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0727 SHOOTFLYING HILL RD
M yw"O, Yong .......... W T ,1 0" oil it, 113 -Xcl I w PA, "W Av u g VO NOMPY" X FA �,117xV oy ei�x 11 0 MPf ,cf"q fff -011 1 opf Kew 744 y, 41 I;, Ag; ZVI It - u y1f p OA rs t gal fir 14 Ugly- I 'PAIR vowl ffflA, ff,4�1' ,W ®r"N i ri MAR --m 4:;,A%p 4 1, 11 A IV--U"x U, J,1 SAW NV vrog h W-If 141;M 144-1, 'Aw, Ig 11 W�/Y,Ism> A"A r , 4 Or IVA" SEA OK 16 ilia iiv, jt %A14 44 'all W'014Y"0 %AjA yvv as )-Yt,A g f I ,V" OK R 19A gr FIR, 'Y 0 T.. y"wIf V,1 14Y ;11. VIA`" IYE Z �Z, W �Z, w W 0 vy"! 54 ;X 14, A X V :'k"A 'FA W;A.014. 'All ixr Zvi - -i It Eggs, T'Yx 'All Aj25" 4 '4"', " 10 10 P A(k WV�ff,74M i Y Aff IN �F4 T5 1 vz' ------- F2) Wit WVh W7 OR J Vy RMIr "rx"I g" , ............. th Aft 1 pm" low ,F, aill, "7 17 7 1,r Of If JK 31, "IVA! Yr Vgp,,Ty t W, o WZ'r ep; 34 "A.MR1 § 104 1 a �n� -r Of K) 1�W-i Him, ri .,& �` N10 V 47— f) tMg fl, 1..WT. TrI I rir q -0161 lo, ORM - ff"Al,pqjq fir, YkIt *95 C; V IM v" 'N" gy jwp I Ila 4�w�l AM. 2-i W; A ��l I �Jjogx zw p ? R" rZ;�Jtl 1;,T, Afe ym, At� wi, Y �l v. e IRTI(I'l . V` fi WA Lvwn I's/I AA I Illy, OMIT Ppv k C V V,It I 6"Xf,R 9 14 "k, b j,; w F74?o, A W""UT' Mir ".1P A 7-11AKF' % OY71 I T, I V4 A K4 Y rip �41, .00 fly 7; 1 75 aq �Eli, �,rftl'� �R 1A I Ov, w Y Tv. w 4v :1n;. f' Town of Barnstable Building " -_:, �' ;;So That�tas Visible"From the,Stree�t yA roved Plans Must beRetamedon Job anduthis Gard Must;be Kept Post This Car-d rf + 11�.. • ,�. .Sa, ;° .Tt �'" Y¢ x .rf PP st,"i"", P63 ,463 ostedUntil Final inspectionHas Been Made � T Permt • °i Where a Certificate�of Occupancyas Required,ksuch Budding shall Not"be Occupied until a:Final Inspection:has been made _ .-.. ., .:... .. Permit NO. B-18-3332 Applicant Name: NAGORKA, PETER A Approvals Date Issued:" 10/25/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04/25/2019 Foundation: Residential Map/Lot: 192-018 Zoning District: RD-1 Sheathing: Location: 727 SHOOTFLYING HILL RD,CENTERVILLE Contractor Name.:.;_, framing: 1 Owner on Record: NAGORKA, PETER A Contractor License; 2 Address: 727 SHOOTFLYING HILL RD Est. Project Cost: $ 10,000.00 Chimney: CENTERVILLE, MA 02632 Permit Fee: $101.00 Description: renovate 2 bathrooms Fee Paid:` $ 101.00 Insulation: Project Review Req: BATHROOMS ONLY. Date: 10/25/2018 Final: f� Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application a"ncl theapproved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures;shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street"or road and shal►be maintained open for public inspection for the entire duration of the rx Electrical work until the completion of the same. Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officals are,prowded on;fhis permit. Minimum of Five Call Inspections Required for All Construction Work: y Rough: 1.Foundation or Footing 2.Sheathing Inspection Final' 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "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 All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application Number........... t # s • Permit Fee........./0/..................Other Fee........................ W 163 13UILDING DEPT.9. ��� TotalFee Paid...............�:1.......�............................ .00T®9 2018 �' Y f , - lzsli�. TOWN OF BAR1i3Nr � P�icAppr�al by... . ........_.............on.../.o..................� BUIELDINO PERMIT -`x9-........:.......Par. . ... .,!' APPLICATION CJh,W;L— S CIi-r Section 1-Owner's Information and Project Location , Project Address Village.— r, r r� Owners Name Qbca a � Owners Legal Address 'I City P (� - ,P,!''1�>`� State ` . zi Owners Cell# 50 g�- i d Frmail Section 2—Use of Structure Use Group ❑ Commercial Stricture over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit. ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use Demo/ entire structure) ❑ FinishBasement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar N Renovation ❑ Pool ❑ Insulation Other—Specify G _ Section 4 -Work Description C T s,ct nndshed_2/9/2019 z Application Number.................................................... Section 5—Detail . j Cost of Proposed Construction Square Footage of Project 1 (70 l x k Age of Structure Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms(proposed) a 110 MPH Wmd Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Oil Tank Storage Smoke Detectors 7r" a (' Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply Public Private Sewage Disposal ❑ Municipal On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I an using a crane ❑ Yes ❑ No Section 7—Flood'Zone j Flood Zone Designation p. Within or adjacent to a wetland, coastal bank? Yes El No i Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) { Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required. Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No r ast,maatati-2V2018 W ux � - w © 0 CD zco Barnstable Bldg.Dept. o { ` Approved by: Permit#: 00 6P - O 061 = , ------------- SDI l ------------- voA;� The Commonwealth of Massachusetts Department of Industrial Accidents ZUK Office of Investigations 600 Washington Street , Boston,MA 02111 www.mass.gov/dia r Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ' Name(Busineesss/Organizationdndividuall): Address: !�7 I/1G ( 1 J/ City/State/Zip: C do 3a�Phone#: �v Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 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 mein any capacity. employees and have workers' # 9. ❑Building addition [No workers'comp.insurance comp.insurance. El required.] 5. ❑ 10.We are a corporation and its officers have exercised their ❑ ectrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers comp. o 1(4),and we have no 12.❑Roof repairs insurance required.]t § employees. [No workers' 13.[1 Other comp,insurance required.] 'Any applicant that checks box#1 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ' employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office_ of Investigations of the DIA for insurance coverage verification. I do hereby certify u er he sins and a allies of perjury that the information provided above is a an correct: Si afore: Date: 9 Phone#: Official use only. Do not write in this area,to be completed by city or town official 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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." a MGL chapter 152,.§25C(6)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,MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)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 affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 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 call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MA.SSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Application Number........................................... Section 9-.Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Daze Contractors Email Cell# I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signat= Daze Section.10-Home Improvement-Contractor 4 � Name Telephone Number Address City State zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11—Home Owners License Exemption Home Owners Name: Telephone Number Cell r Work Number, I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Budding Code. I understand the construction inspection procedures,specific inspections and documentation regn71W-780 CMR and the T6wn of Barnstable.Sig nature Date �� ?Zf APP ICANT SIGNATURE Signature Date 10 ,9 i Print Name ¢�' / /a d'-� Telephone Number E-mail permit to: f "a Section 12—Department Sign-Offs Health Department © Zoning Board(if required k' Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the f4 a deparbtent for approval Section 13—Owner's Authorization r as Owner of the-subject property hereby auth a to act on my behalf, in all mat ers relative to work authorized by#is building permit application for: (Address of job) Si a of er ; 104r4t PrintName F i Last wdale:2/92018 i Town of Barnstable *Permit# �7 Building Department Teees 6monthsjrom issue�date BARN m 61'0— an Florence,CBO 1639. .m " lding Commissioner iOlEo p�p'l°i 200 Main Street,Hyannis,MA 02601 AUG 0 2 2018 www.town.barnstable.ma.us Office: 508-86 Fax: 508-790-6230 WN1 O� MHNS ABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press InWtznt Map/parcel Number /Ja Property Address 7 7 Sk"71,. X ll a' J-/i'// X4 , OV y-V 1'/1 e &4 CA-e'sidential Value of Work$ 9, 0 0 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 10,-V e r A Q' btA�t 10, 727 Sl vaj%o� �t �// 0, 6 4 w'll e /��- Contractor's Name /ne,1/? Telephone Number e"O 0 Home Improvement Contractor License#(if applicable) 8 3 Z0 Z Email: Construction Supervisor's License#(if applicable) l i�1/0 Z ❑Workman's Compensation Insurance Chec e: am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request( Sbpxk box) -roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ,� �#- ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *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 Pro rty Owner Letter of Permission. A copy of the Home Imp Tn Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXYW\RESIDENTILONLYEXPRESS.doc 09/26/17 CuREY . & COREY 66 The Roofers 66 67 SEA STREET PT#A4, HYANNIS MA 02601 PHONE 1-500 -775-8240 CERTAINTEED LANDMARK LIFETIME ALGAE RESISTANT ARCHITECTURAL STYLE RE - ROO ING PROPOSAL April 14,2018 PETER NAGORKA 727 SHOOTFLYING HILL RD. E : pnagorkahyfd@gmail.com CENTERVILLE,MA Te : 508-685-9204/617-797-5690 COREY & COREY hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturer's specifications and local building codes. Remove and Haul Away All of the Old Asphalt Roofing Shingles (Both Layers)from the Whole House and the Garage. Supply and Install CERTAINTEED LANDMARK AR: LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION CLASS A FIRE RATED, COPPER/CERAMIC STONES for a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT,240 POUND,EXTRA HEAVY WEIGHT, 130 MPH WIND WARRANTY,CATEGORY III HURRICANE STORM/HURICANE NAILED 6 NAILS PER SHING E MULTI-LAYERED,LAMINATED ARCHITECTURAL ST