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HomeMy WebLinkAbout0052 SKUNKNET ROAD mod'�s,�v����-`tea �,e�� q :� }� . ., .., y. �.-..,: :.�. � . m , . .� �. ? a `� r:. '.:` ..-.ls �,�,. . ,...� * ,as q,. 'tom s ."� ,w ° Tx a. a..'f�7 '$aa'�. Yt...V. �',rid s,, :� .'r ri� �.. :,,��{{ `�:G�. '„ a �.,- � �,:s:.�q:. ,. - ,,. r..,�.,•. .i ;,t:� .Sa ,r` .y• 1.�b, ',�s S- tL`` ,_.. t ....�..., �,.-.. .�i .�,•� :,.:• �: ..� D. '.[a N'��: -s{r :.i._.... :g.. ,t ,� :�a a.. ;,.� n �.c� .... .., �. F, u;a.. r - � /'x c!'; �s w .� .s ,.t is. 5 i�'�� y, 4ry�. � ...�x r ��'; !� �^a ..,r _St ¢� �P new � �]n 3 � _ �� 4 - o ' � ' ` � - - i � -. - iI� d _ -. � - c y1 - - - - +. �. - 1 ... � - .. .. `. � -� � - _. 9.. �.. .. .. � - - .. - � ` { _ { a - � ... '. _ � .. r, , .. ,. ' F (Dk -311tJ15' Town of Barnstable *Permit# Expires 6 nths from issue d e �T Regulatory Services Fee sArazn U , MASS. Richard V.Scali,Interim Director 1639. -0 Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us ` Office: 508-862-4038 'Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY, O 6 1 Not Valid without Red X-Press Imprint Map/parcel Number, "� , / (� K Property Address i/► l '� l�®P-� t Residential Value of Work$ 'rCTt 0 O G -.'Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name A lr<—l ✓� �t,_I` Co xq5� V Jc�o W LL C. Telephone Number T. 1 Home Improvement Contractor License#(if applicable) t7? r"514-?Z Email: 1L-4 we �o I VV e co►"t`L Construction Supervisor's License#(if applicable) Q- � t: MVorkman's Compensation Insurance 1 Q 2U�J Check one: t MAR ❑ I am a sole proprietor ❑ I am the Homeowner TOWN GF.gp,RUSTABLE [ have Worker's Compensation Insurance, Insurance Company Name EiN� ) .S S'd� �o-- O i_-rS Workman's Comp.Policy# o Cc _ob_�'d 1 2 Z 56 w Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to e.Ae-sid roof(hurricane nailed)(not stripping: Going over existing layers of roof)e 15, SQ . .- 1eplacement Windows/doors/sliders.^U-Value 0-31 (maximum.35)#of windows -2 #of doors: - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. ` !Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. - ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: �. T:IKEVIN b\Buil ' Changes\EXPRESS PERMIMXPRESS.doc Revised 061313 - .- the GOMManweawt oimassacnuseus Depmfent of Industrial Accidents _. Of we of Invew9ations ` 600 Washington Street Boston,HA 02111 wwx.mass govhHa Workers' Compensation Insurance Affidavit:Budders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/0Tankafion/IndMdvaD: AP [Zli v-.(6,_-I I (fG A.-S4 t v e , D K LI,C, Address: '7 - City/state zip A1. AWuan employer?Check the appropriate bow Type of project(required): 1. am a employer wii-h. 4. [] I am a general contractor and I employees(fail and/or part-time).* have hired the sab-contractors 6. ❑N construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. oodelintg ship and have no employees These sub-doctors have 8. Demolition working for me in any capacity, employees'and have workers' [No workers'comp,insurance comp.insurance i 9. ❑Building addition required_] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work ' 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.[]Roof repairs incnra„ce required.]t c.152, §1(4),and we have no 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 infuriation. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside conf actors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sob-contractors and Starr whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'crap,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: 56C e GJ C,J_ Policy#or Self-ins.Lic.