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0754 SHOOTFLYING HILL RD
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'�`. i .�. } ! 1 4�} 1 rs , r •f: ,:t y (,k � t 1 i' 1 • ,$ i}fir, �� � ' ;!�• ; : 1 t � u � , [ yY .� � ! {, k • TOWN OF BARNSTABLE Permit No. ___-i.7972_____ Building Inspector Cash wa '639 ""', OCCUPANCY PERMIT Bond Issued to & Larry Hadfield Address 754 Shoot FiXing dill koa— ,enterville Wiring Inspector f�/ �- Inspection date / Plumbing Inspector Inspection date // , Gas Inspector , f � Inspection date Engineering Department Inspection date Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. 19......_._ z :: .....: �. :. '�•'� .W Building Inspector C' TOWN OF BARNSTABLE BUILDING DEPARTMENT Z IARIST : TOWN OFFICE BUILDING rua i619' �� HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE:. An Occupancy Permit has been issued for the building authorized by Building Permit #_r,:_ /. ... ._ ................................................... _.... .. issued to. ` .......�� /1/ly.. -:-l�w .............». V � U Please release the performance bond. `\ _ a a N I I 3 N Y E �^-- z . GE,eT/�/EO P�oT P�fv No. Y t*•i � z .ATE 7`1-1--1-- S%OE.0 A,,</r-I SE'TBA Ck ' �Eglii.2E�-JE.vrs. o.� T.�IE TowtiOF P.L�•�c/ .2E�E.2�'�(/C� ,C O CA 7,-de'z:> W17'yl v T//E FLoa�PG4/.fi /'L ti/ �,cv /�,g _) �lo OA TS% �� ( .SA XT,E.o2E Al)y T///S P,CA.v/,s' i(/OT B•4Sf"O Oiv Apt/ �c?E�/sTE.2Eo / /v S�.eYEyOr�� /NST.2U�lE�/7"$U.2YEY� Tye �ST.E.21i/�.,C�a /'1,QSS. D�•r,SE'TS SyOf,�/y S.�,bvL� SOT 491c-- I ...j //V2 t�E 5167AJ OA TA � - v17 AN //G�/lgAG� 6/��1Dt3Y tiI 3 '<//o US F /500 GAG T4• D/SPv sat /,,>/r i000 6A6 A s/aaura� q - 72G sF �• Z 2 G C S Par7b�Gi A�d 7 i i 3 S F / W1E /Z �p� 0 b 77Vr4 1- 5 .1 e,/,! 679 l. ,�Es/G c/ ����OL�lT/a✓ PLT " /""/c/2of//V. ECG 1 N 91? ',YEN of :!., N OF �qs P�� /B•3 r� rcry`, RICHARD o PETER I� A 1 v BAXTER ,,,+ � SULLIVAN No.24C4,3 • No. n733 y pp 23,200 cc rfl 7� A� tSTEf�4O�Er�/ /g /eo 5 /00 /oo /vo a ,�/,✓ GAL. mv 6 aL. /y�/ BOX 77 G SEo�G LEdClJ P//' 97 . To / Zr y /,v✓. /,�� W�rHEv 97•Z 97d GP�1!" • • ,rrz,vE /o � ,3•}— G '--�3.1 LOGQT/osi L"E.cf•--�,�i�i'.,L.� /Z, 67 �O-'— / GEP�iFy Tf/,QT T,�F_ Gi�.�iV, SNact/.v �C•t� �•�! /f /�6• .�/E.c'Eo,v G-0�1��•Y.S W/T�/Tf/E SiO�'.c./,uE B,eXr�,2 E�NICE, i.vC. 4.vp sETI�/�Gi_ ,eEOIJ/eEMENT,s O�• T,�/� ,eE6/•Si�.Ptp L�i✓O _S!/.e�/Eyf�s .4N0 /.s it/OT- G2ST�.2Y/LLc a ��r. L OC.QrE,p N//Tis//mot/ T.�/E �L Qo��L4/� T//!s oj_jA1 /.r it/Or- 134-,C2�0!,N A Al -!/�fE.3/T-,fv,2✓Ey�J,vO TNT o�FS�� ,. S�c.f/�/yE,eEa/✓.5.�'Ou�O .t�oT!�E USEp ,-,�-.,. ,.--- -T. Gr-rr1/I/ .�C'L� �/_..�-- .• GARNICK 8 PRINCI, P. C. ATTORNEYS AT LAW GERALD S. GARNICK 22 MAIN STREET MICHAEL J. PRINCI POST OFFICE BOX 398 HYANNIS, MASSACHUSETTS 02601 KATHLEEN FRANKLIN (617) 771-2320 JOAN LAFFEY NELSON April 11, 1985 Mr. Joseph DaLuz Building Inspector Town of Barnstable Main Street Hyannis, Massachusetts 02601 Re: LAWRENCE AND JANET HADFIELD Dear Mr. DaLuz: Please be advised that I have had the Barnstable Registry of Deeds checked, and I have found that there was no property owned by Moses Tokee and/or Irma Tokee which abutted Lot No. 5 on Plan Book 198, Page. 49, after 1971. Very truly yours, Gi/! GERAL S. G RNICK GSG/als Ass6ssor's e410 and. lot number "' SEPTIC SYSTEM MUST BE ypi 7HF ...-sewage Permit number .......� - ?1g........ ...... INSTALLED IN COMPLIANC Ay� WITH TITLE 5 t BAHHSTAELE, House number `s g� p........... ENVIRONMENTAL CODE :-9p0 1639 e0w TOWN OF BARNSTABLE - BUILDIHG ' INSPECTOR APPLICATION FOR PERMIT TO 7—/?V<G7.... .....s�� TYPE OF CONSTRUCTION ...............................................:19........ TO THE INSPECTOR OF-BUILDINGS: The undersigned hereby applies for a permit according to the following in [matt n: Location .. 4t2� U . L ..... ....... . ..... .�.. ... �.... Proposed Use .............. ..... . . .. .. . ........... . .... ....... ...... ............... .............. . . .... ........ .......................... � ZoningDistrict .......... ...............................................Fire Di trict ....... .......V........................................................... Name of Owner Carr/ 3qn...... � IQ.........Address N +4 F fin.•.....c - .C...@...n....�..�.'..r..,.�..,..1.1.� )4&- J.'.r,....A.:...rnc)rr,'s o N P•� QO I �Og °� C Q n i-E? I I @, Nameof Builder .......... ......................................Address ........................................`............................................ Name of Architect gm. ...................Address ... l-lCzh.T..DRI.✓:......r�RP'NHXT lu�..... ...... .............. Number of Rooms ....... ........................................................Foundation lU ��CeDg /NGuf Iy S / Exterior ...f�.............. ..irt�I' fll...... f9R. ! .Roofing .... /�`/ �!/Q eyG..,Sly Floors PArG ..(//4407119y'IYfG'h/i-(.I/�G/.........................Interior ./✓RyGY/�r�. ......... .. ................ .... .... ............................................................. tr/�✓....�U ....... 1G{Ct .....Tv..............Plumbing ...... ^� .... ' Heating ........ .............................................. ..... ,,�� �i - Fireplace ...AIOA ! .........Approximate. Cost S°l l(�� �....... .......C::::2. . ........ PP Y 9 ` ' 1 � - - ........./ Definitive Plan Approved b Planning Board.___________�_'_/9�______19________ . Area . ........ ....... .... . Diagram of Lot and Building with Dimensions Fee � . /1 ...... . . SUBJECT TO APPROVAL OF BOARD OF HEALTH l ' OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Tow of Barnstable regarding the above construction. Name .` ........s...... . ......... .................. y Construction Supervisor's License .0:!f 21S....... HADFIELD, JAN & LARRY c No ... Permit for 4 Sin g;L��...]�-jMi lyDwellin g............. ation ...14Qt...5,... 754 ..S.hoo.tFlv.i.n.q Hill Rd .. ....... ....... J- en .... .. ............... ................................. Ll Owner ...Jan...&.1.Lar.ry..)�(q.�i.e.ld............ .... .. .. .. .. .... Type of Con$truction .....E-TAMP........................% ...................................................:................:........... Pl,ot .............. .............. Lot ................................ June 5. Permit Granted .......................................J9 85 Date of Inspectio Ava.... 1 L-' Date Completed ............19 t Application number.,!` BUILDING DEPT. .............................. ��� Fee . �- , .. ..................... . ................................. • NOV 1 9 2019 Building Inspectors Initials.... .. TOWN OF BARNSTABLE Date Issued.:.... . .....L. ......l... ................ Map/Parcel.........1242........ ` .. ................ TOWN OF BARNSTABLE ' EXPEDITED PERMIT APPLICATION: , ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEA'THERIZATION PROPERTY INFORMATION Address of Project: 5 S ROOT&I 1 /✓y '� I�t'�( a l"Q -tZL�i �C , NUMBER STREET VILLAGE Owner's Name: -e Ck jZ i —el Phone Number (0 l •�LIT• (Q Z4 Email Address: i)N yA f t-e beiZ 00 Ce 1 Phone Number e Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION. As owner of the above property I hereby authorize -aJe o b L,4-") (---to ov to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK' II iding E Windows(no header,change)#�❑ Insulation/Weatherization Doors(no header change)#_L_ Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name -R 061-!j _PQ C j ,;�A)b t+Q V 9- CO • /C tVi-S C4 66L J61 J_ Home Improvement Contractors Registration(if applicable)#' AO L 7� (attach copy) Construction Supervisor's Licensel# CC-:.,--OUD (00 (attach copy) Email of Contractor Alt U � I IOU P t Phone number� ���A 7 `� ALL PROPERTIES THAT HAVE T UCTURES Ovich 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS1N d wc7-nwr nicroirT vAi i MI LT nPTd/M utcrnm Apps?ntmi arrnmF d PERMIT rdN Al:tW wn . APPLICATION NUMBER............................................................ *For Tents Only*j , 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. Purpose of Event 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 Fuel source being used LP tank 20 lbs. or>Yes - No , if yes, a gas permit is required. Natural Gas Yes' No ,if yes,a gas permit is required. df food is being served at your event plea a obtain a Health'Departmenhgpproval between the hours of 8:00am A30 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 EXEMPTION Homeowner's Name: F Telephone Number Cell or,Work number 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. Signature Date ` APPLICANT'S SIGNATURE Signature Date �v b All permit applications are subject to a building official's approval prior to.issuance. The Commonwealth of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plumbers Applicant Information ' Please Print LeWbly Name(Business/Organization/Individual): �b e✓L, p o l t�,c( ,Yu )TU u V '66. Address: City/State/Zip: inJoSiY�3t' Phone#: ( I(pg' . Are you an employer?Check the appropriate box: Type of,project(required): 1.