YLE,FIBERGLASS BASED ASPHALT SHINGLES. COLORF Supply and Install 8"WHITE ALUMIN CK'S VENTED DRIP EDGE on All of the Eaves. Supply and Install CERTAINTEED ER-GUARD (lee&Water Shield)WATERPROOF UNDERLAYMENT SY TEM on Roof Eaves & Valleys Under the Step Flashin ,on the Skylights and Chimneys. Supply and Install CERTAINTEED'S"R OF RUNNER" SYNTHETIC ROOFING PAPER Supply and Install AIR VENT SHINGLE NT H RIDGE VENT on the Ridge. Supply and Install ALUMINUM&NEOP NE SOIL PIPE FLASHINGS Clean and Remove Debris from work area af er job is completed. . TOTAL INVES MENT ------------- $99000.00 i i CORE '17 & .COREY 66 T a Roofers " OPTIONAL ADDITIONAL WORK: RE-ROOFING THE SHED WILL BE ADDITIONAL-------------------- $500.00 POSSIBLE EXTRA CARPENTRY: Any Rot ed or Otherwise Deteriorated Trim Boards,Plywood Sheathing,Missing Metal Flashing,Side Wall g or Any Other Carpentry Needing Replacement will be done and charged for as an Extra:Matei ials Plus Labor at the Rate of$ 50.00 per Hour. PAYMENT SCHEDULE: A Deposit of One I lalf is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immedi ktely Upon Completion. WORK SCHEDULE: All Roof Work is Scheduled for Completion Within 90 Days of Acceptance and Deposits Received are Non-Refundable After Three Day Cooling Off Period from the Date of signing. Please Make Checks Payable to: CO Y & COREY COREY & COREY Warranties the Shingles and Labor for 5 years. CERTAINTEED Warranties the shingles and 1 bor 100% for the First 10 Years and the Shingles.your LIFE IME if the shingles becomes defective. CERTAINTEED Warranties the Shingles up to a CATEGORY III HU CANE-130 MPH WIND WARRANTY. CERTAINTEED Warranties the Shingles to be Algae Resistant for a Full 10 Years. COR Y & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: OC. -'K'. I ACCEPTED BY: SUBMITTED BY• TER NAGORKA AFARYAN HOMEOWNER COREY & CO j , j ;j 17te Colin o wealth of Massachusetts _ Depariltt t ofLtditstrialAccidents OMcr ofltn-estigations ` 60 aslii»gton Street o >ott,'IJA 02111 r-nlassgm/dia ' Workers' Compensation Insurance_ daiit:Builders/Contractors0ectricianslPlumbers Applicant Information '` Please Print LesibIh. Na1llP(Business'Org�aon�Indianal): & t2 Address: 7 e CityiStatefZip: WyezffGZr / Phone SD 8 776-Z962 ire you an employer?Check the appropriate bo 1 Type of project(regtired): 4. I �'1 a;eaeral contractor and I 1 1.��am a employer frith�_ ❑ � employees(full andfor part-time).* lured the sub-contractors 6. []New construction 2.❑ I am a sole proprietor or partner- Ion the attached.sheet. 7- ❑Remodeling ship and have no employees e stab-contractors,have 8- ❑Demolition vvodcing for we in any capacity. a o-wes and ha-,e workers 9_ �Building addition [No vsodms'comp.insurance insurance regtured.) 5.❑ �t r a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work- o have exercised their 11.[]Plumbing repair or additions Myself.[No workers'comp. ri of exemption per NIGL 1'[Z v�tfrepairs insurance required.]' C. 1(4)1 and we have no `6+�"'0 13_❑Other ogees.[NO workers! co insurance required 'Ant•appticavt That checks box T1 m L-.t&-o fill oat the section belo awing dheir Workers'compenotlon policy idonnadoa HomeoWnets sbo submit this afndadt indicative thr are daia� �� nk wad then bite otusidt+conaaccon mast saomi;a nes afFidsrt indicative such. 7C0111FactOT-3 mat dMCS this box must attached=additional sheet Sh a the nee of the sub-cavttac:tors and state tchedw or not chase enwies hn-e empkryees.If the sob-coumcron bare empiaRes,dr=_r�tst pmtideir hers'comIx policy mimber. I ant an enipim-er ritat is prosidbig porkers'conipens n inszirance for nnv entplos*ees. Belo",is the poliky and job site irrfonnatiorr. Insurance Company\Tame: is Policy r or Self-ins.Lic. Expiration Date: Job Site Address: �' rty:C `State'T.rp: Attach a copy of the.corkers'compensation polio- laration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 2 of hIGL c.152 can lead to the imposition of criminal penalties of a fine up to S1300.00 andior one-year imprisonment as ll as chil penalties in the form of a STOP R ORK ORDER and a fine of up to$250.00 a day against the violator. Be advised t a copy of this statement may be forwarded to the Office of- Investigations of the DIA for insurance coverage yerifi ' 'on I do hereln'certii6 u dr ' s nd penaltie of pe"wry that rite btforinadon prodded above is bite and correct. Simmiure: I, Date. w �• r� / Phone= S0Y-77ti 290U i t Official use ands_ Do nor write in this area,to be c it plered by tits•or tomb afficiaL City or Iovrn: PermitUcense rr Issuing Authority(circle one): } I.Board of Health 2.Building Department 3.Cii Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: I` Phone#• I` 6 ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 1*� 1 9/21/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ashley Paiva Southeastern Insurance Agency, Inc. PHONE (508)997-6061 a No:(508)990-2731 439 State Rd. E-MAIL ADDRESS:aP aiva@southeasternins.com P.O. BOX 79398 INSURERS AFFORDING COVERAGE NAIC# North Dartmouth MA 02747 INSURER AArbella Protection