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0678 SHOOTFLYING HILL RD
V/ �60 _ . t a 0 Town of BarnstableBuilding Post90",This Card So That at„�SVisibleFrom the Street AlSproued Plans Must be;Retairied:on Job and th�sCardUMuSt,,be Kept �•, ABLE, ' �..< �.:•�','. `; �d_ �''.,, - �. x a, • Posted Until Final�lnspection Has Been Mades b a �Whe e a Certificate of�0ecu anc s;Re uire�such Bu ldm shall Not be Occu fed ulntil`a Fin I Inspecttoh has beenimade Permit lijlt Permit No. B-19-1299 Applicant Name: Henry Cassidy Approvals Date issued: 04/22/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 10/22/2019 Foundation: Location: 678 SHOOTFLYING HILL RD,CENTERVILLE Map/Lot 193-046 Zoning District: RD-1 Sheathing: , � . Contractor Name: HENRY E CASSIDY_ Framing: 1 Owner on Record: FAZIO, PAUL L& DARLENE A � Address: 678 SHOOTFLYING HILL RD Contractorf Acense GCS 100988 2 y . CENTERVILLE, MA 02632 M�I. ( V. Est Protect Cost: $775.00 Chimney: Description: Insulation/Weatherization Permit Fee: $85.00 ` Insulation: Project Review Req: ?F Fee Pad $85.00 Date 4/22/2019 - Final: i Ts �^ Plumbing/Gas t ks k i fY r. Rough Plumbing: is .. r, ;Building Official Final,Plumbing: This permit shall be deemed abandoned and invalid unless the work authonzed by this permit is commenced within six inonthsafter issuance. - All work authorized b this permit shall conform to the approved a licotion and the a roved construction documents for which this permit has been ranted. Rough Gas: Y P PP PPk PP P g All construction,alterations and changes of use of any building and structures$hall be in compliance with the local zon g by laws and.codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public mspectiob for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe Bwldmgand°Fire Offica e m ihiskpermit. Minimum of Five Call Inspections Required for All Construction Work ; ? _ Service: :• 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 S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final- "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT D hri►.�rrE TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map k C 3 Parcel Application Health Division Date Issued y /S Conservation Division Application Fee s� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address i Village Owner Address Telephone a z Permit Request N, -30 r Co. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio<n4s�, Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 2" Two Family ❑ Multi-Family(# units) Age of Existing Structure -ti Historic House: ❑Yes ❑ No On Old Kir g'�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 >i new Number of Bedrooms: A existing _new Uj 03 Total Room Count (not including baths): existing new First Floor Room Coorit Heat Type and Fuel: O'Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coalstove: ❑Yes q 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# t"J4 i"YY Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) a Name Telephone Number Address _z �o,.�� �3a License # dZ-=k=t'g �4% . ��. A Home Improvement Contractor# ��k z5 k Email Worker's Compensation # c.o -s,,u -ati ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER `t DATE OF INSPECTION: FOUNDATION FRAME INSULATION III' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f Massaciaustat€� -f1�P�t�rt#�nt cr°I��I�tr�aafety B�arc#o:�8:.+ticl.°�Rcgs�t�tt©ns.aar3�t�nrt�tt Li:edge-CSSL-102778' CONOR D MCUBY .: 39 suSfolvsE SAGAMOREB C th i,92'03: Ccrrrcrait rhsro OWIW2018 ,, r°t <ttr err vtrr f+KAX =-� Oftce or Goasatner Affairs&Bn 'n License or Istrat n valid for 'v' ' s• ess R�gulatitin reg . Io d o indt tduluse only__: ME IMPROVEMENT CONTRACTO before,the expiration elate, If found return to, eg stration:, t7125 Type_ Office of Consumer Affairs and Business:Regufatli n xpiration: 13t1t201& Part hiP ItI Park Plaza-Suite 5170. Boston MA t121iG CQN-SERVE EPdEI?CY.,.i k CONQft MCINERNEY. ... 376 ROUTE. 130 SUITE C SANDWICH,M.A 0563 " Uodersec etary; . Notvalid without signature. 1 i n=rrsczcn 1a 1 Ivr_Sin:rnuuuL. anu I no LICK I B-nes 1 It nuL urm. IMPORTANT:If the certificate holders an ADDITIONAL INSURED,the pollcy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the temps 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 endorsements.: . PRODUCER CONTACT '-NAME:: .. CSSSIWORKCOMPONE PHONE Fax c1 ,r AlC,No,Exl: __ AIC,No PO BOX 946580 EMAa ADDRESS: Maitland,FL 32784-6680 INSURERS AFFORDING COVERAGE. NAIC# 1477-724 2669 INSURER A Continental Casualty: Pay Com n 20*13 _. 4 _. '• INSURED INSURER B. CONSERVISION ENERGY INSURER c 376 ROUTE 130 INSURER D: SUITE C MSURER E: SANDWICH,MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: J REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE.LISTED BFLOW HAVE BEEN ISSUED TO THE INSURED:NAMED'ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONQITION OF ANY_CONTRACT OR OTHER DOCUMENT WITH RESPECT TO :WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY .PERTAIN, THE INSURANCE1 AFFORDED BY THE POLICIES DESCRIBED HEREIN Is SUBJECT.:TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY,HA1/E BEEN REDUCED BY PAID CLAIMS; DrsR DDL SUBR ( POLICY EFF POLICY EXP LTri TYPE OF INSURANCE MR WV0 POUCY NUMBEF�_. MMIDDrM IMMIDDNY) A GENERAL LIABL" Y 6011.316335. 