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HomeMy WebLinkAbout0102 SKUNKNET ROAD ..� .. :< x i _ _ � ,. �� � � �;. a e o - 3 �. � _ , � �' f TOWN OF �ARNS TAcAPE FOLe I N S U LA If } +J fi1 8.' 56 118ER 04ASS SEAMLESS SP T p SLgREN�� BATES UURERS IN I j+C LLINO�Ecay, �� 1-800-696 { '° Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: Y/I 1,3 Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Pro e�rty Address Village P 66u Skuk.kn0 r16L 6"4/V ale, n Insulation o Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ( �) ( ) (K) Slopes ( ) ( ) ( ) ( ) ( ) Floors Walls ( ) ( ) ( ) ( ) ( ) C� Sincerely hECasJr, President on, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map q l Parcel oil Application Health Division Date Issued I �� Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board t'iSJl3 �� Historic - OKH _Preservation /Hyannis Project Street Address 102 �tw k yL&� Village G -�,,V'V6/1-e- . ol n- Owner 4f,2A i t 45&x (i lti Address Telephone 60W -71(f 1 �S �� //,^, Permit Request Vl 9WI ZW IV -_ to V n015 a I r `a-Waw keg Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ��' Construction Type 1k45V&1hA_7­1 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 Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Numbew'_ f Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other -4 c� o Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal�il6ve: ❑la's ❑ b Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existi,"ng ❑ new5ize Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ sv rr+ Commercial ❑Yes a<o If yes, site plan review# "- Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name i�1�G� �d c0 /.�,�f�j i d� Telephone Number �-3-3y Address / d . License Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO y SIGNATURE DATE LA � 0013 t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE 'y OWNER ' } DATE OF INSPECTION: FOUNDATION FRAME ti INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL t GAS: ROUGH FINAL FINAL BUILDING t I DATE CLOSED OUT ASSOCIATION PLAN NO. ;J Massachusetts - Department of Public lafCI% Board*of Buiklina Regulations and Standards_ Construction Supervisor License Licenw.. CS 100988 HENRY CASSIDY 4 8 SHED ROW WE8T.IJARMOUTH., MA 02673 Expiration: 11/11/2013 ('uuuuisiune'r Tr#: 7620 - -_ Office of Consumer Affairs and Business Regulation -- 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 , Home Improvement Contractor Registration - Registration: 153567 Type: Private Corporation Expiration. 12/15/2b14 Tr# 233831 CAPE COD INSULATION, INC . HENRY CASSIDY 18 REARDON CIRCLE -- ;r SO. YARMOUTH, MA 02664 r Update Address and return card.Mark reason for change. Address Renewal (� Employment ( Lost Card SCA 1 �'.� 20M-Os;1 t Office of Consumer Affairs& Business Regulation License or registration valid for individul use only, _i OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 1.53567 Type: Office of Consumer Affairs and Business Regulation xpiration 12/1'5/2014 Private Corporation. 10 Park Plaza-.Suite 5170 Boston,MA 02116 CAPE COD INSULATION �,I HENRY CASSIDY F 18 REARDON CIRCLE'. ,_ SO.YARMOUTH, MA 02664Ao Wnat Undersecretary with0 t Gllentif:4507 CCINSL1t 4. ACO1 D,,, CERTIFICATE OF LABILITY INSURANCE UA'I't IAIhIIpUJY1Y'y) THIS CERTIFICATE JS 1`S-iUE la AS A MATTkR OF INFORMKiIoN ONLY AND CONFERS NO R(GMT9 UPON THE CERTIFICATE HOLGC'R�i11OIS� CERTIFICATE UOL$ NG'I"AFFIRMATIVI`LY OR NEGATIVELY AIM:NI),EXTEND OR ALTER THE COVERACE AFFORDED UY THE P F.Ik4.UVV. 11115 CER1'WICATC OF INSURANCE DOES POLICIES - N - RFI RC3l:N rA'I"I V= UT GUNS I I1 u I k A CUN1"F2AL'T BET I. C1ly F r1C�4]UCtFV, AND THE CERTIFICATE IIC)LL)ER. WktN THE fSSUING INaURf=ilt(S),AU1 rrGR12.JL) ._.._______ , ANT IF tllo cartlfll�tw huld�r is an AbUll'IUNAL INtiUI,t u, lln 11ulicy(ids)must be enduraecl.IP SUBIiUGATICAN IU WAIVfiD,subl,,,,l w uIc Icnnu Il lcl co or ill ,of ttln policy,cnrtaln pullclao nLny I,,,,,I,„ II gndnranmanl.A atlltanlerlt tan WIS r:ISllrficula aclev nul c-onNI nUllla to the I.