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0001 VICTORIA STREET
l� }� � . . / l� / �� ( � .� a .+! � - � ., -: �.. .. .. f _ - .. ,. ft n L � � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ��3 Parcel Application #, (O 3-S Health Division Date Issued /F?-1—/(0 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Villageaw6&19f�z !Iqp, T1 �. . Owner , S Address Telephone Z f R ">_t Permit Request rg. / ,-CMbX o� ;Z.,`S p S,rr A Square feet: 1 st floor: existing YD6 proposed �2nd floor: existing .proposed 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 Two Family ❑ Multi-Family(# units) Age of Existing Structure �7� Historic House: ❑Yes o On Old King's Highway: ❑Yes I4 Basement Type: II ❑Crawl ❑Walkout '❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) lJ� Number of Baths: Full: existing 2 new Half: existing new Number of Bedrooms: 2 existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: K1 Gas ❑Oil ❑ Electric ❑Other 81AD��,' Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stdWowI >w Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Ban: ❑ new size_ Attached ara e: existin ❑ new size Shed: Q existing ❑ new. size Other: g®�6 g g + g — — �n-q 4STq Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes o If yes, site plan review # Current Use Proposed Use S APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �0!9R�kj AQOrsGi> Telephone Number d��� S�3 Address pc (61 License # G� I Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Ulo FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. -� ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. _ I i r - - V 1LF'i V/@4JL47ICtRtLPCL��fL Q�Ul�GC7rJC!/,'fILIO� t Office of Consumer Affairs&Business Regulation . —' ME IMPROVEMENT CONTRACTOR gistration 163296 Type: 4ExpiraUon 6/_1/2017 y Private Corporation TIM SHERRY-'HOMES'�INC $ TIM SHERRY i � 2 SIGNAL HILL DR — _ N s.,,A, — DENNIS,MA 02638 Undersecretary Massachusetts Department of Public Safety, Board of Building Regulations and Standards License: CS-078486 Construction Supervisor or TIMOTHY SHERRY PO BOX 169 E DENNIS MA 02641 4 4 CA, . Expiration:.- Commissioner 10118/2018 Town'of BarnStabe Regulatory Services Richard v.Scab,Director y Building Division. Tom Perry,-$uitding:Gommissioner. 30o Main SReet-JyanaisrXMA 02601 wWwMown.barastabi a macs Office,-50 Fa 509-790-6230 Property-Owner. Must . Complete and Sign This Section. If 76ing-A Builder s ;: Ly. `. l.�3�1 1._h ,:as C)wner:of the subject property . hereby aufiorize 11 Im to act on rny-behalf, mall rrdarm relative-to work authorized.by this bua44*peotr utapplication 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 fuia. tnspec ar e Formed and accepted., ign re a- er Si - lure rrlppficant Print Narnm Pant tame Date e Cttzrrmretti ofsrac�t Apartment t frudxs&idAcddamtr . $AO WasbirT ngtr,Ia S rwt i Boston,MA 02HI w�v�sa.m �mgVdia Wurlm& CumpensafanInsurmce Affilavit lkgder-JC` [h-zcbwsJFkcftic-iausffl rnrr.he Please Print f.e Na= S Adddyes-s: Xm K Pne Are you an employer?Checktht:appropriate btu L❑ I am a 1 v� 4. ❑I ant a general confoctar and I" Type of project{reg,�ed}= �P * have Isiredtfie suer-cotes 6_ ❑New co Uucti� • emplayee�(�11 a�for part-iime)_ _ • listed aathe attached sheet ?-Nr�v�,,,' g 2.❑ I am a sole proprie#mr orpattuer- �"`6 . slip and have no employees These sub-ca�is have 9- ❑Demolition wotldag forme in any capacity. aadbxVe Wado rs' 9. ❑Bnddmg addition [NO .rap-iasurancti comp-ksam+�# required-] 5_ We are a coapotat ion and its 16-0 cad repaim or adc€ Qus o$cers have excised ih . 3_�Zama bomeo�er doing all wad _ 11-0 Piumbiagrepaiss or additioss + ra workers' u�of urtamptiau per MCEI. r - c-MJIMa•�ndwe7�eno L-Dl�naf employees.L N a wppa&�Me& 13-0 Other cam-msQ[BII .•LY"'� '� '�YgFF���stchedsboz�l�staLSaffia�thesectFoaheIaars�csdagt3�eawadc�m�P,•@A�,,•peycginfocros¢o� �u�eoaagrstelmsabmht7rissffidaegi gt3regaa=dc elf Wadsadtheahiigaut crn amstsu7nmtaneW2ffid2VA smrb z,=w cft=-ff sr chxlcthis b=m=attach suaddiTmaat dfbeat shmxngthena cf the smt-camtsctom and stateorhethu armMihnse eati sI; empfeyem If the m,h..r�+*� ,�hace=TiQSfe%tfiegamstg—idethev Rod—'-mP.paficg a+M3her I am an empLaar tliatis prat d ivQrkets'coo rrsrifien utsrirartcs forury enrptoywet ffeIarp is fliepvFiry turd jala site �,jatzrseriiort - - Ia i a Cam.pang Nate . Pafic or del€-inL Tic-, aQDate` Job Site Address: CitglSlai Af#ach a copy of&e woxkere compeusationp.olicg declarations page(showing the policy number and expo-zdon(late). Fafl=e to swm—F--coverage as requimdunder Section 25A of MGL m IT-caa lmd to ffie imposition of airnmal penalhies of a Fine up to$L50D 0D andlor one-yrarimpdsanneuk as well as civR peaaliit=s is$he fart of a STOP WQRK€]RDERand a true of up to$250M a cky agahut the viola nr_ Se advised tlkd a capy of this sha zmmt may be fnsv coded im the Office of . Investigations of the MA for iins>mc-covmge vedficaticdL lido hffdT Garftff undcr tlrs pams and penalfirs of.