❑ I am a employer with 4. [Kam a general contractor and I employees(full and/or part-time).* • have hired the sub-contractors 6. ❑New construction u 2.❑ I am a sole proprietor or partner-� listed.on the attached sheet. T.DlI emodeling , ship and have no employees These 'sub co, have = S. ❑Demolition workingfor me in an capacity. employees and have workers' Y9. ❑Building addition,: [No workers'comp.insurance '' ' comp. msurance.t required.] 5. ❑ We are a corporation and its A0.❑Electrical repairs or additions 3.❑ I am a homeowner doing,all work officers have exercised their 11.❑Plumbing repairs,or additions myself. [No workers right comp. - of exemption per MGL - 12.❑Roof repairs insurance required.]t a 152, §1(4),and we have no - employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. " t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �e Insurance Company Name: 1 t L , AW k;Zl C'W ✓wi,1 `-� Policy#or Self-ins.Lic.#: lSJ D Z.y rT l� �N f Expiration Date: 0 ^ zo70 Job.Site Address: _*SLl (; L-LI/)Ah J?C4 City/State/Zip: �I�. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as;re'quired 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 fy e a nal ' perjury that the information provided above istrue and correct Si Zngfore: Date: Phone#: C>� L&__C/LP tev Official use only. Do not write in this area,to becompleted by city or.town,ofeia[ 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 &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,coni6cti6n 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 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 perfonnance 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 permittlicense 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-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia AC RO U® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYY1fY) `� 1 10/17/2019 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 endorsemen s). PRODUCER NAME: Jane Logan BOWLING &O'NEIL INSURANCE AGENCY PH M,N . (508)775-1620 AC No: ADDIL RESS: jlogan@doins.com 973 IYANNOUGH RD INSURERS INSURERsi AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED _ INSURER B:'. UGLY DUCKLING HOUSE CO LLC INSURERC: INSURER D: - 194 MAIN STREET INSURERE: WEST BARNSTABLE MA 02668 ' INSURERF: COVERAGES CERTIFICATE NUMBER: 461809 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. ILTRR TYPE OF INSURANCE ADDL 8R POLICY NUMBER MMOIIDD EFF MMfDPOLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ' CLAIMS-MADE OCCUR A E PREMISES Ea occurrence) $ i MED EXP(Any one person) $ N/A f PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO P BODILY INJURY(Per person) $ ALL OWNED SCHED UTOS ULED A AUTOS N/A BODILY INJURY(Per accident) $ , NON-OWNED ' PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE NA •" AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION - PER OTH- AND EMPLOYERS'LIABILITY YINJ X STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE `' ' E.L.EACH ACCIDENT $ 500,000 A OFFICEWMEMBEREXCLUDED? NIA NIA NfA 6S62UB7H71178419 16/04/2019 10/04/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yas dncmhe unc er 1. - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ bUU,000 t N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. 1 his Certificate of insurance shows the policy in torce on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance): The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensationrinvestigations/. CERTIFICATE HOLDER ( CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN, a;Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. �' � ` • 367 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601J I, F Daniel M.Cry,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered mar d AC Ra CERTIFICATE OF LIABILITY INSURANCE °ATE'""/°D/YYYY) 10/25/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS =IFICATE 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 have ADDITIONAL INSURED provisions or 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 NAME:NTACT Jackie Stewart The Fair insurance Agency Inc. PHONE (508)775-3131 FAX (508)790-1677 -.a{AIC,No,Ext: A/C No " `eel n DRESS: Jackie@thefairagency.com Suite 1 INSURER(S)AFFORDING COVERAGE NAIC p Centerville MA 02632 INSURER A: Safety Insurance Co. 39454 INSURER B: ^ - Marciano Home Improvement Inc INSURER c: 40 AUrara Ln INSURER D: INSURER E: - S Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL19102501983 