:;•,±:i?'.iiit?:5}:r•}.r•:•>}±x:.;::. i;`.:;:'oi%:±".'•:':'%::i'? mnrance oli Baf3m a to aecun c coverage as required under Section 25A oCMGL 152 can lead to the imp ostloa of ettminal penalties of a fine up to S1,500.00 and/or one yam,impryonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 3I00.00 a day against ma I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and corned Date - Signature ' (1 Phone# 7 Print name —ILA— 4) 41 ------------- official use only do not write in this area to be completed by city or town official city or town• permit/license# ❑Building Department ❑Licensing Board El checkitimmediate response is required ❑Selectmen's Office []Health Department contact person: phone 4; _ ❑Other lir;.ea 9195 PJ� 1 t Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. M,quoted from the"law", 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 I' al-repres. tatives of a deceased employer, or the receiver or trustee of an individ ,partnership, association or other legal entity, ploying employees. However the owner of a dwelling house ha ' not more than three apartments and who resides erein, or the occupant of the dwelling house of another who employs p ons to do maintenance , construction or rep `work on such dwelling house or on the grounds or building appurtenant the shall not because of such employment deemed to be an employer. MGL chapter 152 section 2 o states that every state or local icensing agency shall withhold the issuance or renewal of a license or permit to oper e a business or to construct b ildings in the commonwealth for any applicant who has not produced acceptable evide a of compliance with the i urance coverage required. Additionally,neither the commonwealth nor any of its polite al subdivisions shall ent into any contract for the performance of public work until acceptable evidence of compliance the insurance re ements of this chapter have been presented to the contracting authority. Applicants .x Please fill in the workers' compensation affida ' ompletely,by checking the box that applies to your situation and ° supplying company names, address and phone rs along with a certificate of inran_ce as all affidavits may cn r. submitted to the Department of Industrial Ac dents r confirmation of insurance coverage. Also be sure to sign an _ date the affidavit The affidavit should be etumed to a city or town that the application for the permit or license is being requested, not the Department of In . Accid Should you have any questions regarding the "law"or if you are required to obtain a workers' comp atioa policy,pl a call the Department at the number listed below. City or Towns Please be sure that the affida complete and printed legibly.`i. Department has provided a space at the bottom of the affidavit for you to fill out in a event the Office of Investigationih to contact you regarding the applicant. Please be sure to fill in the pe a number which will be used as a ref ce number. The affidavits may be returned o the Department by mail or AX unless other arrangements have been e. The Office of investigati ns would like to thank you in advance for you coo on and should you have any questions. please do not hesitate a us a call. �D artrnent's address,telephone and fax number. eP The Commonwealth Of Massachusetts Dep artment artment of Industrial Accidents amce of Investlgatlons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 r Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE z1.7 square feet x$64/sq.foot— x.0031— pl s from below(if applicable) GARAGES(attached&detached) square feet x$32/sq. ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= ` (number) ' Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee ®� y 7 projcost Jan-06-03 04:47® P .01 PAT[(MMOM AMM CERTIFICATE OF LIABILITY INSURANCE 11912 03 �ypUgp� THIS CERTIFICATE IS =UBD AS A PATTER OF INFORUATION ONLY AND CONFERS NO ROOMY$ UPON THE CERTIFICATE mc®haa Insurance jLvancy, Xnc. HOLDER. THIS CERTIFICATE DOES NOT AUIND, WIND OR 330 West Main Stc66t ALTER THE COVINAGE AFFORDED ®Y THE POLICIES BELOW, INSURERS AFFORDING 'COVERAGE syaamis, �► OZ1S01 INSURED Ray (town Rom Repair INSURER A >RATj :O><Al z >E[ M&L —— __4 • INSLINtHIx w����i mom.�e �/ ...._w. 34 Koratio Lane INSURER0 Coutervi l le. Us 02632 INAURI:R a. . IN3URER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 10 YHC INSURED NAMED ABOVE FCR THE POLICY PERIOD INDICATI:U.NOTWITHSTANDING ANY AeOUIREMENT,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 FOUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TFRW EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGOREeATE LLWS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ 111- TV PC OF INSURANCE POLICYNUNNA T r 6KUTI OKNKRAL LIAYILITV EACH 00CURRENLY $3 00,00.0._ x GOtaMtll�itALtltlN$RAL LIABILITY ! ;. Flgi DAMAOG(Any"tire) S CLAMS MAW �j OCCUR Imo EW lair a+t wft.m} S 100 o o.o._ A WX34477 05/05/02 05/05/03 PCRMONAL$ArIVINJURY $ GENFRAL A00ft iATE $ 6FNLAOOREQAIt LIMIT APPLIESPER. PRODUGTS-oOww PA00 S POLICY LOC AUTOMOSILK L."ILM ccMSINFD SINGLE LIMIT g rwr AUTO . (EA waluml _.._ ALt OwNFD ALtT05 I BOUIL� INJURY Il 1 WHWULWAUT ( � DS - HIRED AUTOS BODILY INJURY NON•OWNED AUTOS (PM Boom) 3 PnOPIRTY DAMW Y (Pr naidom) SAM"LIABILITY � AUTO ONLY•FA ACCIDE N I S _ ANY AUTO I EACCO S J AUTO ONLY: AGG S iXCKEE 16"LITY h.ACM OCCURRCNCE. S OCCUR U CLAIMS MADE S S aSDUCT b - S MVIINTION I M Is WORKERS,COMPENSATION AND T I .6 ItH , 19MROTERK LWILITY 88GX262-2-01 05/31/02 05/31/03 6L.EACH AGCIDENT s FL DAEASE-EAEMPLOrs G.L.DIIGLtC•POLICY 1IMT $ OTHER— DiommoA10F OftERATo mm ocAT7DNS1iiiWCLib vim looms ADDED EY INDON&MIMAPECIAL PROvium! t. CERTIFICATE HOLDER A MTNONAL INURED:INSURM UKTTKRI CANCELLATION SNOULDANT OP TNKABOVK 0611ORNE0 POLICES BE CANDELLAo 6EFORE THE EXPIRATION Tom Of I♦arniotable DAY!THEREOF,THE ISBIANO INMUIViR WILL ENDEAVOp TO MAIL 10—DAYS WRITTEN Building InVootOr NOTICE TOT549CARTweATe HOLDER NAMKOTOTHELLPT,BUT FAILURE T00050SMALL IMPOBI NO OBLIGATION OR LIABILITY OF ANY KIND UPON TNK W11114RSR,ITS AGENTS OR rams 505-775-1036 REPREBENTATrvAs. AUTHOWBD REPRESENTATIVI C ACORD 25.9(7/97) ACORO CORPgRv • F ' Board of B uilding Regulations and Standards HOME IMPROVEMENT Registration: CONTRACTOR , 126560 Ex p i ration: 6/21/2 0 04 TYpe: DBA ALBERT ROY BROWN HOME REP AL'6ERT BROWN 34 HORATIO LN CENTERVILLE, MA 02632 A dillillistl-atol. F ., •.'i . „-~ � G' ecr;LC/z a��%l�aaacrof+,udeC�b . ,�� lei anzrnzaruu BOA CONSTRUCTION SUPERVISIORS OF BUILD NG RE ,I R License q Number•�GS 065525 l " ' Tr.no: 16117 EXpires 0211212.04 M; 3 00 a Restnctec�F ALBERT R BRO u6 I 34 HORATIO LN CENTERVILLE, MA 02632 Administrator F R , E i y 423 art , .Mimi TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application z2®/ 3 6)2 v Health Division Date Issued A 7// Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board alp 7/ I/3 Historic - OKH _ Preservation / Hyannis Project Street Address 50 Ox['\eX- V-6 - Village Cl-r-I PX'Yi I LQ_ Owner R i CftYM 4nP6 MA-e r Address JM CYf)2-Y 'LA- Telephone C1 1-1 - 2-(Q 3- —751Dq Permit Request ►1\5, 0., ,1 CxtE YC 1L7t�AA ��,a�,� i�r� b \6��t1 C�IL,. _&, _Q Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay w o Project Valuation`39C)0 Construction Type C_ � a C) Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup orting deeum4ation Dwelling Type: Single Family 9"' Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's F ighway:iU YesJ❑ No- CD r- Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other v Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) , F 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 ❑ 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 V &Ac,-nd K.(` A_9aR v� Telephone Number Address 416 C:r Q_ (5+ License FQ J, PC_A\J e.r1 Y-M 6Q_7 a 0 Home Improvement Contractor# i U1.e3 l Worker's Compensation # -I-N WC �3l:P ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 411 i e A_Cxjaf) F SIGNATURE DATE COI " 1/ ?J FOR OFFICIAL USE ONLY APPLICATION# DATE-ISSUED ::< _. MAP/PARCEL NO. ADDRESS VILLAGE OWNER i DATE OF INSPECTION: FOUNDATION { FRAME INSULATION FIREPLACE p ELECTRICAL: ROUGH FINAL .y PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING f DATE CLOSED OUT. ASSOCIATION PLAN NO. r , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant'Information 1n Please Print Legibly Name(Business/Organization/Individual): !t Iy�J_� 6 is a ' -3f^Arf Address: 410 A_MJ(? City/State/Zip: 1(1f�N Phone #: Are you an employer?Check the appropriate box: ` � Q Type of project(required): 1.2I am a employer with JS 4• ❑ I am a general contractor and I '* have hired the sub-contractors .6. ❑FNew construction employees(full and/or part-time). ' 2.❑ I am a sole proprietor or partner= listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors`have 8. ❑ Demolition working for me in any capacity. employees and have workers - insurance.+ 9. ❑ Building addition [No workers comp.comp. insurance p• required.] 5•.❑ We area corporation and its 10.0 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 n� ,� <� employees. No workers' 13.�Other V ►� comp. insurance required.] *Any applicant that checks box#]must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below` is the policy and job site information. Insurance Company Name:A a Yd .S Policy#or Self-ins.Lic.#: � I t Expiration Date: - (�i f Job Site Address:5 ne k- IQ �- - Ci /State/Zi 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 maybe forwarded'to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: : Date: Phone#: Official use only. Igo not write in this area,to be completed by city or town ofcinl. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: r DATE (MMIDDIYYYYI ACOO CERTIFICATE Of LIABILITY INSURANCE 12/11/20.12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMAT VELY 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. IMPORT-ANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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 such endonsement(s). CONTACT PRODUCER NAME_ -- --— ANTHONY F. CORDEIRO INS. �,GCY. , INC. inlc�No._ExtI. (508) 677..... 1FAIC NOV.(508) 677-0409 — - ( —E-MAIL 171 Pleasant Street ADDRESS: --- —'--_ ------ PRODIICER _ _ ..—.__._._... ............ ... Fall River,_ _ MA 02721=_ INSURERIS�AFFORDINGCOVERAGE _.. _ _._. __.. NAIL INSURED INSURER A Atlantic Casualty, Ins., Insulate 2 Save Inc. INSURER a Torus Specialty Ins , Co 410 Grove St INSURER c Great American ..