#:_ C( !�,Co Z Q ZO 6 Expiration Date: © � Job Site Address: 551Z SV0A V t-0,�- ~ City/State -- ce't'6-W A 1 C M 1 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 civiil penalties in the form of a STOP WORK-ORDER and a fine of up to$250.00 a day against tine violator. Be advised that a copy of this statement may be forwarded to the Office-'of Investigations of the DU for insurance coverage verification. I do hereby c under the pains andp�malles of perj that the information provided above is true and correct S' Date: Z Z q /3 Phone#: �0��7�7 1 Z 3r Official use only. Do not write in this area,to be completed by city or town official 'Ckty or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electri6d Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#. Information and Instructions tu. Massaclusetts General Laws chapter 152 regmres all employers to provide workers'compensation for their employees: Pursuant to this statute,an eWloyee is deed as"._.every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in*a joint enterprise,and including the legal representatives of.a.deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter-152, §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 prodaced.acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C()states"Neither the commonwealth nor any of its political subdivisions shall enter into any comtzad for the performance of public work untT acceptable evidence of compliance with the in�ce 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 mcnrrance. 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 resumed 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-insuran re 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 is the permiVEcense number which will be used as a reference number. In addition,an applicant that must submif multiple permit(license applications m any given year,need only submit one affidavit indicating current policy information Cif necessary)and under"Job Site Address"the applicant should write"all locations is _ (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 (Le. a dog license or permit to bum 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 Commoni�edth of Massachusetts Department of Industrial A.oUdemts 015ce of kvesUgations 600 Washingtan fit. Boston.,MA 02111 TeL#617-727-4900 ext 406 or 1-V7-MASSAFB Revised 42407 - Fax#617-727-7749. Client'#:45578 2KIMBALLAP ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE TE(MM2095 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(les)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 NAME: Dowling&O'Neil PHONE ON o,Ell:508 775-1620 MAX, 5087781218 Insurance Agency EMAIL A/c No ADDRESS: 973 lyannough Rd., PO BOX 1990 P.Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC d INSURER A:Lloyds of London INSURED INSURERS:Associated Employers Insurance A.P.Kimball Construction LLC ! INSURER C: 84 Homers Dock Road Yarmouthport,MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE.AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INS LSU pR POLPOLICY NUMBER MM/DDY EFF MM/DDY EXP LIMITS ' A GENERAL LIABILITY XSZ41002 7/13/2014 07/13/201 EACH OCCURRENCE $1 000 000 TO [IX:: COMMERCIAL GENERAL LIABILITY PR DAMMAGE RENTED ISE9 Ea occurtence $50 000 ' a CLAIMS-MADE �OCCUR MED EXP(Any one person) s5,000 BI/PD Ded:500 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED id BODILY INJURY Per accent $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident I , - $. UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ B WORKERS COMPENSATION WCC50050122502014A 7/09/2014 07/09/201 X WC STATu OTH- AND EMPLOYERS'LIABILITY TS ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $SOO OOO OFFICER/MEMBER EXCLUDED? 