$erjuty tliatitia inf brnra€ia4 prm tded a ig bus mid correct — - :Dkte_ lr a Pbaue O&W uas Da wt write in the=ea, be=mp&eJ by coh)?artown,a�'irciat My or Tams: Permifl;tense# Issming 4 °zdy uncle ane): L] am-d of Ht2ff ll 1."'ffffin;DepartrIIent 3.CRylEowat Clerk 4.Ele triml hmpectur 5.Phmbfiig Lector Contact Ptarsnn: Phom#: - 6 Sarmatian and lns c ons ' M�rc�r3rr�cef fS�-�I.34PB C I�rcQdacs a'Q c�Io'yeS'�Ptff4I�B�'P��.P��fI��IF C¢�IO�. . pmso�.{iris sf�,an�£oyee is dammed as¢.�Yezypawnm$ire s¢vice of an�rr ffider airy coM±ract ofbUr, czpress or iDIpl OCL oral or wr:h=." An ezv&va is dmimcd as"an.mrfividual,Pam,assocfilfi ,ccrPD&°a-or Ora=legal=±±y,or my two or moan offhe forteg�=apged is a3oint=taPjse,,md.inclndrngf3m Iegalr=e mt3fiV s ofa deceased=gAoycr,or ibz rerciyes or trustee of an in� p association or of=Iegal ed3iy,eoq g=PIDy=S- Tioweve'f0 own=of a.dweI�og house having not mar-t3�three apartme�s andwirD resides ii�em,or the- office. dw lag house of�who employs pms=to do maw,constru�on or repair work on such dw-I&ng baus- or am.tbo givunds or bmZdmg apg�f-a=fo sban=tberaase of surds esploymeatbe deemedto be as m3ploya:" MGL chapter 157,§25g6)also states that aeYrsp sf or Iocal Ficea-sizxg ag-neg sFsall w fioI3$ie t Amer,ce err rmew2j of a)cease or permit to opmate a busimess or to cnnstract buildings is f r.c 3_ nwr_21$i for any applic=tw•ho has notprocluced acceptable evid=c=of edropTtanm wUk fb"hmarrancz coveragere� AdrTrtianaIly.NM(H chapter 152,925CC7)states-N=fbccthe nor any ofifspoTfical sobEvisions shall the fi=M.C6. P-71 i3 , any contact fnrthep ce ofpnb"r Vorlc�7l a ble a videace of comphance wrfii rcq===ts ofthis amptcrhavEbeenP=errdedto fbe CMftaCtjng`anihoufy." Applicaafs - Please fill oiA tine wow'=mpearsafion affidavit completMIY.by Ong$e booms ihat aPPIY to YO=sltaa and,if necessary,snpPfy�DrCs)narne(s), adch �cs)B33Apb(=mTmbet(s)a1ongw1affi=certffieate @)of insurance. Limited Liability Companies(LLC)or LimttcdLlabi-My Parfnessbigs.(LU)wAno empIo-pees offi=fhMflM members or pmta=-s,are not required to carry wm ix&camPa'M�M insurance. If au LLC or LLY does have empIoyees,apolicy is reqaired. Be advisrdthatfbis affidaYrtmaybe saw to fbe Department of Iudastial Aecide�s mr confamaiion of instance covasga: Also Be sure to sigu a3.d daf the aftrdayit. The affidavit should be mtimed to file cifyy or iDwn that fire agplic gm for f=permit or Iica sc is being rnqucsted,not the Department of wolArm,d� nouldyou hate any quest Ms regajm.g the law or ifyou are required m obtain a sbnld UICI ii�eir rs' =npcnmtrmpolicy,pleasecaafi=Departmeatatfhennnumb=listedbelov- Self-msmeda�saniesen r self-il curer»ce Hccose nurah r ozr the apprcm Im-_ City or Tower OfUdals t Plcase be sore fhat tbz affidavit is=njI-fc andpriofedlegibly_ 'The Departme than pm-vided a space at.fbcbottom of the affidavltfor youta fOl orrt in.the evert the OfficeT� ofestigaiicns has to corrfactycraieg�gtbe app cant. PI-asebesureto fMinthopeu�jif'CliceosemrnbezwbichwM be;used as a=fezeocoM=bcr_In-addifion,Mn Tlicant shirt mrlst submit multiple p�I'ceuse appIit�ians in any given yew,raped°nIY��one affidavit .g�t polic�r infozn ation�rf nccy)and ceder`fob Address"$�appIicaat�horld wrd��aII Iouns an (cry or town)_'Acopy offhe-affidavitihathas bceat offid zny stamped ormaximdbytlm city orfDwnmay bepmvidad in ' applicant as proof that a valid affidavit is on frIe for frdur-pmmifs or licenses_ Anew affidavit rest be filled o each ear.Where ahome owner or Cad?is obbi�g pcommercial�, alice�sc or ermitnot=elafEdin anybvsinrss or VdMh= (i-_a dog license or permit to b=leaves d�.)said person is 1\IOT XCT)iedbn com.Plctc tliis affidavit eafion and sbovl:d you have any quesii®s, • The 0$re oflny� o�^** wovLiIl�fnthankyoniaadvancafOr YoTm co DP pIcsse.do not h csaEsz to tin us a call i The Department's ad&w s,t-l�and fmnmiber - M&OilIl xeviscd¢24--07 iP, j C-A - S 01 TA d',UIL c DING DEPT, nOV 14 2016 TOW OF BARNSTABLE :S e FI►,E t Town of Barnstable *Permit# ^/ A 2. Expires 6 months from issue date �-- Regulatory Services Fee �� 60 MMSTABLE, g Y 9�A 1639 MAS& Thomas F.Geiler,Director Building Division . Tom Perry, Building Commissioner j 1- e� 200 Main Street, Hyannis,MA 02601 m R ; �n Office. 508-862-4038 . APR Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL OAT - �STPZLE Not Valid without Red X-Press Imprint TOVVNU Map/parcel Number Property Address �d Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name �1t11/,y �.�1J�i Telephone Number L Home Improvement Contractor License#(if applicable)/2a zl4z--7- , Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: C ❑ I am a sole proprietor ❑ I am the Homeowner (,I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy Copy of Insurance Compliance Certificate must be on file. t., A Permit Request(check box) �2/Re-roof(stripping old shingles) All construction debris will be taken to �7�/�✓� ❑Re-roof(not stripping. Going over. existing layers of roof) ❑ Re-side. , ❑ Repiacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town — �,/vcaaaac`cuael�o i Board of Building Regulations and Standards . ***Note: Property Owner must sign Property Owner Letter HOME IMP OVEMENT CONTRACTOR Home Improvement Contractors License is required., RstrAwi\100497 egi t 006 Signature h P to Corporation • a 1. 