__... . • - ,, INSURER D :Guard Insurance Group_ _-_ INSURER E - Fall River MA 02720- INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED'NAMED ABOVE FOR THE POLICY PERIOD' INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY RERTAIN, 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. .� __ LIMttS INSR.._. __. .: LTR TYPE OF INSURANCE INSR 'MD POUCY NUMBER ,(MMIODIYYYY) (MMIDDIYYYY) A GENERAL LIABILITY y Y M 081000174 96/12/2012 06/12/2013 1 EACH OCCURRENCE $ 1,000-,000 '6Ah G5 oR9N_TEO — $ 10a,00.6 PREMISES- ocrurrencel 000 X COMMERCIAL GENERAL LIABILITY I (Ea -- CLAIMS-MADE X..OCCUR MED EXP(Any_one person) $ ., _� ... _._ -— SONAL Et ADV INJURY $ 1,000,010. O PER I2,000,000 GENERAL AGGREGATE _ $ GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP Al $ - $ X POLICY PRO- LOC AIITOMO&LE uA81UTY JECI COMBINED SINGLE'LIMIT $ �Ea accident) ANY AUTO - BODILY INJURY(Per pefsbn) $ ......ALL ONMED.AUTOS =/ / / / ! BODILY INJURY(Per accident). $ ,. SCHEDULED AUTOS { _ ./ / / , I PROPERTY DAMAGE - (Per accident) HIRED AUTOS NON-OWNED AUTOS - --' X UMBRELLA LIAB XOCCUR Y Y 782640120ALI - - 6/12/2012 06/12/2013 EACH OCCURRENCE $_ 2 r OOD,000 B -- - --- ExeEss uA6 CLAIMS-MADE: AGGREGATE —. $ DEDUCTIBLE _ —. --- —-... t X RETENTION S 10. 000 $ WORKERS COMPENSATION INWC311431 I12/10/2012 12/10/2013 X WC STATU OR D TORY LIMJL� _AND EMPLOYER'S' UABWTY Y/N - / '/ / / ANY PROPRIETORIPARTNERIExECUTIVE E.L.EACH ACCIDENT $' — 5_0O,000: OFFICEaMEMSER EXCLUDED? IT / / /• / E.L. DISEASE EA EMPLOYEES$_ _.50_0 i-000 (Mandatory In;NH) - - Ifyes,describe tinder / / / / E.L.DISEASE-POLICY LIMIT!$ 5:00 000' DESCRIPMONDF OPERATIONS below p6/12/2012 06/12/2013 C Equipment Floater 3759976 I Stop Storage Lmiit 75,350 Vehicle Storage Limit 76,25U DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ARach ACORD 101, Additional Remarks Schadule, if more span is reQuuad) Proof of Insurance. Residential Insulation Contractor. CANCELLATION CERTIFICATE. HOLDER. ( ) ( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,. NOTICE WILL BE DELIVERED; ,lN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable 260 Main St AUTHORIZED REPRESENTATIVE 0. H.C'�I1I1.1S Ma 02601- y ',�•./' r •`: i:�.r--"`r'`"' r y, ACORD 25-(2009/09) OO 1988-2009 ACORD CORPORATION,. All rights:n served, INS025�'(200909) The ACORD name and logo are registered marks of ACORD r Office of Consumer Affairs and Efusiness Regulation ° 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement C or Registration Registration: 166311 - Type: DBA -- Expiration: 5/11/2014 'Tr# 222532 TE 2 SAVE '=r ' INSULATE ' _ ROLAND LANGEVIN �£ — 410 GROVE STREET x FALL RIVER, MA 02720 - ' Update Address and return card.Mark reason for change. ❑ Address Renewal [] Employment Lost Card DPS-CA1-w 50WW04-G101216 - Ff��!rA_ uiea a � License or registration valid for individul use only Office of Consumer Affairs&B mess egulatt�on� HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ;;�66311 Type: �' Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ' Expiration: .5�kO14 DBA Boston,MA 02116 I TEE 2 SAVE-,",= \ /yG ROLAND LANGE"` ��, 536 EASTERN AVE,_,-," FALL RIVER,MA 02723 `y== Undersecretary - ✓ Not valid with signature Mac.achu.ett - Dcpartn" of Public Safety Board of Building Rewlati(rm and Standard Construction Supervisor License LLicense: Cs 103861 Restricted to:,00 ROLAND LANGEVIN 536 EASIEM AVE. FALL MVER,:MA 01=1 c�� h Expiration: &24R013 Tr*: 103W I , OWNER