Insurance 41360 INSURED INSURER B AEIC Armen Safaryan, DBA: Corey and Corey INSURERC: 67 Sea Street INSURERD: Unit A4 INSURER E Hyannis NIA 02601 INSURERF: COVERAGES CERTIFICATE NUMBER:2017-18 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE PREMISES Ea occurrence $ A a OCCUR DAMAGE TO RENTED 100,000 9520046441 03 9/18/2017 9/18/2018 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accdent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAR 11 OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? F]N/A B (Mandatory in NH) WCC50050150912017A 9/18/2017 9/18/2018 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Display Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ashley Paiva/AMPcr x ©1988-2014 ACORD CORPORATION. All rights reserved. . ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSn25 rgninmi i Sw nd zz ARMW 9@h Aa EKpirathuz IBM= • . , i Ochn at der �, Wd S PAgUWm one •sum I= `;. cos - HOnt+�remg Types i ARLIM SWAARYAA{ _J` 4 - 7 il8i li i S Hamn - MENSAFAiTlA _ r i t � I ' it ItE �v .a A � 7 'THE - y`� Application number...T. Date Issued.................... 9 NAM x639. BuildingInspectors Initials....... .. SAP p ......... JUL Q ZOIi Map/Parcel.........!.2.z.. ..c la ..................... `f a- LH,AA PEADI r M&STABLE EXPEDITED PERM APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION ��®��R�'�I INFORMATION of Project: 7,Z 7 S:&,o-F-�j y/,i< 4-) 11 Rco, [�e,��✓ �/� NUMBER STREET VILLAGE -- Owner's Name: /,_�l y .� A/� o K Phone Number— 7 g�r -- 7 7- 5 G 9 O Email Address: Cell Phone Number 2-0 Project cost$ 11 �; �, _ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: le A-6 sna C�,s,�-{r��- Date: TYPE,OF WOE ❑ Siding ffWindows (no header change)# 3 ❑ Insulation/Weatherization 2- Doors (no header change)# I Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 14f gs4e-�G�a _ -4y1co/,,i IP -7 CONTRAtCTOR'S INFORMATION Contractor's name Sc a n `74 n•r,'so r, - SS,, e cr. �e�J F� (�,�(l 'n rA S Home Improvement Contractors Registration(if applicable)# !7 3,L y 5 (attach copy) Construction Supervisor's License# 7 07 (attach copy) Email of Contractor Phone number0/- ALL PROPERTIES THAT HAVE STRUCTURES OVER TS YEARS OLD OR IF TIME 5USiECT PROPERTY ISIN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER *For Vents 011 b Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If,food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval "WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEWTI014 Homeowner's Name: Telephone Number Cell or Work number I understand nay responsibilities under the males and regulations for Licensed Construction Supervisor in accordance with 780 CAM the Massachusetts State building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance I Renewal Agreement Document and. Payment Terms Andersen. dba:Renewal B Andersen of Southern New En land' y B Peter Nagorka Legal Name:Southern New England Windows,LLC. 727 Shootflying Hill Rd. Rl#36079, MA#173245,CT40634555, Lead Firm#1237 . Centerville,MA 02632 WINDOW 6E LAcEmENT 10 Reservoir Rd I Smithfield,RI 02917 - _ - - - H:(617)797-5690 - - - Phone:.866-563-2235 1 Fax:401-633-6602 1 sales®renewalsne.corn C:(508)685-9204_ Buyer(s)Name: Peter Nagorka Contract Date: 05/29/18 Buyer(s)Street Address: 727 Shootflying Hill:Rd.;.Centerville, MA 02632 Primary Telephone Number: (617)797=5690 e Number: (508)685-920.4 Secondary Telephone Primary Email: Pnagorkahyfd@gmail.com. . . Secondary Email; Buyer(s)hereby jointly and severally agrees to purchase the products acid/or services.of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents_listed in the Table of Contents,and any other document attached to this Agreement Document,the terms.of which are all agreed to b the parties and incor orated herein by reference(collectively,this"Agreement"). y pp ' Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $111563 By signing this Agreement,you acknowledge that the Balance Due;and:the Amount Financed must be made'by personal check,bank check,credit card,or cash. Deposit Received: $5,782 77 Balance Due: $5,781 Estimated Start: Estimated Completion: Amount Financed: 8 to 10 weeks: 8 to 10 weeks $11,563 Method of Payment. Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is.only an estimate.We will communicate an official date Wand time at a later date.Rain and extreme.weather are the most common causes for delay: Notes: Taxes.paid in Barnstable, Ma. Buyer(s)agrees and understands that this Agreement constitutes.the entire understandings between the parties and thatthere are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement Will be . valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby 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 Cancellatio ,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreeme n nt. a NOTICE TO BUYER:Do not sign this contract if blank:Tou are entitled to a copy the,contract at the time you sign. YOU,THE BUYER, MAY.CANCEL THIS TRANSACTION AT ANY TIME NOT.LATER THAN MIDNIGHT OF 06/01/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal NamedSouthern.New England Windows,LLC dlia-Rene�ial y Ande s of South n'New England Buyers) - il?r - y Signature of Sales Person Signature Signature . Gino Montesi Peter Nagorka Print Name of Sales Person Print Name Print Name UPDATED: 05/29/18 Page 2 / 12 Office.of COhsurner Affairs and Business RecrUllation 10 Farb Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 " SOUTHERN NEW ENGLAND WINDOWS LL BRIAN DENNISON 26 ALBION RD - LINCOLN, RI 02865 Update Address and return card.Mark reason for change. , • _ Address Renewal t.. Employment Lost Card '-Office of Consumer Affairs&Business RegWation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: Office of Consumer Affairs and]Business Regulation Registrations: 1732,45 Type: 10 Park Plaza-Suite 5170 Expiration: 9/19l2018 Supplement Card Boston,MA 02116 >OUTHERN NEW ENGLAND WINDOWS LLC. IENEWAL BY ANDERSON MIAN DENNISON // 1 ✓� INCOLN, RI 02865 �->bndersecretary Not valid without signature . y u-`....7Y v L; NCI i t•.'1'�" I t �J V��J.: V L ~L� v, c' of C�: ddk-E Ca Rea-lations ,and etas^;Cau�•'uS J L :V CS-095707 BR!kN D DENNISON LAMBS POND CIRCLE a^ CHARLTON MA 01507 The Commonwealth of Massachusetts ' Department of Industrial_Accidents I Congress Street,suite 100 . Boston,MA 02114-2017 _ www mass-gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeLyibly Name (Business/Organi=ionMdividual): Address: City/State/Zip: 4 p Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1 K1 am a employer with -ZO femployees(full and/orpart-time).* 7..D New construction 1[]I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp-insurance required.] 8• D Remodeling 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required-]t 9• ElDemolition 4.Q I am a homeowner and w01'be hiring contractors to conduct all work on my p p�'S'ro . w r. I ill 10 D Building addition . � . ensure that all contractors either have workers'compensation,insurance or are sole I I.Q Electrical repairs or additions proprietors with no employees S.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.Q Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.$ 13.. R of repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 1 4; Other W�'�j 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 0o o r rep n *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. u (Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy a�iid job site information Insurance Company Name: _ire man$ Policy#or Self-ins.Lic.#: CA 31-5�r7 Z q — Z.0 Expiration Date-- Job Site Address: 7 i,l City/Statetip6 y, Attach a copy of the workers'compensation poli declaration page(showing the policy number and expirdfion date). Failure to secure'coverage as required under MGL c. 152,§25A is a criminal violation pilmshable by a fine up to$3,500.00 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_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th sins and penalties ofperjury that the information provided above is true and correct T Signatlue: JL a D2te: .— Phone#: Lo Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# J 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 E '4C& CERTIFICATE OF LI DATE(MMIDD/YYYY) ABILITY INSURANCEF12/2912017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER;AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to .the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CoBiz Insurance, Inc.-CO NAME: . PHONE Den Lawrence St, Ste. 1200 303-988-0446AIL A/c Not:303-988-0804 Denver CO 80202 ADDRESS:: COMail cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC S INSURER A:Acadia Insurance Company 31325 INSURED ESLERco-01 Southern New England Windows, LLC. INSURER B:Firemens Insurance Corrpany of WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 ` INSURER E: INSURER F: _ COVERAGES CERTIFICATE NUMBER:1252851165 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF IPOMUU EXP - LIMITS LTR WVD POLICY NUMBER - A X COMMERCIAL GENERAL LIABILITY CPA3158728 1112018 1/12019 EACH OCCURRENCE $1,000,000 G�LAIMS-MADE a OCCUR PREMISES occurrence $300,000 MED EXP(Any one person) $10.000 ` PERSONAL&ADV INJURY $1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECTT LOC � PRODUCTS-COMP/OP AGG $2,ODD,DOD OTHER A AUTOMOBILE LU181LrrY N CPA3158728 1/1201e 1112019 COMBINED SINGLE LIMB Ea accident $1 ODD OOD X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X AUTOS PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB X OCCUR CPA315872B 1/12018 1/12019 EACH OCCURRENCE $10.000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $10.000.000 DED X RETENTION$8 WORKERS COMPENSATION WCA3158729-20 1/12018 1PI2019 X PER OTH- $ AND EMPLOYERS'LIABILITY Y I N -_ STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? N/A + EL EACH ACCIDENT $1,ODD,000 (Mandatory in NH) E if yes describe under L DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1.000.000 C Pollution Liability 7930073340000 1/12018 1M21719 Each Occurrence $1,000,0DO Ciaims-Made Policy A99regare $1.000.000 . Retroactive Date 06202013 Deductible $10,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached iF more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,' NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved( ACORD 25(2014101) The ACORD name and'logo are.registered marks of ACORD Cape.Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 " Tel: 508-398-0398 Fag: 508-398-0399 11/11/15 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 ZOO RE: Insulation Permit 201507157 � Dear Mr. Perry CD --- This affidavit is to certify that all work completed for 727 Shootflying Hill Road, Centerville has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map q Parcel Application # Health Division Date Issued r596�41 low— Conservation Division Application Fee Planning Dept. Permit Fee i., Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address o o-�-Village lbfftSfAb iP, (�/' 0 Owner I Pr (' NO-5 o A, Address S a rA e Telephone Permit Request Aeh� a �► -��e ��semcn� erase ark w; I' 'r [A,' r S am LS&Aen-I" MTh expavo, , 401, ran Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 't3w Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Areas ft. Basement Unfinished Areas ft Number of Baths: Full: existing new Half: existing _ ; new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count' :.� a Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other 1 ;.w) r- 01 M 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 Au horization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes No If yes, site plan review# Current Use Proposed Use - = - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name M111(lo Telephone Number _ U P� of Address _�-1 1'f Nll � n AV-t- License # , r to P q 6 S� novu4 096 6 q Home Improvement Contractor# Email Worker's Compensation # WVic 3(3 fit/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1 Q�n1ow,�I-I� SIGNATURE DATE 5 r FOR OFFICIAL USE ONLY " APPLICATION# DATE ISSUED i r MAP/PARCEL NO. } ' ADDRESS VILLAGE OWNER I� DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r ty..Tlie Commonwealth of Massachusetts •• Y r. " A'�,"Department of Industrial Accidents " a 1 Congress Stree4 Suite 100r Boston,MA;02114-2017=: t "� a ,}: ,Y r, r t ?z 1. », E t.'•. 1k ;ta �rq«a lit t. �� • o . _ www.massgov/dia' t '� :,• } " NV16rkers"Cons '-ition.Insurance Affidavit;Builders/Contractors/clear icians%Plumbers. t TO BE:FH.ED WITH THE.PERMITTING AUTHORITY. Applicant Information Please Print Letribly ' 4 Name(Business/Organization/Indi Cape Save Inc vidual): Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 phone#:,508 398 0398 Are you.an employer?Check theappropriate box: - — _ 20,i . . . .~` e�q Typ f project(required). 1..0 I am a employer with' •employees(fu11 and/or part-time)° T. 7.J0 New construction M..w t 2.�I am a sole proprietor or partnership and have no employees working for me in •s y t- $; El Remodeling ,•� any capacity.[No workers'coinp.insurance required], • `; : am a homeowner doing all work myself[No workers'comp.insurance required:]t g Demolition1 ,w< ,', _.. 0;1 Building addition 4.❑ 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 11.0 Electrical repairs or additions proprietors with no employees. e,�«•..• ' ,r.t 12.❑Plumbing repairs or additions s f„ 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs I These sub-contractors have employees and have workers'comp-insurance t _ 14.[]✓ Other Insulation . 6.E]We are a corporation and its officers have exercised their right of.exemption per MGL c, - 152,§1(4),and we have no employees.[No workers'comp.insurance required,] - *Any applicant that checks box#1 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:aew affidavit indicating such. *Contractors that check this box must attached an additional sheet.showing the name of the sub-contractors and state whether or notthose entities have - employees. If the sub-contractors:have employees,they inust provide their workers'comp:policy number'. I am an employer that is providing workers-compensationYnsurance for my employees. Beloiv is the policy andjob site 'information. _ .. . .G_ . Insurance Company Name: Wesco Insurance Company «. � ' .. -. •' .. . _. ; ; .WWC31.36274- ' 04/Q9/2016 Policy#or Self-ins.Lic.#. _Y - �»,r» r :X Expiration Date: : .,Job Site Address: 727 Shootflying Hill Road =+ •�•City./State/Zip: Barnstable 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 it 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 against the violator_A.copy,of this statement:may be forwardedto.the,Office of Investigations of the.DIA.for insurance.. coverage verification. t; „ 1 do hereby cerdfy under th pains and penalties of perjury that the information provided above:is true and correct ; =•' Si attire: Date: 10/21/2015 Phone#:508-398 0398 "Official use:only. Do•not write in this area,"to be coin leted t c or town o rcaa City or Town ; . ,r�.r Petlnit/Li cease r ,� .. i- � -�. • .. a -1. , Issuing Authority(circle one) ;: _- 1.Board of Health_2.Building Department 3.City/Towri Clerk 4.Electrical Inspector 5 PI inbin0nspector a re, 6.Other Contact Person: Phone:#: l . _.. i