HomeMy WebLinkAbout0071 WHITMAR ROAD " 71 Wf{/TMa2 R.0
earU� r
i
�t"E,�a. Town of Barnstable *Permit#. d - 3V 73
Regulatory Services w ee 6ma": romis�edate
� g ry
= IBU LING UEI��f
• sAaxsTAeis, • .
y MASS. 8 Richard V.Scali,Director
�A 1639. ♦0
r�►��' Building Division NOV 28 2016
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601 , TOWN OF BARNSTABLE
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PEPMT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number D5-;? /l S '
Property Address �J-j A
,Residential Value of Work$ l� "�Q� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name Telephone Number 5N
Home Improvement Contractor License#(if applicable) p 4 353 Email:
Construction Supervisor's License#(if applicable)_ �
❑Workman's Compensation Insurance
Check one:
❑ 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 accompany each permit.
Permit est(check box) •_ - � -
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to
❑Re-roof(hurricane nailed)(not stripping. Going over, existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ 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
requi d.
SIGNATURE: '
QAWPFILESTORM building permit forms\EXPRESS'.doc ,
06/20/16
Ftt '
Rze t✓omwompeaith ofMasyadrrrseift
Department striatAedidents
Ofike ofrnw—s igatims.
600 Washbigion,S`treet
- Boston,41A 02111
IPFVIV MaMgvvfriia '
Warke& Caere.' Ai .Inmrance davit Btr'lders/C�mtractur-JEle6Ukians/Phmbers
scant Tmfarmat an Please Priut
-Name Mu
-
ess: ►� s
cat
Are you an employer?:fheck.the appropriate b Type of project(required)_
I_❑ I ant a employer via � am a gea�eral contractor and I 6. ❑Netiv eonsf�ctiort.
employees(fall andfor part-time)-* have hiredfhe sub con ractm -
2.❑ I am a sale propdetor orpartmr- Ssfed onthe attached sheet. 7_ ❑Remodelirxg.
ship and have no employees _ Thew sob-contractors have 9- ❑Demolition
wodang forme in any capacity: employees andhave workers' 9..❑Suildmg addition
[N¢ 'temp-irtsurz r� CCMP-inerera,Err#
required-] 5. ❑ We are a corporation and its 1 ❑Electrical repairs or adfians
3-❑ I am.a homeoumes doing all work officers have exercised their IL Piumbiagrepaiss or additions
myself o work=' right of emmpfion per M(M
i mm=e required]� c_152,§I(4),andwe hmm no I ofrepairs
13-❑Other
employees.wo woxkers'
codrep.insurance required_]
;Any Wffcsat:dbatchedsssbaxit must also MoutthesectiaabdowwsbowmSdmirvm&erecampeasRflaapaycginffimnzti a
ffameoivaeM t¢ho submit fis zffidam i g tbzy Rm dmn=-nH wc*and ffimbi a outside contmcmr wm submit snew afdZeit mdi—fin sorb_
ZCaffiscdars that cbect this bout mast attad 1 as additional sheet shawi'ag the name of the sub-cam bxcmm sad stzte whether ar natilme emdtiesbs¢e
empiayees.Ifthesab-co-atm xshsvemuploy r dfie}rmutstpmv-dethea—dEE s'-mp•palmaumb-
I am an eleip r tlidrt isgrauidirc�;nforkers'com�rerdsro tau irtszirance for�c3*empbly�ees Setoav is 7YdR ptrlicr�rutrI jok e
inforazatinn
Insurance Company Dame.
PvRey4,ar^celf-ins.11c_;t q ll F_pirationDate=' 1
Job�Address: 'q i W'h T( Citplstzwz� is cV
Attach a,copy of&e warkere compensation.policy declaration page(showing the policy mmaber and expiration.date).