7 N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION ti Town Of BarnstableSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE*DELIVERED ,IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 y AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.'All rights reserved. ACORD 25(2010105) 1 of 1 - The ACORD name and logo are registered marks of ACORD #S144153/M144152 LS1 C�/lredr,v,�ca,uoe�c�t/r,a�C�/l�ia,ac/uaetta License or registration valid for individul use only Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Wx egistration: ,�78472 Type: Office of Consumer Affairs and Business Regulation piration:-4116%201;6.- LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 APKIMBALL CONSTRUCTION O t� PETER KIMBALL 84 HOMERS DOCK YARMOUTH PORT,MA 02675'" Undersecretary v Not valid without signature 1 u Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-085071 PETER V KIM A-181, `• ' 84 HOMERS DOCK ROAD- Y e Yarmouth Port MAA 02675 Expiration 03/29/2015 Commissioner Town of Barnstable 41 Regulatory Services. MAss. Richard V.Scali,Director " 639 . Building Division - ' Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 WWW-town.barnstable,maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. . ; K Using' i, 2-4L /� � Z K A5 ,as Owner of the subject pro petty rbY authorize n �� he �w J_ I (.M;S "to act on nay behalf, r in all ratters relative to work authorized "razed by building permit application for.; .` (Address of Job) , _ Pool fences and.alarms are the responsibility of the•applicant. Pools are not.to be filled or utilized before fence is installed and all final inspectio are performed and accepted. Signature of Owner ignatvre of Applicant 101-1A /Y, i ns PriatNamc Print Name t 691 Date QcFORMSUR'NERPERMiISSI0NpO0IS f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z, Parcel 0(o l ;p'ploication # Health Division Date Issued �\ Conservation Division Application Fee 4z V Planning Dept. Permit Fee Ifu Date Definitive Plan Approved by Planning Board ' Historic - OKH _ Preservation/ Hyannis Project Street Address �Z S�v �V� e. Qa,� Village ✓t k e t- e Y" Owner &,t �- 1, kr..�S Address �� Q*- Telephone Permit Request Square feet: 1st floor: existing 21-proposed 77C 2nd floor: existing 7JWproposed 3j02LTotal new Zoning District Flood Plain Groundwater Overlay to,000 Project Valuation Construction Type Lot Size_ 0-X C.. y/ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ud Two Family ❑ Multi-Family(# units) Age of Existing Structure � �l ?2 Historic House: ❑Yes ANo On Old King's Highway: ❑Yes )d No Basement Type: 0 Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) ® Basement Unfinished Area (sq.ft) 7 Tj� Number of Baths: Full: existing_ t new l Half: existing l new B Number of Bedrooms: existing 3 new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other Central Air: ❑Yes 4N0 Fireplaces: Existing V New Existing wood/coal stove: ❑Yes ANo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑sxisting. 0,new size_ Attached garage: 0 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: .'; •� ;ems Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes �No If yes, site plan review# , � Current Use acts Proposed Use 12 &S 1 e��•� 1 7 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name (,c t Telephone Number Address �owte rs p6c l,, 9- License # pot-V, tA44 OZ,615 Home Improvement Contractor# 7 g ILI 2 Email Z. ll CO vac UJ. /le- Worker's Compensation # WC( o0 ( 2 Z D Z Dt y � � v � 4 ALL CONSTRUCTION DEBRIS.RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE I_ FOR OFFICIAL USE ONLY APPLICATION# < , DATE ISSUED i MAP/PARCEL NO. y ADDRESS VILLAGE s OWNER ° f DATE OF INSPECTION: FOUNDATION I ) 5! ? f 5_ FRAME INSULATION r ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL i F; GAS: ROUGH FINAL FINAL BUILDING J rY IS zi DATE CLOSED OUT t : ASSOCIATION PLAN NO. L; vns ter Affai s& u s aJ s Regulation License or registration valid for individul use only, Office of Consumer Affairs&Business Regulartion � Y` , ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ioxii istration: ,ljgg72 Type: " Office of Consumer Affairs and Business Regulation iration: 4/1612616 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 APKIMBALL CONSTRUCTION- PETER KIMBALL 84 HOMERS DOCK RD YARMOUTH PORT,MA 0267Y r� Undersecretary u Not valid without signature f z - Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-085071 PETER V][(JMA r. 84 HOMERS DO X AUI� Yarmouth Port MA 0$67` ` � .�r►ti��` Expiration www Commissioner 03/29/2017 lk• 9 L - ' 1 Town of Barnstable' Regulatory Services • rsrrnsia. MARM Richard V.Scab,Director Building Division _ Tom Perry,Bu ldin Commissioner 200 Main Street;Hyannis,MA 02601 www.towwn.barnstable.mams i Office: 508-862-403 8 Fax: 508-790-6230 .. Propeity Owue.r Must Complete and Sign This Section If Using Auilder ` ( K f S , as Owner of.ih,e subject ro . J p PeriY hereby authorize1( t ��. l to behalf,-- d �G�; act on my � • a in all matters relative to work authorized by this building permit a hcation for. pp r (Address of Job) Pool fences and.alarms-are the res onsib' ' of the a licant. Pools P Pp- x. are not to be filled orutilized before fence is installed and all final ` inspectio are performed and€accepted. • _' Sigpatun±of Owner nature of Applicant °R 4 AS e L F Print Name Print Name Date 47 v 1 r 4 . Y office • wec�Ft .grr�ci Wbrke& Campensafimtla=mce- davit RmfdersICAm racbms/EEec-bL c ambers AppEcmthifurmatim Narn>v E c m;� ; d�—�,�,: rn.l l C.0 n S .� D-4 L L L dress: P()VI-ta t-S Are yn ait employer?Chwk&e-wAw�ba= T�''�of o _ k� I am a � - � � I rsrt a gel rtmfrar(rsr aad L FF:imt�'�m* =Ployms{fu ar CVO Batt#i 4* havel f � '` is-_ ItTeu� ll 2_El I am a sole praprietor Orpar€nzrr- • Listed an the attached shy. 7- ❑Rr�rradelizrg ship sadhatre n o employees Thew~mb�f rs have g_ DeMQ ta,d forme in e-mpluyem and have van s' �o�zug any city. rt,�,�� Q_ Q$ui}dmg addiii-an Rl 6 WMJMM' camp." � l 1•741��•,re .1_ We am a catpara[imt mff ifs I4 0�ec4ical repair ar additions 1❑ I em a homes doing all wUlk dicers have cmr ci sad 1 es 11.0 Ph mhiag repairs or addifim, myself[I7o"�arlmrscomp_ lig Of`eaumpiiOM per MCU L2�oaf r-15Z§I(4} andirehavafar _ � ' � �stn��zggaized-JF employees.[Na WMkeM' comp_snsoranm j ��Y�F���ateher�sbar,�l amstalw ffiovtti�sec[innhrlusPshaum��eawot�s'mmn�satinuperi�-iaa� . ffnmetswn�nix Y 3zis r d- i t pep c�r?ning`II r r{• t h�a amsi contraatssmast=bC s aPr endarit MITI' sates s$st rl-k-tbis b=mast st2arhed a vift;,. O sheet it Pdi g the nie of die i-om#-omirxh3s inE Ntala trhetiver ornatfi}nse have aanloyePs. Ift3:e soh cnsr�a�s h�re Ala es,rheg�st gmviae th-—k-e comp.paw m bee tr�ri rEZE�rrgtInper rhrctis pt`trvi�g tvorkexs'c-atriosr trrsttrruics for trr�etr:�l�ecs. BeTvr>?zs fitep�F�cp artd job nits irt,�otmm�ratz � _ p � - FacrtrAnrP Cotnpanyl'£an.ia: A��� C Z P-- � PoFu-y t9 or S$If-ins > F�cpuafioQl?ate. -7 F11-56 Job�ite1fddi �Z 5'�u L` � .