7 'C Q:Forms:expmtrg DAVID COX,IN - Revise063004 li, David Cox _ 0 { 19 LAVENDER LN W.YARMOUTH,MA 02673 Administrator . .a x The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street, 7rh Floor ?f Boston,Mass. 02111 Workers'Compensation Insurance Affidavit:Buildin lumbin lectrical Contractors name ✓rf'�/ �� address 1'57 14 e&,42Z� City state: / /� " zio ,UZ?phone#'�?2 work site location 0UH address): I am a homeowner performing all work myself. Project Type: ❑New ConstructionERemodel I am a sole proprietor and have no one working to any capacity. Building Addition •P.'+w .>1k'�„ �_ry a r.^a...I�.r...h;.v.v�r .:y. :i�A 9t..r">'�":^-z-'.�°;'3`..."�}[".,.,. ...,"��Y�a•.:.:.�.�ac.%:� � ��'�,� .�'S:�:ty.," . .,ram,:,;Yea :.;,'�'�''s' ts�'-.'`�`�,•`-•...:14..,a":,ca' ,f l:•:,:r.::':.;.....c ....._.. I am an employer providing workers' compensation for my employees working on this job company name address city: NOUN insurance co. � oli # ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: namei_ address: city phone M insurance co. company name: address: city phone#• insurance co. ° # Failure to secure coverage as required under Section 25A of MGL 15.2 can lead to the imposition of criminal penalties.of aline up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a + copy of this statement may be forwarded to the Office of Investigatio°s of the DIA for coverage verification. l do hereby certify under the pains and penalties of per•ury that the informatio provided above is true and correct Si afore Date j t :���e?� �. �X # — z Print-name Phone official use only do not write in this area to be completed by city or town official city or town: permitilicense# ❑Building Department ❑Licensing Board C3 check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other trcv'ised Sept.20031 �J Information and Instructions Massachusetts General Laws chapter,152 section 25 requires all employers to provide workers' compensation'for their employees. As,quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied,oral or written. An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 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,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. NINE Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation: Please 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 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. City or Towns 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. The affidavits maybe returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,. please do not hesitate to give us a call. • FK The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7te Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 7274900 ext. 406 . arnstale Regulatory Services :.:.Building Division - -Tom Perry; Building Commissioner 200 Main Street, 47=is,.MA 02601 wwwAown.barnstable.maxs Fax. 508-790-6230 Office: 508-862-403 8 Property Owner Must .a Complete and Sign This Section if Using ABuilder as Owner of the subject property uthorize: ?/-lei` to act on n behalf, hereby a A"' in all matters.relative to work authorized byt1a binding permit application for, �5 8��� (Address of Job) stare of Owner ate . Sign . . - ' .' � • Print P�ame . , Town of Barnstable *Permit# 95qq Expires 6 months from issue date Regulatory Servicespip Fee :�srnai e t m ✓ ' v � es 11� ,��' Richard V.Scali,Director ft b MAt Building Division SFP , efew 60 Tom Perry,CBO,Building Com > pyev /� 072016 200 Main Street,Hyannis,MA 02601�/ V U� �J,�p t,,�n www.town.barnstable.ma.us ! S ABLE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Al — Q Property Address ! i cl ri A 5-t '- [Residential Value of Work$ �T2 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address�0-bei" SGj U�Il i P-r t Contractor's Name &�/? AfEj41j.17joJ fC/l 1 //ts'o4 Telephone Number NO Home Improvement Contractor License#(if applicable) 73 Z q S Email: v Construction Supervisor's License#(if applicable) 0 S 7 a 7 (2Vorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lArm the Homeowner EY"I have Worker's Compensation Insurance Insurance Company Name con f' l Alai i Len, 1./I-s Workman's Comp. Policy# [� 3 3 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 ❑Re- oof(hurricane nailed)(not stripping. Going over existing layers of roof). ❑ e-side I Replacement Windows/doors/sliders.U-Value -30 (maximum.32)#of windows `/ #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this pen-nit does not exempt compliance with other town department regulations,,i.e.Historic,Conservation,etc. ***Note: Property wner must sign Property Owner Letter of Permission. A copy the Home Improvement Contractors License&Construction Supervisors License is require t\,, SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.OUtlook\2PIOI DHR\EXPRESS.doc Revised 040215 mr-fiewal. 