AUTHORIZATION FORM - 1, � (Owner's Name) owner of the property located at' (Property A/gdress) ( . (Property Address) hereby authorize— J, (Subcontract r) an authorized subcontractor for RISE Engineering, to act on my, to obtain a'building permit and to perform work on my property. Owner's Signature i Date RISE ENGINEERING Federal ID#05-M5629 RI Contractor Registration No 8186 A division of Thicisch Engineering` MA Contractor Registration No 120979 CT Contractor Registration No 620120 ti 1341 Elmwood Avenue,Cranston,RI 02910 (401)784-3700 FAX(401)784-37 10 <� CONTRACT Page 2 RI S E _ PROGRAM _ THIS CONTRACT IS ENTERED INTO BETWEEN RISE C LC-RCS ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING DESCRIBED BELOW CUSTOMER - • - PHONE GATE client Richard Hofrichter. (917)863-7569 05/03/2013 143796 SERVICE STREET - ......- ......-.. _..-,..._.__.. - BILLING STREET 50 Oxner Road 50 Oxner Road . SERVICE CITY,STATE,ZIP .,..._.._..... ......._, -.W. BILLING CITY,STATE,21P-• • - ` Centerville. MA 02632 Centerville,MA 02632 JOB DESCRIPTION Total: $3,674.47 Program Incentive. $2,948.35 Customer Total: $726.12 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF } ***Seven Hundred Twenty-Six&12/100 Dollars $726.12 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY - UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. .......... ...-..... _........_ - _.._........._ _ ._.., _ .. ___ i� 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY B SPAC AUTHORIZED SIGNATURE-RISE ENGINEERING - CUSTOMER ACCEP ANCE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE - _ ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK , . .._,. GAYS: a AS SPECIFIED.PAYMENT WILL BE MADE AS S OUTLINED ABOVE i �L(I 1y ' TA , su e .# n- Weatherization & Insulation 410 Grove St Fall Rived Ma 02723 Insulatusavenet March 31,2014 Town Of Barnstable Thomas ferry, CBO 200 Main Street Hyannis,MA 02601 RE: 50 Oxner Rd 06 s ; Dear Mr.Perry, This Affidavit is to certify that all work completed at 50 Oxnar Rd has been inspected by a certified BPI Inspector. R35 cellulose was added to open attic space_2"FSK was added to kne@wall area All Work Performed Meets or exceeds Federal and State Requirements. Sincerely, Roland Langevin Insulate 2 Save,Jnc President CSL 103861 HIC 166311 Assessor s'map,and lot number.... :.... ....,..( ......... ....,. .ti � - Sewage Permit number .........01..i�K.... ��.. .... BARNSTABLE, House number .. ..................................................... MAO& f. _ 9�C 1639 `e0 MUS Sr'P-M SYSTEM TOWN OF . BARNS AF&!��UA',,Cr&.- �TL ENVIRONMENTAL 0.- BUILDING ' I-RS P E T'O7m�������� rc . APPLICATION FOR PERMIT JO s. .... f ............ . ............ . .. .............. �� �� pp TYPE OF CONSTRUCTION ..............wc?.oA. ............................................................................................ �L.. Z .......................19.kZ— TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies .for'a permit according to the, following information: ..: �.� � ...�.. .6m .:E. .... .....Location . ............................................................... 4,Proposed Usey ... e�JC� . : c t1.. ................... Zoning District ...........................�..(................. ....... ....Fire District .... -"a...... ............... .. Name of Owner4 ?w... ...... ...........Addressor ..................Ga ?. ......... ,4... ! ?........................... Name of Builder .