Failnm to secure coverage as required.under Section 25A of M-0-c.15 can lead to the impositiaa of criminal penalties of a
fine up#o$1,54D DO and for o6i.:y arimpdsa=eut,as w&asrivil penalties in the fona of a STOP WORK ORDERand s fine
of up-to$250-00 a clap against the violator. Be adidsed dint a copy of this statement=_U be hrwarded to the Office of
Idrrresfegations ofthe DIA for insurance coverage verifrtatim
Fria fwre6y csrtror rutdar the pains an psriaNes of
perjujy fJtatf7da irtfornirdiorrprm-t&d abad%is tru$etrtd correct
Phuae '• 7/ �Z
Ojokid um an, Do lwt crate in 693 area,ter be cinnpletesd by cify artown a,Olddat
City or T'oww PermitUcense:g,
Issuing Aufh$rity(code one):
L Board of Health I BuMing Degartmfat 3.Cdytrowa Clerk 4.Eecfrical hmpertor S.Phmbing Impecfar
Other
Contact Person Phone#-
o rmation and Ins coons
Maz etls General Lxmffi.,fr 152=Z es all employers to provide Wmkm 'cc`mP=`aIon f"their a %: a5`ees.
Pm sr fn tisfs sfm�,an anpinj,�is defn ed es=everypersonfn t'fie=vise of der order ally contarx ofhue,
c3l3r=or in3pli5A oral or wriftEn."
Au�Iaj,�is dcf red as-aa ha ividral,partnership,aWC)c fi n,corporation or other legal erdiiy,or any two or more
of the foregoing engaged�aJo� ,and��the legal*��°��of a deceased emPloges,or the
receiver or trustee of an fiLffvldaaL Pam ,association or of =legal entity,employing=13PmYCCS- However the
owner of a.dvmIling house havmgnot morn thin three apartme�and who resides therein,or the occupant of the.
dw mag house of another who employs persons to do maiid=ancq cons'',*rfi on or repair work on such dwelling house
or on the grounds or boil mg appurfenaritthe ztD shaIlnotbecamse ofsurlt can:
or deemedfn be an employer."
MGL chapt=152,§2SC(6)also Stt�4 that"everysfaie or local Rcensi g agency shall wRhhold the issaa^ce or
renew�j of a license or permit to operate a business or to consfi-¢ct buRdhigs is the commGnwe21th for=y
aPplicantw•ho has notproduced acceptable evidence of compliance wj&the h snrance coveerage requh7ed_
y,
MQ,chapter 152,§25C(7)states fiNmfher the nor a'uy ofifs political snbdiYfsions shall
AdditionaIl
enter into any contract for the perf=ance ofpubho wotic unI acceptable evidence of compliance with the insurance.
of this chapter have Tieen presented b the mnixar tug ardhozzty."
PIease fill oirt the wor3=' compensation affidavit completely,by g the boXes that apply to yo=situation and,if
necessarL sUPPI3' r(s)n=e(s), addresses)and Phone— er(s) along withtheacertifcat`Cs)of
hiMIonce Limited Liability Companies(LLC)or LfiHtcd Liabffity-Par61=hrps(LIP)withno cEapIoyees other than the
members or partners,are not requid to cally wolkc&compensation fiisnrance- If an LLC or Lr LP does have
employees,a.policyisrmpfird. Be advisedi33atthisaffida:Vitmaybe iimdto the,Department of Industrial
Accidents for comfinnationoffiLsuran=coverage Also be sure to sign and data-the of davit. Tho affidavit should
be retamed to the city or town that the application for the peuoit or license is being requesbA not the Department of
LnAastnA14�ci dew. Should you have any gnestioms regardmg the law or ifyou ate regnaed to obtain a worlds'
conapensationpoficp,Please call the,Deparimentatthexnbcrl-istedbe.Iow Self-mscaed-compaoiesshouldencrtheir
self-n,sora„ce license amber on the appropriate line.
City or Town Officials .
r
Please be sm;a that the affidavit is campleit-,and.priatedlegibly. The Departmer¢has provided a space at the botmm
f the afffida.�for you to fill out in the event the Office of Iuvesd9 o�has to contact you regarding tb e applicant-
0
Pleas e:b e stagy to fll is the pem 11 cease number which wiII be used as a refercace number. In-addition,Ea applicant
that mast S bnit nzulfple peam,Vhcense applitatics m any given yew,need only sabmit one affidavit mdicatmg current
policy infornatiazl(ff necessazy)�d midea`job Site Address"the applicn should vt "all locatiims in (city or
town)--A copy of the.affidavit that has been officially sfampe or marlo;d by the city cr tnwa may be provided to the
applicant as groo-fthat a valid affidavit is on file for fntore putts or licenses A new affidavit must be fMcd oit carh
year.Where a home owner or'dd=is o in 9 a licm=or permit not relaiad to any business ness or commercial'4&nt=
(Le_a dog license orpemiit to bum leaves et,--.)saidperson is 1�TOTt°complete this affidavit
Ile Of of Inycs;figetinns wouldHIM to tbamk youm advance for your cooperation and should you have any gnestims
please do not heszf�to give us a call
The:Department's a&ress,telephone and fax number:
czft of Masmchmatb. .
