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0020 GENERAL PATTON DRIVE
_ - - _ _T v ` �__._.. _.� �� � � F - -� II I No. �" o� Fee So,i v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppIication for Iniopogar Opotem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel..No. a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &_-C-L Li Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil gf: ,�� Nature of Repairs or Alt rations(Answer when applicable) S - <1 `�'• , �-c MCI 14 4 w! p u gm�.L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisi of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ss d by IMs Board of He th. Signed � Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE. MASSACHUSETTS Certificate of Compliante THIS IS T ER ,that On-site Sew a Disposal System installed )or rep ' ed/repIaeed on �' °"002- by. fA r, r „� for O�l U - as 2 Q Cow---c c has been constructed in'accordance, with the provisions of Title 5 and the for Disposal System Construction P rmit No. s ��� dated /d' `9_ Use of this system is conditioned on compliance With the provisions set forth below: � .r7Y''. b�-''' 1+"'in. ..-''.'^ , ...;: ...�1Y���..y ,. -� .-:.:,v[;;u�R...i.,^t: ,Y,��gagwT:z�^:•"*,w..•;} ..e'ri.rs.:.•r.^^r-.—..._......;yr.,...�7r 7 +..27,.y,wJ„ The Commonwealth-of Masscichusetts l . Department of Ptubtic Safety 527 CiVIR 4.00 '.Form% 1 'Application for Pertm>it,;P&znit,rand Certificate of:Cotmpletion for,the Installation:or Alteration of Fuel ng.Egtu><pment and the Storage of Fuel Oil.. (City or To (Date) #11 r17 w,Permit #'s: FD 1:7 4 100�`Zhlec FDID # 01922. Fee Paid, $ Owner/Occupant Name: Tel;#: z � Installation Address: �✓ ;��/ 'Serviced'Floor. or,:Unit #: ❑Heating Unit Q Domestic Waterl Heater <Q Power Vent ❑Other: { Burr: Q New 64-—Zs ing Q Location: of0 5 e'�` Trade Name: </P Mfg: P Type: �//✓� Model# or Size: '009, Nozzle Size. ❑Fuel,OJI'.'L Q Kerosene. ❑Waste Oil Storage Tank:. A<eow ❑Existing - 'Location: Type: C V" iC pacify: ' ' , gallons No. of Tanks: v: Special requirements (or additional safety devices) ❑OSV Valve. Oil Line Protected p,Sheet Rock. p Sprinkler AFUE: Q yes p no EF:Q yes Q no _-- (Furnace and Boilers).(Water heater) Co. Name: 6 Tel01 Address: City: .� wr�'fi ?ip: 0", Completion 'Date: Combustion Test: Gross Stack Temp '.: Net.Stack_ . pax - W_ CO2 Test r I_r Breech Draft• Smoke: Overfire Draft: F ' ` � Efficiency Rating %: I, the undersigned certify that the installation of fuel burning equipment has been made in accordance with M.G.L. c. 148 and 527.CMR 4:00 currently in effect. Furthermore, this installation has been tested-.in accordance with such requirements,.is now in.proper operating condition and complete instructions.as to its-use and maintenance have been furnished to the person for whom the,installation (or alteration)-Wag, Installer: l// - .�'Q� "` Print Name Cert of Comp. # - ignature (nttar`'rtp) " ' ! r' Address:` /���! /,��/� ''' City: Once signed by the fir-e department, this is a PERMIT for the storage and.use'of oil burning equipment. Approved by: l�: .�.----tip r l` 20 Date: �'��/ I� REFER TO CHECKLIST ON REVERSE SIDE Form Distribution:White: Fire Dept. (Application) Yellow: installation (Permit To Store) "Pink: Installer(Permit To Install) This form approved by the State Fire Marshal and provided courtesy of the Mass.Oil Heat Council. Form design in NCR by Cotuit and COMM Fire Depts. July 1,1996 ... .C`�-_�._.�;?� :�� n+3. ._..-v_-v--:,.«..�,H:: .s••--•.,� •�;,�'--agars."�.,,,,,'a,sr+-•�-•S�.-..-...-._...---..::v..:..i.:-.-.�:�� •.+..ti•�...yr.. _ ALL INSTALLATIONS UNENCLOSED TANKS ❑4.03 (1)d All applications must be on Form 1 ❑4.03 (6)b Single tanks shall not be larger than 660 gallons ❑ 4.03 (1)e Over 10,000 gallons on site requires License& Permit ❑ 4.03 (6)b Maximum aggregate capacity of unenclosed multiple from local community tanks is 1320 gallons p 4.03 (1)g Certificate of Competency required, no other license J 4.03 (6)d Unenclosed tanks shall be at least five feet from an acceptable, plumbing, electrical, etc. internal or external flame p 4.04 (3)a Verify emergency shut-off is outside burner room J 4.03 (6)d Unenclosed tanks shall not obstruct service meters, service panels and shutoff valves 4.04 (4)b Verify separate circuit for oil burner J 4.03 (6)e Bottom outlet tanks pitched to the opening 1/4"per ft. J 4.04 (4)e Verify presence of overhead thermal switch J 4.03 (6)f Tanks exposed to vehicles will be protected by barriers ❑4.04(4)c Verify presence of service switch within 3' of burner ❑4.04 (3)b Verify presence of high limit controller p 4.04 (3)c(1) Primary control has safety timing of 45 secs. (max.) ENCLOSED TANKS p 4.04 (4)d Stack type primary may be easily removed ❑4.04 (3)d Steam boiler equipped with low-water cut-off p 4.04 4)f Clear access to clean out and services