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OujaW agfm*- and underscnn&daai rhLSL Apccjwiemco�mai refit the ea di ujkkzirffuMilrV krerRVn EhC pU&Sanal 1110'rh re are N)�S winalies and' elaarti;5iz ao airurla�yuri arr�*s�L'I lac c tail a�!(rEus r�4 nGtrtiairie. i t nlaeaa9iEi ar rw aa i le i;iASnih i ur r an itir 5 Gli l valid �n i rho i i ,vecl5rv�rn s of hr�rh the iai 9 rrmr rnr f i,. >rsl 9r ask°°ra +►1 aPsa>t r(� t laai=r ,ill hls r p&mcar,unJ rsund,r h reins of tllhts�r rm�ni�aad has r€cived a,.+ m'kick, dar��� lrr€larw iiri,r�riaiiln� . thi. Z'ubc ell Nvtici Wi�331tdt�Imilan,or. `6{I�be,fim vmri ien 3*.1xwe 26d�) �rill7.:emf�r.rar�+s@ m�El uxes� � eam�9 this M(mil 1" : dJ'�'r<�E1t Dpl"6 z sa9i�,Chas�v)itiea t a '.It�raild:"gnu tit EfSearl l a air. - IJe� rsierai+t tt iFr€iogn�Wmj gh.' YO1111'�.TIE BUYER MY.CAUNICELTMS TRANSACTION ATANYTIMIENOTLATER THAN MIDNIGHT . --081291.201,16 - -- DOLANArlION OF THIS RIGWI. AM filar}mdemem of&cAcxsa Kirland' r pzairarL�(` ilr,l's.rsu :: 5i i etis il;ia�tiise fR-.%n Aharn Bober$a ,11nier- Ptim mll&O s:16 l'etsuat Fri mc N 6 ffv t P`riiit NAU— e. Southern New England Windows d.b.a Renewal by Andersen of SNE - Massachusetts Department of Public Saf?ty Board of Building Regulations and Standards License: CS-095707 =,of�struC O t Supervisor BRIAN D DENNISON 7 LAMBS POND CIRC _ CHARLTON NIA 0150 71 v �--- txP irati.o.n: Commissioner 09/0812018 Office.of Consumer Affairs d Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvem_ent.lContractor Registration - ReglWaWn: IM45 Type: Supplement Card Ei SOUTHERN NEW ENGLAND WINDOWS.LL" Vra 911B2016 DENNISON BRIAN 26 ALBION RD LINCOLN,R102865 Update Addrm and return card.Mario reason for chow i— sui0 Cie�nrrrao+wueu/af gf�aa of Cave er AIIain d Badaen Bego660a Lk me or regntradoo vadd for hrdividul we only E WlPROVEMENi CONTRACTOR hd are the e:piradoo date.If foand rdaro to. Of a of Comomer Afain and'Beaiom Regulation btra0on: 1,T32�$ Type.. 10 Park Plaza-Soite S1T0 ExpiratlOk:amem1ti Suppk+merd;,ard Borten,MA 02116 SOUTHERN NEW 6j6j D WINDOWS LLC. RENEWAL BY ANDERS&; DENNISON BRWJ 20 ALBION LINCOLN.RI 02865 Uode retry - - Not valid without aigaatarc The Commonwealth of Massachusetts = Departnient.oj°htdrestrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/CoiitrActors/Electricians/Plumbers. TO BE FILED WITH THE PERUMITTING AUTHORITY. Applicant Information Please Print.Legibly Name(Business/Organizationi.Individual): (,(, J'ft I Address: �Q City/State/Zip: �9 ���6 ` Phone#: O/ Are you an emplover?Check the appropriate box: Type of project(required): 1.)X i am a employer.with 1201temployees(full and/or part-tune)." 7. New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No worker'comp.insurance required] 9- ❑Demolition 3.Q 1 am a homeowner doing all work myself.[No worke;'comp.insurance required.]t 4.EJ I am a homeowner and will be hiring contractors to.conduct allwork on my property_ [will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I LF0 Electrical repairs or additions propnctnrs>vith no employees. 12.EJ Plumbing repairs or additions 5.Q 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.❑RO f repairs These sub-contractors have employees and have workers'comp.insurance.- 6.❑We arc a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] rQ (A C-e/!7 *Any applicant that checks box p t must also fill out the section beloi showing their workers'compensation policy information. t Homeowners who submit this affidnvit indicating they are doing all work and then hire outside contractors trust 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 nrnot those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I alit air employer that is providing workers'compensation insurancefor nry enrPtoyee& Below is the policy and! b situ` inf6rinat►on. i f' Insurance Company Name: 9 Policy#or Self-ins-Lic.#:_WLA a 13&o S/ Expiration Date: 7 /Z 1-17 Job Site Address: / 1/hC IY-d CL City/State/Zip: 6-4 ter y I./I c-` A Attach a copy of the workers'compensation policy declaration page(showing the policy.number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation-punishable-by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against.the violator.A copy of this statement may be forwarded to the Office of Investigations of the.DIA for insurance coverage verification. I do hereby cei• ' hider the p 'is and penalties ofperjrrty that the information provided above is true and correct Si nature: e Date: — 7 Phone.n: Official rise only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department. 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing:Inspector 6:Other Contact Person: Phone#: -- 1 SOUTNEW-01 UOLLINGER A`CORvR CERTIFICATE.:OF LIABILITY NSU IRANCE . IinTE(MMl�orrrrY) 6129/2016. . THIS-_CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS.UPON,THE CERTIFICATE'HOLDEP-THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR-.ALTER THE COVERAGE AFFORDED'BY THE POLICIES BELOW: .THIS.CERTIFICATE OF INSURNC AE DOES NOT CONSTOUTE,A CONTRACT BETWEEN THE:ISSUING INSURER(5),AUTHORIZED REPRESEN. TIME;OR PRODUCER,'AND THE:..gWFICATE HOLDER: IMPORTANT: If the: certificate holder is an.ADDITIONAL INSURED,.fhe polity(Ies)must be endorsed .If SUBROGATION IS WAIVED,subject to the terms and conditions of;the policy,certain policies may require an endordement: Astatenlent on this certificate does not confeurights to.the. certificate holder In Iteu of such'endorsement(SO. CON ACT PRODUCER NAME:: Co Biz Insurance,Inc.