[lulflwly rlulLh.r in It�U ql'SUGh nI1C1Uf9GRIG111(9). Rut(r:r.; Y Gray Ills. -Su. I-Atirmu; NAME Mat LdfetYoun --� Nt1oNe aid Kiulte 134 IArC.No,Ear1.508-760-4602 11 rHX - e'MAIL a16 11�6 Su1.Ilh t)unrylc;, MA U2U41)-1 GU 1 � i 1`)iA 7UlID . INGURF,IiIG)ArhUW(11NUCIlUL-flAlrli ....... -... ___ IN!URERA;Peerloss 111St1railc) ._. Inn — ---..__...._._ C':,pe Cocl Insulat{nn {nc wsulieRtl:tvanxtan Innw'ancll Cc)rnp;4ny ZI:;S altnl)utfL F;cJa<l NsuReac:Atlantic Charter Insurcrncc Ilytuuli-1, NIA 0260.1 In9ukr'R0•COrI1It1CfC0111FIUri111C@C011lhllly 3{I75q u0M-R c:: _:OVJ J(A( I:_ -__ _. rveua�r r -- 1 L I�flh IC'.AI L NUMBER: __ __ VISION K)1 II fcJ <,t-1 111'"1 JA1 I 6{ NUt.14Ir' fir wSlJHHNIe „!_ I rIAVt tIEENISSUEQ 10 1HE INSURL•D NAMt_GAnow-, FUR I-Hk I"Ot.IC1'PtttIOD WUIt„UI.LI. I•JQIWI1hia1ANDINI; rCNY Rt-QUIRENIENT I1 RNI OR IONI;11101,10F ANY CONTRACTOR OTHER DOCUMENT WIII-I RLSPLCI TU WI-IICd-I Ililti .LRIIHGAIL. MAY BL IB$t1C;t) OR MAY PERTAIN. THE INSURANCc ;irrinWE0 BY THI_ POI-IC12S DESCRIBED HEREIN IS SU0JEG'I- '1"0 ALL. TH I'LitNI )rAJ_t_1151UN5 AIVD CON____ iTIONS OF SUCH POLICIES. LIMITS SNOwiv ra;l1'H,SYff BEEN RCOUCED BY PAID CLAIMS. iTR I'YF"h,Of"INyUNANGE AROLSUBR — PULICYkFF M20`1'ra.l rvL u`I1 IA1Al10UryYYyfuLNL'LiAL LIALtlr111' "-" CGP02630n 4/01/20'12 U4/ EAGrloCC41t4rtErtr.,PT T'1,000UOU x CQMMEMCIAL GI Nt LtAL LIAL11L11-Y nrcu„nn a 9'1011 UUII _ l I.AIMti•MAUC r.,X1 OCCUR ...._.___ .. 011 L0 4'.hP(AIIY 1111,1 Plll11hr11 _. 5 Ut)l).... ._.._ .-_-.__-----...._�....----•--=- L1kN4RALNC11;111hCiAllc �2,000,000 L-NLAU41LLUA)kL.Im,IAPPLlQm119R: -- --..__......--_.-•- I I 4'hI_)- ( - .�, PNuuuc.l s•GQMI Jw' no)i)• yl2(1U11 IAl1U...:.._ _, I) Al1TiIMuF�ILk uAIaILIrY ---_.._.__.-. _ 12MMbCKVivo, 01(2012 04/0'1/901- COOMI3llgV -�INGLCIINIn rILUUURUUU 000ILY INJUM' P,11.1-UWNL-U x , t 1 I I - AC)'I US - 49001Ly'INJLINY lPu , d nl) � X (UHLO Autos X NON Oyma) NROPEI'�li IIANIACtk'-- -- _ — All ra3 lIJILUGsl4ttltul . __._.._.....___x........----......__ -._...._.. X x l"{ U .MiNkI LA l TAN __.... _,-__ ._ .... . _ OCCUR XQNJalS h I dlU'112U'I Z U41U1l.'U'1( rrcrL cTL:r ura. Ne 1 J 1 000'GOU t 1l l,LSt LIALI - . . �IAINIS-MADE y1 UUU UUU nI Xlr+rlrr�Irur! 'IUUUU —••---- —_____L__. _. WurtttrtN t Uh11 tNtlA1 wrv -��—'.�- , AND ry WCAUU525;1U 613U12U12 Y/N 061301'10'1' k we 11A1N II IIoii'i Ary I tnl,u,L ,)LP,ArI"rIL j/ I( I Iv a 1)LAJnJ111,1 ..lkli_ _.._.._ NIA C L.CACI I AC C1fuzN1 00(1000 _.. IM1IunUuLo, -y nl NH) I:A CgaPL)Y6k vI I— UUU ON) I UI'SI'NI!'rION OF UPL•RAONS Noltlw ..___....__.,.___.__1_.__t.. _ C.L.n1sLASL•POLICY LIAUT y I ODU UUU !ItJ�all'lu)N pl'UPL•I<A 11ONS I LUCAI IONS tVLNICL65(Agauh ACORU IUI,Alldlib, I i a,ic liShduulp,It IAVIti dNAG'd IG ftltIUIIHGA ,' „Woriiers CurrtlJ Infulrr4rstiorl �" � � . hltau(iG,GI Officers ar I'rpprll�tol"s . Cvrtlrlca4a l luliJrrr'.I.T trlyludovcl tits arl add,itiUnBI II1Surt111 u11iIIJl (;LJnurat LioOility wllon roqulrod by wrlttlill cuneract or agreement. CFR1irIC AI F 1-1 L.I11:1. �. �_ _..... ... _~ —.-.•- - --- _ — CANCELLATION Ca)]n C.aQ II1KU1r,It1U11,1(IC, - 3HOl1LU ANYOF THEA60VC IJESCRIOED POLICII;I OE GANGha.u:h url UrtG THE EXPIRATION DATE THEREOF, NOTICE WILL BL.Or:LIUt.kEP IN ACCORDANCE WITH THE POLICY PROVI;HUNu. AU I'MON120 RCNRNSL'N IATIVE (O 1911 1U1U ACORD CO RPORA"I10K All rlyhlu tvvvi4vtl. AI:UItII:'�j�U'IUIU ) 'I G)f"I The ACORL)Rama and logo:uLl r(;Ul:;lurud marks OACORD - - - IM3840/M836411 w MkY The Commonwealth of Massachusetts Pr.Int-For-m Department of Industrial Accidents Office of Investigations. 