�` s Attach a copy of the vrk xe cnrmpen=tian polio-declzmtiou page(-,h Fhe PaB-Y .a lion iiAe): Fax�tue fA secare c erage as requirednnder S=6on,25A ofMM c 152 cau lead to the imposifian,of criminal peg l&i of a,. fine np to L SOQ-fJD andlor a yearimpasa as�ueIl as cizrs1 ge alti�in thL form of a STOP WORE:ORDER-and a fine of up in$?50-QO a dsy against the violater_ Be advised that a copy of this maybe ceded tts fhe Office of ' IrrresEigafiorrs of the DIA for mmra a caw an vacation_ l dg horeby xuier t csptuus�nrt psua €css rrfiser�urp fhatfh�irejArmatiarigrm ab *e is true tmd enrxsct fiiansifrrrR ' I}ate `L / Phom Q cur£nsa rru£, Da trot tt'ribr'in this erect,to be cQratpiew by ciLp or fawn OfficLL City ar Toga: f psi#lf,,re�e# Fssnzu�t�IIt�QTLf�l�'CIC 4ItL'�: . LBmardef$exWx 2.BRuMngDeprtracut ICifi `Fawaa=k 4.Pl=tricalEmpecfar -5.Pftrnslxing bmpmtor ti.C)&Cr Cadet gersr}.u: - FI�nt=� • �ccar�sss� General Laws chapter 152 ryes an emPloyers to provide workers'comP=atian for their employees Purs¢a:tto this sty,an epfapee is deemed as=__eY=:y person is the service of anpfher under any canfract ofhire, e ss m implied, oral or wEiften." . An mTpTzyea•is deaaed as ,an m±VjdaA pnt=ship,associaton,mrpa-atoa or other legal entity,or any two or more ofthe foregoing engaged in a oint enierPIIse,and iacludingthe legal rep=mtdi es of a deceased employer;or the receiver or,tU-Lt e of a a mcrviidina pa tamzhip,association or other legal entity,employing employee,. However the owner of a dwelimghanse havmg not more thm three apadmm s and who resides thereur,or the occupant of the - dweIIiaghorse ofanother vtho employs persons to do ma_ ance,conshuciion or repair work on such dwelling house or on the.groIInds or Molding appurtmaztthereto shall not because ofsmh employment be deemed to be an employer." MG°L chapter 152, 925C(6)also states that"every ShLte or Iocal IiMnsing agency shall withhold the issuance or reuewaI of a license or permit fe operate a business or to construct buildings in the common r-alth for airy applicant who has not produced accepaable evidence of compliance with the inS r .ce.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 perfumlance of public work uatR acceptable evidence of comPliance with the T„CU7a„ce TC:T em.ents of this chapter have been presented to the contracting authority.- Applicants Please fill o-ot the woikers'compensation affidavit completely,by checking the boles that apply to your situation and,if necessary, supply svb-watractnr(s)name(s), addresses)and phone number(s)along with their mrdficaic(s) of insurance. Limited.Liability Companies(LLC) or Limited Liability Partnerships(LU)with no employees other than the members or partners,are not required to cairy workers' compensation inner- =- Han LLC or LLP does have employees;a policy is rexluircl Be.advised that this affidavit may be submitted to the Department of Industrial Accidents for confr ation ofinsnrnce coverage. Also be sure to sign and date the affidavit The affidavit should be rtturaDd to the city or town that the application for the peuoit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding ffie law or if you are_required to Obtain a workers' Mmpensation policy,please call the Department at the number listed below. Self insured companies should enter their self-mince license number on the appropriate line. City or Town Officials ,. .. Please be stye that tht affidavit is complete and.printEd leg>bly- The Department has provided a space at the bot M, . of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sine:in fill in the penaitlIieense number which will be used as a reference number. In addition- an applicant that must submit muktipIe pcm itllicense applications m any given year,need only snbmif one affidavit indicating cuzr-ent policy inf =anon(if necessary)and under-Job Site Address"the applieaat should write-0 locations in (city or town).