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HomeMy WebLinkAbout0081 HAWES AVENUE 14 cL R � 1 e COX go, rd NO. 7521/3 ESSEbTE 1 o°i° o oFtf+r r 'own of Barnstable * `36J Permit# o Regulatory ,services Erpires 6 months from iasue date Fees:� S�, +�* BARV57ABi�S. + y dgss. �q j61q_ 1� Thomas F. Geiler, Director Building Division X- -PRE-SS PERMIT . Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnst TOWN OWN OF BA�RNSTABLE Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY . Not Viz irl withotrf Red X-Press Imprint Map/parcel Number �. OG l Pro erty Address ,os ile v Residential Value of Work Minimum fee of$35.00 for work under$ 000.00 Owner's Name & Address li wl1du �, Contractor's Name , A/Y) AOA/ //l/o' / J Telephone Number t9�//'"C�l' Home Improvement Contractor License# if applicable)- 9 P ( "ruction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ am the Homeowner have Worker's Com ensation Insurance Insurance Company Name )66 C 0jV xlu/lv,/- Workman's Comp.Policy# U S g Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) El Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to ❑ Re-r of(hurricane nailed) (not stripping. Going over existing layers of roof) �/Replacement e side #of doors Windows/doors/sliders. U-Value G_ d _(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 Home Improvement Contractors License & Construction Supervisors License is required, -NATURE: �e MFORMS1bui ding permit fornuiEXPRESS.doc W 1237 Park East Dane 0.f.Reg p:122S9/30M iMdon Associates Inc} Woonsocket,Rhode Island 021195 w�iaaw�,n Cams MC.OS6212S(Moan Associates Inc.l (800)975.6666 -- Mass.M p 119535(Moon Associates Irrc.) Purchasers)Name: C l I 1=F O rc 1� f- J'y9 A•si S TA/x Nf ? Installation Address:S,j H ig 1 a S ✓� I�r,�dl}/S, R a t�-6 O/ r Mailing Address Home Phone: C - 03 cell Pho_ �I -70 11 tL E-mall: Year Home Built: . Customer Initials: Taxes Paid in Town of: &M b t 7A�r-E UWe,the above purchaser(s)("Purchaser(s)")and the owner(s)of the property located at the above installation address,hereby jointly,and severalty agree to contract with Moon Associates,Inc.("M00nwor-W),to furnish,deliver,and install of all materials as described in this agreement("Agreement"l,the attached Spec Sheet(s)and diagram(s)which are incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all jobs at the end of the installation. Order Number: Order Number: Order Number: Project Type: W ztLk 1,-3 Project Type: Project Type: Agreement Amount $ 10 _ Agreement Amount $ Agreement Amount $ Less Deposit* $ j3 �!kl� _ Less Deposit$ 5 Less Deposit* 5 Balance Due on Completion S G f s 3 Balance Due On CornpleMon $ Balance Due On Completion $ //�/r IWmmum33%ofAgre&ventAmount due Low emutim tMinim=34%eiAgreeneentAm,e oa du*upon e efsfi n. tMiw ee num33%ofApmrnt Amaantdveupone.ecuriw- v Indicate Payment Meuwd For Balance Indicate Pwiment Method For Balance Indicate Payment Method For Balance JI i Due at Time of Installation: Due at Time of Installation: Due at Tone of Installatlow Est.Start Date: Est.Completion Date: Est.Start Date: Est Completion Date: Est-Start Date: Est Completion Date: DEPOSIT/PAYMENT OPTIONS(.sublet to nnm va lficanon and/or ace approval) 1.Check,Cashier's Check or Money Order Ck p 3•Finandng (Made payable to Moonworks) Acct a Approval Code 2.Credit Card`(circle) Visa MasterCard Discover Acct a Approval Code •,ogee to,Ikw Moonworks to charge the referenced credit card for the deppsA amount Acct xp Date Security Code indicated.9alame to be charged to creel t card upon cpnpkt an or tstagat on if noted shove. it is agreed by and between the Parties that this Agreement constitutes the entire undertandhlg between the Parties,and there are no verbal Understandings changing or modifying any of the terms of this Agreement.purchasers)hereby adBawledges that Purcigimts)1)has*road the front and reverse of this Agreement and has received a completed,signed,and dated copy of this Agreement,including the two accompanying Notice of Cancellation forms,on tiro date first written above and 2)was orally informed of MOW tight to cancel Oft trardwill rt,DO NOT SIGN THIS CONTRACT iF THERE ARE ANY BLANK SPACES. Purchaser rcha er Moon arks vs'Iw ��l 5.ignatug, Signature gnature t, r 64P D 8 r wz sl-Ablf s 7�>,ti dL�iX- A3S�lyiJ/ Print Name Print Name Print Name YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELOW FOR AN EXPLANATION