Depaiimwt of in al Accidents
=MA Ed111
Ta1617' -4 Q:xt4-06ocI-97TMABSZ.,�
Fax 617 727'749
Reviscd 4-24-W - ,�Vldia.
*Moe ft
AV AIM
AMTF AN
_ Ar At _
12 Baldwin Rd. Dennis, MA 02638
CERTAINTEED LANDMARK PRO
LIFETIME -ALGAE RESISTANT
ARCHITECTURAL STYLE
RE-ROOFING PROPOSAL
November 3, 2016
Fran Boulos
71 Whitmar Rd. Tel: 508 273 5898
Cotuit,MA EM: fboulos160otmail.com
HyTech Roofing Solutions hereby proposes to perform the following services in a neat and
professional manner and in accordance with the manufacturer's specifications andlocal building
codes.
Remove and Haul Away All of the Old Cedar Roofing Shingles from the entire roof area of
the House.
Inspect and Re-Nail Any loose or popped plywood or boards on the Entire Roof Deck Area -
of the House
Supply and Install CERTAINTEED LANDMARK PRO: 50 YEAR TRANSFERABLE
LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION,
CLASS A FIRE RATED,COPPER/CERAMIC STONES for a
FULL 15 YEAR WARRANTY AGAINST ALGAE
CONTAMINENT,250 POUND,EXTRA HEAVY WEIGHT, 130
MPH WIND WARRANTY,CATEGORY III HURRICANE,STORM
/HURICANE NAILED (6 NAILS PER SHINGLE),MULTI-
LAYERED,LAMINATED ARCHITECTURAL STYLE,
FIBERGLASS BASED ASPHALT SHINGLES.MAX DEFF
COLOR:
f -
Supply and Install HICKS VENTILATED ALUMINUM DRIP EDGE on the entire roof
eves of the house
Supply and Install CERTAINTEED WINTER-GUARD (Ice&Water Shield)
WATERPROOF UNDERLAYMENT SYSTEM 3 feet coverage on
the entire house eves and on top of soil pipes,roof vents,under Step
flashings,valleys,and running up the walls of the Chimney.
Supply and Install GRACE TRI-FLEX SYNTHETIC UNDERLAYMENT PAPER on
the entire roof deck area of the house
Supply and Install CERTAINTEED SWIFT START adhesive asphalt starter strips on
all eves and Rakes with a%inch overhang
Supply and Install CERTAINTEED FILTER RIDGE (SHINGLE VENT II)ridge vent
on the entire ridge area of the house using the 3"hand nailing
method.
Supply and Install CERTAINTEED HIP AND RIDGE CAPS on the entire ridge area of
the house using the 3"hand nailing method
Supply and Install ALUMINUM&NEOPRENE SOIL PIPE FLASHINGS
Clean and Remove Debris form the work area after the job is complete
TOTAL ROOF INVESTMENT: $15 500.00
POSSIBLE EXTRA CARPENTRY: Any rotted or otherwise deteriorated trim boards,
plywood sheathing,missing metal flashing,side walling or any other carpentry needing
replacement will be done and charged for as an Extra: materials plus labor at the rate of
$80.00 per hour.
PAYMENT SCHEDULE: A deposit of one half is due at the signing of this roof proposal
and the final payment for the balance is due immediately upon completion.
WORK SCHEDULE: All roof work is normally scheduled for completion within 30 days of
acceptance and receipt of deposit providing the materials are available.
Please Make Checks Payable to:
PATRICK CLIFFORD
HyTech Roofing Solutions Warranties the Shingles and Labor for 10 years.
CERTAINTEED Warranties the shingles and labor 100%for the First 10 Years
and the Shingles your LIFETIME if the shingles becomes defective.