-A copy of the affidavit that has been officially st Lped or markeed by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit notrtlated to any business or commercial Yentrae (Le,a dog license or permit to bum leaves etc.)said person is NOTregr to complete this affidavit The Office of Investigations would.ae to the you m advance foryour cooperation and should you have any questions, please do not hesitate to giveIIs a caII_ The Department's adrhess,telephone and fax number: at eom-mDaWmltbL of Massachuae#s Dena tz t Gf Industrial Aoaide its RUSIX) 02111 Tel-..9 617 727-4 4-66 ar I-� R=4 617-727- 4-4 Revised 4-24-D 7 �dEa r Client#:45578 2KIMBALLAP ACORD., CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 01/14/2015 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 policy(les)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 NAME: Dowling&O'Neil ac"r o f 508 775.1620 a,No): 5087781218 Insurance Agency E-MAIL 973 lyannough Rd., PO Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAtC# INSURER A:Lloyds of London INSURED A.P.Kimball Construction LLC INSURER B:Associated Employers Insurance 84 Homers Dock Road INSURER C: Yarmouthport,MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. LTRR TYPE OF INSURANCE NSRLSUBR WVD POLICY NUMBER MMNDY EFF POLICY EXP LIMITS A GENERAL LIABILITY XSZ41002 111711312014 07/13/201 EACH OCCURRENCE $1 OOO 000 pAMpGE7 RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $5O 000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) s5,000 X BI/PD Ded:500 PERSONAL a ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JPE CEl CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 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 LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050122502014A 7/09/2014 07/09/201 X T. STA AND EMPLOYERS'LIABILITY TU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N E.L.EACH ACCIDENT $500 000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 LLI DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addidonal Remarks Schedule,If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town Of Chatham SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 549 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Chatham,MA 02633 AUTHORIZED REPRESENTATIVE C. ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S144155/M144152 LS1 CA x �. ; � J ID � f x enNY- L F Z20/201. 4 Capacities for Pin Foundations Diamond Pier Capacities " Normal Soil Conditions Downloads Diamond Pier foundations sold through retail outlets are designed for projects that are founded in normal sound soils.Normal soils are typical in most residential neighborhoods throughout the •Load Chart United States and are defined in the International Residential Code(IRC)Table R401.4.1. •Cross Pin Grouc Presumptive Load-Bearing Values of Foundation Materials. •Cross Pin Grout Of Supporting Soils L 'BuiJfrgB Some soils may not be appropriate for supporting Diamond Pier foundations.Where unsound soils exist,a registered design professional may be required to review the project. t dASs� #, ` See the Installation Manual for a full description of Normal Soil Conditions �{ ' Residential Diamond Pier Load Chart y. ,zrr ddyy i�aarea woe + 47uotr:7 Make.1'cal O •1°ayrnedt He» a Bearing in 2000 psf SandslGravels' 3600# 3600# 3600# 5150# saw ff V e •, Bearing in 1500 psf Sawelays' 2700# 2700# 2700# 3870# 4400# " Y Equivalent Bearing Area 1.80 118 SI 1.861 2.58 sf 2.93 st �,. Base Area Cumpanson 18"cyFrber ' 18 cyllnd#i„ 107 cyilnd r 2t cygnder; 'eyltn�r. '� 1 �� � "s' g� € s5 .rr..,,o.... .