03111/16 0311.1416 EACH OCCURRENCE 1`000 000 . . S COMMERCIAL GENGENERALUABIUTv dAMAGETGRENTED PRWIMEs(Es oCMUWM) :. a 300 600: CLANSMADE: OCCUR MED EXP(Any one Person) _ 10 QQQ PERSONAL$ADV INJURY $ ,1000 OOQ GENERAL AGGREGATE' a':2 000 000 GEN L AGGREGATE L@a(TAPPUES PER: PRODUCTS:-:COMPIOP AM. $:.::Z'000 QOO PRO- POLICY &CT 1/\i LOC . Mrr A AUTOMOBILE LIABILITY 601131633 03/11l15 03/11Z16 COMeuIED SINGLE LI (Ea a�ddeni) $ 1,000,000 ANY AUTO: L BODILYINJURY(Per person). ALL OWNED SCHEDULED - 'BODILY INJURY(Perdanq AUTOS: .AUTOS " eid NON-OWNED - PROPERTY DAMAGE HIREDAUTOS /� AUTOS' ;(Peracddent) _ $: A X umeReLLa Lore X Or-CUR, 601131635 03111/15 03/11/16 EACH occuRRENCE;` 2 000 000 EXCESS CLAIMSMADE AGGREGATE $ O00 QOO DEDIXI RETENTIONOTW WOPICER MMM A o Lasnrry Ynt 6011316349: 03111115 03A 1114 X Toav AIN ER ANY PROPRIETORIPARTNERADOEcunvE OFFICERATMBER EXCLUDEDr NIA EL.EACH acclDErrr _ .500 000' (Mandatory In NH) �ELDISEASE-EAEMPLOYEE $ 5OO QQQ: U yes;desafte under - DESCRIPTION OF OPERATIONS WOW EL.OLSEASE.POLICY LIiIiT $ 500,000TATU ,. OTHER TORY LIMITS ER EL,EACH ACCIDENT `EL.DISEASE--EA EMPLOYEE _ El.DISEASE-POLIO Umrr, $ Certificate Holder Is`added as an additional Insured as.provided In Lthe blanket additional.Insured endorsement as it pertains to work being performed by named insured underwritten contractC INCLUDES PRIMARY AND:NON-CONTRIBUTORY CERTIFICATE HOLDER CANCELLATION` RISE Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE' WILL BE :DELIVERED IN ACCORDANCE WITH 'THE POLICY RROVlS10NS 1341'Elmwood Ave Cranston;Rl 62916 AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION.All Nghts reserved. ACORR 25 j2010105) The ACORD name.and I..n are registered marks of ACORD { TheCon o�ewealth of Massachusetts DepaXce t of IndusMat Accidents of Iwadga&ns tS 0 Washington Street oston,MA 02111 www:massgov/dlo Workers' Compensation Insurance a a�lt- . e { wlders/Contractors/El. . 11 clans/Plumbers A lic n I form do I Pleas Print L Name(Busiptsa/Ocganizadadindividuat): Cons rVisioh Energy Inc Address: 378 Route 130 Ci /State/zi : SAndwich, MA 02563 phpne#. 508-833-8384 Are you an employer?Check the appropriate bo s a employer with 6 4 ❑ I am a general contractor and I ., Type of project(requlred). employees(flrll and/or part-time).• va hired the sub-conpactors 6 01 New construction 2.❑ I am a sole pr�trietor or partner I on.the atisched sheet. 7..'❑Remodeling ship and have no:employees ese suh-coattaa ton eve �mohtton : working for me.in any capacity.:: bytes and have worifers' [No workers'comp Insurance.,: c mp.insurance.t`. 9. ❑13uildmg addrhon required:] 5,. ❑ e are a cotiwration and its 10.❑ Electrical repaus or°addtnons 3.❑ [am:a homuowner doing ail work o cars have excrrised their 11. Ptumbin myself.[Na workers'co ti t of ea g repairs or;:additions mp eruption per[N(}G 12.0 Roof insurance'regwmd l t c.;15Z$1(4),and we have no repairs: 3a.❑ I am a homeowner acting`aa a e We [No vtrorkers' t 3.( Other Weatherizafion, general contractor(refer to#4) co .insurance required 'MY a"W=t`checb box#1 MM also fiA out the seetiou be sbowingrheit wotttes• t Honteowrmta who subndt this affidavit indicatat th ere doin 00 cY info.maaon tcoutt ac"that eheett this box must attached as 8 ry 8. 'work and dtrn pine outside cantractots must submit a nm affidavit iadtcating such employees ti die snb oont or�have eddttionsf sheet wins the tmme of the sub-coa�etaas gad state whed�or dw"endtia have en*gem they ctuu pruvi their worker,'comp.POUCY mtmber. lam an enohyer tlhat lr pravld�bg awrkers'compeni a liunrwnct of Jnjorrmadan, I m3'employees Below tr the pn/lcy and job sifts Insurance Company Name: CS&S/1NORKCOMP 1 NE Policy#or self-,ns. 601.1316349 Expiration Date . 3-11-20'16 lob Site Address: City/State/Trp: Attach a copy oEthe woeken'.compensatloa poBcy on page(showft me policy uomber and esplratlon date) Failure b secure coverage as requited udder Section 25 of MM c. t 52 can lead to the imposition of criminal fire up to.$1,500.00 and/or one- tar' penalties of a' y tmprisonmen as ' ell as civil penalties in:the form of a STOP WORK ORDBR and a fine of up b g250.00 a day against the vioiatos. Bergdvised t a copy o f this stattemer,t,rnay be forwarded;to the Office of Invddgationa of the Dr.nee:coverege verift tioa. do c da pslnr d pensl of p tkat flit onrrmlorr rovlded p abow b&w and COO,�'Tclal ass ontys Do Kot tt7ltts!rr thls;amr;,!o be col, plaord by cl[y or rorvn 0,07clatt City or Town.'`- Permit/I;icease!t: isautn Aatho city(dicta one): 1. Board of He>,ith 2.t3nUding Departmeot`'3.City own Clerk 4 EiecMca!Inspeetor S.Plumbing Lnspeetor. b-other O Person 1 Phone#: O �$� '`'.