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 WrikrATFn. NpTyVI,T.H.qTAN9ING.ANY REnUIREMI NT TERRA QR GQND„ITIQNQF ANY FQNTRACT OfROTHER_OQCUMENTWITH RE$PEGT 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. INS ADULbUSK LTR TYPE OF INSURANCE g POLICY NUMBER MMIDD E PM/LDICY LIMBS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurFT'rence $DAMAGE TO R 15 100,000 MED EXP(Any one person) $ 10.000 A BMA0027575 02/25/2019 02/25/2020 PERSONAL&ADV INJURY $ GEML AGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE g POLICY❑JET LOC PRODUCTS-COMP/OPAGG $ OTHER: Bodily injury limit(s) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED LY SCHEDULED AUTOS ON AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident b UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION d X1 STATUTE _ ER BH- AND EMPLOYERS'LIABILITYY ANY PROPRIETOR/PARTNEWEXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 �OFFICER/MEMBER EXCLUDED? NIA N WCC5005021092-2019A 10/26/2019 10/26/2020 (Mandatory In NH) - _ E.L.DISEASE-EA EMPLOYEE $ 100.000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S Z)UU,vuu DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) a , CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TH,E FXPIRATIQN DATE,TH€RI QF.,N,QTIC_E IK1.l-t,.@•€DELIVERED IN The Ugly Duckling House ACCORDANCE WITH THE POLICY PROVISIONS. 194 Main Streeet AUTHORIZED REPRESENTATIVE West Barnstable MA 02668 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD _ m-v .f•�; 'x t)F` L(AWLf `Y INSURANCE 10/29/19 C R11F1CATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 11CclQ"ATTKFI Y nR R1FC'ATIVFI Y AMEND.-E?CTEN.0 QR ALTE•R,THE COVERAGE AFFORDED BY THE POLICIES _.u•«�:lu�ti L ud 'IN ouKr+tic.t UU1:$NU Ii(;0149f1TUf1 A ONTPACT BE WEEN THE ISSUING INSURER(S),AUTHORIZED ' " -.UVEK.AND THE CERTIFICATE HOLDER. must haye ADDITIONAL INSURED provisions or be endorsed. „4W.allhtAGt.tf1 thA tRCtt1S and`�QRdltIOrIS Ot the oolicv,.Certain policies may,require an endorsement A staterment oii j urrr aty ui"rfui d6fi(de Agin,to tine d6reficate hof der In lieu of such endorsement(B). PRODUCER UUNTAUT NAME: Nicole Poitras Legacy Insurance Agency Group, PHONE 508-295-1315 No): "'RAair cte<awf A/C,�. w fin.lA.�tl«lac lagpt killcuraRce rou .com INSURERIS AFFORDING COVERAGE NAIC A • .-;-.... I�11�ekh,E�al!I,IrtC.11�f'lcf1C@.(aQ111�ar1Y �I . r+t�tllktK'El �ii(if I(fWl(ldf ., - BHI Exteriors LLC t INSURER C• �11,f'1,!�a�fllrta Ae�ae� .. i �Ii(1 WiY14i1,If1ht 1lLJGiJ � INSURER£: I I 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 nk1T1r-XTFr1, NOTWITHSTANDING ANY REQUIREMENT,.TERM.OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ICERTIFICATE 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. w x COMMERCIAL GENERAL LIABILITY / EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 50,000 MED EXP(Any oneperson) $ 5,000 A WS344954 04/02/19 04/02/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,UUU POLICY❑PRO- ❑ I JECT LOC 4. PRODUCTS-COMP/OP AGG $ 1,000,000 111 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acci ent l $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS [ABILITY YIN STATUTE ER ' ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N❑ NIA AWC400-7035372-2019A 03/07/19 03/07/20 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 600,000 If yes.ee�cdbe Unger i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION FOPERATIONS/ y PTK) O LOCATION /VEHI LE +A 0 S.VEHICLES( CORD 1 1,Additional Remarks Schedule,may be attached K more space is required) Adam Boegel,as sole owner,IS covered under Workers Compensation CERTIFICATE HOLDER ' CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE f'. THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Ugly Duckling Builders . ACCORDANCE WITH THE POLICY PROVISIONS. 194 Main St W Barnstable,Ma 02668 AUTHORIZED REPRESENTATIVE COG t+/ �- ©1988-2 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) 3 The ACORD name and logo are registers 4 - V s�Fl-LlO w(, ZL� AdDJ�1�2J C�i)"o r� 1 Z 1 F � • { 4 ons L Y � l ROBER T i HARMS �, 90 NYE RD t A ' xe t w�3t' JoneF t o a• N i rg maa . `X,y r E S' u y r ts „ ay w a K 1w ""', Y '. y O s a r ( a OR ce g a .4Z z a Fy r V p * �N �8NMI $ zs'. ..�n ai �` '� 1T F k d �k a w t, a e s O 4'4�a o• E 1 � � ert4aR ax Yx av+ g *+ NOW {;zas- '�-5' x 4��' ' £'fiaO a�, ap�fg' ;�py� g '«W < .. � �� MSP4 [mA!E ' E4 � .,• �, as Hot-" Z Stu � , 441 a � My9te;"`k* Srill N`# � 4 r ',a. ✓ za'^r EE€EE „nw��a'F r 'yy " " ( � W � A. ws NOW" sa,� JU� OF yeYm'nw.t44 F y 4 Y k "aa �,q✓#N� r ?