-CO PHONE'_ FAX,Nc (30.3)988-0804. 821.17th"St AIC.No Ex*RP)9 7"o Denver,CO 80202 DRESS:CoBlzlnsuran cobfz nsurance.com INSURER( 'AFFORDING COVERAGE NAIC4 INsURERA:Continental Westbrn:Insumnce_Company 10804 INSURED INSURER'B:. Southern New.England Windows LLC INSURER'C: DIWA Renewal'b.Andersen 26 Alblon.Road INsuREre D:. Lincoln,RI 02865 INSURER.E: _ INSUREItF COVERAGES' CERTIFICATE NUMBER:,,.. REVISION'.NUMBER: THIS IS.TO CERTIFY THAT THE POLICIES OF:INSURANCE LISTED.: AVE BEEN ISSUED°TO THE INSURED NAMED ABOVEEOR THE POLICY PERIOD INDICATED.. NOTW[FHSTANDING ANY`REOUIREMENT TERM OR'.CONDITION 16F ANY CONTRACT OR OTHER;'D000MENT WITH RESPECT TO.WHICH THIS CERTIFICATE MAY SE.ISSUEp OR.MAY PERTAIN, THE INSURANCE AFFORDED BY THE..POLICIES'DESCRIBED-:HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS'AND CONDITIONS OF SUCH POLICIES LIMITSSHOWN;MAY HAVE BEEN REDUCED BY PAID dl:AIMS: INSR' - Ll ,'EFF POLI LTR: TYPE OF.INSURANCE: INSD.WVD r' POLICY NUMBER MMID LIMITS. A X COMMERCIAL,GENERAL*UteILT.Y EACH OCCURRENCE $ 11000i0O DAMAGETO RENTED CLAIMS MADE K]OCCUR CPA3136080 i 07,10112016 0710112017. PREMISES Ea occurrence $ 1,00poo MED EXP(Any one Person) $ 1000 PERSONAL&ADV INJURY. $ 1,0001000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,60Qi00 PRO PRODUCTS-COMPIOP AGG $ 2,000,00 X POLICY JECT LOC EMPLOYEE_BENEFI $ 2,006,000 OTHER: AUTOMOBILE LIABILITYCO Ea BI DI SINGLE LIMIT' $ 10000. A_ X ANY AUTO: _ CPA3136080.,... 0710112016, ,OZ101/2017. BODILYINJURY(Perperson). .$_ --ALL OWNED SCHEDULED BODILY INJURY(Per,eaident)' $- AUTOS AUTOS NON-OWNED PR PERTY DAMAGE $. HIRED AUTOS AUTOS'. Per-aceident $ UMBRELLALIAB X OCCUR , EACH.000URRENCE $ . 5,000�OQArx- EXCESS LIAB- CLAIMS-MADE CPA3136680 . 0710112016 0710112017 AGGREGATE $ DIED. X RETENTION$ 0 Aggregate. S 5;000.000 H- WORKERS COMPENSATION STATUTE ER' ANDEMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N CA3136081 0710 12016 07/01/1017 E.L'EACH ACCIDENT $ 1,000i00 OFFICERIMEMBER EXCLUDED? H/A 1,000,00 (ManddM In NH) E.L.DISEASE-EA EMPLOYE $ If yea,desaibe under E.L.DISEASE-POLICY LIMIT $ 1,000,00. DESCRIPTION OF-OPERATIONS WOW DESCRIPTION OF OPERATIONS I LOCATIONS,I VEHICLES(ACORD 101;Additlonal Remarks Sehedule,may.be.atfaehedB more apace.la:requIred) CERTIFICATE,HOLDER CANCELLATION SHOULD ANY OF,THE ABOVE.DESCRIBED POl ICIES.BE.CANCELLED BEFORE THE EXPIRATION DATE- THEREOF,. NOTICE :WILL BE DELIVERED. IN ACCORDANCE WITH THE POL.Y PROVISWNS: AUTHORED REPRESENTATIVE ---- - ©1988-2014ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD.name and logo are registered marks of ACORD r °FIHEE Town of Barnstable *Permit# � C�3� U b y Expires 6{rypnths k 571, date Regulatory Services Fee�—� t EMRNSPABLE. : Thomas F. Geiler,Director y MASS, g q, 1639• �� Building Division 11 Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY / Not Valid without Red X.--Press Imprint i Map/parcel Number 1 4 V3 Property Address 1 G C'c 4✓ Q Residential Value of Work 60 Minimum fee of$25.00 for work under$6000.00 rr ],tt t� Owner's Name&Address �Ilzi'+ t r Contractor's Namekewe"Ux.( figs,4phone.Number SS p � Home Improvement Contractor License#(if applicable) ( � �Vorkman's Compensation Insurance X-PRESS PERMIT Check one: i1/� ❑ I am a sole proprietor JUL 14 2008 WI am the Homeowner have Worker's Compensation Insurance, TOWN BARN STABLE Insurance Company Name &a�6ae� go Workman's Comp.Policy# � Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles), All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ;:y r _ ET/Replacement Windows/doors/sliders. U-Value ©• 3S (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.l&$ric,ConseOORtion etc+ ***Note; Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. FS �4r c:r) r rn SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 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 Le: ibly Name (Business/Organization/Individual): /U ©GJQ ' I Q Address: �i�t� ��-5 t •. . . City/State/Zip: 0ANr Phone #: ArFe you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with. 4. ❑ I am a general contractor and I employees,(full and/or part-time).*. have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1. ❑ Remodeling shipand have no em to ees These.sub-contractors have P Y 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof relAirs insurance.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 information. f 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 boz 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. / . Insurance Company Name: n�ejCC6�g71 Policy#or Self-ins.Lic.##: o��S cJ �3 Expiration Date: ML // Job Site Address: <// City/State/Zip: C.