�� PARTICIPATING COWMAC MR PERMIT AUTHORIZATION FORM I, Darlee Fazio ,owner of the property located at: (Owner's Name,printed) 678 Shootflying Hill Rd Centerville (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform ins lation and/or weatherization work on my property. Owner's Signature Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date o.. M For Office Use Only Rev.12132011 k s Z o�T„E r Town-of Barnstable *Permit# 4� - v� '�'0 Expires 6 months from issue date Regulatory Services Fee • k BARNSTABIA Ss. Richard V.Scali,Director JAft Alh _ U-11u1n 9 — Perry,CBO,Building Commissioner APR 1 6 200 Main Street,Hyannis,MA 02601 'A' 20� www.town.bamstable.ma.us 1:05 - P� Fax:508-7 0-62 Office: 508�t�40.3���� 9 30 EXPRESS PEW APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address (S)3 �Aom--t`/ V q I`1 C I( (L®, L¢NT'22UG[( f Residential Value of Work$ 3msD 5 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address POU-k L2 7\0 6 Hm-r t 1� o QJV_;N_-eke t k< Nk Contractor's Name Telephone Number S-D8 36Y O 9 Gq. Home Improvement Contractor License#(if applicable) Email: 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 bNC)Q-0 Y &JG V Pl Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. 1 Gk v,V-4 0 l,.a-41A Permit Request(check box)Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to alp-.wAc,, ❑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 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 Pr9perty Owner Letter of Permission. A of the Home Impro ment Contractors License&Construction Supervisors License is e d. •- SIGNATURE: Q:\WPFILES\FORMS\buildin p orms\EXPRESS.do ,. Revised 061313 .Sze Town of Barnstable Regulatory Services 9� i'E'� Richard V.Scali,Director _ 163.06,�m Building Division 'T'om Per-ry,-Building-Commissioner-� — 200 Main Street,Hyannis,MA 02601 ---- www.town.barnstable.ma.us Office: 508-862-4038 - _ Fax: 508-790-6230, =Property Owner Must Complete and Sign This,Section ' -- If Using A Builder as Owner of the subject property J CJ hereby authorize -I ' i tr act on my behalf, in all matters relative to work authorized by this building permit application for. (Address o Job """Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name LI Date Q TORM S:O WNERPERMISSIONPOOLS f 1 Town of Barnstable Regulatory Services 4°F rOty,L Richard V.ScaIi,Director Building Division Mn eas. Tom Perry,Building Commissioner saxxsz 1639 .�� 200 Main Street, Hyannis,MA 02601 ArED �A www.town.barnstable.ma.us Off-1ce: 508-862-4038 _ Fax: 508-790-6230 - HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: - - - - number - street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &ReguIations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFII.ES\FORMS\building permit forms\ERPRESS,doc Revised 061313 scachmeffs " Vie'Ct�.mrtricr�rsct�Qf?�2�as _ Deprtmt mt of hu&strid Accidents r Bcrsfoq,M,4(J?M, .. 4rkLt-s' CompensatianE ara-ace davit:Bidfders/Conk-a:cfnrsfE ectricianMumbers A,ppEcan;t Infarmatiort Please Print Legibly Name �z� gaor> dnan_ e( lSt���•.�c, aw�e �w�t�c Ar&e.ss_ 6 q5 S V W V"r 4�y t V k!( R c) , l..cn- -tO-u c V r N CiWState-/zip_ _ Pi one A- S-Do' 36 V 6�?O'q Are you an employer:`Check tite appropriate burz: Type of r Cct fi-_ ❑ 1 arrt�gem-al c�nfr3ctor wad`I PT oj�e e�= - 1_❑ 1 am a c�uployer with 5- ❑Ides mnsfivc#oa ezitgioyees(full andlorparf tame}* have t e sub-conlaadors. 7__[�1 aIn a sore p oprietor ar partner Iisted oa the attached sheet 7- ❑Rct odeling 1 drip aad have no employees These sub coatractors have g- ❑Demolifina for me in any c ci r emplo ems and have workers" working _ y apa t1- 9- ❑Euildiieg a d'ditiort !7Vo worker!;., comp:ins, 6 comp-msnrar'cf-ll . 5-❑ We are a corparationandd ifs 10.0 El,edxical repairs or additions 3.El > r ] officers have�erdsed their am a bamemfines doing all work 11�_.0 Plumbing repairs or additions rcryse1£ [No tvoAM,comp- right ofex sn fioaperMGL IZ❑Maof repairs it'mmince require-d_]1'• - c- 152,§1(4} and we'hasego eusployees-INC,wmkets' 13_.❑f?tiier comp_msurance regmred.j -any sapEcm1 ffixt ched-s box-,I amst also fill of the seffioa belo cc sha ludo woes'compegss=m p 7HLT 9 TKIIM� ,-s xr-1 0 S:atrmit rbis afdWd jar v mey—ring-U trait and dim hoe oadside coatmcrom nmsi snbollt a uer x f5davh mdiic.t_ mdL G,i,,,rEns fist cF eck this bmc mist steadied sa sdidid nsI sweet shmcmg n�o�8�e sir �md state xhetler ocnnt ibnsa Nifies I R,.pj,ers_ Lrih°r co-ntrrcfats h-ce employees,they—p--ide tl-- omp.po]acy ntiber_ I am an grrdpr brat is pratd rE�oriers'cotrzpRrurtivn i7Lrrtrrrrtcs far rear e-mtpF�ye� �aLatr is fh�paTic}and job ante Insurance Gompam�I�Iame: �.. bQ� �-��1U �N Policy ffCrSelf.=-Is Lic-:�: c [ r p FxpirationDate_ Job Site Aid&ess_ c � J �T \ {�l(� . Cit3,,,state zZp-- GL V.,�e-p-.