� `� All11 �`/ag a , et WAN E ,N e r P Pf l.a v q Oc "" z MENk UM qq„ p WC low � ;a ` 387,-k�fr�.S3zrS`n as an` " r f .dP:� ?4a Fi 3 Nov r nya ,f'i a, § d� rep 1 4 C 3 a\ t iff n Y +� Y� 4� •,.gy;x�+'mod pN'ro > rC' 6 � _ _ k'2 �11 s{ S GYM.' ,yYY�` 5 rF: '/, y _ BBjg zrPs/,y Edx t R �'"' r z� ' y z X ✓. � i fX +� _ r M r �v mxrr Y r WN , c' Y =f IN � o y ✓ s / � / 3 / � F r V ✓,ry'� < ' z '� 2s � /,fir rz w E'��"R,v �Trot �,;, x ION13 �e�' .g? �, ,.i J R % ,�,. v ✓,r"� x z,F;✓ d � 5_ �f- T Y yi. �E�� � �s k WFITAW .0 ' Fam rr�(i�l"n`,��` 2 � zr:: �•' a3Y r E � t/ � �� ,� 4 r,. -yv if g rrza, a�v I� k ^ + .a. r 5 a� E < Sol 1j '', 77 �r • Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 - _ Boston, Massachusetts 02118 Home Improvemeet Q ritractor Registration Type: Corporation - �-- �. ' THE UGLY DUCKLING HOUSE C Registration: 169134 OMPANYrxl_- - ' I Al -' sI 194 MAIN ST �V� Expiration: 05/18/2,021 W. BARNSTALBE, MA 02668 } ` ..r Update Address and Re SCA.1 0-20M-05/17 • --------------------- ;. � .4. � .�'�e �iynrncv��ecr,��a�. c .----- _ w.... •. Office of Consumer Affairs&Business Regulation $ 'HOME IMPROVEMENT CONTRACTOR ,• 9 Re istration valid for individual use only TYt�E Corporation r before the expiration date. 1f found return to: gistl&tion Expiration Office of Consumer Affairs and Business Regulation ;� 1 �� 05/18/2021 10 00 Washington Street -Suite 710 THE UGLY Due, G COMPANY,LLC ` " ♦ Boston,MA 02118 ;\ .. a k'. ♦' ' • /�'f � � .. r . y CHRISTINE CALfl )=1 �' 194 MAIN ST W.BARNSTALBE,MA ozs68 Not valid without signature Undersecretary . 4 a .♦ oFTMF Ta,, Town of Barnstable m =, } Regulatory Services E`S 6m° tI`s�i° 'usr�e rt 16 ��� Thomas F. Geiler,Director, rFD � ( DK,1[Diul/I Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 www--to wn,b arnstab l e:ma.us Office: 508-862-4038 EXPRESS PERIYITT APPLICATTON - RESIDENTT L ONI,y� 508-790-6230 �{ Not Valid without Red X-Press Imprint Map/parcel Number Property Address �- j /e 02,�3 2 ["Residential Value of Work_/__(�,O r Tno 1Vhnimum fee of$35.00'for work under$6000.00 Owner's Name&AddressW y ZO Contractor's Named j7 9 Telephone Number — �0 Home Improvement Contractor License#(if applicable) r '2 :' Construction Supervisor's License#(if applicable) 2 — n ❑Workman's Compensation Insurance 0 Check one: 0C� [�-Tam a sole proprietor ❑ I am the Homeowner OWE OF BARN ❑ I have Worker's Compensation Insurance nsurarice Company Name Vorkman's Comp, Policy# 'opy of Insurance Compliance Certificate must accompany each permit. ermit Request(check box) eRe-roof,(stripp'ing old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof), ❑ Re-side #of doors Replacement Windows/doors/sliders, U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic;Conservation etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction.Supervisors License is required. NATURE: 'PMESTORMSIbuilding permit formsTXPRESS.doc ised 070110 r :^ i The Commonwealth of Massachusetts ' Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass,gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/orgmization/Individual): Address: 2. _ 24��---J9 City/State/Zip: r /' Phone #: Are you an employer? Check the a ropriate box: 1.❑.I am a employer with 4. ❑ I am a general contractor and I Ty pe of project(required):. employees (full and/or part-time),* have hired the sub-contractors New construction 2.�I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have working for me in any capacity, employees and have workers' 8' Demolition [No workers' comp,insurance comp,insurance.# 9, ❑Building addition required.] 5, �] We are a corporation and its 10.❑Electrical repairs or additions 3,❑ I am a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions myself. [No workers'.comp. right of exemption per MGL insurance required.] t C. 152, §1(4),and we have no 12•[]Roof repairs employees. [No workers' 13.[] 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. $Contractors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers compensation insurance for my employees. Below is the policy 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. . I do hereby certify under th�/pains and pf nalties of perjury that the information provided above is true and correct Signature- ao 217o fov �'a"go Date: Phone#: U F e only. Do not write in thisarea, to be completed by city or town official wn: Permit/License# thority(circle one): Health 2. Building Department 3. City/Town Clerk 4.Elec tr�c al In sect or 5.Plu mb' P mg Inspector rson: Phone#: OfficMLW0nr�sumer ifiarrs Atfsiness egu(nt40en& �? � r ti vi t3craltltn�j fi,. 