CERTAINTEED Warrants the Shingles up to a
CATEGORY III HURRICANE-130 MPH WIND WARRANTY.
CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 15 Years.
HyTech Roofing Solutions
Carries Workman's Compensation and Public Liability Insurance on the above work
DATE OF ACCEPTANCE: - I
ACCEPTED BY: SUBMITTED BY:
zn:2re 0 d :�6L- 4
Fran Boulos PATRICK CLIFFORD
HOMEOWNER (Business Owner)
MA CSL license 105951
MA HIC license 184383
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 184383
Type: LLC
';. . Expiration: 1/5/2018 Tr# 274212
HYTECH ROOFING SOLUTIONS LLC: .' '"''
PATRICK CLIFFORD
. 12 BALDWIN RD
DENNIS, MA 02638
Update Address and return card.Mark reason for change.
SCA I 0 2OM-05/11 Address Renewal Employment Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
istration: 184383 Type: Office of Consumer Affairs and Business Regulation
xpiration: ; 15120t8 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
HYTECH ROOFING SQlUT10NS LLc
PATRICK CLIFFORD
12 BALDWIN RD
DENNIS,MA 02638 Undersecretary Not valid without signature
Massachusetts Department of Public Safety
OF Board of Building Regulations and Standards y
License: CSSL-105951
Construction Supervisor Specialty
PATRICK CLIFFORD
12 BALDWIN ROAD
DENNIS MA 02638
r-jZK C4— Expiration:
Commissioner 06/02/2018
j
1/29/2016
THIS CERTIFICATE LS 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: It the cerRcate holder IS an ADDITIONAL INSURED,the poilcypes)must be endorsed. N SUBROGATION IS WANED,subject to
the tears and conditions of the policy,certain policies may require an endorsement A statement on this cerMcate does not corder rights to the
r,P Uncate holder in lieu of such endorsemerrt(s).
PRODUCER CONTACT Joanne Bretton
mum
Southeastern Insurance Agency, Inc. PHONE (508)997-6061 FAX I5081990-2731
439 State Rd. Jbretton@southeasternins.com
P.O. Boa 79398 INSURERRAIVORDINGCOVERAGE NAIC0
North Dartmouth NA 02747 INSURERAArbella Protection insurance 41360
INSURED INSURER B AEIC
All Cape Exterior Remodeling Y.rr INSURER C:
12 Baldwin Road HERD:
INSURER E:
Dennis XIL 02638 NSURERF:
COVERAGES CERTIFICATE NUMBER:2016 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.
LTTRR TYPE OF RNURANCE POLICY IRIlrBER POLICY EFF POLICY EXPam LBrns
X COMMERCIAL GENERAL LIASHIiY
EACH OCCURRENCE E 1,000,000
A CLAWS-MADE R OCCUR
PREMISES ooamafae E 100,000
9520048113 1/14/2016 1/14/2017 ryIEDpXp(pnyompemm) E 5,000
PERSONAL BADVINJURY E 1,000,000
GERL AGATE UNFIT APPLIES PER GENERAL AGGREGATE S 2,000,000
B POLICY❑, T LOC PRODUCTS-COMPIOPAGG S 2,000,000
Oiler $
AUTOMOBILE LIABILITY COMBINED SINGE UNIT E
aw4en
ANY AUTO BODILY INJURY(Perpersm) E
AUOMIED H SCHEDULED
TOS AUTOS BODILY IKRIRY(Pwa=de" S
HIRED AUTOS PROPERTY DAMAGE S
S
UI/BREL9 LIAR FcLARASMADE
CUR EACH OCCURRENCE S_
EXCESS LUIB AGGREGATE $
DED RETENTION$ E
WORIaM COMPENSATION PER
ANDS IPLOYEr6 IMBBRY Y/N STATUTE 2411-
ANY PROPRIETORIPARTNERIEYECUTIVE E.L.EACH ACCIDENT E 1,000,000
B OMCERIMEMBER DUILIDEDr NIA
yIn In iTCC5007896201" 1/9/2016 1/9/2017 Eunder .LDI -EA E 1,000,000
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMB E 1,000,000
DF.SCRUgM OF OPERA7WM/LOCATMM I VEH CLES(ACORD 101,AddftkxW Remarks Sdcedtft may be aftedred B more apace Is requlngo
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
display purposes only THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORRED REPRESENiATNE
Joanne Bretton/JB
019813-2014 ACORD CORPORATION. Ali rights reserved.