panels ❑ 4.03 (7)a Over ive gallon tanks enclosed by two hour fire ( P resistive assembly ❑4.04 (5)0 No oil leaks present at burner ❑ 4.03 (7)b Tank enclosures provided with 6" high tight sills or 4.04 (5)d Installation instructions present on site ramps ❑4.04 (5)f Overhead combustible clearances within 5 feet over J 4.03 (7)d Tank is 4" above floor supported by 12" thick masonry unit Gypsum board or sprinkler required unless unit is saddles spaced not more than eight feet on centers AFUE (boiler)or EF(water heater) and 15" from top and walls of enclosure ❑4.04 (5)g Combustion test results on Form 1 J 4.03 (7)e All oil must be transferred by pump, and connections ❑4.04(9)b(12)Three metal screws at each joint in chimney must be at the top of the tank ❑4.04 (9)b(7) Thimble present at chimney connection ❑4.04 (9)d IF POWER VENTER IS USED.- Check for air pressure switch, post purge control and secondary ALL TANKS control - Air pressure switch is adjustable Listed type As close to vent hood as possible ❑4.03 (9)d Two tanks may be cross connected as shown Installation instructions present on site J 4.03 (10)bReturn lines must enter the top of tanks p 4.04 (9)f Draft regulator is present unless exempted ❑4.03 (9)c Vent pipes must be two feet from building openings ❑4.04 (5)m Adequate air is present for combustion J 4.03 (9)c Vent pipes must terminate 3 ft. above grade min. ❑4.04.5(o)1 Adequate clearances per manufacturers listing J 4.03.(9)c Vent pipes must have weatherproof caps ❑4.04 (2)i Thermal valves at burner and tanks ❑4.03 (10)a Fill pipes must be two feet from building openings ❑4.04 (1)b Listed flexible hose may be used. J 4.03 (10)a Fill pipes must have tamper proof identifying caps ❑4.04(1)c No Teflon tape on oil line or on oil line fittings ❑4.04 (9)d IF POWER VENTER IS USED: 4.04(1)c No compression fittings are permitted All outside connections sealed Vent terminal must be three feet above all air inlets within 10 ft. p 4.04(1)c Solder joints made with 1000 degree F solder are Burner air intake is exempted allowed Vent terminal must be four feet from doors and windows ❑4.04 (1)e All oil lines must be protected from injury Vent must be one foot above finished grade All new lines must be continuously sleeved with non Three foot clearance from inside comers metallic tubing Not above or within three feet of an oil tank Oil safety valves may be used on existing lines not Seven feet above a public walkway exposed to freezing Overhead lines require no sleeve and are permitted IF UNDER PORCH OR DECK: Space heating use only. ❑4.04 (1)f Oil lines exposed to freezing temperatures must come Four feet below deck AND not enclosed under deck off the top of tanks Lines for kerosene, and range oil (#1) are exempt ❑4.04 (1)i No oil leaks present at tank OUTSIDE TANKS p 4.04 (1)j Listed oil filter is present ❑4.03 (5)b Tank is UL80(under 660 gal)or UL 142 (over 660 gal) J 4.03 (8)a All UST's and tanks over 660 gallons must be installed ❑4.03 (5)e Shutoff valve located at bottom of tank as per CMR 9.00 p.4.03 (5)f Size of vent as per Table 4.03A J 4.03 (8)c 660 gallon max. aggregate capacity to each oil burner ❑4.03 (5)g Oil tank gauge must be present to determine oil level J 4.03 (8)c Tank protected from physical damage ❑4.03 (1 1)c Inside tanks have audible fill device (vent alarm) J 4.03 (8)c Tanks exterior coated with organic alkyd resin or asphalt ❑4.03 (5)i Outlet cross connection at bottom of.tanks must be paint 1/2" pipe or tubing. J 4.03 (8)c Damaged protective coatings must be recovered ❑4.03(5)k Non-combustible tank supports, tank secure. J 4.03 (8)c Tank does not block means of egress J 4.03 (8)d Tank mounted on continuous 4" thick slab that extends Note To Installer: Inspections will be conducted using this 8" beyond tank perimeter checklist as a guideline. Current regulations will apply. J 4.03 (8)d Tank is supported by rigid non-combustible supports Note: Local codes may require anchoring of tank to bldg. July 3, 1996 �R US- � 86_ n i.o Jn o� 'ed5 o S ' i ,p M bb 7 p I Wo F \ ` 4b a�S. R°e 8 •i a �-9,p ♦ .n /x,iae Q Z + r 9 LI ♦ _ `� Iai o,N � q9p , V'1 �; ✓lo ,`;l ap�� M pp�`� .pf. /Ri9 an fa°of '"1• d •y\ 4I6 7.11 1 1 b 7 p) g p 2S 29 s♦ N,rar>.N k$ g 0 �uaiaA ° /;J.v2\1✓/ ~6a `\��•/ Pdp 4 0 ° u a.. 92 4/ n$ 9 xL ar>r /.JarrA a 3 •h a ,W b 0 .p� > Arasy yf Y5 9./r6,.. � ✓ `/ � � 10 .40 ==+,e.. �'� �l•�5a 3 e na �1y >09 Nr.•N'�sa'M 1l" W. �S ..i z ✓��8ao p, V 2/ ! G _ IL9 C is 20 Or. . p.y1•JO•w as 1 •'_ /Ra:/rc p v '•�✓> cl ., /8 .. /c•ra/ate n' C� /3 C,00d., �f•.L` a;Ja/u .