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HomeMy WebLinkAbout0089 LEWIS BAY ROAD (17) c:Zp.�C3...�z t' ' ti Town of Barnstable Building Department - 200 Main Street � * Hyanni 1639. s, MA 02601 9 MASS. (508) 862-4038 �� Argo�°i Certificate of Occupancy Application Number: 201006779 CO Number: 20110125 Parcel ID: 32722300L CO Issue Date: 08116/11 Location: 89 LEWIS BAY ROAD 208 Zoning Classification: Proposed Use: CONDOMINIUM Village: HYANNIS Gen Contractor: OCEANSIDE CONSTRUCTION & DEV Permit Type: CC00 CERTIFICATE OF OCCUPANCY COMM Comments: C.O. FOR UNIT 208 2 t Building Department Signature Date Signed Town of Barnstable Building Department - 200 Main Street Hyannis, MA 02601 MASS �' (508) i63 862-4038 9� RFD MA'S a Certificate of Application Number: 201006719 CO Number: 20110125, Parcel ID: ` 32722300L CO Issue Date: 08116111 Location: 89 LEWIS BAY ROAD 208 Zoning Classification: Proposed Use: CONDOMINIUM Village: HYANNIS Gen Contractor: OCEANSIDE CONSTRUCTION & DEV Permit Type: CC00 CERTIFICATE OF OCCUPANCY COMM Comments: CO. FOR UNIT 208 Building Department Signature Date Signed TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map-3XI Parcel Application # Health Division Date Issued a Conservation Division Application Fee Planning Dept. Permit Fee IIJU Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis 01 , Q Project Street Address "v Village kA�my)w S YY\A ,D t6 01 Owner lg 2 �' r t� � MA C_�JA �R:2SCE f4 Address Telephone (o 3L S33 Permit Request ISI R LA-)a(DEZ- ]�LOQJZ I� / t3Id Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatiot*1 .®� Construction Type Lot Size Grandfathered: 0 Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new 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.2LI Yes<❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn ❑ existing Jn'ew ,size_ {k ^^w y Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: m.`a Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ 19 Commercial ❑Yes ❑ No If yes, site plan review # ilk _ Current Use Proposed Use APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) Name C ( j}� C, j a M uvOGAU-4�)f MS Telephone Number SO'S `-27 6 ,S Q' Addres,:�b X I0-D License # 51311 OP'Molict �> e (�Ck Home Improvement Contractor# A ar')�-6:Z Worker's Compensation # COW Ca�l0°1 S3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 'I)A M 5C A b)(_ SIGNATURE DATE l ` 16 - 7,017 FOR OFFICIAL USE ONLY APPLICATION# Yf DATE ISSUED MAP/PARCEL NO. r ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME t INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH f FINAL GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT _ ASSOCIATION PLAN NO. Office of Investigations 600 Washington Street. Boston,MA 02111 Uw - www.mass.gov1d4a Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecfricians/Plumbers Applicant Information Please Print Le . l -• Name(Business/Oxgmiza imvImlividuan: `. .C„ , To o t (j'0 v Address: ` City/State/Zip:,'-- I ojzo ' hone.#: 150� _776--S17 8 0 AFI u an employer? Check the appropiiate bar: Type of pro]ect'(requis ed):, 1. am a employer with • 4. •Q I am a general contractor and I have hired the sub-conlracinrs 6. ❑.NeW construction . employees(fall and/or part Ei 1..* 2.111 am a•sole propaetor or partner- listed on the'attached sheet: 7. ❑Remodeling ship and have no employees These sub-cars have '8. ❑Demolition working for me in'aay capacity. employees and have workers' 9. []Bmlding addition [No workers' comp.immn=e. camp.ins�-anre.t' required] 5. We are a corporation'and its ID.❑Electrical repairs or additions officers have exercised their '3.[] I am a homeowner doing all•worlc 11.❑Plumbing repairs or additions•. mys �o eI£ workers' comP• right of exemption per MGL - � � _ . insurance required]t c. 152, §1(4),an 12.❑Roof repai eesd we have no rs ��� ' employ .[No workers' 13.