Loading...
HomeMy WebLinkAbout0495 SHOOTFLYING HILL RD VON& n. k i rj, T, T 'Aft y i v® 4'3 r a , r rt , � n \�� . , F •: ... ;;; .. . ... ,` � ., n 4 1 .._ '. _ y „ - �. �. �� . �, . .. . c >: 1 ' a a C4:. .i� � r r r • � �' h � 1 '. y it • .. � v , ' A M .. � r �� ' �. .. 2. n .. :. i i i ,.�! �fig' > .. �. ,. .. .' .. .. � � ,. '.. .' �� � .. �. y '� .. C. :.. - 1`Y «. .. .. .f e � �. � ,y} - �, + .. '.:�. � .', :' p.' i, .. .. ' � � .G .� � n .. .. .. -: ... .: i ' c.' .. . .. . 3, . .. Town of Barnstable � . -. �..�. � � � , . Building, . t hisCard So That it�saVisible Frorrithe Sheet ApprovedePlans.M'ust beRetamed on Joband,th�s Card Must;be Kept ., , :u •!pos,7 PostedUntil F nal Inspection Has BeenMade _ , �3 , .E Permit Where a Certificate,of Occupancy s;Requ`red,auch Buil'dmg-§hall Not be Occupied until a Final Inspection has been made „s Permit No. B-20-102 Applicant Name: Michael Maher Approvals Date Issued: 01/13/2020 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 07/13/2020 Foundation: Location: 495 SHOOTFLYING HILL RD,CENTERVILLE Map/Lot: 213-001 _ Zoning District: RD-1 Sheathing: Owner on Record: DOHERTY, BARBARA C Contractor Name Framing: 1 Address: 495 SHOOTFLYING HILL ROAD Contractor License:, 2 CENTERVILLE, MA 02632 `" _ `Est: Protect Cost: $7,300.00 Chimney: Description: Air seal"crawl space, install vapor barrier,insulate crawl space walls, Permit Fe $87.23 air seal and insulate the attic " Insulation: a 3. _Fee Paid:- $87.23 s Date: 1/13/2020 Final: Project Review Req: Plumbing/Gas l� Rough Plumbing: This perm it shall be deemed abandoned and invalid unless the work authorized by this permitis commenced within six months after issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. 1 f h h local zoning by-laws and codes. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the oca o" g y „ _ g This permit shall be displayed in a location clearly visible from access street or"roadand shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures�by the,;Bui(ding_and=Fire-Officials are provided on this-permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing _ 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue l bin is installedNm . . Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Final: 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Fn►prSL $ —,rvT Town of BarnstableBuilding This Cad,So That,it:�sxUis�ble:,From-the Street A , rovedaPlansxMust be>'Retamed on Job'andahis Gard Must,be,Ke t &AUWKt'ABLB,. PoPr st '.r�s, ,., F Pp€,�. ? ,f ., ,d.`, •r try , a.. ,s p '�� �.F 6 NAM Posted Until`Feria) 1639- } �3r,xe�°s � �.:`, :.` .a. . <;; , Fin I<.In i n..has been`mad R e ,au+ Where a Cert�ficatewof=�Occupaneyis Required,�such Buildmg shall�Not be Occupied�unt�l a, a spect o. e , �.. Permit No. B-18-3569 Applicant Name: Dean Fraser Approvals Date Issued: 11/08/2018 Current Use: Structure Permit Type:' Building-Siding/Windows/Roof/Doors . Expiration Date 05/08/2019 Foundation: Location: 495 SHOOTFLYING HILL RD,CENTERVILLE Map/Lot: 213-001 Zoning District: RD-1 Sheathing Owner on Record: DOHERTY, BARBARA C Contractor Name: DEAN C.FRASER Framing: -1 Address: 54 GERALDIN'ELN 4 Contractor•License: CS-097668 2 BRAINTREE, MA 02184 Est. Project Cost: $13,000.00 Chimney: Description: Re-roof entire and replace minimal trim rot Permit Fee: $66.30 Insulation: Project Review Req: -Fee Paid: $66.30 Date. ; 11/8/2018 Final f ,, Plumbing/Gas 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 months:after:issuance. 