1 I Congress Street, Suite 100 .� -,; +' Boston MA 02114-2017 _ www.mass.gov/dia ` Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): At7a la h d Address: fa &Vdbu. City/State/Zip: UVLt MA' Phone #: '2_0�— 7 1Z Are you an employer? Check t e appropriate box: Type of project(required): l. I am a employer with 20 4. ❑ 1 am a general contractor and I employees (full and/orMpart-time). * have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have S. ❑,Demolition working for me in any capacity. employees and have workers 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof re��j1a��rs Q insurance required.] t c. 152, §1(4), and we have no 13. Other We���tG(�f Z( � employees. [No workers' comp. insurance required.] Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'onl.ractors 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. II'the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name: ck V, Ci Policy #or Self-ins. Lic. #: W6AQ,9 SI-9 01 Expiration Date:A�_I ' Job Site Address: f DZ r kU 4-a City/State/Zip:C i(ew •C._i V�k OZ 3 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 tine 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 tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. L do hereby certify railer the aims grail penalties ofeer'iirr that the in ormation provided above is true and correct. Sionature: t ' j / Date: Phone#: ' Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector'5. Plumbing Inspector 6. Other Contact Person: Phone#: P mass savecoffrum PERMIT AUTHORIZATION FORM , -,-owner of the property located at: (Owner's Name, punted) (Property Street Address - ---- hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform_ insulation, and/or weatherization work on my property. �wrier's ignature FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project. Participa ' g Contractor : Date Rev.12132011 J 4 �• �_} f. "�Y .. J ,rJ k'x 4 ar }_t 7 �, far-* J;' + `t .. n d v• � 1 i< S �J� .rk e,n r., •' d rJ t , �f' k `'t �5 . - .y�' t .,+, -'� r ' ."t ,}• "`,rc` r. �''yq ;µ`' Imo. �{ f," ; .;?} r} ,,k �3 1K^µ, .Y-43�' :yJF t .�. � C� . '� \, ' t'fa ,5tt 4..n i a d, ,» Y �,- � n'n '1 N.<'. 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'p•a.�.`^ •r y Y g 'V•€"' �' ` %''. ,"" rim� +.lFd. �'v�t¢ ��.F. �� �,'y, j° i:. c f Ar'4 U y. t• 'C /,"� r, r r .. ^wJ '.-�5^ �� `k�"• �,,,�• ,,,y �4 ; � y fq'3 �3•f vtiiv'i.'#-�,� > i r t.� � ,t; 5 a n "_� ��.� ` r,dr5 S;i ���, <' �, � � � � �. '�1F+ 49. ^ • •�,'� �$'.�y�• �'���a 'F ��•'. -,�,y, � " '��c �t`:i s ;w°r��� `:;�� F i r s ,S, eY� 7•'K`d w � � �•'"� n �'��ar � yea ;*.�;J y ,� �, �,� .: v� JXA.PA -. , { .. .7' J4. 1 5f � M1i� � t�M r �4 e'. 1 �f �'� ♦ ♦:8 � h '- 'S. O' E,S�S`b'6���1N ES' �r� � � C �h d e} y y >rfr;\ '� * 9 +r •' '^ ...: •4'� "4r ,r ta".. � `� �,. •M1rr 'T';� 'r � s P z��d����gg��} ~� e'?a A. ��"`.t� �.-+t���� y;'. J . t F a 1 .,s .^per z& Y�.'.� R� ic7 ik.t'4wi .ri �••' , �„ ` 3 r. PP •t, J, �. t r. wit{ x� ��491Ptii� � '�^y^}„,+Jy� xp�ip!