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HomeMy WebLinkAbout0174 OLD TOWN ROAD l� Oky �Ul i I I Town of Barnstable Building Department �oF W TOk y Brian Florence,CBO Building Commissioner LARNSresrE, 200 Main Street,Hyannis,MA 02601 MAM 1639. ��� www.town.barnstable.ma.us �prED MA'1 A Office: 508-862-4038 F 08-790-6230 Approved: Fee: Permit#: HOME OCCUPATION RAGISTRATION Date: DZ 2 '7 - A2 Phone#: Name: c elms ✓► /'^a�T ks �� 77� 6�� 6 073 Address: Village: Name of Business: Cc/,., e.o ) � L,vS17JM� Type of Business: C^,J�A"C 5a�.� I S''t '"ate Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1 A of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust oT other particular .matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant r ���a' ws ��G _Date: 02 7' Z '2 Homeoe.doc Rev.10/17 -�-� Town of Barnstable � ��` Building Department_ `� ' C) Brian Florence, CBO ej�&-Kz S Building Commissioner , 200 Main Street, Hyannis, MA 02601 Q www.town.bamstable.ma.us Pre-application for Business Certificate Date O �' Q Map��(J Parcel 0����� Applicant Information Applicants Name (J C,(' 1n _ ( `�)fl C Applicants Address 1-7 1-1 0 18 j ayti Qr] Email Address_echOCgjpP'C� rno I.e0m Telephone Number 17Y- 6 64- G073 Listed El Unlisted Business Information New Business? _ _ es No Business is a registered corporation? ________________________. Yes No If yes Name of Corporation Does business operate under the registered corporate name? Yes Is the business a sole proprietorship or home occupation? _________ es No If yes then a Home Occupation Registration is required-See Building Division Staff Name of Business Business Address 1N 1wri Q , l j!',nl ,S A h d�� 'Type of Business��p� c%k �n�i f►C -- II Building Commissioner Office Use Only Conditions S-)T.L — CL.NP - ( i-os .9(Z:F`• ':�'Ot-n u Building Commissioner Date 27h-a zz> Clerk Office Use Only f 02-27-20 Attn:Town Clerk's Office RE: Business Certificate Home Occupation Registration To whom it may concern; I; Carlos A Martins Rocha, hereby state that the operation of my DBA business, ECHO CAPE COD EIN: 30-1223153, will be done from my home address,174 Old Town Rd, Hyannis, MA 02601.All sales that will occur will be done through an online marketplace. No physical items will be sold from my address. If there are any questions or concerns, feel free to contact me.at 774-606-6073. Carlos A Martins Rocha F z Assessor's map and lot number..(?:... FTIIET Quo Sewage Permit number ...............`3.r�.!2'............................. Z BAHHSTA.BLE, i Housenumber ......................................................................... 90� 163 0� �0 0 YPY a' ► TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .... ..�'t�1�.�.................................................�✓GtlC i'//r✓�.............................................. TYPE OF CONSTRUCTION ........ %n.CI1�� .'.'/79// " Gist'✓D / TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies,for a.ppee-r'mit according to the following information: Location ... ". '... ..... ��!....../ i'�1f✓!°✓....J/`'`'.'. .►r'�� li! !V/ 1 �Jft............................. . ... t Proposed Use ....../°,��1c�r,^+-/✓� ................................................. ....... ..... ........ ..... .. . .. ZoningDistrict ......y.....................................................................Fire District .....,.......`............................................................... Nameof Owner .:.....:............................................ `.......Address ...........:..............,........................................................... Name of Builder � �' ....................Address Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .............................................................:....Foundation .....� ..................�...�.............:.................................... Exterior � .� •�.'!...................................Roofing ..... �.,,��'! . ......................... .................. Floors . .. . -.....................................Interior '.............. ...��©.... .......................................... Heating ......� •'r✓f'� ......................Plumbing ........................r.`. ............................................ Fireplace .........f �i�� �: ..................................................Approximate Cost ... !.:t6. ...................................... AlDefinitive Plan Approved by Planning Board __ r _________19 Area Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH A-9 iy^ ,tea I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................ .....................................;................. •' vvc Greenbrier Dev. Corp. A=268-78—/ No ...2.1463... Permit for sing•1•®••fami1Y•••••••• .........................dwalling.................................... Location ..... G-1d••Town..Rd................... WP-st..IZY.annisp©rt............................... .. f jfi9 Owner ............Gre bra---r•..De-Y....eO. •rp.......... Type of Construction F` .......................... I.............t, ............... ........... � Plot ............... ....... Lot ........... ............... Jul 13 79 Permit Granted .......... ............Y...,,s.........19 y Date of Inspection ...,-,... ,�...........19 Date Com eted ....�................... .............19 PERMIT REFUSED ......... 19 Z° f�. ..........�. i. 1............ Z- 1 ........... ...... .............. ................................. . .... ....................................................... l...... ............... .................................... L--j 1 ............................................................................... ............................................................................... os*N`r TOWN OF BARNSTABLE ` 21-463 Permit No. ------ ---- ---- 1 s Urr,U a Building Inspector. Cash — �'"'Y� OCCUPANCY PERMIT . Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without �a--Building Permit therefor first having.been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the.Building Inspector." Issued to Greenbrier Development .COrpAddress I 1nt 67. Old Tnwn lioad^ 17est Hua.rrinnort Wiring Inspector. Inspection date . �--' A) w... _ /I e, Plumbing Inspector /� Inspection date �, �,..e_ Gas Inspector Inspection date Engineering Department lC(y /�� Inspection date 4- THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. c _..� rBuilding�Inspector E ' 5"�, x r�4°�°`"*'t'<,`u 7 n.+�: .♦Y.. 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PiYAIVNI$, MASS. �,EET 1®� �. DATE �?�®. LAB® gA�(RY E �' '. ,�y' d lot nurn er /C'��z 4'Asepor's map an X> ....... THE I........... �pf SeXge Permit number 77 ............................................ M11C qVMM M ABLE, House number .......................................................................... WTAUED IN COM WITH TITLE 5 AL COOZ OF B A—R NS TOWN rf lur. V BUILDING 'tN-SPECT0.11 Y. e APPLICATION FOR PERMIT TO ...... ....... r')' ...........I.... ..... .................................. ... ......... TYPE OF CONSTRUCTION ........ .......... ........................ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...4��'... o .......................... ..... ? .. .................. % .................................... ProposedUse .... .111.61 ......................................................................................................................................................... Zoning District ....../1_'415 .................Fire District ............. Name of Owner67M�M&Z -Aw�-41V Address .... Nameof Builder ...................................................Address ..............✓...................................................................... Nameof Architect ..................................................................Address ..................................................................................... Numberof Rooms ..................................................................Foundation .... ........................ ............................. Exterior .......Cl/n ..............Roofing ........V, ................................... .. ..... .............................. Floors ....r_^-e ......................Interior ....... /......i..................................... Heating ...... ....................................................Plumbing ..... .. .....................;........ Fireplace .......... ....................................................Approximate Cost ...................................... p,l 17 ....�".O Definitive Plan Approved by Planning Board -----------19 Area ............... Diagram of Lot and Building with Dimensions Fee ........ ........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH Its 00 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..A-1..... ..................... . ( Greenbrier Dev. Corp. \ --------.�������!� ----------. , ' --..l�t..��.���.��mv�.J2d~----.. Location— - � ^ ~ ��� . ' ~-------. . °------ Owner ...... . - ^ ^^Type of of Construction ........frame....................... . ..-------'------^'~—'------^--' ' 4 , . . Plot ............................ Lot ................................ ~. . ' , . ' ' ~~ ' Permit Granted lV_ � |----''`J�l�—���--' /9 ' � ` Dote of Inspection ....................................lg � uo/a Completed »0^ . , . i ' | . . . PERMIT REFUSED ' . ' � lV ----- . . . ---. ' ' ^ . - _ . . --__— . . .�. ............ � — ` tr ' . . ' lg " `-----_.-----.--~.-----.----. - ----------..--.--.-----~..—.,. , ' U 8 n '„ w _ I Vr � -01 47, AV Al 11/14/14 Thomas Perry, CBO Town of Barnstable Building Division 200 Main St Hyannis, MA 02601 RE: Insulation Permits Dear Mr.Perry, This affidavit is to certify that all work completed for insulation work at 174 Old Town Road (application#201402388) has been inspected by a certified Building Performance Institute (BPI) Inspector. All work performed meets or exceeds Federal and State requirements. Sincerely, Conor McInerney Consei Vision Energy 376 ROUTE 130,SUITE C SANDWICH,MA 02563 508-833-8384 WWW.CONSERVTODAY.COM �V TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Lam{ 64 Map z�'B Parcel a o pli ijn # 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 Village Owner Sor+••.� S�,.���o Address �, �.c�iT e►s E, Telephone3-���- 'Permit Request e-,K i a'�--a .. T41%A--4--4iNA,. 7 Y—U-11 Q-.0 W A. r Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation*Z.c�00 .no Construction Type CD ZE Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sGpporting documentation. Dwelling Type: Single Family 0' Two Family ❑ Multi-Family (# units) ' Age of Existing Structure \°0kc1 Historic House: ❑Yes ❑ No On Old King's ighway: ❑Yef❑ No Basement Type: W Bull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)L Number of Baths: Full: existing -t- 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: 3Gas ❑ 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 ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION - -(BUILDER OR HOMEOWNER) Name C_e..e� Telephone Number So•% - �S3 - $'S"g�► Address License # % N o zS Z Home Improvement Contractor# Email Worker's Compensation # teo��'� ce3 �+►g ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ti DATE ��- - r FOR OFFICIAL USE ONLY c APPLICATION# s DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL—, PLUMBING: ROUGH FINAL r, GAS: ROUGH FINAL � FINAL BUILDING D'jk E-CLOSED OUT A Q ION PLAN NO. c. _.�_ r-%fc�frerjur�rmantr�fl r�r ��i.rfnr�ar/1s Office of Consumer Affairs&Business Regulation License or registration valid for individul use only Vw ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: glstration: 171251 Type: Office of Consumer Affairs and Business Regulation xpiratlon: 3/1/2016 Partnership 10 Park Plaza-Suite 51.70 Boston,MA 02116 CON-SERVE ENERGY 376 ROUTE MC130 SUIT 376 ROUTE 130 SUITE C SANDWICH,MA 02563 Undersecretary Not valid without signature ��\✓Jf 3�dlu '3�3N7 v� ���.,afiiwa�a ::� �t� �a'�5 f 4Wp CSSL-102778 CONOR D MCINERNEY 16 'h 39 SIASCONSET llRNE SAGAMORE BEACH MA 02562 08/19/2014 AC6RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD""") 03/17/2014 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 WANED,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 CS8.S/WORKCOMPONE NAME: PO BOX 946580 PHONE FAX MAITLAND,FL 32794-6580 E-MAIL Phone-877-724-2669 ADDRESS: Fax-877-763-5122 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Continental Casualty Company 20443 INSURED INSURER B: CONSERVISION ENERGY 376 ROUTE 130 INSURER C: SUITE C INSURER D:Continental Casualty Company 20443 SANDWICH,MA 02563 INSURERE: Continental Casualty Company 20443 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 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. INSR ADDL SUBR POLIC POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDY E MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300,000 CLAIMS MADE OCCUR PREMISES(Ea occurrence) A ® Y N 6011316335 03/11/2014 03/11/201 a P E PERSO EXP NAL &ADV one INJURY 000,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2,000,000 17 POLICY JET LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 (Ea accident) .ANY AUTO BODILY INJURY(Per person) ALL A .AUTOS OWNED SCHEDAUTOSULED N N 6011316335 03111/2014 03111/2015 BODILY INJURY(Per accident) [HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE 1,000,000 D 'EXCESS LIAR CLAIMS-MADE N N 6011316352 03/11/2014 03/11/2015 AGGREGATE $1,000,000 DED RETENTIONS 10,000 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY.PROPRIETORMARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $100,000 E OFFICER/MEMBER EXCLUDED? N N 6011316349 03111/2014 03/11/2015 - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) Certificate Holder is added as an additional insured as provided in the blanket additional insured endorsement. CERTIFICATE HOLDER CANCELLATION Rise Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1341 Elmwood Ave THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Cranston,RI 02910 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105)" The ACORD name and logo are registered marks of ACORD caataes The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia If Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): ConserVision Energy Address: 376 Route 130 Suite C City/State/Zip: Sandwich, MA 02563 Phone #: 508-833-8384 Are you an employer?Check the appropriate box: Type of project(required): 1.EJ I am a employer with 8 4. ❑ I am a general contractor and 1 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. # 7. ❑ 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 required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑� I am a homeowner doing all work right of exemption per MGL I 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' comp. insurance required.] 13.® Other Weatherization xAny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 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: CS&S/WORKCOMPONE Policy#or Self-ins.Lic. #: 6011316349 Expiration Date: 03/11/2015 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 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 hereb tify der th p ins nd penalties of perjury that the inforneation provided above is true and correct. Si ature: Date: Phone#`. 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#: N z� �r ` OWNER AUTHORlZATIO V FORM 9-01K Sw-too (Owner's Name) owner of the property located at (Property Address)�4\1 _ 6,vg n i p 2 t9 O (Prope y Addre s) hereby authorize Se i S`) (�( f ('Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to'obtain a building permit and'to,perform work on my.property. :Owner'ognature Date Town of Barnstable. *Permit,#7040 bo 5 7 _ Expires 6 niontAsfrom is e-date Regulatory Services Fee 3� .a• •ARNSTABLE * -� MASS. Thomas F.Geiler,Director Building Division y Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.m4.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Zi(p� Property Address Residential Value of Work Minimum fee of$25.00 for work under$6000.00 . Owner's Name&Address � L Contractor's Name—� '�' �' 2 Telephone Number c4?)kc Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) - 7� � ESS_PERUI ❑Workman's Compensation Insurance FEB ® 8 2010 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABLE ❑ I am the Homeowner �✓ I have Worker's Compensation Insurance Insurance Company Name 15;::2C. >� �; ��jj�� e✓ Workman's Comp.Policy#zt,)C`' Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) a ❑ Re-side _ #of doors (, Replacement Windows/doors/sliders.U-Value d (maximum .44)#of windows *Where required: Issuance ofthis 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 . r ired. SIGNATURE: C:\Users\decollik\AppUata\Local\Microsoft\Windows\Temporary Internet Files\Coni n't.Outlook\4STGU5Q0\EXPRESS.do'C Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organizationlndividual): Address �_V/ >o City/State/Zip: c_4 kY,&& a Phone#: Are/ou an employer?Check the appropriate box: Type of project(required): 1.R I am a employer with 1 _ 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. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LE]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 �/�t'� 13.®Other Gl, 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 then hire outside contractors must submit a new affidavit indicating such. IContracton that check this box must attached an additional sheet showing the name of the sub-contractom 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: � '®o� � ✓�/G2'�f�E�'-L�JSG'rC'0�1C"�' Policy#or Self-ins. Lic.#: &Ze (2-W Expiration Date:e- 2-3/0 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 S 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. .[do hereby,cer *1 he pat s and penalties of perjury that the information provided above is true and correct. Si ature: Phone#: [6.i cial use only. Do not write to this area,to be completed by city or town officialy or Town: Permit/License# uing Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other Contact Person: Phone#: Date:. 6/26/2009 Time: 1.17 PM TO: 0 9,15083626115 Page: 002 s . Client#:9742 2BAKERAS ACORD- CERTIFICATE OF LIABILITY INSURANCE 66126109°O1YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box,1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A. National Grange Mutual Insuranc Baker&Associates,lnc. INSURER 13 Associated Employers Insurance P O Box 923 INSURER C. Centerville, MA 02632-0071 INSURER D INSURER F. COVERAGES 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 CONDfT IONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. OLICY LTR TYPE OF INSURANCE POLICY NUMBER DATTE MM/D� POLICY MM1D01YYY1 LIMITS A GENERAL LIABILITY MPJ7223M 04/19/09 04/19/10 EACHOCcuRRFNCF 51,000,000_ -- X GOMMFRC,IAL G[NFRAI.I IABII.I'TY °AMAl' 10RFNIFD $500,000 _ CLAIMS MADE rX]OCCUR MI-D I-AP IAo' we pereonl $1 O 000 FIE RSONAI&ADV INJURY $1 000 000 GENERAL AGGRLCA IF: s2,000,000 GENT AGGRF GATE 1 IMI I APPLIES PER PRODC1C15 I;OMPIOP AGG s2,000,000 POL ICY jE l I.00 ___ ----- ---- AUTOMOBILE LIABUTY CC7ME3WFIJ SNCiIf I.IM!1 $ ANY AUTO IFa ercidenl I All OWNED A010S BODILY INJURY (Per persca+) $ 5CITFDt1LrL7 AU'i05 _ HIRED ADIOS 1:30DiLY IN.iURY $ NON-OWNED AUTOS PROP[Rl Y DAMAGE $ (Per ardAnnll GARAGE LJABIJTY AU TO ONLY-LA ACCIDI N 1 $ ANY AUTO OIFIER IHAN FA ACC $ Alll O ONI Y AGG $ EXCESSIUMBRELLA LIABIUT'Y EACH OCCURRENCE b __ OCCUR EICI AIMS MADE ACGRFGAI7: b DEDUCII lf-, .----- -- $ ------------ RETENTICNd b $ B WORKERS COMPENSATION AND WCC5002454012009 04/23l09 04/23/10 X I.yllm[Ts EH STATU 077i EMPLOYERS'LUIBILJT'Y L.I. IACIIA.CCIDFNI $100,000 __.. ANY PROPRIE :l1 TOM'ARTNER/FXFl1 W . OFFICFR/MFMBER F.XCLUDE07 NO I:.1,DISEASE- EA EMI9.O1T:.P 5100000 !1 voa.describe under SPECIAL T'ROVISIONc below L-.L UISE ASE- POLICY LiMl1 $500 OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCL.USIONs ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Officers are included under the workers compensation policy. 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 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _-JfL- DAYS WRrrTEN Thomas Perry NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS ON Hyannis,MA 02601 REPRESENTATIVES. AUTTH�OyRI1 D R€PRESENTATIVE _ it/.wlLa/ G t:E" - b, ACORD 25(2001108)1 of 2 AS59110/M58469 LS1 @ ACORD CORPORATION 1988 •ABxsrABM 639- Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, ,as Owner of the subject property hereby authoriz to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Si ature of Owner Date --L4 a j12,0& Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\4STGU5QO\EXPPESS.doc Revised 090809 k,onstruction Supervjsor License License: CS 74477 Restricted.. BRETT J BUSSIERiE111 WAREHAM LAKE SHORE D EAST WART: A �����8 Expir __- - ------- -- t 8715 C <,ctibatasisesFt° r ��,, Tie (Jonzrnaru���i ��/�ac�iudr,�d Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 1.62600 Board of Building Regulations and Standards Expiration .,3)26l2011 Tr# 2$2115 One Ashburton Place Rm 1301 Boston,Ma.02108 Type.,.,Private Corporation BAKER&ASSOCIATES.INC MARK BAKER 521 SHOOTFLYING HILL°'RD ,,,,q�,,� -------,_--- —,_ ___--------.__ CENTERVILLE, MA 02632 Administrator Not valid without signature .,� ✓tee i�o»vnaaouuP,a`� �`/`�,aaoaatiiiarll6 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration'; .102600 Board of Building Regulations and Standards One Ashburton Place Rm 1301 Expiration 3/26/2011 Boston,Ma.02108 _.Type.Supplement Card BAKER&ASSOCIATES:INC. BRETT BUSSIERE / 521 SHOOTFLYING'HILL-RD �W` CENTERVILLE, MA 02632 _.__ Administrator Not vali ithout signature I