�.,�hc DVil L _r 0�63Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided aboveis, true and correct. ! Sirtature: i��� Date: —I`` `Z) oo Phone#: Official use only. Do not write in this area,to be completed by city or town official f City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as ...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as`-`an individual,partnership,association,corporation or other legal entity,,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or_.the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. Howeve r 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 P P g „E applicant'who,has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-.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 for confirmation of insurance coverage. Also be.sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a'workers' compensation policy,please-call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate.line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Commonwealth of Massachusetts Department ofIndustrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.##617-727-4900 ext 406 or 1-877-MASSAFE Fax##617-727-7749 Revised 4-24-07 www.mass,gov/dia .................... From:Shaunna Robinson.,Hunter Insurance At:Hunter.Insurance,Inc. FaxID: To:Denise Date:9/17107 12:56 PM Page.2 of 3 OP ID 9 DAM(MMIDormy) RT: LIABILITY INSURANCE M90 -- d_AcoRD- CERTIFICATE OF LIA 1 09/17/07 PRODUCER THIS GERTIFICATE49t"SUED AS A MATTER OF INFORMATION ONLY A I N I D C.ON'F UPON'SHE CERTIFICATE HOLDER..TH16,t kkt FICATE DOES NOT AMEND,EXTEND OR Din old River Road,ter insurance, IncP...0. BOX I A�::tHe..COV I E I RA6:E,A`FF'0RDED BY THE POLICIES BELOW. 89 Manville RI 02839-0001 Phone: 401-769-9500 rax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Ff.tj.—i a..nq. zo.—A.C.Co moon Associates Inc. INSURER 8! klut"I In.u...— Co. DIBA Gutter Helmet INSURER C: DBA ztenewal by Atiletsen of RI 1137 Park Eas Dt, ve INSURER D; Woonsocket RI 0289'5 rl-NSYFIE E- COVERAGES 11-F POLICIES OF INSURANCE LISTEMD BELOW BEEN ISSUED TOTH�E INSURED NAJv1ED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER Doc umENT WITH.RESPECT TOIJIMICKTHIS CeqTIFICATE MAY BE ISSUED OR NVW PERTAIN,THE INSURANCE AFFORDED BY THE poLiCrES.DC-SCRIBED HEREIN IS SUBJECT To ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS 117W MDU POUCY NUMBER DATE(MMJ1DD1YYL LTR'NSRr TYPE OF INSURANCE EACH OCCUPPENCE $1000000 GENERAL LIABILM V R A X comAERCIAL GENERAL LIABILITY MPS26619 09/16/07 0.9/16/08 =s6(rE me) $500000 CLAIMS MADE r-1 OCCUR WM EXP(Any orw pwsonj $10000 PERSONA.&ADV INJURY $1000000 GENERALAGC-MGATE $2000000 PRODUCTS-cohipio I P EGG $2 0 0 0 0 0 0 GENUS AGGREGATE LIMIT APPLIES PER; POLICY PRC- 1-�] I 'E T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A X ANY AM BIS26619 09/16/07 09/16/08 (Es ecdclent) ALL OWNED MOOS BODILY INJURY jPer Verson)SCHEDULED AUTOS HIRED AUTOS BODILY INJURY NON-OWNED AUTOS PROPERTY DAMAGE (Per a=kM) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT EA ACC S AIJY AUTO OTHER OrN Y AGG $ excESSirUMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A x OCCtJR I . D C.LAIMS MADE .CUS26619 09/16/07 09/3.6/013 AGGREGATE F $ DEDUCTIBLE x RETENTION 1100.00 $ TIIA1717-17-70717 WORKERS COMPENSATION AND TORY LIMITS I I ER B EMPLOYERS'LLAsILaY 28586 10/01/07 10/01/08 r:LEACHACCIDENr -$500000 -,uY PROPRIETORIVARTNER&KECUTIVE OFFICER/MEMBER EYCLUDED? E.L.DISEASE-EA EMPLOYEE S 500000 If yes describe underEl,DISEASE-POLICY LIM T $500000 SPECA.PROVISIONS bakm OTHER DESCRIP ON OF OP ONSILO TIONSIVEHI j-5 I.EXCLUSIONt ADDED BY ENDORSEMENT I SPECIAL PROVISIONS TIL� CERTIFICATE HOLDER CANCELLATION 09 CANCELLED BEFORE THE EXPIRATION SHOULD 40 00 THE ASOV&bESCRIBE0 POLIt 1400HASS moon Associat68, Inc DATE THEREOF,TH0.19tUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN dba GutfL-Z. Ifielmet No'nCp-To ng CSRWJCATE HOLDER NAMED To THE LEFT,BUT FAILURE TO DO SO SHALL dba ReineWil, by; Andersen IMPOSE NO OBUGA'nON OR11ABILFTY OF ANY KIND UPON THE INSURER.ITS AGENTS OR 1137 Dark k"t D-Zitre RE Woonsocket RI 01095 :'A PRESENTATIVE ACORD 25(2001/08) Q ACUKD CORPORATION 1988 0/ze Paninwea/C1 o� ra�aclucaeC�d License or registration valid,for individul use only '\ Board of Building Regulations and Standards before the expiration date.,If found return to: HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards One Ashburton Place Rm 1301 Registration: 119535 Boston,Ma.02108 Expiration: 7/24/2009 Tr# 130185 Type: Private Corporation MOON ASSOC INC JAMES MOON 1137 PARK EAST DR. ��o, Not valid ithout signature WOONSOCKET,RI 02895 Administrator Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 119535 Type: Private Corporation Expiration: 7/24/2009 Tr# 130185 MOON ASSOC INC r JAMES MOON 1137 PARK EAST DR, WOONSOCKET, RI 02895 Update Address and return card.Mark reason for change. DPS-CA1 0 5OM-05i06-PC8490 Address Renewal Employment. Lost Carl Customer Name: K0tW -�)A ui-A!IEK Year Built: 7 Renewal Address: kj ->sfzl 4 S T- Customer ID#: Renewal by Andersen of RI&Cape Cod Sales Agreement ( 1137 park East Drive Andersen. City State,Zip: C��is"L-L C Order Number. Woonsocket,RI 02895 Phone-Home �Cl- -1 I�4 [�• WINDOW REPLACEMENT an Ande„e„C-Many [� �O O license#RI 12259-MA 119535-Cr Phone-Work Page: of Date-. ✓ 0 0562725 Email: UNITS T GRILLES s ca a Et. - Aa oa€I gg88 g� ea s sff� Rom Description $ � � B _g �`o�F A �G uc 9� 3 cod j�gg ^j sPRICE$ =3 = � S- Lid L7$ L`a o ~`0 !