[Other �tw comp.insurance required] *Any applicant that checks box#1 must also fill out the section below.showiug fhcir workers'compensation policy information- t Homeowners who submit this affidavit indicating$icy 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 shoot showing the name of the sub-contractors and state whether or not thosi c entitirs have employees. If the sub-contractma have cmployecs,they must providt their warts'comp.policy number. '.I wn an employer that is providing workers'compensation insurance for my employees. BeLow is the policy and job site information. Insurance Company Name: `9U Yl Policy#or Self-ins.Lic.ff- Cjn C—oo LA 6-7 S3 Expiration Date: t 1 13•�e�(Z:' Job Site Address: �4,(� r� 'T—?Qj� City/StatE/Zip: a' Attach a copy of the workers' compensation policy declaradon page'(shoWing the policy number and expiration dafe). Failure•to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a fine np to$1,500.00 and/or one-year imprisonment, as-well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.DD a day against the violator.:Be.advised that a copy of this statement may be forwarded to the Office of Iuve,stigalions of the j7TA for M' surance covera.Fe yeafication. I do-hereby certcfy nder ains• enaldes of perjury that the information provided above is true and correct- 3r tore: Date:: : L 'hone#1` i Ofj'!r_W use only. Do not write fn this.are ,to be completed by cfty or town official City or down PermitlL.icense# t Isstung.Authority(circle one): Z Baard'of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: . t THE r Town of Barnstable Regulatory Services &AMNSz,BLF, MASS �► Thomas F.Geiler,Director 3L639. �En " Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder nc , as Owner of the subject property . . hereby authorize � � rb m wme-It.&VAr�A to act on my behalf, in all matters relative to work authorized by this building pet=t- A IN U At T Z04 (Addres 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 Ow r Signature of Applicant i Print Name 4PtName Dat Q:F0RMS:0WNERPEFMISSI0NP00LS 6/2012 Client#:20662 2COASTALCU ACORD,T., CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/18/2012 THIS 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 CONTACT NAME: Dowling&O'Neil A/co No.Ext,508 775-1620 FAX ,No Insurance Agency E-MAIL Alc : 5087781218 ADDRESS: 973 lyannough Rd., PO BOX 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:National Grange Mutual Insuranc INSURED INSURERB:Guard Insurance Group Coastal Custom Woodworks,LLC P.O.Box 102 INSURER C Sagamore Beach,MA 02562 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER ADDLSUBR MM/DD�Y POLICY EXP LIMITS A GENERAL LIABILITY MPOS2143 3/22/2012 03/22/201 EACH OCCURRENCE s2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence) ccurrence $500,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 POLICY E 0 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED INJURY BODILY INJU Per accident AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION COWC246753 11/13/2011 11/13/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 000 OFFICERIMEMBER EXCLUDED? a N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 OOO If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Bldg.Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S100919/M100918 LS1 z Ben and Debra MacPherson June 27,2012 P.O. Box 674 Barnstable, Ma 02630 508-362-1053 Mr. Chad Doe, This letter is a request for permission to install new entrance doors on units 415 and 208. As youknow per_our_conversation_thereare_so.me_inhe_rPnt_is Thermotrue doors that were installed on our units at 89 Lewis Bay Road. ^ The doors have very little in the way of sound deadening and Thermotrue does not manufacture a higher quality door with the proper sound transmission classification in a fire rated door. We have found a fire rated door manufactured by TRUSTILE. Th is doo r not only has the fire rating required by building code in Barnstable it also has a much higher sound transmission class and comes very close to matching the style of the original Thermotrue doors. Permission Granted: Chad Doe: Date: Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:9 150297 Type: Office of Consumer Affairs and Business Regulation Expiration: 31-2 312014 Ltd Liability Corpor 10 Park Plaza-Suite 5170 Boston,MA 02116 CO STAL CUSTOM WOODWORKS LLC THEODORE POMERQY's-- =�-i i1iI 2 OCEAN PINES DR. r Q SAGAMORE BEACH MA:02562' Undersecretary - Not valid without signa re — Massachusetts- Department of Public SafetN M Board of Building-, Re-ulations and Stan(hirds Construction Supervisor License License: CS 51311 THEODORE S POMEROY , PO BOX 102 ''$ SAGAMORE BEACH, MA 02562 ��-- Expiration: 2/15/2013 ("unm issioncy- Tr=: 11668 tti Town of Barnstable Building Department - 200 Main Street EARNSZABLE. # Hyannis, MA 02601 MASS. 1639. , (508)A 862-4038 rFD MA't Certificate of Occupancy Application Number: 201006779 CO Number: 20110125 Parcel ID: 3272230BH CO Issue Date: 08116/11 Location: 89 LEWIS BAY ROAD 208 Zoning Classification: MEDICAL SERVICES DISTRICT Proposed Use: Village: HYANNIS Gen Contractor: OCEANSIDE CONSTRUCTION & DEV Permit Type: CC00 CERTIFICATE OF OCCUPANCY COMM Comments: C.O. FOR UNIT 208 Building Department Signature Date Zigned w 5 Off- �� i I,iE TOWN OF BARNSTABLE� r°�ti Building Application Ref: 201006779* BARNSTABLE, * Issue Date: 12/16/10 Permit 9 MASS. �ArFO 339. OR Applicant: OCEANSIDE CONSTRUCTION&DEV Permit Number: B 20102721 Proposed Use: Expiration Date: 06/15/11 Location 89 LEWIS BAY ROAD 208 Zoning District MS Permit Type: SPECIAL PROJECT ADD/ALTER COMM Map Parcel 3272230BH Permit Fee$ 330.02 Contractor OCEANSIDE CONSTRUCTION&DEV. Village HYANNIS App Fee$ 100.00 License Num 48102 Est Construction Cost$ 36,596 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND BUILD OUT FOR UNIT#208 THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: GREENERY DEVELOPMENT LLC BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 52 SHIP'S EAGLE LANE INSPECTION HAS BEEN MADE. OSTERVILLE, MA 02655 Application Entered by: PR Building Permit Issued By: THIS PERMIT CONVEYS.NOAIGHT TO OCCUPY.ANY STREET,ALLY OR SIDEWALK OR ANY„PART THEREOF,EITHER TEMPORARILY OR PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION. STREET ORALLY GRADES AS WELL AS DEPTH AND LOCATION OF:PUBLIC SEWERS.MAY BE OBTAINED FROM THE DEPARTMENT OF:PUBLIC-WORKS. THE ISSUANCE'OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM,THE CONDITIONS OF ANY APPLICABLE.SUBDIVISION RESTRICTIONS.' MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION 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. r 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). h lry, Y R tip' P a'' P u F y R> F M— M BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS I 1 XpovId rjt".11"e 1 2 2 2 lee,, 3 t r(V� 1 Heating Ins ection Approvals Engineering Dept '7_ I,k - II 1f Fire Dept 2 Board of Health �17�ft—A14) TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ParcLC2� Application ® � Health•Division Date Issued Z( �(.a Conservation Division ' Application Fee',/p Planning Dept. Permit Fee. Date Definitive Plan Approved by Planning Board v Historic = OKH _ Preservation/Hyannis "v Project Street Address Bc 1.6-2k S U N i '_ o Village �YAnn� S Owner (�,R LeX--.)kS qAAJ LLC- Address 6 m4mj Ss"r v N Tr '�1-7 Telephone SDO `7-79 S70 G Permit Request 1'NfitiiXt0C Q,-.)LLp e> S `j_7: rz GL� Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size' Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes U46 On Old King's Highway: ❑Yes .dlo 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 `a Total Room Count (not including baths): existing new First Floor Room Count ' `,a Heat Type and Fuel: ❑ Gas ❑Oil Ai-Electric QpOther Porno a Central Air: &Te-s ❑ No : Fireplaces: Existing New Existing wood/coal stove:, l Yes2u:% t Detached garage: ❑existing ❑ new size Pool: ❑existi g ❑ new size _ Barn: ❑ existing ❑Qn,.'ew Size_ A- Attached garage: ❑ existing ❑ new size _Shed: ❑ exr st g ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - - pC,�+us�x Name Telephone Number `17q 22:>?, l Address S m`al'N �`� N iH-L License# 048l o Z �y4n^�S rY1� 6Z6a1 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO CP�S� LW,5k1 , SIGNAT DATE___ 111,41. Ec, FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION, FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r r +D 1ST uC'q�6N RQ AfT- 04 T'. Project: Lewis Bay Court- Hyannis, MA In accordance with Section 116.2.1 of the Massachusetts State Building Code, 780 CMR,' 7rh Edition, I, Wayne J. Jacques, Massachusetts Registered Architect/Engineer #6935 of Jefferson Group Architects, Inc., hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specification concerning: Entire Project Architectural X Structural Mechanical Fire Protection Electrical Other(please specify) For the above named project and to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts Building Code Th Edition, all acceptable engineering practices and all applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved of the building permit and shall be responsible for the following as specified in Section 116,2.2: 1, Review, for conformance to the design concept, shop drawings, samples and other submittals, which are submitted by the contractor in accordance with the requirements.of the construction documents, 2. Review and approval of the quality