OF THIS RIGHT. NOTICE OF CANCELLATION NOW OF CANCELLAIM Date of Transaction L4`30-V Date of Transaction :30-// You may cancel this transaction,without any penalty of obligation, You may cancel this transaction,without any penalty or obligation. within three business days from the above date. If you cancel,any within three easiness days from the above date- if you cancel, any n property traded in,arty payments made by you under the Contract or property traded In,any payments made by you under the Contract or Sale,and any negotiable Instrument executed by you will be returned Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt by the Seller of your cancellation within 10 days follOVA09 receipt by the Seller of your cancellation notice,and any security interest arising out of the transaction will be notice,and any severity interest arlsing out of the transaction will be canceled,if you cancel,you must make available to the Seller at your canceled.If you cancel,you mast make available to the Seller at your residence,in substantially,as good condition as when received,any residence, In substantially as Bond condition as when received, any goods delivered to you under this Contract or Sale;or you may,if you goods delivered to you under this Contract or Sale;or you may,if you wish,comply with the instructions of the Seller regarding the return wish,comply with the Instructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk.if you do make shipment of the goods at the sellers expense and risk.If you do make the goods avaUable to the Setter and tte seller does not pick them up the goods evalglble to the Seiler and the Seller does not pick them up within 20 days of the date of your Notice of Cancellation,you may within 20 days of the date of your motilre of Canceuation,You may retain or dispose of the goods without any further obligation.If you retain or dispose of the goods without atgl further ob lgation. If you fail to make the goods available to the Seller,or if you agree to return fail to make the goods available to the Seller,or If you agree to return the goofs to the seller and fail to do so,then you remain liable for the goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the Contract, To cancel this performance of all obligations under the Cantract To cancel this transaction, mail or deliver a signed and dated copy of this transaction, mail or deUver a signed and dated copy of this cancellation notice or any other written notice,or send a telegram to cancellation notice or any other written notice,or send a telegram to MOONWORKS, 1137 Park East Drive, Woonsocket, Rhode Island Moo-works, 1137 Park Eat Drive, Woonsocket, Rhode Island 02895,NOT LATER THAN MIDNIGHT OF ��y'// (Date). OMS,Nor LATER THAN MIDNIGHT OF (Otte), I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date Consumers Signature Date REP'.' a w o'ra ...._r.. 14."... .,d:•. .._. ..— .,A..gu,n l;g+t� t'u-:.4ocr P:,-t',I•. P.,I:..>y,,.[.,. , 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 Legibly Name (Business/Organizatio ividual): ) O 3'r-cac /i/G Address: Ud EdsI City/S to/Zip: (�(, Phone #: 40 C?/— (J Are on an employer?Check the appropriate box: TyVRemodeling ject(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. construction 7.2.❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' y p n'• 9. ❑ Building addition [No workers' comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.El officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 11❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: RMCON Policy#or Self-ins.Lic.#: �` 0 S$ Expiration Date: Job Site Address: V Mwes kve— City/State/Zip: 914/y/W(. Attach a copy of the workers' compensation policy declaration page(showing the policy num er an 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.II Signature: is,- Date: /J Phone#: 7 2z — 6 7/ !o ` 106, Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE /05/1a ROOUGER THIS CERTIFICATE IS ISSUED AS Al ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI. 02838-0001 Phone: 401-769-9500 Fax:461-769-9502 INSURERS AFFORDING COVERAGE NAIC4 INSURED MOOn Associates Inc. INSURER A: a national Grange Tn -nce Co 14788 DBA Gutter Helmet INsuRtRe. Beacon Mutual DBA Renewal by Andersen of RI DBA Gutter Helmet Roofing INsuR R c DBA Moon Works 1137 Park East Drive INSURERD: Woonsocket RI 02895 INSURERE: COVERAGES T POLICIES OF INSURMlCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOiVVrf> AIMING Hi~ ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SLSJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH. PQLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN-sKLTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MhVDD/YYYI� DATE(MMIDDIYYYY) LIB EACH OCCURRENCE $10 0 0 0 0 Q GENERAL LIABILITY A X $500000 COMMERCIAL GENERAL LIABILITY MPS26619 09/16/10 09/16/11 PREMISES(Eaocasenoe) CLAIMS MADE K OCCUR WED EXP(Any one Person) S 10 0 0 Q PERSONAL&ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $2 0 0 0 0 0 0 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 0 0 0 0 0 0 POLICY SEC F7 LOC AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $1000008 A X ANY AUTO BIS26619 09/16/Ia 09116/11 (Easccident) ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIREDAUTOS BODILY INJURY $ (Per accident) NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY-EA ACCIDENT $ GARAGE LIABfL.ITY ANY AUTO OTHER THAN EAACC $ AWO ONLY: AGG $ EACH OCCURRENCE $ 10 0 0 0 0 0 EXCESS i UMBRELLA LIABILITY A X OCCUR CLAIMS MADE CUS2 6 619 0 9/16/10 09116111 AGGREGATE $$ EDUCTIBLE FRETENTION $10000 WORKERS COMPENSATION X TORY LIMITS ER AND EMPLOYERS'LIABILITY YIN $ ANY PROPRIETORIPARTNERJEXECUTIVE 28586 10/01/10 10/01/11 E.L.EACHACClDENT $500000 OFFICERAMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $500000 (Mandatory in NH) It yes,describe under E.L.DISEASE-POLICY LIMIT $50 0 0 0 0 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIf MOOKASS DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRiTCE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT•BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABLI TY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 070-7. ACORD 25(2009/01). ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 40 1� C2 44, Fri f� 1 Ij S;�rtt tit•�•'l+�. .f � '�'� Assessor's office(1st Floor): Assessor's map and lot n bar 3 �� / l� Hof THE To` Conservation Board of Health( rd floo : i ssae�r�nt e Sewage Permit number MAN IL Engineering Department(3rd floor): �o s639. House number �o rsr d Definitive Plan Approved by Planning Board 1g APPLICATIONS PROCESSED 8:30-9:30 A.M.and.1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Z!52 � TYPE OF CONSTRUCTION ��, yr�7 19 �3 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Proposed Use Zoning District Fire District Name of Owner lr�/�rDa2SJ �,T7�i�lr�J Address �/ /mil � ,� r`i`yi9�r/�✓If Name of Builder Name of Architect �— Address Number of Rooms Foundation Exterior Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost ^ / ��p Area /V W4EA I..7T% 49 Diagram of Lot and Building with Dimensions Fee 529 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above co truction. Name Construction Supervisor's License _�J' �Gl TROVATO, FRANK. C. dd No 452-r9—Permit For DEMOLISH Single Family Dwelling Location 498 Main Street Hyannis Owner Frank C. 'Trovato Type of Construction Frame I Plot Lot Permit Granted April 27 , 19 93 Date of'Inspection 19 Date Completed 19 ;,, _� TOWN,.OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# 50SR 8 Health Division Date Issued vU Conservation Division Fee e3b 7 16 Tax Collector Treasurer CRD Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address M Aw e� Av e Village 141Othh15 Owner.C'1_%-0oR1D S i A-rhm Address Telephone 5'01— 7 7 I - 03A 4 Permit Request P rtoo-� Sy 50VA. g i L-41 erL, Rjy--�Ig& 2 f ft# P 6 ©� c zhJAiL b DI*' i Square feet: 1stt(floor: existing proposed 2nd floor: existing proposed Total new 1L Valuation I Jul Zoning District Flood Plain Groundwater Overlay v Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family V Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new 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 Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded Cl Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name 43 -+e LL0CA -r+%0Usfi1z►-S Telephone Number _0� 660- 666s Address VPi I T' -7 .1,5' t—At ro i,, h bias SovfiN License# \r,AIY Yr)A Q g Home Improvement Contractor# W 3 6 q Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE J DATE : 0--6~00 FOR OFFICIAL USE ONLY -PEkMIT NO. r ;} DATE ISSUED MAP/PARCEL NO. d t- ADDRESS 4 = . :� VILLAGE OWNER f DATE OF INSPECTION:: F' FOUNDATION FRAME 44 - 1 INSULATION r 5 - t', FIREPLACE f' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL r , FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t y a L '• « �aRr,srasz.E, • The Town of Barnstable MAM Regulatory Services 0 o. Thomas F. Geiler, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. I Type of Work: PLO- 140__ Estimated Cost-A2,Go, Address of Work: AV S T Owner's Name: C Ll F f-0n- TA ►�1 Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply four a permit as the a ent of the owner: t ort �e�Ser l.DC� T_,,VVS-1 k S �1 b - coo pAy1n L"ossler-, Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav I .... The Commonwealth of Massachusetts Department of Industrial Accidents = , = ONCE oliffestlBatfcos 600 Washington Street r Boston,Mass. 02111 Workers' Cam ensation Insurance Affidavit name: 1 `�'cat21� �?A-PAhc� location: 1 e S city U-YA-n n 1 phone ❑ I am a homeowner performing all work myself. ❑ I am a sole netor and have no one working 1n auv cavacitv ❑ I am an employer providing workers' compensation for my employees working on this job. :.... comaan -name:: ri t' YI 4' ;:.. .: .;: saaIT d 'ti-�:: _..�.......... � '��C� .. :: .,:.:..,:.:,,,;:::.:;:<.,,.:;:::::.�:::.:: hors#::: ��� .: :�..::. �..g. .......:..::E;: insurance ca. ... :. . olicv#.. . :; PON ❑ 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: comoanv ..:::. .::... .................;'.;:.;:::;:;.;:: .........................:.::.. ::::::::.:;.::.:: a ' .;.:.:;.:,::::<:<:::«:::::;»:;:.;:.:;.;:;:;.;'.: . ...... . ... .:::;:,:..�.;;;;;;:...... .... .. 4r.. :•;:; ...... ..;.I i oils::'tilt ^^<s�������"� (?��s� {�{ � ��} � ���� j}tivYj;:i::;ii:::�{:Jiiy::i{;}::{.i•.:i�: L:ij:i:::�'s::ji:}:j:::i:{•:•::ik;i:;iiv ...4nC.....:............ .... .:::'1:,•: ........................................ .....................:..:.::.....::.:.:.. :.:.K:.;;:;;:;i:.:.�;:.;;::.;;;::;.r:•::.>;is. .................�.................,..w v::•niv}.C4i«.4...... 4w:::.�..... .. ......................... ...................................n...:.........:.r... ::::v;}:-.:......::!:F.:r?{:{S.;`•... .:.:�::::.:.vA(:�:4:i{vi.:4:•}}i}'.}v::.;�?•:i•:t:+.:i:.i::Y:.v.:,v, .,.:� ----------------------- ;:;::.:,:;;:;;:;<.; .... ....•.:.; w aditress, city. ....................................................... 4':',•:' afnrance:ro::: i;;::,.; >:::;::::::>.. .......:..........:::. :.:. .:. .............. o ry /. iz; a to secure coverage as required under Section 25A of MGL 152 eon lead to the imposition of criminal penaiHn of a are up to$1.S00.00 and/or one years'imprisonment as weU as dvfi penalties in the form of a SPOP WORK ORDER and a an of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is Inw.and correct Signature - Date 11-(a-Ql U Print name y i A LA-Q o SS I Q U' ' Phan# (70%_ offidal use only do not write in this area to be completed by city or town official city or town: permit/llcense# ECIU uilding Department censing Board ❑checkifimmediate response is required elecunen's Otilce ealth Deparmnent contact person: phone#; ther��� oevued 9195�P1A) I� iJ 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 to be deemed to be an to �g PP employment 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 requuemen s of this chapter have been presented to the contracting authority. Applicants yr 5 � e Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits maybe ' submitted to the Depart<neat of Industrial Accidents for cation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be rearmed to the city or town that the application for the pennit 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' compensati6 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 pei ih/license number which will be used as a reference number. The affidavits may be retnmed to the Department by mad 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, The Deparnneat's address,telephone and fax member. The Commonwealth Of Massachusetts Department of Industrial Accidents 0mce of IOYBidQauOus 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat 406, 409 or 375. i i 11-21-2000 00:2Sam From-MARSH CANADALTD. NAN) T-133 P 002/002 F-940 Manta lr,n,lao MARSH A13OU.SJO B 3i0 Barran!Sate, V;Mcvavcr,tat: vb<112 An 4W Company 7e zmw(404)685-3763 FA,(aw9)6 95.3112 issue oaae imW65ro) Nar¢n',Orr a�.2rxw CERTIFICATE OF LYWILITY IN U CE NO.DBP 00-009 1 Trlis is to cert,ty that Me pa9,c,sa of{nsurxnce gesCWO n n ri va bean is6uad to the Name4 inurso for me policy��►n44cam