11 S+�ulr-� Is<� 1r tr i 'r r}+ HOME IMPROVEMENT CONTRACTOR a . 1 x Registration 152206 Type Ur; n S SL 101027, dP s Expiration W 2012 DBA Restricted t.la. RF;W$ a� H OOFING } RONALDO SOLANO RONALDO S.OLANOj r m �q1 25 UILBEF2T.STREET ` � rr 625`WINTER ST R 70 FF�AMINGHAM, MA 01702 ny Undersecretary G�-�'— Lx)iimiora "l2/912011 W.tM'rg r a e r ati 10102T �LL a.. r t .. [ IAA• L ... +4Y,. .... -. ...�. rfteec f, egis'tTat�on'VaIid for ind►vidu use,only" y `{ efore theuexpiration date If found return to +Office of Consumer Affairs 'pd Business Regulat�onF ti „z{ u+ r 1,O�P�rk°Plaza quite 5170 +��n�� k Boston,lvIA 02116 vi3� 4 MOR e'Not vJalid without s►gnaturehy '" 1C r' RECEIVED 01/04/2010 22:55 OCT. 12011 1 ; 19PM SPINE CENTER . 10, 824 P, 1/2 Insured,Free estimates, H&1t ROOFING&1�Ir?INCr , F y www�br-roofin , 6 WINTER ST Cell today(508)348-4348 F mingham Ma 01702 ppopOSAL Roofing & Siding sal Submitted to;Alec Me-10ger Sob Name: Roof Date 9/19/11 dress:20 Strathmore City:Brookline Rd. State: Mass 02445 . ' x�e#617-935-6898 Emaii;ameleger@mail.com Location:754 Shoot Flying Rd Centerville Ma 02632 hereby submit specifications and estimates for: _ Strip roof and haul away all roof related,trash. a eS,valleys, Install GAF Weather watch ice and water shield at all the gutter dg ` s To meet All GAF standards(6FT) es on all vent pipes. chim:oeY dri edges to all edges and Hang - - Install Eight in, aluminum p �, Install GAF shingle maze,fiberglass re-enforced felt paper• Izzstall architectural shingles e vent and ridge cap sbi agles. Install new GAF cobra ridg Re move that chimney and residing Install 18 soffits vents Ul6 Install 12 soffits (3 inches) _ bstall new guttex and that right side of that house secohd level only - Removed the plywood on the exatire house&i"Stall new plywood. - install gutter leap pmtectioa to the entire bouse. to furnish material and labor-complete in accordance with the above e propose hereby 5 358.00 payments to be made as follows:��completion C. cations for the sung of$16,075.00 with paym on the signing of agreement, 5.358_p0at the start of Work and 5 59.0 up Work. i RECEIVED 01/04/2010 22:55 'OCT. 12011 1 : 19PM SPINE CENTER_ NO. 824 P. 2/2 alteration or deviation from above specifications involvirxg extra cost will be e uteri only upon written order,and will become extra charge over and above the ir te.If a deterioration of the structure requires repair or replacement is found after ir,addition costs will be paid by the property owner.All agreements condngeat upon es,accidents or delays beyond our control, 1. pectfally Submitted Ro do 3olanq A.ccentance of invoice . e above prices, specifications and condition are satisfactory and we are hereby epted. You are authorized to do the work as specified. payments will be made outline above. Signature 1�Q to of acceptance 10 1 signature s I i i i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 1 � Map F"1 CI 2 Parcel_ 03 - Permit# Health Division �r l �ffb��� Date Issued Z-2� �T Conservation Division to D� Application Fee Tax Collector Permit FeeC' Treasurer fivj 8MOMMMBE IN C=PLI14= Planning Dept. TITLE g Date Definitive Plan Approved by Planning Board ALCM TM AEOUTATIONS Historic-OKH Preservation/Hyannis Project Street Address 7 L �h 0 0- 41�j i n T [ Village C'e-n k_p,L,�) le Owner at`"1 I�� K 2�y 1, Me-1-0- Address 20 � � ✓v»✓L¢ �.�t' Telephone 6/ Let— 0.QL( �2���j�►'`� �'1� cD2 �(�tS' Permit Request 2�oc,&J 0"—. �,iZ� ► ©�+ I�4- 1'l oo Q 4 e 4 ✓C.��- 6a f goo,►, 0,4 ?A1 J : �e�v � - cv. , 2.v7J Square feet: 1 st floor: existing Q-` proposed L1-2nd floor: existi proposed wA�Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family erl Two Family ❑ Multi-Family(#units) Age of Existing Structure 1 S Historic House: ❑Yes "�fQO On Old King's Highway: ❑Yes Basement Type: O Full 0 Crawl ❑Walkout C-Other h 01 -1' Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 2 new Half: existing ( new Q Number of Bedrooms: existing new Total Room Count(not including baths): existing new 0 First Floor Room Count fit° Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air: C �es ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes c(-]446-1" Detached garage:❑existing O new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage: xisting .