\J f V ( H tl ttacTx a ropy of the--vmrkers'campensationt po�cg decTarstior¢pab(showing the pol ley number and ezjrsatiou date). Failure f x 3 secure eavrerage as let jaireci under Seddost 25 Ai o€MGL e. 152 can lead to the impositi m of trim;,a I penalfics of a fine up to$1 501)Oa andlor o=year as welt as cizai penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a-day against the violator_ Be advised that a copy of this stoat may be forwarded to the Office of lix estigations of a far insurance coverag�ation- I do hezreb4d c thsporis antipen es af.P�a 'ihatf3rs irrfprrrtrdian prm2dczif above is h7-w and correct Sienatum- Bate._ O Y•;�-7 " 20(S Phone r. Sb$ 36 6' OjcjaZ tt�e ati[y. Da n dlt trot write in this area,:a be campLeted by y or town offiic aL Cites, or TOWO-z _PerrodtlLicemse 9 Ls min Antharity(drde one): 1.Beard of He.-Jth 2.Bugding Deepartneut I CitWT,owa Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other COat—V ct P erg on.- Phone#: - 6 r Information and ins -xCfio)EtS Massachusetts GleneraI Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this sta-tote, an employee is defined as"__.every person in the service of another under any contract of hire, express or implied, oral or Written-- Am employer is defined as"an individual partnership,association,corporation or other legal entity, or any two or more- of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual partnership,association or other legal_entity,employing employees- However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also steams 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 a17.y applicant who has not produced acceptable evidence of compliance vritiz the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonvrealh nor any of its political subdivisions shall enter into any contract for the pt ormanee of public work until acceptable e-,dderice of compliance v illh the insurance requirements of this chapter have been presented to the contracting authority." Applicants — Please fill out the workers' compensation ar`ndavit completely,by checkin-g the boxes that apply to ycur situation a_d,i.f necessary,supply sub-contract-or(s)na ne(s),address(es)and phone n,LnT-,be,-(s)a)ong wih tueu certiuca.it(s) of insurance. Limited Liability Compaq es(LLC)or Limited Liability Pa1lDershi Us(LLP)vela, no employees other tan the members or partn(--rs,are not required to carry workers' compensation,;,)q„rance- If an LLC or LLa does have employees, a policy is required, $e adv-;sed that this affidavit may be s:bmiited to the Depot-L72ent of Indusem.'al Accidents for confirmation of rnsm—ance coverage. Also be sure to sign and date the ate, dav t 'I1ie afEda"it sbo-_-ld be returned to the city or town that he application for the permit or license is being recxuesed,not the Department of Industrial Accident-. Should you.have any questions regarding the lam!or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self=iii.nired companies sro ld enter--Leis sell-=' urance license number on he alipropriate line. City or Town.Officials Please be sure that the affidavit is cnmplete and printed legibly. The Depar;rnent has provided a space at the bottom of the affidavit for you to ill out in he event the Office of Investigations has to contact you regarding the applicant, Please be sure to fill in the permitJLce nse number which will be used as a reference number. In a.d.c tZon,an applicant that must submit multiple perm.it/Ecense applications in any given year,need only submit one afi-davit indicating cu-er,t policy information (ifnecessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affiidavit is on file for future permits or ltce-nses- A new affidavit mast be',filled out each year.Where a home owner or citizen fie obtaining a license or permit not related to any business or commercial venture (i.t.a dog license or permit to burn leaves etc.)said person is NOT required to complete its affida,•-it_ The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a coil_ The Department's address,telephone and fax number: Commonweal&of Massachos i_tL Qf (- e Of uyeesfigatian.i Bastozj_MA 02111 Tvi,414 6I7 727-/-9-QO W 4-06 oz I-977 hLkSSAFE Revised 4-24-07 Fax : 617-727-7^749 YARMAL- OP ID: KD DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/09/2015 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 endorsements. PRODUCER CONTACT NAME: Hyannis Office _ • 88 Falmouth(livan Road Ins Agency a2NN Ext:508-775-6060 a No).508 790-1414 Hyannis,MA 02601 E-MAIL - Margaret Rose ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Western World INSURED Andrei Yarmalovich dba INSURERB:.Commerce Insurance Company 34754 Bel Islands Home Improvements 29 Mill Pond Road INSURER C West Yarmouth,MA 02673 INSURER D INSURER E: 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 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 A S POLICY EFF POLICY EXP LIMITS N POLICY NUMBER MMIDD MMIDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ". 