� 4 PACK (,PC 1 'I i T PW F 37811 91 155 Pf: I P R k Miscellanrnµs Credits or Fa�rnses Sub Total a.a,l 570 Propped:As of the.m..miadova and daou- priavSded for,he misl ae,wre ammd;n d,e The Payment Method peop_ool vill nmdo valid fix 30 a,d , m.e by both Ca and Rencva ny `n`•Mm grs m (Sminiog,wrap.not Repafy pmn. o,eoe) Ym bdoa_ D—Wtioo INam $PrkeS Sub Total lVa NowI g33.60 ❑ ��. UO q �-7 Sub Total W eewl . Customer •You ao,hamed m f—h 11 v.d—,ad moo requi d m:vmptea cbm - I I�' /b PI y�I�l� ✓-7/0,N O Mks Credits or Expenses � �t Cd p bereoL.gsermmt for vhkh 0ie�eimdeoi�,ed m pry die amount,pad in d+L sgtummt end.aurdmg ro drc olw See Reverse Side for Terms and Conditions of Sale.You,the buyer,may cancel Tau, 33. b 0 ❑ 9 this transaction at arty time ppaant to midnight of the third business day after _ the date of this transacti on.Ylease see a ed notice of cancellation for an Saks Tax 114 C. atomdMge.y explanation of th - Total M6cdlaowut Ctedita or E p-=I wdltNer o�ao ro3vasAteee.d (arty uter tool to mkc aedk/-p—col—n right Work Penldt Cost I C, time Cu,tomet Sago.-re 1pk+d d.ADid VW Awcpod Special Order Nom Total AmwulN of A�eement 3 333 t W ""°°°°' St—Door egleaw 6.ey Doano, Dme R—QbyAod--M-.S- S r -I AfA.A (4fn"S3T F ?-TK)m Deposit Required 1 tQ0 spnlalywa,dew NgpNgpg aiiga, Retool WMdeua Rm,wa rd rtl-C6tl- Remo roN,h.twe re uuhkmeidm apeYhq �� �uCK'� /'r BakR[e Due on Completion trapnpedng Mieh miy don as uN avedw an maee�da-qe RowerCEN7 wee3Mrge r b..ndedianaamdm eaaiww.w :oaahnw, aga edunu ,•..R-aarN - Ftlk Wen -aebgr aRv saw uNn theamao urea ed dayepo cur da wpdn a_yarappord. Prim includes labo 4 oureria4,inatalladon, speawy mN.ebwa ae eaaNd oMewee nad uteeaddhluEdmeaualm dehhw®G mmoval.and tilt ieoowdwd we.ra ties,yo.new wiido.a e,0 White-Renewal by Andenm Yellow-eutakdre PM-Flo„Nowl,er - poaal ofproducu"laced. CustalNr e/ CusbanM I(� CleLomen!��/ 7+imraRao aNa Initleb: �/'A's'/a- dlitiab: Initlah: /"p'� ' •am...i4n.e®•ee a,.am..ab,�.a.�e.ems,..msa.a�G.v��emoe ti.e®ea,,,v au,ye.�.as um am.aQ ae-wme e , City • ! A#sor'ss map and lot number 1 .. �oF / w4rQ y �y� Sewage Permit number '....� .�.���.... ...1....... ..... .. ., k Z MAR33TSDLE, i ...........House number ....:... . ................................ a �i 6 q. YPY •� a' TOWN . .OF . . , B�UILDING h�NPEC0 rT R tt� S INSTALLED t PP IW<-T� RMI ION FORPE f EN�I R d LAT / �!@ T� r PE OF CONSTRUCTION .........w.Q�IJ�..... ... t�..................................................................................... 3....... �1�..d.2.............J- fi TO THE INSPECTOR OF BUILDINGS: I` The undersigried hereby appli s for a permit according to the foll wing information: CL Location .......: 1..... ...... ......... ..... .... . . . . ................. ................................... Proposed Use .... fh�f.�f....L.. / /. l .... �7C'!.(.l. ....................................... ... ... .......... Zoning District ......lf�.S� ...... ..L....................................Fire District l� / �.. �lf. iK..�j / ........ f Name of Owner ..... ,Ome5......................Address rl... C� 4 i� �C........�.� ..... .. Nameof Builder ..d. ^ .......................Address .................................................................................... l l L l Name of Architect ......... ....................................................Address .............................. t. � Number of Rooms ....... ....... .. .:........................................Foundation ... ......... .......:.................... Exterior ..C:: �`G�.l`.. �!� . 1........................................Roofing .... . ... . f. :.. . ......................... Floors P//�v.....9 ........................Interior Heatingts........ .. . ............ .............................Plumbing ......... .............. .. ........................................ Fireplace O.Pe............ IC� ...i.1..►/'tI.QP ........Approximate. Cost ........ . .cam ......................... Definitive Plan Approved by Planning Board ______________________________19________. Area ..... ...... Diagram of Lot and Building with Dimensions Fee `�—� SUBJECT TO APPROVAL OF BOARD OF HEALTHQ N�, 3 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the To of B stable regarding the above construction. Name .................. ..................................................... ' Construction Supervisor's License �( � � .. . �u_ . COOLIDGE HOMES 25366 One Story ................ Permit for .................................... .. Single Family Dwelling t A ....................................................... ............... Location ....Lot...4.i....l...V?Gt.Q' .d...S. eet e,1 ...........I�Centerv„i.1l e............................... Owner ....Coolidcfe...HomeS.......................... :. ''� ? , �,-�` uti- Type ofi Construction F:r4J.4Q............................ ......... ........... .... ...... .......... ................ - Plot. ............ ............ Lot .... .... - '? rs y 4 a Permit`Granted ..August.. l'... t ..:19 83 Date of• Ins ection+ ..�..P `:?19! <4 p ............... ....... --' Date+Complete . �../�f,• ,,� C„`,•"4 '• ,,,r meµ. ,;,r Asse�so4,map and lot n�ber ..........f.. :.._........ N Sewage Permit number .....'.�w.........:..... .... �Jtrtls,,: :. w `�f^ I Z BAWSTME, i House number .........p!........................................ 9�0 M639 �y .W iOT�r91 MAX a. TOWN OF BARNSTABLE " BUILDING INSPECTOR APPLICATION FOR PERMIT TO 6 . .Sfl ... . P. a ...........................,.. .... ...... �.......... L TYPEOF CONSTRUCTION .........! ® ..... 9.L ..................................................................................... ..... I...... .............199.3 F BUILDINGS: 7 TO THE INSPECTOR O The undersigned thereby applies for a permit �according to the following information: f Location �a%: L�.......(...� �F'► .. ' ` .. ._ ; ,.�1�? ?.l4.�.Ck.... I;... ..... ................................... ProposedUse ..... G..��.... ..............��......l.ny........ /.. :. ........................................... ... .......... .......... Zoning District ....... . .. � .ew v� �..•......................................................................Fire Distract ..Y.y.....�,........��....;�..�........�.....!...!............ Name of Owner ..�%' !�.1. .r .�.. ?r'.. ......................Address ..................?.. ��"....I`� .:... llcvl......).......... r l Name of Builder .........: Address ............................,............. or Nameof Architect ...............'.................................................Address ........................................................ Number of Rooms (` ..........................................Foundation f ,& �' ��(.:`.�.E 1��. / ...••••,5................. Roofing .. .....��r� Z f........................ Exierior ,/ .... g ..... ... `. Floors Vy../ ,.... . .�?... E:.. �{/�(>d t'/......................Interior .�?. �// �hP� C�C Jt—.......................................... Heating .......�.�/-! /� ...............................Plumbing /� P/� / � la T .....r.................. A&I �..Af`.......Approximate CostFireplace Definitive Plan Approved by Planning Board -------------------_-----------19________. Area ..}........................................ Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH irr 1 ' i Y 1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Towfi of B�nsf#able regarding the above construction. / Name .....: eV,�.�..................................................... .. Construction Supervisor's License ..................................... r COOLIDGE HOMES A=148-38 ° . . ' . 35366 One Story No ----.-' Permit for .................................... ' ^ t Single Family Dwelling ' ._. � Lot 4 l Victoria Street ` - Location ............................................on —.------ - . - _ - Centerville ---,.-.---,--.----..---------... . Coolidge Homes Owner -���.�—� ....—.—..—.--.--.—.--.— � ^ ' Frame Type of Construction .......................................... . - ~..,..-......~~,_.—_~,~..—_.~..-.--.,' ' Plot ............................ Lot .............................. ' ^ ` August I, 83 , pernnh Granted ......................................... ` Date of Inspection ... ................................l9 ' . ' Dote Completed ......................................1g ^ . ' ^ , ���^~� � ��~—' �� ~ ««� ' .. ' . . ' ' ' ' ' ' ' � y I L D-7- S r -as cR4. i• `-2p L�RTL`� s '! Y % lye 5HD Pv�,j /^J LAJ .� �,:�.��e3r' ct��T/�r� •ro-��T rx�tt� G'tvE=.n•-v� OI./ 7W& �OF ASS TAe,*r /T �p S OO.V1-OtA-4' 7-07-"&- �—C)A.//.t1G Q� (.to c �G BY-- L.gln/S OF T/�E 7�v✓JV OF ,e,V5'e241:5 C- g `^ WAW,&A-1 y A�2 M O FROM TOWN OF BARNSTABLE BUILDING DEPARTMENT Own CteAh ��� 367 MAIN STREET HYANNIS, MA QM • To Phone: 775-1120 L SUBJECT: FOLD HERE DATE 7 1994 MESSAGE WoAk has been comptMd undeA Bu,i td tng PeAm.i t 025366 (Cootidge Homea). Pte"e u teaae Bond. SIGN D DATE REPLY SIGNED N97•RMI RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY PRINTED IN U.S.A. SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT. y4\ � •. � Yr. � .off r a ' 25366 • y�„o� `* TOWN OF•BARNSTABLB Permit No. -------------------------------- Building Inspector s.an�rn Cash -------------—- — � �YL OCCUPANCY PERMIT Bond IT ---------------------------------- Issued to CooW ge Homu Address tot 04 1 Vi"O,%ia Stceet, Cen viue. Wiring Inspector ` � rrfi.��d Inspection date fi Plumbing Inspector.- Inspection date Gas Inspector. Inspection date . 94 Engineering Departme t� I�, +A''1abC _ Inspection date wBoard of Health 1 � ± 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. i ....................s ✓. 19 T 7' ...........r.......................................r f ;s� . ....._._ Building Inspector