#f{, y ITS, •5 r yi t Assessor's office(1st Floor): > Qf Assessor's map and lot number 11 o �J � O*TW E TO Board of Health(3rd floor): y-7LO.E® BN ®M �'�'`'��C Sewage Permit number l/f WITH T 5 • Engineering Department(3rd floor): V �@ 1 ONMEWA�.CODS A •' = BeaMAS& tL I �0k1 V LG cam, � 7 raei � House number /1) off, �Y✓t TOWN RIEGULAMONS 1639. \®0 Definitive Plan Approved by Planning Board 19 �o.0 a• APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only F BARN STABLE ® TABLE S BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION 19 r� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: � T. Location ��02 u w K m-e�"' Proposed Use Sudl iZ Zoning District �,-�- Fire District ' Name of Owner\:YA4 S e>t7o, Address Name of Builder Aa ress /�3 �d4aAli- J ,f�P Ce-f�-r�'�� Name of Architect Address Number of Rooms � Foundation Exterior L44 S4/,4gkC Roofing As t7AA4''"— Floors eT Interior Heating b�`E3 Plumbing e �m Fireplace st/®� A 1� pproximate Cost Area ` D� Z�o S, Diagram of Lot and Building with Dimensions Fee b �to r 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. .Nam Construction Supervisor's License DO�G�a3 10; SEXTON, JOHN No 33461 Permit For Build Sun Rcom ' 'Single Family Dwelling Location 102 Skunknet Road Centerville Owner John Sexton Type of Construction Frame Plot Lot Permit Granted Janiiary 1 7 , 19 910 Date of Inspection 19 Date Completed 19 co Town of Barnstable: *Permit#c�; 0 -a Expires 6 months from issue d e `C.pRE Regulatory Services Fee �. p omas F. Geiler,Director OCT 12 2006 Building Division *QwN O Tom Perry,CO, Building Commissioner d© �b�j3G))a iD BARNS-rA 20OF Main street,Hyannis,MA 02601 BLE www.town.barmtable.ma.us Office: 508-862-4038 Fax; 508-790-6230 t. EXPRESS PERMIT APPLICATION - RESEDENTLAL ONLY Not Valid without Red X-Press Imprint ap/parcel Number Ujlb roperty Address CI i esidential Value of Work � . Minimum fee of$25.00 for work under$6000.00 wner's Name&Address �1 - 1 C�a ,UM P.� - 0,0Krt-P.&0 11[ ontractor's Name�, + .3 P, S��„� I Telephone Number )���� ome Improvement Contractor License#(if applicable) (� ( C(C( onstruction Supervisor's License#(if applicable) 6 v 4 Workman's Compensation Insurance Check one: ❑❑ I am a sole proprietor am the Homeowner I have Worker's Compensation Insurance surance Company Name ��©( � S oikman's Comp.Policy# Wit, 1[� opy of Insurance Compliance Certificate must be on file. ermit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof j Re-side Replacement Windows. U-Value 3 (���.44) *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. Hom Improvement Contractors License is required. 1:Fose071405 NATURE: c� . mu:expmtrg . t � B0- of Boildii e nS la HOME IMPROVEMENT C and Standards - Reg istratro: CONTRACTOR \1,01149 Expr.at{ x 2008 s � t1ANlduai A JOHN p' DUNN t. } _ yt John Dunn O �--���/j 80 MAR E 'lE ANN T j!`r CENTERVILLE MA D"PtIty Administrator 1 - r ` Department oflndustrial Accidents W Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: a) ��lA2c� k�40 l V.Rs2 a City/State/Zip: Phone Are yo an employer? Check the appropriate bog: Type of project(required): 1,P'lamaemployff,with 1 4. ❑ I am a general contractor and I employeesfr6Vnietor d/or part-time).* have hired the sub-contractors 6. El New construction 2.El am a sole or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8: ❑ Demolition working for mein any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' Comp.insurance 5• ❑ We are a corporation and its . required.] . officers have exercised their 10.❑ Electrical repairs oa additions 3.❑ I am a homeowner doing all work right of exemption Pei MGL 11.❑ Plumbing repairs off• additions myself.(No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other -5r AJ, 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 thateheckthis box must attached an additional sbeet showing the name ofthe sub-contractors and their workers'comp.policy information. 