DATE(MMIDD/YYY1) ACOI o® CERTIFICATE OF LIABILITY INSURANCE �i 10/14/2015 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 pollcy(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 NAME CONCT Colleen Crowley Risk Strategies Company PNICNN E (781)986-4400 FAC No: (781)963-4420 15 Pacella Park Drive _ EMAILs:ccrowley@risk-strategies.dom ADDRES Suite 240 INSURER(S)AFFORDING COVERAGE NAIC3 Randolph MA 02368 INSURERA:Selective Ins. of America INSURED INSURER B:Allmerica Financial Alliance Ins Co 10212 Cape Save, Inc iNsuRERc:Wesco"Insurance Company 7 D Huntington Ave INSURER D: + INSURER E: South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL15101402127 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL TYPE OF INSURANCE S POLICY NUMBER MPMIDD EFF MMIM EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADEFil DAMAGE TO RENTE17 OCCUR PREMISES Ea occurrence $ 100,000 S1994480 10/16/2015 10/16/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�PR a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED Ea accident SINGLE $ 1,000,000 8 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AWNA46796600 11/6/2015 11/6/2016 BODILY IN (Per accident) $ AUTOS AUTOS X HIRED AUTOS X AUTOS VED Per accident SAGE $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE_ $ 110001000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ —1,000,000 DED I I RETENTION$ Nil S1994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION Officers Included for X AND EMPLOYERS'LIABILITY STATUTE ERH YIN ANY PROPRIETORIPARTNER/EXECUTIVE NIA Coverage E.L.EACH ACCIDENT $ 500 000 C (MandatoryOFFICERIM In ER EXCLUDED? a WWC3136274 4/9/2015 , 4/9/2016,, E,LrDISEASE-EAEMPLOYE $ 500,000 (Mandatory in NH) _ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar . Electric are all included as Additional Insureds with respects to the General Liability coverage of Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Michael Christian/CLC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Building Permit Authorization I, Peter & Alicia Nagorka , as owner - hereby give my permission to k Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office: 508-398-0398 to take all necessary steps to obtain a building permit to perform work at my property located at . 727 Shoot flying Hill Road Barnstable, MA 02632 R Signed Date . F Office of Consumer Affairs and Business Regulation t; 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation �i Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. - WILLIAM McCLUSKEY — 7-D HUNTINGTON AVENUEvY— SOUTH YARMOUTH, MA 02664 f = ----- ---- Update Address and return card.Mark reason for change. sca i zonn-0sni E] Address Renewal Employment 0 Lost Card • _Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: =171380 Type: Office of Consumer Affairs and Business Regulation Expiration 31-4l2016. Corporation 10 Park Plaza-Suite 5170 �`- '� � Boston,MA 02116 CAPE SAVE INC. f WILLIAM McCLUSKEYj1 7-D HUNTINGTON AVENUE"y SOUTH YARMOUTH,MA02664 Undersecretary Not vali ithout signature Massachusetts -Department of Public Safety Board.of-Building_Regulations and.Standards �.�n�+triiG`ui+rt ouue�.ri�u� onc�i8�cr •+a►asr»Srs License: CSSL 10277fi WILLIAM J:MC 37 NAUSET ROAfl I West Yarmouth N1A - Expiration Commissioner 06128/2017 Assessor omae ( .st floor):. ?NE r- s �_p and lot number r.. ... ....;.......... Board of Health (3rd floor): Sewage Permit number............r..).1C. .....:........�.�` t HASd9T11DLL, S Engineering Department (3rd•floor)c °° "639- House number ° APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only r TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO . .! .I�...../.Y....X...�. ......✓.....�1 A..�.....�./s..�. ..�� .:................ TYPE OF CONSTRUCTION ............ d .!a......Z�I�A.1?.4...........:......................................................:. •---......--•-•.................................19........ i TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..... ., .. .... / .1�.. ..... aL. //,V.C�.....yl!L.L-...... /..�.. .e. 0 /l�T .Y��� ....... ProposedUse ............................................................................................................................................................................. ZoningDistrict ........................................................................Fire District ..........................................................:.................. Name of Owner� IYWW .n....h-1.4AW.0d1 ...Address 7,2..7..SAPA7...64,yll, :.6...?Y . . ............. .: Name of Builder ..�...;,Viv' !1��..�...`....................Address�j....!'v,:.T/T.........�..............�... G. Name of Architect ................................................................:..Addressr. ...................... . ............:............................................... v Number of Rooms .... .. CMS'r l Foundation ..................................... S ,C S. Exterior .�EX..... �../�'_:. .........................<....................Roofing .............. ...../" � ... ........ .....:.............. .Floors ................................. ....................................................Interior ....... .� .-�-----. . . J Heating Plumbing .. Fireplace ..................................................................................Approximate Cost .,... "a......... ...... r.�Definitive Plan Approved by Planning Board ________________________________19_____:__ . Area ..........�v............ ....,,..., Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF`HEALTH r f � N � Hn uS t m - Yip 6 --- -- OCCUPANCY, PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree fo conform to all the Rules and Regulations of the Town of Barnstable regci ding-1he above construction. - .,6 , r Name ... .. .. ......... .. 7 ,. Construction Supervisor's License ...... ...... ... . ... ..... . w . r Lawson, Kenwood H. A=192-018 No .....30698 permit for garage .......................................................................... Location 727 Sho.ot. ...Flying Hill..Rd. ...... . . .... Centerville . ............................................................................... Owner Kenwood H.....Lawson. . ........................................ .. . ........ Type of Construction frame .......................................... ............................................................................... Plot ............................. Lot ................................ Permit Granted ..............May...4...............19 87 Date of Inspection ....................................19 Date Completed ......................................19 n Assessor's offioe (1st floor): qq SEPTIC SYSTEM MUST BE Assessor's ma and lot number `.l.. .s 4. cF THE TOr p WSTALLED IN COMPLIAN Board of Health (3rd floor):. WITH TITLE 5 Sewage Permit number ..........0.�4.� G..... ' qa p� sQ N ........ Sl .... .... 7 C���®1\I�EBf3TF9L �0n� t,_ ARIUMDLE Engineering Department (3rd floor): � r; �'• �a 16 House number ...................................�.h. ..................... Or� IE��LA6 �'►�0YPY6�! APPLICATIONS PROCESSED 8:30-9:30 AM, and 1:00-2:00. P.M: only TOWN, OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO f.Y...X...r .27:...... AA. .....C�../.4. TYPE OF CONSTRUCTION ......... U�.d. . .....�1qA.�..�.�:_................................. ........................................... .............................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: y n • Location .....7-,k-f......s ���.lC?.1......... /%%j'.�.......Ze"1!�.4...... ..... ... ... ....�h`................... ProposedUse .......................................................................................................................................:..................................... ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner „ � ��.D....11,—..!t',.AW.OdA/ ...Address ,7.v2..rf...-S&PAT.. 1.4/ ..... l �l V�1TL Name of Builder .. �. Address .................�...�G.....!!.v�. ...................................... ...... Nameof Architect ..................................................................Address ..................... . ............................................................ Number of Rooms ....t�. ... � '`��..........Foundation ......... "� ......... ............ Exterior �C-x.....1.�.�..f.................................................Roofing .............. .:S.� T �T � l C� ......................... (2o Ajc1.E-7.-c Floors ......................................................................................Interior Heating ................................................:.................................Plumbing ................... ........................ ........ ........... Fireplace ..................................................................................Approximate Cost ............ ..1... .../... ........ ................. ........... Definitive Plan Approved by Planning Board _________________________ Diagram of Lot and Building with Dimensions Fee ..,p�ryry SUBJECT TO APPROVAL OF BOARD OF HEALTH ye, vxr 0 JW00 F.Z.Y14-6 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of aTownarnstable reg ng the above construction. Name .... ..�... . . . .......... Construction Supervisor's License .Op?-O.. ... ....7....... Larson, Kenwood H. 30698 No ................. Permit for .....garage...................................... .......................................................................... Location 727 Shoot FlyjLng HIM Rd. ............ ................................................... rv2L11e Cente ........... ........................................................ Owner .... ......Ke.nwo o d...H. .Larson. ..... ... ........ . .. ... ...... . .-.............. Type of Construction ...........................frame - ............... ................................................................................ Plot ............ ........... Lot ................................ Permit Granted ................ ...........19 87 , Date of Inspection .........19 Date Completed .......................................19 All 'ef 0 10I v