control procedures for all code-required controlled materials 3. Be present at intervals appropriate to the stage of construction, to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. Pursuant to Section 116.4, 1 shall submit periodically, a progress report together with pertinent comments to the town of Hyannis Building commissions. Upon satisfactory completion of the work, I shall submit a final report as the satisfactory completion ad readiness of the,project for occupancy. MA .bwig May 19, 2010 GIN AL AND AL DATE Jefferson Group Architects, Inc. e Wayne J.Jacques,AIA,WCARB 700 School Street-Unit#2 Pawtucket,RI 02860 T:401-721-2245 F:401-721-2238 Construction Control Affidavit-MA Lewis Bay Court.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 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): ®ce-►)r\is v Address: `lo-, City/State/Zip: � �5 ,6�:�t: �.� Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. f am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LE] 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. 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 their workers'comp..policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: b'� 1,-A5, (2dEa0 City/State/Zip:1A Sj r4nn c 5 4� g2 6ci i Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th ains and penalties of perjury that the information provided above is true-and correct. Sign ture: k Date: t2—\ 'C— Phone#• ��la 22,t 8AL' 0 cial 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#: b q Massachusetts - Department of Public Safety Board of Building Re,Tulations and Standards Construction Supervisor License License: Cs 48102 JOHN J HUTCHINS 419 RIVER RD MARSTONS MILLS,MA 02648 Expiration: 9/16/2012 ('umniissiuner �. - Tr#: 3834 � E Town of Barnstable Regulatory Services RMW" MASS, Thomas F.Geller,Director 39. a 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 Property Owner Must Complete and Sign This Section If Using A Builder II I, �� , as Owner of the subject property hereby authorize<---,e�� to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Sig of Owner Date �� - Print Name 6 If Property,, Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMIS S ION I g;OD. 6/1/2010 THI '-CERTIFICATE IS ISSUED A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Paul Petors Agency,Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND,ExTEND OR 680 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW MaShpee,MA 02649 COMPANIES AFFORDI G COVERAGE COMPANY A Atlantic Charter Insurance Company VDAC INSURED COMPANY Oceanside Construction,Inc, B COMPANY 419 River Road G Marstons Mills,MA 02648 COMPANY D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE DEEN 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 WI CERTIFICATE MAY DE*SUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES. LIMITS SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIMS. CO TYPE OF W�JRANCt? POLICY NUMBER POLICY WFECTIVlf POLICY EXPIRATION LIMITS LTA DATE(MMIODNY) DATE(MMIOOm) (In Thousands) GENERAL LIABILITY _ _ BODILY INJURY OCC S BODILY INJURY AGG COmAPREHEN3IVE FORM PROPERTY DAMAGE OOC B PREMISESIOPERATIONS UNDERGROUND PROPERTY DAMAGE AQQ S al&PI)COMBINED OCC $ EXPLOSION a GOLLAPSE MAZARD BI 6 PD COMBINED AGO $ PRODUCTSiCOMPLBTED.OPER PERSONAL INJURY AGO & CONTRACTUAL INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE PERSONAL INJURY BODILY INJURY AUTOMOBILE LIABILITY ANY AUTO (Perpenan) 6 ALL OWNED AUTOS(P&ale Paae) BODILY INJURY ALL OWNED AUTOS (Per aecldent) $ (fter then P&Rte Passenger) PROPERTY DAMAGE 6 HIRED AUTOS NON-OWNED AUTOS BODILY INJURY A GARAOE LIABILITY PROPERTY DAMAGE COMBINED 3 EXCESS 1ABILITY EACH OCCURRENCE S UMFIRELLA FORM AGGREGATE a OTHER THAN UMBRELLA FORM $ A EWLOYERaLIABILITYT16NAN0 UVCV00617205 2/3/2010 2/3/2011 STATUTORY LIMITS EACH ACCIDENT ® I,000,000 DISEASE-POLICY LIMIT a- 11000,000 DISEASE-EACH EMPLOYEE !A,000,000 OTHER � DESCRUMGM C)F OPERATION3160CATIow"NICLN$4PE'GIAL ITEHO 1 Job: 891,ewis 13ay Rd Now" - 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of Barnstable EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL€NuEAVOR To MAIL Attn:Paul Rosa a 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. 200 Main St BUT FAILURE TO AlL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Hyannis,MA 02601 OF ANY KIND VFjttqTHE COMPANY,ITIAGIENTS OR REPRESENTATIVES. 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