6:, Rough Gas: All work authorized by this permit shall conform to the approved application and the''approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures:shall be in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or„road and shall be maintained open for public inspection for the entire duration of the` work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this'permit. Service: Minimum of Five Call Inspections Required for All Construction Work:`s 1.Foundation or Footing ' Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low-Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low.Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the.guaranty fund" (as set forth in MGL c.142A). Fire Department . Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 13N��E G►►�u S a�� t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION f� f ` �. Map � ��I� • Parcel c. (Q,�®'�" Permit# `� r TOWN OF BA `.aTABLE Health Division M 3ka Date Issued ' Conservation Division S i2Y/ w n02 jU 3 PH j' 45 Application Fee t/ 00 Tax Collector_ c 001 1C, 90- Permit Fee Treasurer a— -DIVISION EPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE Planning Dept. WTK TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN RECUI.d^`.7210' Historic-OKH P tion/Hyannis_ Project Street Address � '�� Y/Aq �qla Village - Ce b4e k-y I Ile- owner 3M/ 2- Jmkoz Address L.A/ 9241& Telephone zp/ 00 Permit Request L26-84 3 C& I Z x L6 P60,0 6u t! jr 20 A 2 k— Square feet: 1st floor: existing proposed_ 2nd floor: existing proposed Total new Zoning District Flood Plain _ Groundwater Overlay Project Valuation /°D; '' Construction Type Lot Size Grandfa.thered: 0 Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 5d Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 0 No On Old King's HighuV, y: Cl` EfNo a Basement Type: 0 Full W Crawl ❑Walkout 0 Other ril 47 Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) � cry Number of Baths: Full: existing / new Half:existing new— IMF— Number of Bedrooms: existing ✓ new ^ X- rn Total Room Count(not including baths): existing new First Floor Room Cou t Heat Type and Fuel: W Gas ❑Oil ❑ Electric ❑Other Central Air: : Yes ❑No Fireplaces: Existing ✓ New Existing wood/coal stove: ❑Yes ❑No Detached garage:-1 existing O;new size 2yX Z�l Pool: ❑existing Cl new size Barn:O existing 0 new size Attached garage:Cl existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 0 No If yes, site plan review# • Current Use Proposed Use BUILDER INFORMATION Name S-12TW64) 1.46,94/Ir Telephone NumberN L �`;0 4/2,-r G6 l7'"75-0 2124- Address'`+ �'t/-�'�' J'% License# Q P 2 91 4Z�� M4 E 0211-7 l Home Improvement Contractor# /a l O49 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ,aV ��''1cR�`Z. ©A/ P1—,6 SIGNATURE-­04e� � DATE /`✓rid G FOR OFFICIAL USE ONLY PERMIT NO. t' ` DATE ISSUED MAP/PARCEL NO. ADDRESS s- �; J �f<, ' VILLAGE ��1 •` } OWNER DATE OF INSPECTION-' FOUNDATION i FRAME INSULATION '` .• FIREPLACE r� ELECTRICAL: ROUGH FINALfL PLUMBING: ROUGH FINAL", z-� , GAS: ROU.GFL� FINAL FINAL BUILDING )`� _9 14)7 �1 DATE•CLOSED OUT ASSOCIATION PLAN NO. i rJ iL ' t.t OFZHE lqf; Town of Barnstable o� Regulatory Services 9 ASS. ! Thomas F.Geiler,Director ArE16 p.�a`` Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date s 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 /0e 4 0-0 < Address of Work: 4 3' A4 AZWA-2i AfZZ /ZDt Owner's Name: � � ' � ' � Date of Application: e I hereby certify that: ~ 1 Registration is of required for the following reason(s): ❑Work 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. a SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: 12104 Date Contractor Name Registration No. OR Date Owner's Name Q:forms:homeaffidav 0 The Commonwealth of Massachusetts n - - Department of Industrial Accidents exce efilrestifffi ons 600 Washington Street Boston,Mass. 02111 Workers' C sation Insurance Affidavit name: location: ci ►�9/I'i f-✓/�.i� t`��v city / I CJ /�1 J GitY phone# b /7 Z'?4, 6 l 7r ❑ I am a homeowner performing all work myself. ❑ I am a sole r rietor and have no one worki� in an ca achy ❑ I am an employer providing workers' compensation for my employees worlang on this job. ....:... ..: . :.......... ailressX. phone#. :e.<.: .. ; ,,.:.......... ! ':ar......:%t(":i;i:i >;.i!: .': 5>;::`;: i :'<%i<! ?:i;;^>i<::;:?as5i::%::::`: ::i ;:? :::�i `i; i i i lnsui'anee'eo.. � � : �. . ..... oh ;. ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices: conlpanv name ::>:<::'>;.;.•X..: X. .::....... r<eSSG. >?` ?}jj > "si`Zit%i < ?+sYiif2< S2ii '>`ij` iYyi'2Yi;> >?isii ? ? >>< i'j ;ii!i;ii >isi?? 'sfass ?iiiii'`>+rt :.;.. ailitt .,. # # c1tvA :::.::. ...... <? .> Xx- i.:i;i. >:<:»' h.. �os�iraa ....... X. ....:...... . address .... d. X. Cl ............ :.:::..:::::. .... ion l ............ •v?:::fi;:c+«r':'<':::;:?':::>.:}i:iiii:i ::?::;:�:4:iS:�Y.::.`•:%i::>:?:•.f'>4':i>::::`;;:i`::';::%L'?'^ iS;;;i::::::.%:'i:::;:c:�:;:>: insnr XX bxx Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 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'eertify under the p d penalties of perjury that the information provided above is true and correct Date �`= 2 7`02— Signature — Print name �CiQQl1r( V' Phone# 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 ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (ovised 9/95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As 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 legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a . dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal ,of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. 'Additionally;neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law'or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pi number which will be used as a reference m imbrr. The affidavits may be retained tr+ the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Ottice of Invesugatlons 600 Washington Street . Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 j ���,�•� ..f.. ,:/fie v�amznxo�uuea�C o�,.�ddactivaeCla BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number CS 078292 '� � I' Exp►res'10/302004 s Tr.not 78292 Restricted To 400 ' STEPHEN A ALBANESE �j ; V' 35 RUSSELL STREET QUINCY, MA 02171 - Administrator fie �animarzu�ea�Z a�./�aaacftuoet76 Board of.Building Regulations and Standards HOME.IMP'kOVEMENT CONTRACTOR Registrationr_421049 X�tla ion 41MD4 >y�e=n di'idual r STEPHEN A AL6*41°SE,:  STEPHEN.AI,BA, _= 35.RUSSELL ST QUINCY,MA 02171 Administrator 4 2 X 8 �'2llM I N Cry JJ-- ,YU"07ur3Lip- j 4Pd V� i i II� r a � 1 w ALKWAIJ ,yv pi<S� R FSl oFNC. S, KRepLCa M A 3 � i 17 36 i pfT j Stephen A. Albanese Carpentry & Remodeling 35 Russell Street North Quincy, MA 02171 (617) 479-6175 -94RA)Pi-4rPZZ Customer Name Date ", r V 4 00--- Amount /c6 dc, Terms: t '2 Od''_r Ell 4 Total %Q, (� &S .496600 AC714)6D Deposit 7776 W 200.2, 2,10 ho Balance Due P�oFjHETokti Town of Barnstable Department of Health,Safety,and Environmental Services • BARYSIABLE, MASS. i639. Conservation Division �0 AlF0 MAC 367 Main Street,Hyannis MA 02601 Office: 508-8624093 Robert W.Gate«•ood FAX: 508-790-6230 Conservation Administrator MINOR ACTIVITY REGISTRATION Property Owner Telephone number qS"IOJN<3� Z-Aa- St?