• .. ... . ..............Address . ctuc. ....................... ....................... Name of Architect ...... ....Address Number of. Rooms ............ ..•. Foundation l....... ........................................................ ...Roofing .......:Exierior ..°.`.-.'.8.tl.�...� u'.S. .................................... .......... ............... ...... ... ..��.. . .. Floors' (�— ..........Interior • "".((..... .((... .4............. .. . ..... .. ..... .............................. CU. Heating' 1:'...:!�.....1�1/...... Plumbing ........ a .`4. ............................ 1 �---. Fireplace ........ ................... ...:.............. ..............Approximate Cost . s1�..l:t'.°..°.°............................. .... Definitive Plan Approved` by Planning"Board ___ __________________________19_ ____. Area .......1 ....6 ...... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH " 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 ......... ...................... • 0 o^`;/ ! - - J. P. BREEN CO Inc. Af 24738 One Story 1 NO ................. Permit for • 'Single Family Dwelling r t ............................. ............................................... Loccstion .Lot...#.3O,...50..,Oxner Road.... a b t Centerville........... .. ........ .... ................ ...... ►= ' F. J P. Breen Co Inc'.Ownerr-- - - - j .. ........................................ ............ Type of Construction. ......Frame...... .... '........ .......................... ........................ Plot ............................ Lot ................................ s Permit Granted January 19, 19 8 3 { r a'r sRyLt.z' 7 / p Date of Inspect i�n���..:.....��........-,...,,✓"�......19 - -r 4 Date .Completed 'J,1....el..... :......_.....19(�� r ; J a f ' TOWN OF BARNSTABLE Permit No. ..-----.---------- Building Inspector »ate Cash �,g"Y�� OCCUPANCY PERMIT Bond __ -----* Issued to J• P. Breen Co., Inc. Address lot #10 50 Oxner Rckad, Centerville Wiring Inspector ;,�� !% � Inspection date Plumbing Inspector Inspection date r��=—tee- . r Gas Inspector /? V Inspection date i �r Engineering Department r� �-� Inspection date { Board of Health _ (�- {� Inspection date THIS PERMIT WILL NOT BE VAL , AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. Building Inspector • FROM TOWN OF BARNSTABLE BUILDING DEPARTMENT rx. Francis Lahtpipp ' 367 MAIN STREET HYANNIS, MA o Town Clerk ; 3 Phone: 775-1120 SUBJECT: FOIDHERE f DATE March 19$4 MESSAGE Work has r� s .9 P ,e •. .:) . . Please re,1ease SIGNED GATE REPLY , SIGNED .. N87-RMI ` 9ECIPIENT: RETAIN'WHITE COPY,RETURN PINK COPY •PRINTED IN U.S.A. i SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT. 77 -:f zed /° ,2 7 0 C f,S 44� JIf ' �® 1 off, —" �� • -, j o ` - . � -. _ - des s � , cng����. 040 '/y�czr5. +e r7 v h-0 , .s A/ ram, . ;�. _ ,��'.� ► a....• _.� -. _c r.. — __ __ � ,..,��.,. - - _ -��-•!..—.�.; a _ -- �. V�� V • , � ,t/ a",LG tf/ +fir Al zip 13 'w I. .�; '. j i` + ,R Ra•+?" ` -e. i-• G.�V�..• q•�q fit) , �L , ,r 'I CERTIFY�:'T�A`E' T�iS PL ��aHo ? THE`ACTU,AL•`l:C AT.1C 'T`}-i VASMASS.. }' ,• 8T-.RLJCTURcZ N�E LAND ANO =rtAT' =1'T �'Cli�( OWNED -BY SY LAWS- Off' f�� ��, �,, F..; .� �. � ��4,C7 ' 01 - �' A�RAty- u. FRANK CONERII 12 HEMP LANE f/7rsr/" jr� O K s2az U CONERY _ CENTERVILLE, MASS k --3. k iLL3t ���a .� Nk? G573��4� REGISTERED.ENGINEER &MANE! S1tRYEY01t - • ; Tp 9a Gr,SEP \ , f ,r �� s�' .� sum �p�•�R���� ll 1� 1 -1N -v ✓o�, �' i'- -� C t•% J 9L.r.• `� `WN�1.", Rt, +•.�t \ aae. r r- - Y Y ✓r