} srA :n - Z ..r��`='eo'>/ [^off^ey dua'` y°q �a °i 6>00 "..red, a iJ 1OUch n� Cr + •n a°W,J 1'p.C.N°.ls'olao AVEN u£ w . —572'r0�^+ VINgYARD � UE�R719G8� y ..r>.y.a.a..xwoaoa,ca auamromNgv my •. NFY 6 B6q SU D/VISION PLAN OF LAND/N NrANN/= BARNSTABLE Eoa THE BARNSTABLE HO°/SINO AUTHORITY °aA BCALr://Na QO^ CN�rx<o by OA'YJ:MAa.PH,/JbH E CNARLEN+SAVJERY B e/.vr�aa 9ua✓cro ' NYANM/, Con.. o?D �� TOWN OF BARNSTABLE ■ ■ ti Butming - 201207493 A • * sA><txsTAs1z, Issue Date:' 12/04/12 Permit 9 MSS. 16319. Applicant: Permit Number: B 20122939 CFO MA'i A Proposed Use: SINGLE FAMILY HOME Expiration Date: 06/03/13 Location 20 GENERAL PATTON DRIVE Zoning District RB Permit Type: DECK/PORCH RESIDENTIAL Map Parcel 292107 Permit Fee$ 60.00 Contractor NICKERSON,M.K. Village HYANNIS App Fee$ 50,00 License Num 014358 Est Construction Cost$ 6,075 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND CONSTRUCT A SMALL DECK 8'13 WITH HANDICAP RAMP THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: BARROWS,KATHLEEN B BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 20 GENERAL PATTON DR INSPECTION HAS BEEN MADE. HYANNIS,MA 02601 Application Entered by: PR Building Permit Issued By: C' THIS PERMIT:CONVEYS NO RIGHT TO OCCUPY,'ANY STREET ALLEY.OR SIDEWALK OR ANY PART T:HBREOF EITHER'7W.ORARILY OR PERMANENTLY'.'ENCROACHMENTS"ON PUBLIC PROPERTY,NO r.. SPECIFICALLYRMITTE PED UNDE R THE BUILDING CODE,MUST BE APPROVED:BY THE JURISDICTION; STREET.OR ALLEY.GRADES AS WELL ASDEPTHAND 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 OR ANY APPLICABLE SUBDIVISION RESTRICTIONS ::, MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). P OST THIS CARD SO THAT IS VISIBLE FROM THE STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 (4) 0 I jSJZ l� 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health My File Edit Tools Help Inspection Scheduling Inspection ID 233272 Source FP Violation ref Close/Deny Originating dept 16300-BUILDING DEPARTMENT — ----�� Application ref 201207gg3 A Parcel 292107 Seq r� Project/Activity DECICIPORCH RESIDENTIAL Field Sheet BARROWS,KATHLIDV B Business ID 1HYANNIS MApp Profile Lotion 20 GEN AL MA PATTON DRIVE License number F License location Permit Alerts Inspection Area I AQUIFER PROTECTION OVERLAY Municipality HYAN HYANNIS Lot number Reassign ro Results Main I Fees I Req/Tisc Scheduled Results Import Results Inspection type BFN 1 •.• BUILDING FINAL INSPECTION#1 Result I g PASS ... PASSEDINSPECTION Periodic Insps Active Score 0 Trade type Performed on I O 1130f2013 Paymnt History Level F-0 r Required to dose Travel time Adjust PTD Requested on r— t, at I Onsite time I—0 Priority MOeage .00 Process Bonds Scheduled for at by 1 — Create remsp F E3F— Property Inspector F�RA FRANEY,PATRICK Reinspection cd Link Permits Permit F_:3 C of I refierence WO#f ) Permit number IB2012N39 F Create a violation Field Audits Contractor 10 .. Comment Comment code I- Schedule Inspections. (S) O%'R A. Start 10 Inbox-Micr Ou...I Parcel Loolaap-Win... I Main System Menu-...I Application Entry-M... i Inspection Entry-M... I ]Desktop 8:03 AM T--T ji As AX t r. =F- 44,---i E TOWN OF BARNSTABLE ButMing 201207493 • BARNSTABLE, Issue Date: 12/04/12 Permit y MASS. i639•RFD A Applicant: Permit Number: B 20122939 Proposed Use: SINGLE FAMILY HOME Expiration Date: 06/03/13 Location 20 GENERAL PATTON DRIVE Zoning District RB Permit Type: DECK/PORCH RESIDENTIAL Map Parcel 292107 Permit Fee $ 60.00 Contractor NICKERSON,M.K. Village HYANNIS App Fee$ 50.00 License Num 014358 Est Construction Cost$ 6,075 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND CONSTRUCT A SMALL DECK 8'13 WITH HANDICAP RAMP THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: BARROWS,KATHLEEN B BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 20 GENERAL PATTON DR INSPECTION HAS BEEN MADE. HYANNIS,MA 02601 Application Entered by: PR Building Permit Issued By: �_ THIS.PERMIT CONVEYS NO RIGHT TO OCCUPYANY STREET,AILLEY.OR SIDEWALK OR ANY PART THEREOF;EITHER TEMPORARILY-OR.PERMANENTLY..�ENCROACHMENTS ON PUBLIC PROPERTY,NO SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BEsAPPROVED 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. o MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). 0 Nr BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 (4) 6^'05 0 14zil p< 1 1 2 2 2 ^: 3 1 Heating Inspection Approvals Engineering Dept xFire Dept 2 Board of Health 9 y t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map cA Parcel Gb Application # M Z 'L Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis — Y Project Street Address U Seri -arv- pQ, Village WAlwts Owner &4:ZYLge-� OZOM&450 S Address ;o QeRv- A"4/ . Telephone d 99:5""- 32 3 3 Permit Request &L_f) i4_ e--. an-me 9Q7A-CC `t!0<_ 1?"x 13 Square feet: 1 st floor: existing proposed 0 2nd floor: existing 0 proposed Total new Zoning District Flood Plain Groundwater Overlay ..Project Valuation 4�0 7 S Construction Type WooD 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 R-lqo" On Old King's Highway: ❑Yes ®'Iq'o__ Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other _CAA13 Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing / new AwNie- Half: existing new A.o4A Number of Bedrooms: a existir _new Total Room Count (not including baths): existing `C new Aw C First Floor Room Count k Heat Type and Fuel: ❑ Gaass ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes 2< Fireplaces: Existing New Existing wood/coal stove: ❑Yes Z-Pdo CD Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: LTexisting OF new:" size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: (I'l Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes o If yes, site plan review # Current Use r:+ gE4 rN b) Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name _ �1// R�n� Telephone Number Address /-3 /S f�09'f License # S — O/Y3S'8 ©STe,---2cllu , oa&S-,5 Home Improvement Contractor# `00.6-&o Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO m D� SIGNATURE DATE _ZZ Z 0 /2— r FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED t MAP/PARCEL NO. i r' .• 1 ADDRESS VILLAGE a OWNER' ;3 Y DATE OF INSPECTION: 1--:FOUNDATION, �N) ++•s I� oL FRAME x• INSULATION FIREPLACE V ELECTRICAL: ROUGH FINAL F. PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 600 Washrasgton Street Boston,MA 02111 . :www.mass.gov/dia Workers' CompensationInsurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly.'.. Name(Business/Organization/Individual): - M—e A)1(Y .,Address: r3 '_TP/lS- L✓ `� City/State/Zip: RdILI_C {271� 'ogle Phone.#: �1 Are you an employer? Check.the appropriate box. Type of project(required) 4. ;I am a general contractor and I 1.❑ I am a employer with ❑ 6. ❑New consttvclion 5pployees (fill md/oi part time) * have hired the stib-contractors 2: I am a'sole proprietor or partner- These the'atfached sheet 7. ❑Remodeling ship and have no employees These snb-contractors have •g. ❑Demolition working forme in an ca. aci employees and have workers' y ty. 9. ❑Building addition [No workers' comp,insurance comp msurance.t re ed 5. ❑.We area corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. airs or additions 3.❑ I am a homeowner doing all work ❑Plumb' repairs myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance re ed t �.152, §1(4),and we have no employees.[No workers' . 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 than hue outside contractors must submit a new affidavit indicating such. $Contractors that check this box.must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractnrs have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation ins.urance for my employees. Below is the policy.and job site information Insurance Company Name: = Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: _ Attach a copy of the workers'compensation policy,declaration page'(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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 to$250.00 a day against the violator..Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains-and pe alties of perjury that the information provided above is true and correct Signature: — • Date:,= 'D� �0�•2-- Phone#' Sd S__ klo6 fyk S Official use only. Do not write in this area, to be completed by.city or town off ciaL. City or Town: :' Permit/License# Issuing Authority,(circle one): J.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical.Inspector 5.Plumbing Inspector 6.-Other Contact Person. Phone#: "1 @ a. r Massachusetts General Laws chapter 152 requires.all employers to provide workers'compensation;for their employees -Pursuant t 6 this statute;.an emple 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 ajomt enterprise,and including the legal representatives of a deceased employer,or the. receiver or trustee-of,an individual,partnership,association or other legalentity,employing employees. However the owner of a dwelling house having not more than three apart�menfs 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 notproduced-acceptable evidence of compliance with flie.insurance coverage required." AdditionaIly,'MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the perfomiance of public work until-acceptable evidence of compliance with the insu ance requirements of this chapter have been presented to the contracting authority.'.' Applicants.... .. - c e chocking e boxes that a 1 to o situation and,if Please fill out the workers co ensation affidavit completely,1 bthe your mP mP Y� Y apply Y necessary,supply sub-cont�actor(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 pemut/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 (Le.a dog license or permit to bum leaves-etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions; please do not hesitate to give us a call . The Depar mont's address,telephone-and fax number: D-,partm t of fndustdd A Qidmt Office,of b e!