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-Ms. Lie. #: 0—e&XX)46 Expiration Date: Job Site Address:IDS-SeUl" City/State/Zip:Cewalw'Ac d1a65�-- 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 certi;fy under the pains and penalties of perjury that the information provided above is true and correct Signature: Q� Date: 49, D Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority (circle one): i.Board of Health 3.Building Department, 3.CitylTown 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.. a Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of 1rLire, 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 legalrepresentatives 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 produced acceptable evidence of compliance with the insurance co-Verage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commomvealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of corrupliance 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-contractor(s)name(s),addresses)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 fur 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 OifieWs. 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 yew,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. Anew 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of investigations would hike 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-M-ASSA.FE Fax#' 617-727-7749 Revised 5-26-05 www.m2ss.gov/aia dF THE�p� Town of Barnstable iyo • Regulatory Services Thomas F.Geiler,Director 'pIID) y►,� Building Division.. ,r Tom Perry, BuDding Commissioner 200 Main Street, Iiyannis,MA b2601 W"Aown.b arnstable.ma.us 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using ABuilder as.Owner of the subject property hereby authorize --Tpt-� Q. LJ�J to act on my behalf, in all matters relative to work authorized bythis building permit application for. (Address of Job) Signature-AN Owner Date b(JiL .Bern Print Name a Q:F0Ws:0WNtR?ExMIss1QH ULT'" CERTIFICATE OF LIABILITY INSURANCE 10/10/0 6 PRODUCER (781)344-3200 FAX (781)344-1425 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Malcolm & Parsons Ins. Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Frnan"'St. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 527 Stoughton, MA 02072 INSURERS AFFORDING COVERAGE NAIC# INSURED Jon Dunn INSURERA: Associated Employers Insurance DBA: John Dunn IINSURERB: P.O. Box 924 INSURERC: Centerville, MA 02632-0924 INSURERD: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH CCCURRENCE 5 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S CLAIMS MADE u OCCUR MED EXP(Any one person! S PERSONAL 8 A.DV INJUR" S GENERAL AGGREGATE S GEN'L AGGREGAIF LIMIT APPLIES PER PRCDUOTS'COMP/OF AGG S POLICY JECT L'OC AUTOMOBILE LIABILITY COM IVIED SINGLE LINK ANY AUTO ;Ea accident) S ALL 0"NED AUTOS BODILY INJURY SCHEDULEDAUTOS (Perper&on) S HIRED AUTOS BODILY iNkNRY ------ ---'-—'------.._-- NONDWNEC.4JT0.. U (Per a=ioent) S PROPERTY DAMAGE S (Per nooldenq GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHERTHAN EA ACC S AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE S C•EDUCTIELE S RETENTION S S WORKERS COMPENSATION AND WC0004658012006 09/29/2006 09/29/2007 INC 5TATU• 0TH- _ EMPLAY'ERS'LIABILITY ' Y UMfTS A I ANY PROPRIETORIFARTNERIEXECUTIVE E.L.EACI-ACCIDENT S 500,00 OFFICEP.IMEMSER-EXCLUDED? E.L.DISEASE-EA.EMPLOYEE S 500,00 If yyes.de-nbe und5r SPF.61A1 PRCVSIONS below E.L.DISEASE-POLICY Llwl S 500L000 OTHER DESCRIPTION OF OPERATIONS f LOCATIONS]VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS A CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of Barnstable BLT FAILURE TO MA L SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABIUTY Attn• Building Department OF ANY KIND UPON-HE INSURER,ITS AGENTS OR REPRESENTATIVES. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE �—'-.0' .... Irvin Parsons - 9 ACORD 25(2001I08) FAX: (508)790-6230 (DACORD CORPORATION 1988 a. Town of Barnstable FSHE Tp�� Regulatory Services N 0� * � Thomas F.Geiler,Director 9 MASS. . g Building Division 039. 'Olen Mph a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PERMIT# U FEE: $ SHED REGISTRATION 120 square feet or less \\ f0e� �IK(1m�17P�r �� �e.Yll7'Pr�7t C�� -- Location of shed(address) Village. n Property owner's name Telephone number l � l / / 0 Size of Shed Map/Parcel# Date Signature Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature required) PLEASE NOTE: IF YOU ARE WITHIN�W JURISDICTION APPLICATION F EOM COMMISSIONS,THERE MAY B PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg RFV:121901 3,, LOCAT N OF--P - OPERTY LANE A4 IrqOT BE ACCUR STANDARD LEGEND NOTE:not all symbols will appear on a map GOLF COURSE FAIRWAY 92 1 EDGE OF DECIDUOUS TREES EDGE OF BRUSH T ORCHARD OR NURSERY V" EDGE OF CONIFEROUS TREES MARSH AREA — -- EDGE OF WATER DIRT ROAD ............. t DRIVEWAY PARKING LOT PAVED ROAD DRAINAGE DITCH ————— PATH/TRAIL M1 � 1 PARCEL LINE** pI I MAP 110 AMP# 21 PARCEL NUMBER #1160 HOUSE NUMBER 10 , \� 2 FOOT CONTOUR LINE —i�— 10 FOOT CONTOUR LINE Elevation based on NGVD29 102 `•'4.9 SPOT ELEVATION STONEWALL -X—X- FENCE RETAINING WALL RAIL ROAD TRACK STONE JETTY `Pow SWIMMING POOL 1 PORCH/DECK C� Q BUILDING/STRUCTURE r € DOCK/PIER M 191 a Q HYDRANT e VALVE OO MANHOLE n c) ---'-------- ---- 0 POST 0'P FLAGPOLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C I N F O R M A T 1 O N S Y S T E M S U N 1 T .a SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The James 1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE ❑ TOWER w " e 0 )5 30 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetrics,topography,and vegetation were mapped to meet National Map Accuracy Standards s 1 INCH=30 FEET* enlarged scale. on the map. at a scale of 1"=100'. Parcel lines were digitized from FY2003 Town of Barnstable Assessofs tax maps. � LIGHT POLE O ELECTRIC BOX . r . ... .....'✓•`•.. . `_ _�• k•. ..i--[.Jc,�{�Y'� '.*-.iwrti-t.y'w,. ^.._y},. 7's> •. L ... - ^�:��.._�.. ,, .... , Assessor's office(1st Floor): �/ - Assessor's map and lot number �� Q QJY _ QyoF'TME Board of Health (3rd floor): l�� r Sewage Permit number t PASd9TSDLL J Engineering Department(3rd floor): �^f� (� ., -rasa House number /P1 �. !•Y °o -1639• ®� Definitive Plan Approved by Planning Board 19 �o ypv d• APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M.only TOWN OF BARNSTABLE t_ BUILDING INSPECTOR 1b `AFPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION > / / 19 TO THE INSPECTOR OF BUILDINGS: _ The undersigned hereby applies fora permit according to the following information: Location /0a ,S- to 14 K Proposed Useu Zoning District Fire District Name of Owner 11 401 S� � Address Name of Builder L 'Address / 1_64a*rA P Qt, Ce Name of Architect Address 11 Number of Rooms Foundation t.+f� �- 1�7r C� f�'�►A� r � r Exterior �� �'' �+"� Roofing ` t Floors �/�! oe-7 7 Interior Heating -10 to Plumbing � � e M r� Uac� Fireplace ! �' Approximate Cost �', .7y 00- f< � Area 040 AT401 -- Diagram of Lot and Building with Dimensions Fee CJ it !` Of OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. r'1 Name Construction Supervisor's License � �� SEXTON, JOHN A=191-110 - Jqpl� No 33461 Permit For Build Sun Room Single Family Dwelling Location 102 Skunknet Road Centerville Owner John Sexton Type of Construction Frame Plot Lot Permit Granted January 1 7 , 19 90 Date of Inspection 19 Date Completed 19 PERMIT COMPLETED 1/1/-2L /'IJ //