*Aff MA. 0 Mailing address Project location Map/Par/el# Project description The following minor activities will reviewed,under Art.27,by Conservation staff instead of the Conservation Commission,as long as they are constructed at least 60' from a wetland resource area or top of a coastal bank. * Pathways 4' in width * Fencing that does not create a barrier to wildlife movement, 6"above grade * Conversion of lawns to decks,sheds,patios that are accessory to single family homes,as long as: -house existed prior to August 7, 1996 -alteration within the buffer zone is less then 250 sq. feet. -sedimentation and erosion controls are used during construction * Stonewalls (this does not include stonewalls for retaining wall purposes, grading and/or fill) ®2—' Sianatur Date S 2 Y Zov Reviewed by D to _GIS Plan Attached(fee charged for plan) mino ct.do c ra NOTE:not all symbols will appear on a map s / 1 ❑ 0 GOLF COURSE FAIRWAY 1 Y"Y_y EDGE OF DECIDUOUS TREES ` EDGE OF BRUSH t i ORCHARD OR NURSERY \,` /T-'T�V EDGE OF CONIFEROUS TREES ❑ MARSH AREA —---— EDGE OF WATER DIRT ROAD # 5 ;I DRIVEWAY E PARKING LOT PAVED ROAD — — — DRAINAGE DITCH \ — --- PATH/TRAIL i PARCEL LINE MAP# # 5O, 21 E PARCEL NUMBER #teo—HOUSE NUMBER 2 FOOT CONTOUR LINE Ja 10 FOOT CONTOUR LINE Elevation based on NGV029 4.9 SPOT ELEVATION / STONE WALL FENCE �� ^3 e w RETAINING WALL 1 t 1 1 RAIL ROAD TRACK -- STONE JETTY y SWIMMING POOL # 521 1 / �� PORCH DECK �] BUILDING/STRUCTURE DOCK/PIER HYDRANT s ` MANHOLE o . POST 0p' FLAG POLE T O W N O F B A R N S T A B L E G E 0 6 R A P N I C I N F O R M A T I O N S Y S T E M S U N I T o S16N ® STORM Dw r1 N PRINTED SCALE:IN I m *NOTE:This ma ls an solo p rga�m of a **NOTE:The parall"litres are Doty graphic represemotions DATA SOURCES:Planim (man-made feature)were interpreted from 1995 aerial phot�mphs�The James n TOWER 1"=100'sarle map aml may NOT meet of property boundaries.They are not hue locatioe and W.Sewall tompany.TopoOmphy and vegetation were inwipreted from 1989 aerial photographs by GEAD 0 UTILITY POLE "' a 0 2U j.40 National Nm Accurary Standards at this do not represent actual relationshipsto cal ob'as ration. Planimetriq topography,and vegetation were mappal to meet Natural Map Aauimy Standards tk fAdgnlconsetvation.dgn 05/24/02 01:46:08 PM w 1 ( Engifieering Dept. 3rd floor) Map 2 1.3 Parcel 69M OOZ -W—Permit# House# 49 S W-Date Issued Board of Health 3rd o -(8:15 -9:30/1:00-4:30)c.//�t4f V-3—?7 Fee !1 - 4th floor)(8:30- 9:30/1:00-2 00) -SEPTIC SYSTEM MUST BE DI--a Dew 1st floor/School Admin. Bldg.) INSTAL MPLIANCE e�lljhroved by Planning Board 19 , I 5 �ENVIR iCODEAND :TOWN OF BARNSTABLE T ���''°rF v\P Building Permit Application Project Street Address l Le7? t -5 r Village Owner Address �7 Telephone — Permit Request - If JJ First Floor square feet Second Floor square feet Construction Type04 ,/f,'-�i�c � . Estimated Project Cost $ /3, 07--b Zoning,District Flood Plain Water Protection t Size Grandfathered ❑Yes ❑No 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 ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. 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 - Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None __ ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information ``// / NameQ �� � Telephone Number / 9�" — 7"O !Q b Add License# Q6S­g7 o21 0 35 Home Improvement Contractor# /d;5�Q09 Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �. DATE BUILDING PERMIT EN/TA OR THE FOLLOWING REASONS) �/ r7 JA - FOR OFFICIAL USE ONLY _ PERMIT NO. DATE ISSUE W 1 } � ` • ' ,. � 1 � t i } a ,. , MAP/PARCEL NO. - ADDRESS — VILLAGE t. OWNER F DATE OF INSPECTION:, FOUNDATION FRAME - ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL,PLUMBING: ROUGH FINAL . - a GAS: �. ROUGH FINAL , 'R fast Ll/ FINAL BUILDIN — DATE CLOSED OUST ASSOCIATIONYLAN NO. e { r The Commonwealth of Massachusetts Dcparinienl of huhtstrial Accidents � Y l _ s Office o1/nvestigat/nns 600 Ii<ashing;tonStreet " Boston. A1u.vs. 02111 Workers' Compensation Insurance Affidavit Applicant information: _-- _ Please PRINT lebil —M - name: location: city I phone# 1 am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity . ... -,y- nrow.=s..r�t�r•--+.+.e+r.fav++.:..:f*ter...'......,n.�'!!a�..........wy,�fi.�.... ....r-;.....,.�;�..•w........_..,.....r..,._�......�,. ,.. I am an employer providing workers' compensation for my employees working on this job. ,Xcon1 ranv name: Vaddress: Jinsura ice co.a / _ 'f" lie if (96 I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers compensation polices: company name• address: cih: phone#• insurance co. polio # '.. .. ...•i'.::•:!:. :Y�'C^. - - .'�,.;1.. _ _`r.. __...141T'^f.'+7ww:1 - --•.- ..M.'-v..:.t. -i.....- __...__._..... __.�_.�._..._. ...I.�..._.�y...-._w._+.�._yrJ.r.ru..luv��.rw -�1'�_ ^��• _..�1.�i:YrYL." �-.� comllnnv nnine: address: citw: phone#• insurance co. policy# Attach additional sheet if a . __-_... i . r_.:R.��ra.a�:r -----:i.:✓.L�..;��� _.,�y�_. .''.jiy .....�-yr' =- '=".w�iSY!•�wl.:�!•.Lfic'wwi rx. Failure o secure coverage as required under Section 25A of NIGL 152 can Iead to the imposition of criminal penalties of aline up to S1.500.00 andiur one y cars'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a cop% of this statement ma} be forwarded to the Office of Itrw•cstigations of the DIA for coverage verification. 1 do hereby certif tt r the p ins nod penniti n perjun that the 'njormation provided above is True(nd correct. q Si_nature _ Date '7 3 / Print name _j e Z e-f t4 r l Phone ar T rofofficialficiii use only do not write in this area to be completed by city or town ty or town: permit/license# rIBuilding Department-W Licensing Board check if immediate response is required Selectmen's Office" (,,;,cont..cr person-_ phone#; nUther !: r. ire�ised is^�I'1:\1 information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their employees. As quoted loom the "law" an etnploree is defined as every person in the service of another under anv contract of hire, express or implied. oral or written. An empinrer is defined as an individual, partnership, association. corporation or other legal entity. or anv two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL cha}ner 152 section 25 also states that even, state or local licensing agency shall withhold the issuance or renewal oi'a license or permit to operate a business or to construct buildings in the commonwealth for any applicant .who has not produced acceptable evidence of compliance with the insurance coverage required. Additionaliv. neither the commonwealth nor any of its political subdivisions shall enter into any contrast for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha\ been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the cite or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law' or if you are required to obtain a workers' compensation police, please call the Department at the number listed below. Citv or-Towns Please be sure that the affidavit is complete and printed legibly. Tile Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to tie Department by mail or FAX unless other arrangements have been made. Tile Office of Investigatioils would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. Tile Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 `Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 : - The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Offices 50&790-6227 Ralph Crossett F= 50&775 3344 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"tzconstruction,aiteraticns�renovation,repair;moderairation,conversion, imprvveme .nunrnal, demolition, or construction of an addition to any precdsting 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 attain c=pdons, along with other