1,000,00 CLAIMS-MADE FK OCCUR NPP1403182 03/29/2015 03/29/2016AGE TO E TED 50 00 PREMISES(Ea occurrence) � �$ MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER:: GENERAL AGGREGATE $ 2,000,00 X POLICY❑PROJECT ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident B ANY AUTO BGBWRR 10118/2014 10/18/2015 BODILY INJURY(Per person) $ 100,00 ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 300 00 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE , $ 260,00 X HIRED AUTOS X AUTOS Per accident a $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIABH CLAIMS-MADE AGGREGATE - $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-FA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT. $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate issued for insurance verification CERTIFICATE HOLDER CANCELLATION r TOWNCIFY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.. Town of Yarmouth 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE Margaret Rose ©1988-2014 ACORD CORPORATION: All rights reserved. ACORD 25(201, 01) The ACORD name and logo are registered marks of ACORD �oanvri�a"eciCdL ° � `q Board of-Building Regulations and Standards �\ Office of Consumer Affairs&Bnsne egulation. Construction Sup -isor OME IMPROVEMENT C RACTOR License: CS-105964 ,t j s egistration:n 76 ? Type`?�' Ex rT�2J 014 P v lement 2 IVAN IVANIU N £ t}GRdBELISLAN OME O . { i Apt 1-14 Dennis Port MA 07,639` ''. I IVANIUSHEiK t �, , E. 9 MILL POND •,.•.,�_ ., �_�' . � �' �. - � � Expir?tion _ W.YARMOUTH,:MA tl26 Undersecretary 01/0112016 / r3 Pi Commissioner f _ . �...aira&Business Re°ulation License or registration valid for individul use only, . 'ME IMPROVEMENT CONTRACTOR - before the expiration date.If found return to: Re istration d Office of Consumer Affairs and Business Regulation 9 172476 TVNr. 10 Park Plaza-Suite 5170 F_xpiration 7/2/2016 Supplemeh. -a Bi;ton,MA 02116 BEL ISLANDS HOME IMPROVEMENT- IVAN.IVANIUSHENKO- ^A 02673 Undersecretary _ j Not valid wi out signature i • I , - 1 ✓fie ✓/iLczd �. Office of Consumer Affairs&Bus-ne egn artiod i Board of-Building Regulations and Standards w Construction S\u�pr v+r liso ,rOME IMPROVEMENTC RCTOR Lice nse: CSA05964 egistratiOn 76 Y I( ' Ex r 14 c WorneriE ISrAN V IVANIUS ENKO' BEL IS LAN j;`� Y f51E-1N1 M(NT 174 Upper Count�GRd' ! _ Apt 1-14 i � �" "� �� Dennis Port NIA 0�63 � w I IVANIUSHEIJ,ffO t� , ; +� � •;?'a� �` _ 4 9 MIL -L POND Expiration i VV.YARMOUTH;MA ! nder ec eta dU s r 0 l01I 016 • '- � �' I;4 Commissioner 1 � _ I --airs&Business Regu►abod License or registration valid for individui use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: W7R e istration;.:: Office of Consumer Affairs and Business Regulation 9 172476 Typ+••L 10 Park Plaza-Suite 5170 F_xpirat+on 7/2/2016 Suppleinei+ -a 4. Briton,MA 02116 BEL ISLANDS HOME-: IMPROVEMENT' IVAN.IVANI,7USHENKO . ^A 02673 — ` Undersecretary Not valid wi out signature - j i Assessor's map',ond lot number ........ fV.. ........1,4....44................ , y�FTHEto Sewage Permit number . ', �/�Q.�' House number .1Y.7 ......:.. BABMAO& E; . MA08 i O 1639. `00 TOWN OF BARNSTABLE . .BUILDING INSPECTOR APPLICATION FOR PERMIT TO ./ YI4,10S.er.....P.X..I., !t? .. �'.P„�C...'.................... TYPE OF CONSTRUCTION !G7 4�1..................................•......................................................... ........................ ..� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .7R..... �111 .1....1�l�rt. ...lt'•'�<....�/ CeAA-.,4,i.Z1e............................. ................................... ProposedUse A.4-1.l.. . .....��CA?.................................................................... . ....... .................................................. Zoning District ................ . ............................................Fire District ..(i. Name of Owner .. l.Z ... a'.�/C..............................AddressI!.........ffogfAyJ. ...... (, .11� Name of Builder .........A),,Ml...............Address I...i; Name of Architect �.�..�.S r.r.. .......................Address .....Al.. ....r�I '.J./����F.l K�.�,�Q......... Number of Rooms ..................................................................Foundation V Exierior i .Kd t... I .. .............................Roofing ..O Sty. „ 40— /........... ................ Floors ..i/. .0./................................................................Interior ......................................................... Heating L.-1�. /'/. .. gS.e40ar44...............................Plumbing .................................................................................. Fireplace ........................................................... . ........ . ........Approximate. Cost ................. Definitive Plan Approved by Planning Board ________________________________19________ . Area ...........40x�� Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH rA y 1✓e Ty 30 S'6 Poo m nx�'S��r�J �OUSG �yara9�, 3�00� l" I"1�Ij►q %l r Gr' 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 Irt/-z i!�J... ...1... .. ....................... Construction Supervisor's License ............. "S FALK, KATHY ` Y No ...2V.3.5... Permit for ...Enclose Deck r '.. .........S aaglQ...Emily.... ................... 678 Shoot Flying Hill Road " Location ...............................y:........................... Centerville :.. ......................... .................................................. „ Owner .......Kathy. Falk........................ ........... . . J r Type of Construction Frame !- ` ................................................. .J. ........................... 5 Plot ............................ Lot ................................ Permit Granted .......December ..........lq 85 Date of'Inspecti ! !......��1? .191a ' ' Date Completed ......19 p r - J rr Assessor's map and lot number .... .......................... THE Sewage Permit number ............................. '0 BARNSTABLE. J House number Z?.............................................. 90 MAS& 1639- DMAI TOWN OF- BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT-TO .....ax ..... .................................................. TYPE OF CONSTRUCTION A2.*/Z2,gene e...............V......................................... ........................19 TO THE INSPECTOR OF BUILDINGS: i The undersigned hereby applies for a permit according to the following information: Locationk..T4?... 17... . . .............................................................. ProposedUse .q................................................................................................................................... . .........................Zoning District .......... ............................................Fire-'6is'trict Name of Owner .............................Address ........ P, � ...... Name of Builder .........lVaal...............Address ....ev. AW Name of Architect '4.. .Address ........ Number of Rooms ........Foundation ............................................................................... Exterior .. .".i,x .............................Roofing,...**.......Roofing . ............................ Floors1,15�0,rl............................................:...................Interior ......................................................... Heating .............................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost .......................... ................. .. Definitive Plan Approved by Planning Board -----------—-------------------19-------- - Area ........... Diagram of Lot and Building with Dimensions Fee ..... .................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 644" E)11 ........... 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 Z, ............... Construction Supervisor's License a4v ............. Centerville - - � Owner -'—'------------------' Type of Construction .......F;7#xw.......................... ---------------_---------- ' ` . . . ^ Plot ---------. Lot ................................ ' Permit Granted -De�embe��5^----lV 85 `Date of Inspection ....................................lV . . . ` . Dote Completed - '` lg ' . --.--,�.----- ~ . ' '. ) / ` � ^ � - ' - ' ' . -. ' ^ . . tbi s Nell r /S ✓G SSO rS ) GtSs Q f�D" OAI �-s �S s� (a•{'e a (/C��E�L � e vL �kti H e� lV I )CI l Itla �160�'— r� �o I _C3-ct rQ qe �oo rS �n �P rn a�rP I you tec ro` The Town of Barnstable '"" M M���. i Inspection Department 7 s, amill ` 367 Main Street,Hyannis, MA 02601 508-790-6227 Joseph D.DaLuz Building Commissioner December 4, 1991 Mr. William Wool 15 Highland Avenue Cotuit, MA 02635 RE: A= 193-046 678 Shoot Flying Hill Road, Centerville Dear Mr. Wool: Upon inspection of a fireplace on the property of K. Faulk .. located at 678 Shoot Flying.Hi11. Road, Centerville, it was,noted. that the fireplace is located in a garage. Section 3410.16 of the Massachusetts State Building Code (copy .enclosed) prohibits such installations. Please contact this office re the above matter. Very truly yours, - i Richard R. Bearse Building Inspector RRB/gr ., • =� COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY xre i OF 1010 COMMONWEALTH AVE. Tr? �ar s MASSACHUSETTS BOSTON,MASS.02215 . ENCLOSE CHECK OR MONEY,'ORDER ' LICENSE . k' c FOR REQUIRED To EXPIRATION DATE• IC.i a e� 9 C O N S T R. S U P E R V I S O R 06/30/199 3 ' EFFECTIVE DATE CIC NO. g MADE PAYABLE TO , RESTRICTIONS "COMMISSIONER OF PUBLIC SAFETY'., NONE U�/30/1991 ' 006404 . . W I L L I A M 0 A WOOL - (�Ofy � sH1 15 HIGHLAINQ AV , _ COTUIT rl-A U2h35 P EASE` iVOTE FEE ;INCR'EASE Wi0T0(BLASTWO.OPR ONLY) FEE: , _ .a� � 15 1991 ; -�~T 100000 E FECTIVE 1, ` 1489 TAN HEIGHT: NOT VALID UNTIL SIGNED DV LICENSEE AND OFFICIALLY ggq11�� .STAMPED OR SIGNATURE OF THE COMMISSIONER �' D NOT DETACH LICENSE STUB 11� ...a.. IA 1.