Nuowdhstwding any regmmmant.farm or oW� MW of any CQflV=CO Omsr ntwdh rt%P=to wni�1 InJ*WMf'Cat!bray bets"or may pertain.me insurance afforamd by fns Pohl as gee AD"narein a subject to all to to s.ezciu"ons Ono oeaait,ons of sugt pollm.kjm,te shown msy navb dbsn reduced by Palo cairns. NAMED INSURED: lntenvck Indus V0 o. inc. MAILING ADDRESS: unit ar 7,25 eklpc le P81%South Walpole. MA 02 1 RE: COMM9RCI"GENERAL LIABILITY includ ng x Owurroneo format Contir>V�ret FrytptAyt�s�,aSyitity X Non-Owned At.9Gt Manile x Employees as Addition8l Insured9 X Producm and Computed OP411 jonS x Slalsnkst Contractua9 ,„Cross liability x Personal"ury INSURER: The Continental InSL ram a LIMITS OF W01-ITY: Company Each Occurrence(MCWSivs 00clily In)ury andtor property damGQC) $2,000.000. POLICY NUMBER: MP'R 274 97 44 Products and Completed®perations POLICY PERIOD: temper 31, 1999 Ag1tegate $2.000,000. Decem"r 31.2000 EVIDENCE OF INSURMCO This cartaficate is,asue4 as a m"@ttvr of 010(matran on end CERTIFICIITB HOl�OER' con1crs no nghts upon the Ceruficale rloWar. Thal ce%ficate does not ambrid.oxmd or alter the WwOn gs eftarded by mesa TO WHOM IT MAY CONCERN polldes. SnOW4 8fs at I"policies descnoeQ nerCan tie calnceim Wore me expiraznn"a mareof,ate insurt r{s$aPtordrnp coverage will endeavaurp�r mail TWA days written ttmt;cs to the Certificate Holder taut J1f9dhua to mail such n®tice shall��it�I1rpose no obl�igat,an 0f liability, any kind upon the inswmr(s)atl014ing coverage.its agents or representatives By the issuance Of this certtticate Marsh Canada t.rmatad acceptm no responaibil,i,ttyy tp marn34a the coverw slate4 or advise of the terminals on Of then Policies. By, MARSH CANADA LIMITED L�miitad a �00!E00"d 8609k Qi`IZ ?i�c�'I�'nZIIi: BT690996Uy? hh�0? OOOZ,L�7'��Q i - , _ o Y } lV N Cl i \ 8 0 _ O IN 5 rd of Building Regulations and Standards One Ashburton pl ce — Room 1301 > Boston, Massac uzetts 02108 Home Improvement Con tl ractor Registration Registration: 129369 Expiration: 8/19/01 _- `- --- ------ Type_ Private Corporation ONE IMMOVERIT CUIRRCIN Interlock Industries , Inc . ,Aegistratio�. M169 Ivor Wenzel i xaitatice: i/1flOi H . 945 Concord St , ' Elpe: fliaate farporalli MA 0170 - [iter�O&k Iadus�i�e�jae. --- - Ivor Keaiel . _ ti�osord Sl. Frteingire jA 01711 N O a — � Assessor's map and lot number .k.--)F� .. .� . ... ,,...........` � FTHEt Sewage„.Permit 'number ... ..�.`� ���� ''� Y� �`" w�Qyo °�♦� �f BAHH9 ABLE, i Housenumber ......................................... ............................... 9°o M6 9 � Om a\ TO OF BARNSTABLE BUILDING INSPECTOR. APPLICATION FOR PERMIT TO 4�...`... "7 ,!! ,.. ...:`. {� � 1 .................................. TYPEOF CONSTRUCTION ................:....................................................................::.............................................. I................................................19........ TO THE INSPECTOR OF-,BUILDINGS: The undersigned hereby applies for (aa permit according to the following information. Location Z. �. .'......" �1�, '✓«::��.......!'A,�i. ........ ... �\............... ....... ................................... ProposedUse . .......................... .......................................................,.`:. ............I............... ...... ZoningDistrict ..,�.....................................................................Fire District ..............................................................................{ , .I, Name of Owner r...7...... �a ..........Address .... �:.1 �.�'S'S� !...�-►t f Name of Builder `• k�„<� :C. ..l !. 1^ ,..........Address�� .. ��•`� � .:.. �.... �kSZ11ry qv Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..a .........................................................FoundationT..C?l�ZSc ..... �lt�.,�... ............................. .Exlerior ................................Roofing ........................................................ Floors .��L?ki4r, .. `yam ' . ._....................................Interior y ,.. ......................... ................... Heating .................................................................Plumbing .tNnm> -'v...... ........,............................................. Fireplace .0 R +-.:................................................. .......Approximate Cost ....... U. ..:.................................. Definitive Plan Approved by Planning Board --------------------_---------19________. Area f Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH r t ��+ �J l � 9 r4 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nome . r..