requirements Type of Work: - Est.Cost 0 ' __ Address of Work: 9 Owner.Name: Date of Permit Application: -3' I hereb%certifv that: Registration is not required for the following mason(s): Work esduded by law Job under S1,000 Building not owner-o=zpied Owner pulling own permit Notice is hereby Shren that: OWNERS PULLING THUR OWN PERMIT OR DEALING WITH UNItEGi5T9 ED CONTRACTORS { FOR APPLICABLE HOME 04PROVEMENT 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 a _. Reidst ation No. OR �T DATE(MWDD/YY) AC�RD,M C I�TIIFICAT'E: �F' L�; L , 'Y IN U ANTE 413197_ . a PRoDucER THIS CERTIFICATE IS ISSUED AS A MATTER—OF INFORMATIONY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE i WALSH 'INSURANCE AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ( 25 Elm Street j Braintree Ma 02184 I-�___.._ ____._-_.COMPANIES AFFORDING COVERAGE 617-843-8538 i COMPANY j .._..-.. _ ___. _.._ ----_1L_ A._.._NOREOL.K--..AND_.._DE.DHAM-MUT j I COMPANY CUSTOM DESIGN HOME IMPROVEMENTS e SA_V._E.RS.. PR-ORER..T_Y_._AND. _CASUALTY___.__.... _i -— — 2 Chanol Dr. COMPANY f Pembroke Ma 02359 _.---___�___.._..__ COMPANY D e. ...,,... ,,,..., (G:OVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I 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. j CO TYPE OF INSURANCE POLICY NUMBER I POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR f DATE(MM/DD/YY) DATE(MM/DD/YY) ----------�.- --_.------.-_..k GENERAL LIABILITY GENERAL AGGREGATE S f , COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ ?A x _, -- - — !- 500------- i I -_XX. CLAIMS MADE -J occuR; RO 17 4 4 4 1 1-1-96 l 11-1-97 PERSONAL 8 ADV INJURY (OWNER'S 8 CONTRACTOR'S PROT I EACH OCCURRENCE FIRE DAMAGE(Any one fire) $ ME_D EXP(Any one person) $ COMBINED `------__--__--____-.__..._--•--I AUTOMOBILE LIABILITY SINGLE LIMIT $ i ANY AUTO ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS BA8002267 4-13-96 4-1 Per person) $ 100 3-9 A I i HIRED AUTOS } BODILY INJURY j - (Per accident) NON-OWNED AUTOS 300 ° k -• - - PROPERTY DAMAGE 100 {GARAGE LIABILITY ! AUTO ONLY_EA ACCIDENT —, ANY AUTO t OTHER THAN AUTO ONLY 1 EACH ACCIDENT -$ AGGREGATE EXCESS f EXCESS LIABILITY EACH 000URRENCE - UMBRELLA.FORM AGGREGATE $ s OTHER THAN UMBRELLA FORM $ WC STATU 'O i R WORKERS COMPENSATION AND XX.TORY LIMITS } ER t j I EMPLOYERS'LIABILITY i WC0000575-00 7-23-96. 7-23-97 EL EACH ACCID ENT _ :THE PROPRIETOR/ I i INCI i EL DISEASE-POLICY LIMIT $ �1 B PARTNERS/EXECUTIVE 1 OFFICERS ARE: XCL EL DISEASE-EA EMPLOYEE '$ 1 0 Q I i I OTHER I j DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS I i 495 Shoot Flying Hill Rd. , Centerville, MA 71`77- CERTIFICATE HOLDER CANCELLATIQN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town o f Barnstable { EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL i Barnstable, MA i ��DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO S; H NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KI UP THE COMPANY, ITS AGENTS OR REPRESENTATIVES. 4._.....__.-.._._._..._.____. TS OR�__.._._��__.,....__.....� AUTHORIZED R RE NTATIVE I ) I ACORD 25 S 1/95 ©ACO.RD CORPORATION 19$S, ✓fee �a..r.,noauecr�I/ �,/�aaaac/zuvelta ?, _ . y DEPARMIT of PUBLIC SAFETY !. CONSTRUCTION:SUPERVISOR. LICENSE Ryaber _ Expires: flesbricted`To 1G JEFFREY B RICHARDS � .x����I 2 CNANOL DR PEMBROKE, NA 02359 : ��it rt.,3•d t�'„gY ��+�'�•'f'�`�' ��'� d�'.+� �y,r.�:y��j .�. M.'S3 'y++�.y{,,,3 9XZ�a' ,°�,5'�+f}�j� �a�-,p�,,j�F,µi,+•'#q '`r � _ lit C9 IRAC7 Q A "Rs�jrl S2fi � r �4 �'"" � sr� � S� Y •r"iti�t� •�� �e BAN:',-f:'t,�,•., r . {(q } " ; CHST01 DESIfiN NOM /�•Y.n11PRQy1/El �o' � ` effreyRicfiar =`t r� 2 C�iano Drive �f x1 ADMINI3TAATOR t` �° r s3, < far,r. f,,hws, zsa 1Pemb 02359 ¢ �` , f?, roke MA vat u L