X"PR ERMI Town of Barnstable *Permit�O/" 005 ?
Regulatory Services Fees T rths ronyssuedat
i
2
�"�' Thomas F.Geiler,Director
` OWN RNSTABLE Building Division
Tom Perry,CBO, Building Commissioner r,Q
200 Main Street;Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint `
Map/parcel Number a'
Property Address ] .I U)"ate 77-1 I�
JkResidential Value of Work . Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address FrIA cP'5 00 I U 5 `
7 I co"C r ma 6?6 3 S�
Contractor's Namemichpd 14,6 IZAC_ Telephone Number 1 /13YV
Home Improvement Contractor License#(if applicable) �1 7 '1P lr'
Construction Supervisor's License#(if applicable) C / ✓
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
® I have Worker's Compensation Insurance
Insurance Company Name co—
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
#of doors
Replacement Windows/doors/sliders.U-Value ..Z (maximum.35)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the H mpr ement Contractors License&Construction Supervisors License is
require
SIGNATURE:
C:\Users\decollik\AppData\Local icroso indows\Temporary Internet Files\Content.0utlook\DDV87AAZ\EXPRESS.doc
Revised 072110
'Sts
• 1ASNSTABLE. •
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas'Perry,CBO
Building_Commissioner
200 Main Street; Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using'A Builder
LI IS ,as Owner of the subject property
hereby authorize A"AG:d k e NO,Y)EAf6 I'f1c I J to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
yl vs
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side. 4
C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.OUtlook\DDV87AAZ\EXPRESS.d&
Revised 072110
The Cci nunnonstw4 the of Massachusetts
Departmt of�ind�rstr�Bl Accidents:
0fiSre:oflnvesdgahOru '.
600 Washin3gtou Street. `
Boston,M.4 02111 ,.
wK m mass:go>~'dia
`Yorkers' Compensation Insurance Affidavit:,BuilderslContractorsXlectriciansiPlumbers `
Applicant Information
Please Feint I.ezibly,
Name(Business tiontlndividual): oa r�eM � di Q, co
Address:
City/State/Zip: 06 'Mone ;
Are you an employer?Check the appropriate bo=:. , Type of project'(ra*gnired)
a employer,with ;❑ I am a general contunctor and fi
employees(full and/or -time):! ha-.T the sub-contractors: 6 ❑Neu,construction
2-El I am a sole proprietar,or Partner
listed.one attached sheet ;7- ❑:Remodeling
ship and have no employees - 'These.sub-contractors have g:'❑ litiou
w for me in an capacity.T '.employees and have w od=s'
c insurance-
9_ Buildia addition
. [lNo.workers'.camp. -instuance � �`' comp.. I �•d � , J ❑ �. . ;
required-] 5 S❑ We are a corporatioaand its 113:❑Elechical..repairs'+oradditions
3.❑ I am a homeowner doing all work, officers have exercised their ` 11.❑Plumbing repairs or.additions s
right of lion r MGL=,-
myself[No workers'comp- exemption per. 1'2.❑hoofis
insurance required:]1 c.152,§1(4X•and we.hame-no
employees-[No workers'
•coma..insurance required.']
;Any applicant that checks tax#1 must also fill out the section below slowing tbea woikeis'compensation policy informateoa
Homeowners Who submit this afi9dwu indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such.
Contractors that€bect this box must attached an additional AM showing the name of the°sub-contractors and state whether:or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
lam an errrplot.'er that is priding itrorken'conrpeusadon irssarance,for rrry errrployWL,Below is fire policy,and job s-itr
u formadon `
Insurance E Company Name: Soo W /� ( c C
Policy or Self-ins.Lic:#: G C o�� ZS V F epiration Date- ,
Job Site Address: I Cit•rState Zip: l.g FV1 l'lfl, �J p31
Attach a copy of the workers'-compeasation policy declaration pager(showing the pt licy number and`espiradon date).