❑new size Shed:O existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use w Proposed Use BUILDER INFORMATION ( �7 ,/�7 Name �� Telephone Number/�'� ` � r 4�T / Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I '23 0`f t + FOR OFFICIAL USE ONLY ; 2 PERMIT NO. DATE ISSUED MAP/PARCEL NO. - ADDRESS �''� VILLAGE OWNER i + ' DATE OF INSPECTION: ' a FOUNDATION FRAME INSULATION till_:+ FIREPLACE {. .• ELECTRICAL: RO FINAL PLUMBING: RO FINAL j GAS: RO U FINAL i FINAL BUILDING DATE CLOSED OUT - 4 ASSOCIATION PLAN NO. _ The Commonwealth of Massachusetts - Department of Industrial Accidents 600 1Washington Street Boston,Mass. 02111 ,- Workers'.Com ens ation.•Insurance Affidavit-General Businesses name: y• : (� address: G of a0l� 1 i state: zi '(�-( 1 phone '!;-I �-j work site location full address): SE'( c3� �� ) I L ' ❑ I am a sole proprietor and have no one Business Types Retail❑Restaurant/Bar/Eating Establishment working in any capacity. Office'[] Sales(mcluding al Estate,Autos etc.)- ❑I am %/ an em to er with ern to ees(full& art time'. Other OUL-t.e!, )0- /G% z %//%%%%%i?%!711, % % %//%%%�//%%%//%% %%/%%//%%%%%%% ] I am an employer providin-g viprkers' compensation for my employees working on this job. ad$re'ss: pone#.:•`.: -G. ol c.� !11"1"111 110 711711711 I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: com e'en• -name': -r eaaress: - . . - O.-.Ile`. C1tV 1-0 DS 2nSuranCe CO....,,.. .. .. .::.�„•',+::,.�:::.�.•... - C com an. aside: - _ address:. citV :Phone y � a. - C insurancvso:• - Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fore of$100.00 a day against me. I understand that li copy of this statement maybe fo . ded to the Office of Investigations of the DIAfor coverage verification. I do hereby certify under(Yyndpenalties of perjury that the information provided above is tru and correct Signature Date / 2 Print name �" / 1 Q)e— Phone EMMIN Echeck only do not write in this area to be completed by city or town official : perm llicense# ❑Building Department❑Licensing Board immediate response is required ❑Selectmen's OfficeHealthDepartmentson: phone#; ❑Other 03) Information and Instructions Massachusetts General I;aws chapter 152 section 25 requires all employers to provide workers' compensation for'their employees.. As quoted from the I'law", an employee is.defined as every person m 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 ajoint 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.main#euance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be of such,employment.be deemed to bean employer. . MGL chapter 152 section 25 also states that every state or lbcal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the.commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the coinnonwealth 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 the workers' ensation affidavit completely,by checking the box that applies to your situation.. Please Please fill nr . eon supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirnmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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 regardinj1he"law"or if you are required to obtain a.workers."compensation policy,please call the Department at the number listed below. . City or Towns . Please be sure that the affidavit is complete andprinted 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. The.affidavits.may be returned to the Department by mail or FAX unless other'arrangements have been made. The Office of Investigations would 11e to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department.of Industrial Accidents BIIIee of InvesUggens 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: 61 727-4900 ext.406 aCIHEr Town of Barnstable Regulatory Services aw s aat,E, : 'Thomas F.Geller,Director 039• ,�� Building Division PIED MAt�` ' Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERNIIT APPLICATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adi acent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. • ��n �C��f` O✓k Estimgted Cost�, Type of Work: Address of W /�f ^�► Owner's Name•_. �/i(��— �'" ��!ln � /'°,e-���',P� Date of Application• 1 23 4yL1 I hereby certify that: Registration is not required for the following reason(s): 0Work excluded by law ❑lob Under$1,000 []B,UjQ not owner-occupied weer pulling own permit Notice is hereby given that: 0wnp-S PULLING TSEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FABITRATIO PROGRAM OR GUARANTYWORK DO NOT FUND UNDER MGL c 142A. ACCESS TO . SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: ContractorAme RegistrationNo. Date JRl . Da a Owner s Name RESIDENTIAL BUILDING PERNUT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 AQ Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONSMXNOVATIONS OF EXISTING SPACE 1 -square feet x$64/sq.foot= x.0031= 2 plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30,00= . (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee projcost oFtNE, Town of Barnstable Regulatory Services BABN6rABLE, : Thomas F.Geiler,Director 9 MASS. �A 039. & Building Division rEc ro►a� 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: �G'V l /1 4"L. / itlCL 'l? / V number f / eet village G�/ "HOMEOWNER": rA ' a 111� b L 7 l /,�6-00 0(s, name /J V / home phone# �J work phone# CURRENT MAILING ADDRESS: ljC L/l ' l�t�ri�{�IiU CKO� —� 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 minimumpsp,ection procedures and requirements and that he/she will comply with said procedures and requir (Signptur cmeowner 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:formsihomeexempt - 3 4G.5 3� � ��� t5g 3� „ i 7 O C . � f n h A!7Al 36 4 & �} 36 Z o tT .. W Li m 27,�'r 13" 3"7 21 N y N Of u � � • lS� L � r 3 'D FROM Yury Voront5ov FAX NO. 6173329287 Jan. 22 2004 09:54PM P3 ol I aCr !'io�° m t t" y New �x4 Ao*& 71 . Le r A ;O'd SC;ST G0, ZL uPC IW zzz— T9:xed ITIStUbN DN3 XW FROM Yury Vorontsov FAX NO. 6173329287 Jan. 22 2004 09:53PM P2 �a. s 177 t �0 i F C-4,A"<f Gr Poo LO'd Vr:Si von TZ UeC ANSd1NW ON3 30W Assessor's map and lot number ........... THE Sewage Permit number .......�..:777�... .0 ......... EARNST LE, ..........4t_ — 5.y M16A3G9LHouse number ..7. I . - Ar. TOWN - OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...... TYPE OF CONSTRUCTION ...jM.5.012.. ............................................................................................. ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .......A.c)4 .............................................. .............. ................................................................................................ ProposedUse .............................................................................................................................................................................. ZoningDistrict .........../ ............................................Fire District .............................................................................. 1_Cie :5.4 A 14 0,CA ;:<>,I ? 10 Name of Owner .............7...........................................4.........Address L .r......S .... .. .... Name of Builder A...... INJ ......... . . .......... .. ..................Address .................................... .. .. ... ....... .... Name of Architect 17...r�n M or"15.0ij...................Address .....Me f,.,(.. kk".d....... Numberof Rooms ....... ........................................................Foundation ...................... Exlerior Roofing FloorsInterior ....................................................................................... ...... ...............Plumbing ................................................................................. Heating F,.�,z.en....... ........ _7.... Fireplace ...M)AIl ..............................................................Approximate Cost ..................................................... Definitive Plan Approved by Planning Board V _19--------- Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ............................ Construction Supervisor's License ........ HADFIET.,.D, JAN & LARRY A=192--35 No ... Permit for ,,,Two S tory Sin(jle Family Dwelling ....................................... Location ....Lot 5, 754 ShootFlying Hill Rd. ............................................ Centerville ' ............................................................................... Owner Jan & Larry Hadfield ................................................................ Type of Construction ,Frame ................................. ................................................................................ Plot ............................ Lot ..'.............................. Permit Granted ., June 5, 19 85 Date of Inspection ....................................19 Date Completed ......................................19 l , 1 UN f I r7 , s � �� V