�...,� ....... 1...r.,c......................... Conttruction`Supervisor's License ..�!�. ?. .... STAMM, CI,IFFORD E. A=323-9 ' ^ No ....25.724. Permit for ....Gre��nhoo�!�_�� {�&ra�Je � . S 'o Ie I7ami Dwellio -' �^��''���� �� ���'����_�����'�����'' Location ...8I_B[avve�_Au/e�_________. � ................. '-----............................................ Owner .Clifford_I�.�_S _____.. - ^ Type of Construction — -------.— ' ^ ' -------------------------- ' Plot ............................ Lot ----------' ^ . � � ` J Permit Granted ......November ..2�--lg 83 � ~ � Date of Inspection ....................................l9 � ' . Dote Completed ------------'lV _ � . � . � � � ^ � . . � � � ' ' � . Assessor's map and lot number ..A... cFHEtoy Sewage Permit number ...473...../.. AB ♦� Q i B89TABLE, i <� �h House number. ......... ...:O..I.... ..... .. ......................... 90o M6 9 e� 0 MAY d` To OF BARNSTABLE BUILDING -INSPECTOR APPLICATION FOR PERMIT TO 0.� .... .:. E,.. .................................. TYPE OF CONSTRUCTION jTO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for (a�permit according to the following information: Location .2.n! .... 1. .......[��.F,,........ `�.... D................................................:................. IProposed Use���a 1(al.................................................................................................... ............................. I Zoning District ...........Fire District ..............................: Name of Owner ...... n, i `11'M. ..........Add ress� C .4 �11„>r,....1��:... t+ .C`�11 3..CT Name of Build; ..........Address`, .. R.=A ... ....1..,, �11L1 Nameof Architectp ............... ...........Address.............................::........: .................................................................................... Number of Rooms ...3..............................................:..........Foundations©�.1�.F ..... 4 . . ............................... Exterior CJ Z.. . 1�1.G-�t,.:�..................................Roofing ........................................................ Floors �fJS�� '�C�, . �� ........................................Interior .. Heating .............................:.................................Plumbing .WzwF....... ....................................................... Fireplace fl.�1J' ...........................:.... ..........:.........Approximate Cost........ .�t.......... Definitive Plan.,Approved by Planning Board ________________________________19________ , Area ........�................................. Diagram of Lot and Building with Dimensions Fee Z� SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .,X . .......................LJ. Construction Supervisor's License .�... . �. .... w STAMM, CLIFFORD E. A 25724 & Garage ... Permit for ............................. '�K No ...... ....... ..��EENHOUSE Single Famil)�..pw llin . ....................................... ...1�...........5............. Location ....8...1.....Hawes.....Ave................................ .... % ..................................... .......... Owner ',-Clifford E. Stamm ................................................................ Type of Construction .......Frame ................................... .............................................. .................. .......... Plot . ............ Lot ................................ -- Permit Granted ..... ......................November 2...... ....19 83 Date of Inspection n ...........................19 Date Completed .............................. .......1WP .4- ff . • I - LILL- _ i 1 aT rv., -- t - - 1 l r -I Ur M4 IT ie- , �u un A��o►.a !fit t N — — w -*► Z 4, L — , 1 I ` t, I � _ i --�- s , Q T j Ems► i LA r q% cOAJc rz u T'r�: r L u�`v •I�a►ry o tv r—Q - , Q - --±r ---T---- --- i I "cr r- No- _- ---r• I I � / u ecw G y� t•t-a.�.t� � v � — A s P+�d i.� !IL /!t-1 1 ►.,�� a^,� �M�,�,� -- - �hz� T rye• —�--- - - - -- -- --- —'- - - - - -- — — — — I' t� ic.Xi` 1 AN. WTI — � �r �4 _ _ .. _ ---- IT { S 1 - _ ,I q .. I Q 9! --*rtP- rO M a74,w 4 A Z E- zo Ma— A A SCALE DRAWN BV r M I L►i.a.�l1_ .�'-�t 0�t:.tL u� t -- _ -- _ H1,`�I REVISED i A hf7 DATE AP►ROVED BY DRAWING NUMBER