(�doax 130 fit n, TAA 0211 l el, f 1 -490 exti 40 1- AMA A.FE '� 4 �aF 8`l7 � . FWD f 17-727;' 4 Revised 11-22.06 W .amass gQV - die oarurrear�usecc%�o�Cauc/iutelts - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration 100560 Type: Office of Consumer Affairs and Business Regulation Expiration:G,-V19/2Q14_ DBA 10 Park Plaza-SuiteS170 ® 1 — Boston,MA 02116 M.K. NICKERSON B,DG--W1 REMODELING Melbourne Nickerson',!Y 13 This Way . Osterville, MA 02655 Undersecretary _ �oialid without signature Massachusetts Department of Public 1 ilding Reg Construction ulatio Safety Board of Buetts and Standards Su ns a per isor License: CS-014358 vSFT ME —Q LBOURN 13 THIS WACKERSOIW y"r OstervilleM - WAS r Commissioner' Expiration — - _ 01/17/2014 • 7 - WORKERS COMPENSATION AND,EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Thi"rd:Avenue, Burlington,Massachusetts 01803 (800)876-2765 NCCI NO 40959 POLICY NO. WCC 5008940012012 PRIOR NO. WCCC 5008940012011 ITEM 1. The insured M Kempton Nickerson dba Nickerson Building&Remodeling Mail Address: 13 This Way Osterville MA 02655 Street No. Town or City County State Zip Code FEIN xxxxx0725 ®Individual ❑Partnership []Corporation ❑Joint Venture []Association []Other Other workplaces not shown above: 2. The policy period is from 03/02/2012 to 03/02/2013 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the.policy applies to the Workers Comp'nsation Law of the states listed here; B. Employers Liability Insurance:Part Two of the 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$ 100,000 each accident Bodily Injury by:Disease $ - 500,000 policy limit Bodily Injury'by Disease,_,$: 100`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 our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 240725 SEE (TENSION OF INFORMATIC N PAGE Ainimum premium$ 500.60. Total Estimated Annual Premium $ 3,774.00 ks indicated interim adjustments of premium shall be made: Deposit Premium $ 994.00 ] Annually ❑ Semi Annually ® Quarterly •❑ Monthly MA Assessment Chg. $3,419.05 x 5.9000% $202.00 "his policy,including all endorsements,is hereby countersigned by 01/26/2012 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY Rogers&Gray Insurance ,TATE CLASS I AUDIT OFFICE OFFICE CHECK GROUP Agency Ins IA 5645. . 1 .26 504 P O Box 1601 South Dennis,MA.02660 Jr-00 00 01 A(7-11) dudes copyrighted material of the National Council on Compensation Insurance, L} ;ad with its permission r N. r ol r a ! Town of Barnstable Geographic Information System December 4, 2012 292129 292274 #19 292130 #97 #23 292273 292106 #105 #18 Q, a 292110 #24 292109 #22 292108 #21 292107 #20 292272 #107 VINFYARD AVE 291132 #55 291133 #80 291126 �it ' #79 Ot 291127 . #50 rn 0 21F DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:292 Parcel:107 boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:BARROWS,OLIVER E&KATHLEEN Total Assessed Value:$119600 Selected Parcel 1'=100'may not meet established map accuracy standards. The parcel lines on this map W are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.64 acres Abutters boundaries and do not represent accurate relationships to physical features on the ma p p p y p Location:20 GENERAL PATTON DRIVE •.� ,such as building locations. Buffer J r'i s t 'ME Town-of Barnstable; Regulatory:Serviees a. iARNSPABLE. • MAB& Thomas..Geiler,Director 1639 'tiFo �" Building Division -. • Tom Perry,Building Commissioner 200 Main Street;Hyannis,MA 02601 www.town.barnstWe.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property.Owner Must Complete and Sign_This Section If Using A Builder as Owner of the subject property hereby authorizetCl< QSDn/ � C, to act on m behalf, y in all matters.relative to work authorized by this building pewit v?O eJ'e_n fs ce_� G1 (Address of Job) **Pool.fences_and alarms are the responsibility of the applicant. Pools are not to be filled or,utilized before,fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of.Applicant Print Name Print Name: pate., WORMS:OWNERPERMISSIONPOOLS 6/2012 s t r Town of Barnstable " Regulatory Services '* snaxsTAais Thomas F.Geiler,Director, p�6,q16 9. �,•� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street. village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESSi city/town state zip'code The current exemption for"homeowners was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person.who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other. applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department, minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section127.0 Construction Control. HOMEOWNER'S EXEMPTION , The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions 1 of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who.use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly 4.. when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with.a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt Office of Consumer Affairs &Business Regulation.- Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) ��� Consumer Affairs and Business Regulation Home Consumer Home Improvement Contracting Home Improvement Contractor Registration Lookup You can search/filter the registration list by any of the criteria below. Search by Registration Number _ _;Search Search by Registrant Name nickerson�__^�_ Search by City � __ _i Zip Code JP2655 :Search Registrants Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Monday, September 24, 2012. Search Results > . REGISTRANT RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS NAME INDIVIDUAL NUMBER DATE M.K. NICKERSON Nickerson,, 100560 13 This Way 06/19/2014 Current BLDG.&REMODELING Melbourne Ostervllle, MA 02655 httD:Hservices.oca.state.ma.us/hic/licenseelist.aspx 9/25/2012 Details Page 1 of 1 Licensee Details Dentographic Information .Full Name: MELBOURNE K. NICKERSON Gender: M Owner Name: License Address Information Address: 13 THIS WAY Address 2: City: Osterville Stater MA ipcode: 02655 Country: United States License Information License No: CS-014358- License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 2/17/2012 Issue Date: 1/17/2010 Expiration Date: 1/17/2014 License Status: Active Today's Date: 9/25/2012 Secondary License: Doing Business As: Status Change: 18 Prerequisite Information No.Prerequisite Information Discipline No Discipline Information Documentum httu://elicense.chs.state.ma.us/Verification/Details.asDx?af4encv- id=1,&license;id=210958& 9/25/2012 i ' } � f � � �• � i i i. � j y i j '1 � � f i I w 4J ... t i AIL i l I i ,� I. t i k j t TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION Map Parcel Application #C;)6,( � Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH _Preservation/Hyannis Project Street Address a� Village _�(1t1iS Owner ��a��I rp.(1 0,rr,0W,211 Address Telephone_ 5�$-�- 5 34-33 Permit Request �la �- aka (�- 3$ CeWAw 43e It A-�e CkA C,. I.ncre"e R' "ic ven�Ja41'on ip cede �1I FA wA' cxeknJ1'nj roam. Verase Crakk wo&s imlA �,- 13 cAA115e. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5 0 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 19 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 Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas )(Oil ❑ Electric ❑ Other Central Air: ❑Yes *No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Others, _7__1 --I Zoning Board of Appeals Authorization ❑ Appeal #_ Recorded ❑ g Commercial ❑Yes No If yes, site plan review# { N Current Use _ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ',I �1 q� 4 Name W � L�'km kckookm Telephone Number 50%- 3 9 s - Og�O Address ' P Iktk4j%-eh... l License # �C OyA Yd�r(MoN.�I�, ��. (� 6 �� Home Improvement Contractor# ��1�13 L Worker's Compensation # 3 d� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 5tt ` `� FOR OFFICIAL USE ONLY F APPLICATION# DATE ISSUED a _ MAP/PARCEL NO. z r* Is ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION i FRAME INSULATION:,. = FIREPLACE ' ELECTRICAL: ROUGH FINAL ti f PLUMBING: ROUGH FINAL -GAS:.—. c�,�, ROUGH FINAL _. .�FLNALBUILDINGs:. t ' a .;DATE CLOSED OUT ASSOCIATION PLAN NO. c S >.. Ov l G 460 West Main Street Hyannis, M 02601-3698 ASSISTANCE ENERGY & HOME REPAIR T (5�8) 790-7106 F (50�3j 790- ;:;:. ORPORAT ION 2425 HORSE OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: 1 THE APPLICANT HOMEOWNER. I 11 • t hereby consent to and agreethat weatherization work may be done by the Weatherization Program of Housing Assistance Corporation ( herein after referred as "Agency") on t`he property roperty located at: a Theweatherization work donewill bebased on programmatic priorities and:availability of funding and it may include all or someof thefollowing measures: Weather-stripping& caulking of windows and doors, insulation of attics, sidenrails& basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows, In consideration of theweatherization work to be done at my home I agreeto thefollowing: 1. I give permission to the"Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basisfor no morethan five(5) yearsafter theweatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (S g nature) �-- Date: Agent: (signature) Date HAC approvedWeatherization Com pany : . L All Cape Energy, Caliber Building&Remodeling, Cape Cod Insulation, Cape Save, reswell Construction, Frontier Energy Solutions, Lobr&.Sons, Peter Smith, Resolution Energy, Rock Solid Construction M1 i ICAPEPSAVE weatherization 508-398-0398 August 22, 2010 To Whom it May Concern: William J. McCluskey is an employee of Cape Save. He is authorized to negotiate contracts and building permits for our.company. Michael McCluskey Cape Save—Owner 929-593-5939 cell X Huntington-Avenue,Sour Yarmouth,MS 026" The Commonwealth of Massachusetts q Department of Industrial Accidents a Office of Investigations 600 Washington Street Boston,MA 02111 www mas&gov/dia MWMorkersmpensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers Applicant Information Please Print lAggi�blpy Name(Business(Organization/Individual): lAA I o 14 A r—t AktfJ A s i4a�_b�i' Address: C. ' [�u a�I nstb'CD City/State/Zip: s • ``r/R!MoykTW t! i 6yoWone#: 3 g- 0 -3 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with k Q,_ _ • 4. [3I am a general contractor and 1 G. ❑New construction eloyees(full and/or part-time).