Failure to secure coverage as required ruder Sectiou 25A of MGL-c 152 can lead to the imposition of c'mnal penalties of a.
fine up to$1,500.00 and/or one-year m4msonment,as well as chril penalties in the form of a STOP WORK ORDER-arid a fine
of up to$250.00 a day against tht;violator. 'Be advised that a copy of-this statement may be forwarded to the Office of ,
Investigations of the DIA for vrerification
I do hereby certify aurder th au , altigs ui ury that the information pmrided'aboue.is true and correct
Signature
Date:
2 _
Phone ' 7#: 7.. (:M l
Ofeial use ondy..:Do not trrite ur tdr is area,to be completed bg cutjv or touva.o,j�idat
City or Town: PermidUcense#-
Issuing:Authority(circle one):
1.Board of Health 2:Building Department 3..Cityffown perk 4.Electrical Inspector 5;Plumbing Inspector Y
6.Other
Contact Person: Phone#. .
b
':6
I
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company '
54 Third,Avenue, Burlington,Massachusetts 01803:
(800)876-2765 NCCI N0 40959
POLICY NO,
WCC 5007818012012 :
PRIOR NO. ;WCC 5007818012011
ITEM
1. The insured Leblanc Builders Co Inc
Mail Address: 12 Mall Way g Mashpee MA 02649
Street No. Town or City, 4 County State.; Zip Code
FEIN xxxxx20441
❑Individual ❑Partnership ®Corporation`; []Joint Venture ❑Association ❑Other
Other workplaces not shown above:
2. The policy period is from 01/01/2012,7'": to 01/01/2013 12:01 a.m,standard time at the it sured's mailing address. R'
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance:Part Two ofthe policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: !':Bodily Injury by Accident$ 500,000 each accident '
- ',Bodilylnjury by Disease $ . 500,000 olicy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance:Coverage.Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules:SEE SCHEDULE
4. The premium for this policy will be determined by.ourManuals`of Rules,'Classification's,Rates and Rating plans:
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code t Estimated Per$100 ! Estimated
No Total Annual Of - Annual.
' Remuneration.` Remuneration Premium
INTRA 037139
SEE E ENSION OF INFORMATI N PAGE
Minimum premium$ 500.00 Total Estimated Annual,Premium $ 9,443.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 2,493.00
❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly'
MA Assessment Chg.
` $8,946.00 x 5.9000% $528.00-
`.
This policy,.including all endorsements,'is hereby:countersigned by` v 11/30/2011 ..
t; Authoriied'Signature Date t
GOV GOV KIND PLACING, CLAIM NAME SAFETY William F Borhek Ins Agency
STATE CLASS.' AUDIT OFFICE OFFICE CHECK GROUP Inc=
MA 5474 14 504 311 Plymouth Street
Halifax, MA 02338'
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
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a MICHAEL L LEBLANC = `
' . o 40 CRAWFORD RD[PO BOX 14
COTUIT, MA 02635
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Z Expiration 71-1,32014 Private Corporatioi
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U L NC BUIcu a- LDERS CO INC
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Michael LeBlanc
40 Crawford Rd —
Waquoit,MA 02536 Undersecretary
Assessor's Office Ost floor Ma '7 iLot l Permit#, v /76—
Conservation Office Oth fl Date Issued �a
Board of Health Ord floor — 44, �,$�Alh
En in ering Dept:Ord floor House#
Planning Dept. Ost floor/School Admin.Bldg.): 5?1 �Pij��
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Definitive Plan Approved by Planning Board — U^/ 19
(Applications processed 8:30-9:30 a.m.& 1:00-2:00 p.m.)
E 'TOWN OF BARN TAB. S L
Building Permit Applieation-
Proiect Street Address
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Village `� Fire District
fhvner /llfl-1 world/ 6173 Address o2 4-
Telc hone
Permit Request:
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Zoning District i)c /P Flood Plain A)IN Water Protection
Lot Size Grandfathered
Zoning Board of ADDeals Authorization Recorded
Current Use �+ i Pro sed Use
Construction T d
Eaistine Information
Dwelling Type: Single Family Two family Multi-family
Age of structure Basement type
Historic House Finished
Old Kings Highway Unfinished
Number of Baths No. of Bedrooms
Total Room Count not including baths First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information
Name ///� / Telephone number
Address / License#
Home Improvement Contractor# 11WI71
n Worker's Compensation # li1)/100t
NEW C0 STRUCTIO TTIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS
PROPOSED TURES ON THE LOT.
ALL ONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO xv7 [fin
<2 474Z44 Pro'ect ost
Fee !:?g��/" �Q
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
BPERM T
PERMIT � FOR OFFICE USE ONLY
MARKWOOD CORP.
ADTj)RES3 71 WHITMAR ROAD, COTUIT VILLAGE COTUIT
OWNER MARKWOOD CORP.
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DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION '
FIREPLACE .
ELECTRICAL: 'ROUGH FINAL _
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GAS: ~! ^3 ROUGH FINAL ` r
FINAL BUII jWG:
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ASSOCIATE PLAN NO. i
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Pr elimindry Plans ano layouts Oy OC Dare IOr[he use of rne�r customers only Any pinfr t/5t is 11r1C[ly Prom Di[e �y
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COMMONWEALTH -
OF DEPARTMENT OF PUBLIC SAFETY
MASSACHUSETTS ONE ASHBORTON PLACE Or"u,'t.,
BOSTON,MA 02108 %t•.:ac.� ...,... " �'��i,t
L.I CEN:=E
EXPIRATION DATE 1 J. of this "'Pcstlow
CONSTR. S►II='ERVIL,IIIR
CAUTION
RESTRICTIONS ` EFFECTIVE DATE
LIC-NO. FOR PROTECTION AGAINST
005:367 THEFT, PUT RIGHT THUMB
g PRINT IN APPROPRIATE
TIMOTHY FEAR N g BOX ON LICENSE.
1 1 CARR I AGE 'LN BLASTING OPERATORS
P•aTOle�wsnNcovRo"�» FEE: - BARN�=TABLE. MA O_'.�,._,c.) +� MUST'iNGLUDEPHOTO.
Q(.:) _..•'� i
NOT YAW UHi1L BYL - �-�
HEIGHT: STAMPED-OR. �/oDFflCULLr
THE COMMISSIONER
DOB: -
JUN
THIS DOCUMENT MUST BE
CARRIED ON THE PERSON OF 7�
OTHER$.RIOHT THUMB PRINT GAGED NTH SOCCUPATIOHHOLDER WHEN . SIG'
RE OF LICENSEE SIGN NAME
�rEpSIG�,e RE LINE
COMMISSIONER
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COMMONWEALTH OF MASSACHUSETTS
-- DEFARrNIENT OF LNDUSTRIALACCIDENTS
+ 600'WASHINGTON STREET
-ames.: Carn=ei; BOSTON, MASSACHUS= 02111
Cornrn:ss+one•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
64
(licensedpermiaee)
with a principal place usiness/ d ce at:
.0
(C.try/Staten-P)
do hereby certify, under the pains and penalties of perjury,that:
[] 1 am an employer providing the following workers' compensation cove
job. rage for my employees working on this
Insurance Company Policy Number
[) 1 am a sole proprietor and have no one working for me.
I am a sole proprietor, neral contractor homeowner(eirde one) and have hired the contractors listed brow
w have the ollowing w tkers compensation insurance polio=
NArne of Conrract r q Insurance mpany/Policy Number
Name of Contractor Insurance Company/Policy Number
fli
Name of Contractor Insurance Co pany/Poliey Number
1 am a homeowner performing all the work myself.
NOTE Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on:
dwc'lin&of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generaly
considered to be ernploye:s under the Workers'Compensation Ac(GL C 152,sea. 1(5)),application by a homeowner for a lice:sc
or permit may evidence the legal status of an employer under the Workers'Compensation Act
1 under-stand that a copy of this statement will be forwarded to the Deparm-tr:of Industrial Accidents'Office of Insu:anc=for Cover:
vc:iiication and th:t failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of aimirW per.:::a
consisting of a fine of up to S1500.00 and/or imprisonment of up to one ycz and civil penalties in the form of a Stop VGork Order:a:c a
fine of S 100.00 a day against me. '
Sipncd this desY f oLle
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LiccascclP i c Liccasor/PcrmitTor
x/SY
TMr TOWN OF BARNSTABLE Permit '+
� No. ......:.........
BUILDING DEPARTMENT
TOWN OFFICE BUILDING Cash
7 Yl p�
,679. xx
��r6or► HYANNIS.MASS.02601 Bond
CERTIFICATE OF USE AND OCCUPANCY
Issued to Markwood Corp.
Address 71 Whitmar Road, Cotuit
USE GROUP FIRE GRADING OCCUPANCY LOAD
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.
March 9 I .. . 19.95............
ram,'
Building Inspector
r7TOWN OF BARNSTABLE, MASSACHUSETTS' :V, �;-, .�, vF ,} . �� � . ,�.��;•����:..
} �B ILDI`IVG PERMIT
A=057-115 � !3? 5
, ' DATE OctC)h r .`rt� 19 94 PERMIT NO.
APPLICANT l.Llll PCi.'srv=G;1/ 1' aL}�47000� t'or,NAD,DRESS �O7 XXI&a Pal'10'i.1th Rd. e }1Jar.1'1is
L7�2 (STREET) ICONT R'S ICE NSEI
Build 1�Wt 11 NUMBER OF
PERMIT TO (_) STORY VNI_S
_ (TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION)
Lot #24, 71 41Thitmar Road' Cotuit ZONING
DISTRICT
(NO.) (STREET)
BETWEEN AND
(GROSS STREET) (GROSS .STREET)
'
SUBDIVISION LOT BLOCK LOTSIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: Sewage #94-631
Bond
AREA OR 1820 sq. ft. $ 90 191. L5
VOLUME ESTIMATED COST / GOO' OO FEE MIT
(CUBIC/SQUARE FEETI � -✓
OWNER
Alarkwood Corp. - ✓.-
-307
rmoU 6Ud6 E
ADDRESS l cC , l YB
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THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY rOR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY.OR*
PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
PROVED BY THE JURISDICTION. STREET OR. ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR
ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN -ELECTRICAL, PLUMBING AND
I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING'STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MINAL INSPECTION
TI TO BEFORE
FINAL INSPECTION HAS BEEN MADE,
3. FINAL INSPECTION BEFORE
OCCUPANCY. -
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
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HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
1
> � BOARD OF HE9LTHr
OTHER SITED/ N REVIEW APPROVAL
lye
WORK SHALL NOT PROCEED UNTIL THE INSPEC PERMIT 'W!LL BECOME NULL AND VOID IF CONSTRUCTION ,
I INSPECTIONS INDICATED ON THIS CARD CAN 3E
TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN
CONSTRUCTION. l PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION.
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LOT 24
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N 86'51 '20'W 290.81
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TOWN OF BARNSTABLE ZONING
BY-LAW DATED SEPTEMBER 14. 1989
ZONE R -F I CERTIFY THAT TO THE BEST OF MY PROFESSIONAL
SETBACKS KNOWLEDGE. INFORMATION AND BELIEF THE DWELLING
FRONT - 30' SHOWN HEREON CONFORMS TO THE HORIZONTAL SETBACKS
SIDE - 15' OF THE ZONING BY-LAW FOR THE R-F DISTRICT.
REAR I5'
PROPERTY LINES SHOWN HEREON
WERE COMPILED FROM AVAILABLE
PLANS OF RECORD AND DO NOT
REPRESENT AN ACTUAL SURVEY THE LOT SHOWN HEREON IS /N FLOOD HAZARD ZONE C
ON THE GROUND. AS SHOWN ON MAP 250001 0018 D. DATED JULY 2. 1992.
OF 44S
THE DWELLING DEPICTED ON THIS ��`� C. '� PLOT PLAN
PLAN WAS LOCATED ON THE GROUND ' = FRANK - ':' IN
BY SURVEY ON NOV. /1. 1994 AND , WHITING IN
EXISTS AS SHOWN AS OF THE DATE �� ,p p +a°/ BARNSTABLE. MA.
EGISIE4`� QJ
OF LOCATION. �' . SCALE: 1'-40' NOV. 'l 1, 1994
THIS PLAN /S FOR PLOT PLAN EAGLE SO r YING 8 ENGINEERING.INC.
PURPOSES ONLY AND NOT FOR 10 Seaboard Lane
RECORDING. DEED DESCRIPTIONS Byann t a. ala. 02801
OR ESTABLISHING PROPERTY LINES. (J08� 798-4422
0 20 40 80
PROJECT NO. 94-34I