• i.f lh;r. / h .. /�/i[/j/////111/n /) THIS DOCUMENT MUST BE "`'• SIGNATURE �EE CARRIED ON THE PERSON OF SIGNATURE OF LICEN « SIGN NAME IN FULL-ABOVE SIGNATURE LINE �'. THE HOLDER WHEN ENGAG. - OTHERf "IfgHY�MUMB.9RINT ED IN THIS OCCUPATION. fj,E- J4 /6� ? (;OMMISSIONER - - 20OM•2-87-81429 T SEPTIC SYSTEM Assessor's office(i st Floor): /'3 Assessors map and lot number <` I' J INSTALLED N MPLIANO poi T� tob Board of Heap(3rd floor): �Q a Sewage Perm14 number —I ,1J E AND Engineering Department(3rd floor): REQY ,p,,� = aaaa9Ssntt House number 7� A'�fON$ 'oo 16y9ASL . Definitive Plan Approved by Planning Board 1 C� �o ! APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only^ Ae sston TOWN OF BAR STAB o — BUILDING INSPECTOR APPLICATION FOR PERMIT TO e P eq /U J }^D1-9 ICJ TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following'nformation: Location G 7 0� /�� ••� r Proposed Use Zoning District /� /✓ Fire District G0 Name of Owner�CfiY��t_ Address M Name of Builder Gl �d� Address efe leu Name of Architect SC1s�,-c_ Address 40& r " Number of Rooms Z Foundation e h Exterior ,5 �� Roofing Qr Floors GO kC k-e 6e---- Interior Heating h on e— Plumbing Zio �e--- Fireplace A414.) Approximate Cost Area S76 Diagram of Lot and Building with Dimensions Fee 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. i . Name G� Construction Supervisor's License&Ob � <J" �r KATHY E No •,3 4 5 6 6 Permit For Renovate Garage Extend Deck/Single Family Dwelling ,- Location 678 Shootflyina Hill Road Centerville - Owner. Kathy Falk Type of Construction Frame Plot Lot Permit Granted September 13 ,-.19 91 • ' Date of Inspection �0/yam 191 Cute Goplet P� 19 r - J 5t 0.1 - s � � t� �oFtNKE Ta Town of Barnstable *Permit f Expire 6 months from issue date BABNSPABLE, : Regulatory Services Fee v� s ; +a Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 318ViMJV8 -10 NMOl Fax: 508-790-6230 _ EXPRESS PERMIT APPLICATION - RESIDENTIAL ONW7 �' ridV Not Valid without Red X-Press Imprint Map/parcel Number 1q3 pL+U 11 3 Sad® Property Address �kd Ed 0v4�frV1d-e_ EV Residential Value of Work VaqOwners Name&Address j� R,�ma -AW Kj— Contractor's Name `� C `' I Telephone Number 0 Home Improvement Contractor License#(if applicable) a4:3 I v Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance �1 C�h,�k one: Lid I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) f dRe-roof(stripping old shingles) All construction debris will be taken to y I Qk " mrod ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. **Note: operty Ow� must sign Property Owner Letter of Permission. Signature Q:Forms:expmtrg .0 Revisedl21901 r °FI E,py� Town of Barnstable yP Regulatory Services + BA LE, MA$S. Thomas F.Geiler,Director 9 A$S. FD�;r ate. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must.Complete and Sign This Section If Using A. Builder as Owner of the subject property � ff hereby authorize I to act on my behalf, in all matters relative to work authorized by uilding permit application for(address of job) Signature o er Date Print N • � . �/ae 1°ovr�azaozcorall/ a�✓�aaoac�urardd , Board of Building Regulations and Standards HOME Il19PROVEMENT CONTRACTOR Registration t24310 xira4��_��5%lT./2003 1�l cividual jo James Curley James Curley PO Box 231/98 Sylv Osterville,MA 02655 ::Administrator t oFt t Town Of Barnstable *Permit# ® Expires 6 months front issue ate Regulatory Services Fee ��_ * BARNSfABtX, Thomas F.Geiler,Director ok SlZylia�d Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY t Q Not Valid without Red X-Press Imprint Map/parcel Number l l V Property Address ( b voN G ✓f Residential Value of Work J `� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address (1,A 1 Ll .�t4LJ Contractor's Name l �i.�` Telephone Number :0 9' `j 0 y 6.) 4 O r . Home Improvement Contractor License#(if applicable) ,112— 51 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance -PR Check one: AY i010 ❑ I am a sole proprietor ❑ I am the Homeowner 4 ��� = [ '`I have Worker's Compensation Insurance. LOON O Insurance Company Name L: _Workman's Comp.Policy# S �, `C5 `{ n�CI Copy of.Insurance Compliance Certificate must accompany each permit. Permit Request tebeck Iwx) Q Re-foof(stripping old shingles) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side,' `- #of door's. ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows *Where required' Issuance ofthis 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 equired. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\4STGU5QOTXPPESS.doc Revised 090809 —t....rw.w.�v,awww.taisy�AL"LiNGri(J 9A Office of Investigations - ' 600 Washington Street `~• Boston,MA 02111 v www.nias&gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electriclaes/Plumben Anglicaut Information Please Print L eaft Name(Business(Orgeniztuiondndividual): Address: Q-1 YY� , City/State/Zip:. A Phone#: 50G Spq c.AbL Are u an employer?Check the appropriate box: 1.["I am a employer with 2 4. [�] I am a general contractor and I Type°i project(required): employees(fu and/or part-time).' have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole Proprietor or parow- listed on the attached sheet. 7. 0 Remodeling ship and have no etnployea These sub-contractors have S. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp.;n4uranee comp.insurance.t 9• ❑Building addition required.) 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.[]Plumbing repairs or addition myself.[No workers'cornp. right of exemption per MGL 12.0'Roof repairs insurance required.]t c. 152.910).and we have no employees.[No workers' 13.