�.:+.+.i*. . -,w..`..,.;<�--,x::,,a'�,.a..r....T.w..ws-.fi..r.....i,.:�:�.;.+:.,. .-r„•...�•.,r•.a.. , x UPER 670# 920# 1175# 1215# 1380# Lateral 575# 820# 1070#, 115M 1310# .. u+±^•,"""'•`"!' W-,.bk-.^-a.*--uwn 9�++{;tea., r..,w>I..»u. -.x,..,...,,.;« � . Zcr��e Rating NOTES: 1. Values applicable in properly drained,sound soils with a minimum 1500 psf bearing capacity.See IRC Table R401.4.1 for bearing soils listing and Table notes. I 2. For simple structures only.No asymmetrical,rotational,overturning,or dynamic loads.For additional information,see the full Diamond Pier Installation Manual. • 3. All capacities use four pins of the specified Iength per foundation.Length includes that portion embedded within the foundation head. 4. DP-50 uses defined in paragraph 2.0 of ESR-1895 and per blue-bordered box above are limited to residential decks,covered decks,stairways,and walkways.For DP-50 uses beyond these types of projects,and for DP-75 applications,refer to Cross Pin Group Test Report (EEI Report No.07-020-8).See Note 1 for applicable soils. 5: 50"Pins are recommended for use with the DP-50 where uplift and/or lateral loads may govern.The DP-50 comes with a 1/2"diameter embedded galvanized anchor bolt.The DP- 75 comes with a 5/8" diameter embedded galvanized anchor bolt. 6. The Diamond Pier system is a shallow bearing technology that does not require"refusal"or "friction"resistance,or the professional installation monitoring or special inspection typically associated with conventional vertical or battered piling. 7 Larger Diamond Pier-models are available-DP-100E and DP-200E.For these larger pier ' sizes,site-specific soils information and foundation loads must be determined by a registered design professional and provided to PFI for calculated foundation capacities. l��[[•��.�..��..s,�,.� �•��� 1twi.•J!✓.11lylLLL'ttL•,i�GL'X`.i6u.•/u.7ryry1}}��f*�� . M 11�%{Jr.L /�1:j . ��JtGJRU'�1('_��+�""- • '�yyn.•.. mRi'iRll:J 1CLX11awYsl►91L��: ':f• , Copyright 2013, Pin Foundations Inc.All images and information contained herein are the property of Pin Foundations,Inc., and may not be copied or reproduced without express written consent from PFI or its affiliates. Web Design by]eff Gutterud Design, hftp:/Aovww.diamondpier.com/Code-path.htm 1/1 NOTESBE - . _ yi 1.DATUM IS ASSUMED o'P of z SYSTEM PROFILE „uKED�11H001wjjON��.x 2. MUNICIPAL WATER IS EXISTING °+ locus ~ Kok .. • -_ O COMTABIE MEANS FOR FUTURE LOCATION.(NOT TO SCAU - ACCESS COVERS To wrrHM 6"OF F'GRADE - - 2"PEASTONE OR CEOTEXIILE F CONCRETE COVERS TO WITHIN 3"WADE 3.MINIMUM PIPE PITCH TO BE 1/8"PER FOOT., c o TOP FOUND. EL. 51 - - FILTER FABRIC OVER STONE �,�; 4. DESIGN LOADING FOR ALL PROPOSED PRECAST \ a` 57:0' Y08NUM.B'0 2M SLOPE,REQUIRED OVER SYSTDA 58.5 UNITS TO BE AASHO H-JQ - ... P1ErAST N 0 NOTE: MIN:WALL THKXNESS 2" - ! BLOCKS. 5.PIPE JOINTS TO BE MADE WATERTIGHT. - t; - 2 'I JIL"%SCH40 PVC I�0 PRECAST RISERS 4.7• TPES LEVEL IST 2' E'^ENOS CG ) INVERT IN 52.70' 4• _ WITH 310 CM6. CONSTRUCTION000(TLE 5.DETAILS TO)IN ACCORDANCE - i.: .., SIDES 53.53' a 50Se 54.9'4 10" 1500 CAL N-10 14• 53.53' TEE SEM TANK TEE 53 28' °°°°°° ®� NOTHTO 8E IS FOR OT�UINE WORK ONLY ANY ' 8"Mlro. SUMP ° e :g8ge . " GAS BAFFLE, •Y°°�°a°°,8°"°".,•,8Y 12"MIN.TNT. DIM. OTHER PURPOSE. - - 5 . 52.81' S0 T ' 4'U0.LEVEL. E OR B.PIPE.FOR SEPTIC SYSTEM TO SCH, 40-4"PVC., - WATERTEST D'BOX - `;.".' e,< . •g�a8e - ` FOR LEVELNESS ,„-10 Soo GAL,LEACHING CHAMBERS BY ACME PRECAST OR EQUAL 9.COMPONENTS NOT TO BE BACKFILLED-OR. 3/4--1-1/2'DOUBLE WASHED STONE 4'MIN. �: (2)UNITS REQUIRED CONCEALED WITHOUT INSPECTION BY BOARD OF. B'CRUSHED SroNE M kAl. ALL AROUND'PRECAST STRUCTURES = HEALTH AND PERMISSION OBTAINED FROM BOARD COMPACTION.ST04E1 R OVERALL DIMENSIONS TO OUTSIDE OF STONE:.25.00'X 12.63'�'. .. OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR (MIX mom (�•5>< E) t 1:gppE) F CALLING DIGSAFE((1-888-344-7233)j ANO i VERIFYING THE LOCA110N OF ALL UNDERGROUND& FOUNDATK)N-- 20' -SEPTIC TANK 20' D' BOX 13' LEACHING 457'BOTTOM TH-I OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF FACILITY NO OROUNOWATER FOUND WORK. I LOCUS MAP , T 11. ANY UNSUITABLE MATERIAL ENCOUNTERED - NOT TO SCALE. SHALL BE REMOVED V BENEATH AND AROUND THE . . " *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL PROPOSED LEACHING FACILITY. /gyp 7 DI1E UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 12.EXISTING LEACHING FACILITY SHALL BE PUMPED ASSESSORS MAP 192 PARCEL 61 _ PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND r 56.47 SAND. / r -99- EXISTING CONTOUR )I 56.44 .v. X mr EXIST.SPOT ELEV. i x57.20 490--" PROPOSED CONTOUR - x56.36 ;. ` _ PROPOSED SPOT EL `6.20 TH1 } � ' SYSTEM DESIGN: - \ a TEST HOLE _ `` ' 0� 1 S �56.20 • 21� SLOPE OF GROUND O /� S4g GARBAGE DISPOSER IS NOT ALLOWED r 4' BENCHMARK: USE CORNER UTILITY POLE //�,, OF CONc.BH AT EL szs'x56.50 EXISTING 3 BEDROOM DWELLING %ss.22 FIRE HYDRANT �� ` ` / DESIGN FLOW: 3 BEDROOMS 0110 GPD 330 GPD USE A 330 GPD DESIGN FLOW NWC NOT ALL SYMBOLS M APPFAR GL GRAO10 - y / oo .aw,� ` ,i - ' - 156,46 7.18 SEPTIC TANK: 330 GPD (2) _ 660 TEST HOLE LOGS 56.02 7.25 1 72 USE A 1500 GAL. SEPTIC TANK DANIEL E. GONSALVES, SE #13587 % 15,LOT 5Sf 4 LEACHING: ENGINEER: / /� 56.91 x 56.s8 g, 5.37 SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD DARREN, MEYER, RS / ` EXISTING .55 WITNESS: / \G DWELLINGR BOTTOM 25 x 12.83 (.74) = 237 GPD DATE: 4/10/15 i \ d• r 56.48 TOP FNDN.. 6.39 TOTAL: 472 S.F. 349 GPD PERC. RATE _ < 2 MIN/INCH. �` Q 0..56.7 x O , O 6. - - - USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) CLASS i SOILS P# 14658 ,(55.44 s 99 DECK / O 56.76 O WITH 4'., STONE ALL;AROUND - r-T ELEV. ELEV. e \z 4 56.7' Q 4 56.7' "/ 6.46 56. A A # 42 SL SL APPROVED DATE BOARD OF HEALTH MA 7" 10YR 3/2 4, 10YR 3/2 x s6.O7 ¢ % 57� 2) EXISTING TREES o° E°E Ms BMOVD TITLE` 5 SITE PLAN SL 4Sl 5 . OF 24" 10YR 5/6" 54.7' 22" 10YR 5/6 54.9' 52 SKUNKNET ROAD APPROX.LOCATION OF C, G CESSPOOL • 7.99 CENTERVILLE, MA FS PERC Fg + PREPARED FOR 60" 2.5Y 6/2 51.7' 58" 2.5Y 6/2 51.9' ry TOMAS & KAREN ZIKAS T DATE: APRIL 15, 2015 M/CS M/CS H TfJ�W �1s, « ASHOF OX ff 508-382-98801 2.5Y 5/6 2.5Y 5/6 ' " x 57.93 DANIEEL down cope.com A cn/Aii A Na v y wa c®pHr en ieeHrPiz uxe . 132" 45.T 132" 45.7' No. ozo iv engineers a65 -_ -_ oleo BTe o¢` gro�ess,o`�o civil Scale:1 20' _ sro nL eel su /and surveyors NO GROUNDWATER ENCOUNTERED H 1, -Is 939 Main Street ( Rte 6A) 0 10 zo ao ao so FEEL - DATE DANIEL A. OJALA, P.E., P.L.S. / YAR44OUTHPORT AdA 02675 _ ^ DCE #15-057 15-057 ZIKAS.DWG