* have(tired the sub-contractors mp - listed on the attached sheet. 7. ❑ Remodeling 2.❑ f am a sole proprietor or partner- ship and have no employees These-sub-contractors have g, ❑Demolition working for mein any capacity. employees and have workers'comp. Building addition [No workers' cotiip. insurance comp.insurance.-' ❑5. We are a corporation and its 10.❑Electrical repairs or additions required.) .3.❑ I ant a homeowner doing all work officers have exercised their 11. ]Plumbing repairs or additions right of.exemption per MGL myself.[No workers' comp. 12.0 Roof repairs 1� insurance required.]} c. 152,j t(4),and we have no 13.®Odic rSn o� l in employees. (No workers' 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 we doing all work and then hire outside contractors must submit a new affidavit indicating such ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors.have employees,they-must provide their workers'comp.policy number. I an an enipioyer that is providing workers'compensation insurance for ney employees. Below a the policy and job site informadon. - Insurance Company Name: I --� n rq� oM f1 Policy#or Self-ins.Lic.#: W C 3 9 "f"d� Expiration Date: G� ,1 �1� C /State/Z W,AA(\N _ Job site aaaress: � � � �� . Attach a copy of the workers'compensation policy declaration.page(showing the policy umbel'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 S25.0.00 a day against.the violator. Be advised that a copy of this.statement maybe forwarded to the Officee-of Investieations of the DIA for insurance coverage verification I do hereby certify under the pains ndRenalties erjury that the information provided above is me and correct.Si ature: &WJ Date: _ Phone# 39&- A Ct Official use onh. Do not nirire in flits area,to be completed by city or town official. City or Tot+n: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other' Phone#: Contact Person: - Y ,acoZ@k CERTIFICATE OF LIABILITY INSURANCE i0/20/2o"1' THLt CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Shannon Sperrazza Risk Strategies Company PHONE (781)986-4400 FAX'IC. (781)963-4420 15 Pacella Park Drive E-AIES.ssperrazza@risk-strategies.com ADDR Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURERB:Safety Insurance Company 3618 Michael McCluskey, DBA: Cape Save INSURER C.Technology Insurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CLI1102041451 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. INS TEFF R TYPE OF INSURANCE EXP A DDLSUBR POLICY NUMBER MMIDDY/YYYY POLICY MILDI D/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE.TO RENTrD— X COMMERCIAL GENERAL LIABILITY PREM S S(Ea occurrence) $ 100,000 A CLAIMS-MADE Fx-1 OCCUR CPPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PIFrTRO LOC $ AUTOMOBILE LIABILITY Ea acciden SINGLE LIMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PerraccidentDAMAGE $ AUTOS X Underinsured motorist 81 split $100000 300000 X UMBRELLA LIAB N OCCUR CPPS1994,480 0/16/2011 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ TATU $ C WORKERS COMPENSATION Executive excluded X WC LIMIT DER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N FCM3297972. coverage E.L EACH ACCIDENT $ 500 000 OFFICERIMEMBER EXCLUDED? aNIA 0/21/2011 0/21/2012(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc., and Housing Assistance Corporation are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. 484 Main Street Hyannis, MA 02 601-3 6 98 AUTHORIZED REPRESENTATIVE Michael Christian/SMS �'6 C« . ACORD 26(2010106) ©1988-2010 ACORD CORPORATION. All rights reserved. INS026 oninnsi ni The Arew l nzime 2nri Innn ore renictereri mzirke of O4V1Rr1 g/mOfoc/e��'o `=nsum=r adan'z_'d usmess Regulation 10 Park"Plaza - Suite 5170 - Boston, Massachusetts 02116 Home Improve :,Contractor Registration Registration: 164432 - Type: Supplement Card CAPE SAVE = Expiration: 10/6/2013 WILLIAM McCLUSKEY 8201 S. HOURD CT CHAPEL-HILL, NC 27516 - Update Address and return card.Mark reason for change. )PS-CA1 50M-04/OQ•G101216 Address Renewal. ill Employment Lost Card �`3 ✓sze-[�omv�7wmcaeal�a�✓C�aaa�u6P/..�i `- - - _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ffl(-HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: la Office of Consumer Affairs and Business Regulation g� Registration:_164432 Type: 10 Park Plaza-Suite 5170 ti j j Expiratii ri v101672013 Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM McCLUSKEY 7C HUNTING AVE S.YARMOUTH,MA 02654= Undersecretary Not valid without ' nature 1laesuchusctts- DclMrtmcnt of Public Sufrt, Board of Building Regulations and Standard. Construction.Supervisor Specialty License License: CS SL 102776 Restricted to: IC WILLIAM MC CLUSKY 37 NAUSET ROAD 4 WEST YARMOUTH, MA 02673s Expiration: 6/28/2013 t+gnnlissi�ncr 7r=: 102776 Y �- rt Town of Barnstable *Permit# ® 06Y700F Expires 6 months from issue date Regulatory Services Fee X®®RESS PERMIT Thomas F.Geiler,Director �� Building Division NOV 2 1 2006 Tom Perry,CBO, Building Commissioner OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 .�.®�N 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 /parcel Number a?9c>? - 14 oerty Address C,96 (, e,, e.f'a-.� Residential Value of Work cw�,")/ Minimum fee of$25.00 for work under$6000.00 ner's Name&Address /(��`j !eG 1rt a- r c e7 itractor's Name Telephone Number 1,5 ne Imp,roveme-nt-Cantr-ac-tor-L-icemse-t-(rf-applicable)— 'sur'-s-Licerrse-#-(-ifapplicable) Workman's Compensation Insurance Check one: 4am a sole proprietor i am the Homeowner ❑ I have Worker's Compensation Insurance irance Company Name rkman's Comp.Policy# )y of Insurance Compliance Certificate must be on file. mit Request(check box) dRe-TOOf(stripping old shingles) All construction debris will be taken to cJ ►,tJ S ?� ❑Re-roof(not stripping. Going over existing layers of roof) El"Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.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. A copy of the ommeeImprovement Contractors License is required. ,NATURE: )rms:expmtrg se061306 _ The Commonwealth-of Massachusetts j Department of Industrial Accidents Office of Investigations 600 Washington Street �M 4 Boston, MA 02111 t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,/(Q �_le— of /,J Address: _74f0 ,,J City/State/Zip: Phone#: -��_3 Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. 0 New construction employees(full and/orpart-tune).* have hired the-sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp:insurance. g, ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its equired.] officers have exercised their 10.❑Electrical repairs or additions 3.n I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself. [No workers' comp. c. 152, §1(4),and we have no 12.[]Roof repairs insurance required.]t 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. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, kContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: fob Site Address: City/State/Zip: attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a :me up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of a STOP WORK ORDER and a fine )f 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. r do hereby certify and r the aims andpen Ides ofperjury that the information provided above/is true and correct ii ature: C1/1 Date: ��1.21/Q ?hone#: 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): 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.*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 bean employer." .MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the 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 snub-contractors)name(s),address(es)and phone number(s)along with their certificate(s).of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to.the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department.of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the 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 of Industrial Accidents Office of Invesdgations 600 Washington Street Boston,MA 02111 T61, # 617-7-27-4940.ext 406 or 1-8.77-MASSAFB Fax #617-727-77-49 Revised 5-26-OS www.mass-gov1dia THE FOLLOWING I IS/ARE THE BEST IMAGES . FROM POOR QUALITY ORIGINAL (S) m � � DATA LD C- 4,. ' t. f TO F. ARNSTABLE v►� SEWAGE #&LOT _ �E,�_� ��:�,.� ,f Ilk— ON ASSESSOR S MAP VILLAGE NO.Cec<1�--� INSTALLER'S NAME&PHONE f : � SEPTIC TANK CAPACITY r . wS- (size) LEACHING FACII-M.. (type) � NO.OF BEDROOMS `` BMDER OR OWNER COMPLIANCE DATE PERMITDATE. I :' Feet Separation Distan ce Between the: ng Facility t Adjusted Groundwater Table and Bottom an�wellsexist �� Feet Maximum AdJ Leaching Facility ( y private Water Supply Well and facility) feet of leaching Wetlands exist Feet on site or within 20� Facility(If any Edge of Wetlad Leaching feet of lead ng facili ) within 300 i Furnished by --- -- --.. - Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 6-8-12 n t Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE:Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 20-General Patton-Drive;Hyannis-has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-38 cellulose M Walls: R-13 cellulose All work performed meets or exceeds Federal and State Requirements. Sincerely, Q t William McCluskey F ..