❑Other co .ituurance required,) . ;Any WPlicam clot checks box Ml must aim fin out the section below showing their workers,conpawtion policy infbrmsdon. Homwwnas who submit this affidavit in dicafing dam'am doing aD work sad then hire outside contractor must submit anew affidavit indicating such, rContrecton that check this bone must atwehed an additional sheet showing the name of the sub.cooftctoa VW state whether or not those entities have employed. if the s+b•eontni ctora have empioyeea,they must provide their workers' comp.Policy numbs Ian ant rmtployer that Is providing wori}ers'connpensadon lnsmrsmce for may ernpfoyent Belotr Is tl pol4y a�rd Job sits lnformtaKon. Insurance Company Name:L Policy#or Self-ins.Lic.!e:__��('_2 �� �� �'( E ' xpn'ration Date• •_12.21 Job Site Addreaa•_ 1�b � �-�(� Y City/StaWZip: Attach a copy of the workers'compensation policy declaration page(showing the policy bomber and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimiaa)pealtiea 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 feu of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lnvestittations of the DIA for iagurar�ccq_,roveraae verification I do hereby cerdo under the pains and pc erJnry that the inforrmaden provided above a teas and co St 5 L >2o�c7. Phone ter Offle use oh y. Do not write In Ina area,to Dt MM—FTWRTY—CiFor lowest o,Q?claL City or Town: Permit/License# Issuing Authority(circle one): I. Board of Realth 2.Building Department 3.CitytTown Cler b.Other k 4.Electrical Inspector S.Plumbing Inspector Contact Person: Phone#: r '`�1• DATE(MMIDDIYYYY) ACCW ® CERTIFICATE OF LIABILITY INSURANCE `-� 3/1 20 0 PRODUCER DOWLING&ONEIL INS AGCY INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PO BOX 1990 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HYANNIS, MA 02601 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (508)775-1620 _ INSURERS AFFORDING COVERAGE NAIC# INSURED - OLIVER KELLY INSURER A: LIBERTY MUTUAL GROUP 127 EVERGREEN STREET INSURERS: _ SOUTH YARMOUTH MA 02664 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE CIMiTSSHOWN MAY HAVE BEEN REDUCED BY PAID-CLAIMS:---' -- --- INSR ADD'L I TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MMfDD1YYYYI DATE(MMIDD[YYYYI GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ._ - ,-_ _ PR EMI SES.Ea.o.."once - $._. CLAIMS MADE OCCUR MED EXP Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ j GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ j POLICY PRO- LOC AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS - - BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: - AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE Is �RETC-NTIOCI::.._$.. - A..- WORKERS COMPENSATION, WC2-31 S=338804-029 1 2/28/2009 12/26/2010 �/ 1 we STATu- oTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100000 OFFICERIMEMBER EXCLUDED? _ (Mandatory,in.NH)____ __-.__ ,_—_._ T_ __ _ , —__EL DISEASE._EP.EMPLO.Y.E _$._._ _ 100000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS. Workers Compensation Insurance:Part One of the policy applies only to the Workers'Compensation Laws of the State of MA. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR OLIVER KELLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF BAftNSTABLE DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 200 MAIN STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL HYANNIS MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. _ AUTHORIZED REPRESENTATIVE Jeff Eldridge ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. CERT NO.: 6933449 CLIENT CODE: 1329955 Anne Chandler 3/1/2010 9:17:07 AM Page 1 of 1 - e - " itMilssiachusttts, Dcli:rrtni�nt'iif Puf�l c Satcis' Board!cif Buildin„ '�� �i4�utsttion�:rnd Stan Cotastruction Supervisor Specialty License license: CS SL 99167 a. f �r Restricted to: RF,Vt'3 OLIVER KELLY k .' " n ' 9 PEREGRINE LANE' SOUTH YARMOUTH MA 02664 r: —75� h '` Expiration 9128_/2011 . t ninn•ann�i Tr# 99167 " - Bo r of'u 'Wingg i regau Catid1i ht1fnc arils" License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 128957 Board of Building Regulations and Standards Ex Iratlon:' One Ashburton Place Rm 1301 p 6L14/2011 Tr# 284841 Type Individual Boston,Ma.02108 Oliver Kelly Oliver Kelly r; 9 Peregrine lane mom.-_ _- ' � --------- -- South Yarmouth,MA 02664-''' Administrator Not valid without signature ��NEti Town of Barnstable Regulatory Services BARN* MASS. E Thomas F.Geiler,Director ''CEO 39. &,�� Building Division Tom Perry,Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: .508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, VA" I CA JL ik , as Owner of the subject property hereby authorize 01--, /£ 2 L/-e to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Wei9turf er ate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION Town of Barnstable Regulatory Services BMWSCABLE, ; Thomas F.Geiler,Director `�: a Building Division rF0 MA't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: state zip p code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit: (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127,0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC