The URL can be used to link to this page

Home My WebLink AboutBuilding PermitsMASSACHUSEi S UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) _d ,/ 9 Mass. Date qs— Building Location Owner's Name /J/i�SO/J Type of Occupancy'�I�� New ❑ Renovation Iff RedaePmPrrt n plans Submitted: Yes ❑ No-0 FIXTURES II Q 24 y O CC C y- N Q¢ Z O 6 ZIY-• ¢ 2- S NU yC - C¢ aQ - Xy -1SFO0 us yOy cc C Qrr =WI y't Sd .Y{�i a O C. j Y W \ J<!- M y O J 0 Jy Q GO C Q 6 SUB-BSMT. IIGOIIII I(I( (II III BASEMENT (I 1ST FLOOR I I 2ND FLOOR I aRD FLOOR ) I I I I 4TH FLOOR STH FLOOR 6TH FLOOR TTH FLOOR I I I STH FLOOR Installing Company Name E. F wrNSLau) pwrnr3iW, 4- krrilalr Checkone: Address g `i° G ►A-2'Do tJ Cr 2e LE Corporation So. Y42nA 0UTl+ M A02664 ❑ Partnershl Business Telephone (5-0 8) 394 — 7778 ❑ F_ irm/Co.1 _ Name of Licensed Plumber UUr N S Lc W _= Certificate 4- 7 94-6 1 Y3 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the req I irements of MGL Ch. 142. Yes Gr No ❑ J If you have checked yes, please Indicate the type coverage by checking the appropriate box I A liability insurance policy ❑ Other type of Indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter ,142 of the Mass. General Laws. and that my signature on this permit application iivalves this requirement Check one: Owner ❑ Agent ❑ 1 hereby certify that all of'the details and Information I have submitted (or entered) in above application are tnre and knowiedge and that all plumbing work and installations performed under the permit issued for this applicati II pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Title [iN/Toxn APPROVED (OFFICE L/sz ONc of my: all is Type of License: Master K Ikense Number 19 3 9 Journeyman ❑ BELOW FOR OFFICE USE ONLY sr� PROGRESS INSPECTIONS E LJ • Commohwealth ofMassachusetts othciaiuse Only Permit No. -' I I C '69— 103 t Department of Fire Services i Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS . 11/99j ve li APPLICATION FOR PERMIT TO PERFORM ELECTRICAL ORK All wodcto be pedo®ed in =wrlawe with the M=schoscas Electrical Cade (MEC), 527 C MR 6 (PLFASEPRINTINMKORTYPEAUBiFORM�IT70NJ Date: City or Town of: YARM= To the Inspector 0f res: "'U4 I By this application the undersigned gives notice of his or her intention to perform the electrical w cnbed bel Location(Street &Number) MaZ POND VILLAGE, Qmp Street gLDt^t -� Owner or Tenant Gatewood Hares/ Jeff Sollows Teleph6aeNa508-778966DI'�J Owner'sAddnss 1600 Falmouth Rd, Suite 25, Centerville, Ma. 0263.2 11 is this permit in conjunction with a building permit? Yes X❑ No ❑ (Check Api i ropriate Box) Purpose of Building single family residence Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ Na of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ Na of Meters -NamberofFeeders andAmparity ' II Location and Nature of Proposed Electrical Work Fire Alarm System (law voltage control panel) with bad='battery. "central_], monitored. i • _ (•�vree/ebeneithetallawinvarblemaybeiaiivi�bvthel.,..>err,retrYbr� Na of Recessed Ynaures No. of Cc& -Su (Paddle) Fans14 sP- (P o: o oral Transformers KVA Na of Lighting Outlets No. of Hot Tubs Generators I I • KVA No. of Lighting Futures Swimming Pool d e . ❑ d. ❑ BatteryUnits I I g Na of Receptacle Outlets No. of Oil Burners FD2E ALARMS No. of Zones —1—' Na of Switches No. of Gas Banners o. of Detection and7 Initiating Devices Na'ofRanges No. of Air Cond. Tans al No. ofAlertingDevices No. of Waste Disposers HeaTotalp Puin , am er. ors Detection/Alself-coertin Devices 7 No. of Dishwashers ace/Area K Local umcrp, Other Connection No. of.Dryers Heating Appliances KW SecuritySystems: No. of Devices brE ivalcnt a of Water I{W Heaters o. o a o Signs Ballasts Data Wiring: Na of Devices or Eouivalent No. Hydromassage Bathtubs No. of Motors Total HP ecommunrcahons iring, No. of Devices or Equivilent OTHEIL• Attach 4dl700nal dda(l irdvUsQ or as rapdred by the bupectorO'Wi s. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE CO. BOND ❑ OTHER ❑ (Specify) 1 ��atroa Estimated value of Electrical Worse $750.00 (When required by municipal policy) Work to Start Z Inspections to be requested in accordance with WC Rule 10, I upon completion. Ica*, under the mina and penalties of perjury, that the information on this application is true and complete FIRM NAME: Baltic Security, Inc LIC. NO.: 1178C Licensee: Jonas R Bielkevieius Signature _ 499D —''' LIC. NO» ({%apph=bk, enter "emnpt" in the turrue rrrmt/re Bus Tel. No.- 508-833-0996 Addrt�ss: ' PO -Box .X609 :Sandwic�r 1��a• 02563 A1tiTc, No., 50�� 7 OWNER'S INSURANCE WAIVER d am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one) ❑ 'owner 0owner'sagent. Owner/Agent PERMIT FEE: S 40.00 SIgnatnn, Telephone No. 20 50. �I N 80•47'49" E _ war• ,Z•6. 9 a+ EpSINTON 'o. joA \ f� w LOT 2 w 1 1.CX55.35' R�'30i F�S� pTpN Fp�NO oR`�WP� ,LOT 1 36 •y". p7•W 5�03� CERTIFY THAT THE FOUNDATION IS II LOCATED IN FLOOD PLAIN ZONE C I CERTIFY THAT THE FOUNDATION IS AS SHOWN ON FLOOD INSURANCE RATE MAP LOCATED ON THE LOTIAS SHOWN. AND COMMUNITY PANEL NO. 250015 0005D THAT ITS LOCATION CONFORMS TO THE AND THAT FLOOD PLAIN ZONE C IS NOT A MINIMUM SETBACK REQUIREMENTS OF SPECIAL FLOOD HAZARD AREA. THE 40B SPECIAL PERMIT. DATE REGISTERED PROFESSIONAL DATE REGISTERED PFVOFESSrONAL LAND SURVEYOR LAND SURVEYOR 1 GRAPHIC SCALE 20 ( IN FEET ) 1 inch - 20 fL AS -BUILT PLAN OF LOT 1 PREPARED FOR MILL POND VILLAGE IN YARMOUTH, MA 1"=20' DATE: 6-09-0 60 Unless and until such ttn�e original (red) stamp of the .-qm sble Professional Engineer. or Professional Land Surveyor oppeap)onathi panr p«son; tiding any municipal or other public officials, may rely upon the Information contained herein; and (B) this plan remalns the property of Holmes t McGrath. Inc. II holmes and mcgrath, inc. civil engineers and land surveyors ;.. 362 gifford street Falmouth, ma. 02540 JOB NO: 201197 DRAWN: LMC I DWG. NO.: A2500A CHECKED- r TOWN OF YARMOUTH P/ I ` /y6 I l JUN 3 0 2( BUILDING DEPT. APPLICATION FOR ITTO DO PLUMBING (OFFICE USE ONLY) By II FAe: PERMIT NO. f " 05 I I Building Owner's �7 �L1900 AT L t' N IF oca lon ame Type of Occupal I cy New me Renovation ❑ Replacement ❑ Pions Submitted Yes ❑ No ❑ II \� `\ \ VN N 0? j 3 U) rA W c=.> Y v1 W Cr O ; J U) M O M J H rn W 33o O= W y Lu = Q G M N a O y Q } tS z � J Z O U _~ a =3 N 3= Y z W Q M co Z H tN Y Z `� O fN Z Q O o= O 1L 0. Q Cn¢ 0 N a O z_ Q z O s Z¢ Y ¢¢ C Z R Q O Z _ a 0. ¢ a co _Z Q cc o M UJ a 3 O0 LL a m L U. M O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR � (PRIM OR TYPE) Installing Company Name Address Business L) Name of Licensed Check One: ❑ Cc ❑ artnership i l i�t�0orrWny INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent. Cr If you have checked YES, please Indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance voerage the Mass. General Laws, and that my signature on this permit application waives this requirement. A Signature orOwnerorOwner'sAgent 1 hereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and L Chapter 142 of the General Laws. OF ►� i TOW - F-YARMOUTH 3q lot NOV 0 1 2004 . G DUILDING DEF,r. APPLICATION FOR P, (OFFICE TO 00 GASFITTING ONLY) Fee: $� PERMIT NO. Gr-05 II 316$- - - - vullaing' 2 C2o P S % AT: Location New [X Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No f' N IM ¢ N Y W Z ¢ W N 0: D: N O U N O J W Q > m Z p S .1 ¢ m rn M W W w O Z 0 F w f- / W_ = W Q Lt a¢ W M f- y Z W -A Z � C1 Z W M W O O LU > LL O F- W 2 . J W D m Z O O N S •+ Q M W > W U. Z Q � Q Q J W S d S O a= O O t7 V rL > G 1.-- O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR � 3RD FLOOR � (PRINT OR TYPE) '�"� Check One: Installing Company Name-�UGTS' U A]� &+r% ITea) ❑ Corp. Address R G i4AS E S ❑ Partnership f4y;4 AIMS M A F7 2 &a 1 t"1 Firm/Company Business Telephone SD K-7 3-7 r 3 6 9 q Name of Licensed Plumber other o Vt tj`S� L INSURANCE COVERAGE: Check One I have a current liability insurance policy or its substantial equivalent. Yes EI�No ❑ If you have checked yes, please Indicate Pe type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. 11 Check One: Owner ❑ II Agent ❑ Signature of Owner or Owner's Agent �^ �-1 / 1 I hereby certify that all of the details and Information 1 have submitted Signature o U ensed (or entered) in above application are true and accurate to the best of Plumber or Gasfitter my knowledge and that all plumbing work and Installations performed Z 1 S� under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and License Number ... .._ ... _ .. roc � rccucc• Daniel E Braman, PE 189 Harbor Point Road squid, MA 02637-0361 Phone(508)362-0016 August 16, 2004 James Brandolini, Building Commissioner Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 u UG 7204 Project: 22604 Mill Pond Village Camp Street Yarmouth, MA Today, I made a site visit to the above property ct an 11 ipspec io o floor joists with holes for plumbing. This was in E et, Lot #1 d in Clo r, Lot #2. The floor joists are 2x10's @ 16" o.c. and have been . t ith 3/4" CD plywood each side. The holes in the joists, Lot # 1, over the kitchen area, are near ie ends and would be a shear concern, not moment. The holes in the joists, Lot k over the bathroom area, are also near the end and are further supported by the closet walls. I believe that these details are structurally sound. Daniel E. Braman, PE DANIEL E. iMidAN .� � o STR ID MI N ► �� U I �vrC> of r TOWN OF YARMOUTH Building Department . B U I DIN G . _ .. _ (508) 398-2231 ext261PERMIT ISSUE -6-041372_ :-..-: PERMIT ISSUE DATE _6/9/2004_ _ : PROPOSE U E ' APPLICANT Frank Capra - - - - - - - - - - - - JOB WEATHER CARD --------- _ PERMIT TO ;New Construction ; AT (LOCATION) 100121CAMPST#1 ZONING DISTRI R-25 Bldg. Type: Residential i SUBDIVISION MAP LOT BLOCK 044.21.1.C7 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4 LOT SIZE O new construction: 2 baths, 3 bedrooms, 1 diningroom, 1 kitchen, 1 Iivingroom as per plans dated REMARKS 0=1104 and BOA # 3546. AREA (SO FT) OWNER 1 ADDRESS F EST COST ($ at 600 FaI tAk R d 25 PERMIT FEE ($) $543.00 .DING DEPT BY CONTRACTOR LICENSE 012430 it Capra, Frank 77-71 1600 Falmouth Road #25 Centerville MA 02632 6087789669 mo oa # Centerville I MA 1026 32 I Certificate Issue Date 7 J-06 -CERTIFICATE of OCCUPA_NCY j' Departmental Approval for Certificate of Occupancy and Compliance Inspector Date Permit Number A proved By Re rks I BUILDING 3'i-16 /7 +I PLUMBINGIGAS... ELECTRICAL `( OS (I �I ENGINEERING II 4 3 G bS StNit -6cp- Izffrr -Da to 3)t os OTHER F- iR 3 aS tE�I ` a-7&a 313), 10 De mea in Dy eacn awtsion uraicateo nereon upon compietwn or ns nnau I W, II OF ,� TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 ext261 PERMIT NO e.04.13'2 '- ._-. _ JOB WEATHER CARD PERMIT ISSUE DATE :_ _6/9/2004_ _ ; PROPOSED USE _ _ _ APPLICANT Frank Capra I- --------•----••---- !I PERMIT TO ' New Const;;c ion ; AT (LOCATION) 100121CAMP ST # 1 I ZONING DISTRICTEfl Bldg. Type: Residential SUBDIVISION MAP LOT BLOCK 1044.21A.C11 LOT SIZE 0 BUILDING IS TO BE: CONSTTYPE15-81 USE I 1 new constriction: 2 baths, 3 bedrooms, 1 diningroom, 1 kitchen, 1 livingroom as per plans dated REMARKS I 03131/04 and BOA # 3546. -AREA (SO FT) 1 EST COST ($ $148,896.00 PERMIT FEE ($) $543.00 OWNER VIllage at Camp St, LLC BUILDING DEPT BY ADDRESS 11600 Falmouth Road # 25 Centerville I MA 102M2 INSPECTION RECORD CONTRACTOR LICENSE 012430 !I Capra, Frank 1600 Falmouth Road #25 11 Centerville MA 02632 5087789669 FIELD COPY Date i Note Progress - Corrections and Remarks I I Inspector , tie II ---- - II II II II it II II I. II I/ x ONE & TWO FAMILY ONLY - BUILDING PERMIT II APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR 0 FAMILY DWELLING . Town of Yarmouth Building Department 1146 Route 28 - Yarmouth, NIA 02664-4492 Tel: (508) 398-2231 x261 - Fax: (508) 398-0836 Office Use Only Permit No.9 � /3 Ate A"L Permit Fee $5y3, / Deposit Rec'd. $560 Dat Net Due $ �. Planning Board Information Plan Type Endorsement Date Recording Date n No. Other Assessors Department Infonnationa Map Lot I1 old i 1.4 Property Dimensions: 1! I Map cot New Lot Coverage Lot Area (sQ Frontage (ft) This Section for Office Use nly I Building Pe Number:04 I Date Issued: 11 Signature, 3,3�_8 Certific a of Occupancy is is not I required Building Official Date Section 1 - Site Information Use Group: R-4 Type: 5-B I I 1.1 Property Address: 1� Sire e�- 12 . Zoning Information: aS _ Zoning District I I Proposed Use . 1.3 Building Setbacks (it) Front Yard Side Yards i Rear Yard Required Provided Required Provided Required 11 Provided 1.4 Water Supply (M.O.L c. 40. S 54) Public Private 1.5 Flood Zone Information. , - Comments: Zone: BFE: ' ' I Section 2 - Property Ownership/Authorized Agent 2.1 Owne of Record: -r C JT . LLc A O 0 0 ✓`��I I" y t I . Name (print Mailing Address (QH V,'X tZ, • O _ 60 Signature ItC,'4 ►. dPr- Telephone 11 2.2 Authorized Agent: Name (print) Mailing Address Signature 7 Telephone II Section 3 - Construction Services 3.1 Licensed Construction Supervisor. Cf(p`R Not Appli le ❑ oa ' y dog a o„�tf„ License Number i b Add 9 Ex iratign e — b Signature Telephone rp 3.2 Registered Home Improvement Contractor: Company Name I License Numb Expiration Date I Address By Signature Telephone 9-15-99 1of2 II OVER 7/ 2 .' V Section 4 -Workers' Compensation Insurance Affidavit (M.G.L c. 152 S 25C (6) Workers Compensation Insurance affidavit must be completed and submitted with this application.; Failure to provide this affidavit will result In the denial of the issuance of the building permit. Signed Affidavit Attached Yes .......... No .......... Section 5 -_ Description of Proposed Work (check all applicable) New Construction No. of Bedrooms No. of Bathrooms oZ Existing Bldg. ❑ Repalr(s) ❑ IAlterations ❑ Addition ❑ _ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: ` I V 4 Section - Estimated Construction Costs Estimated Cost (Dollars) to be Check Below Item completed by permit applicant p b o ❑ Conservation -Commission Filing 0 (if applicable) 101 O ❑ Old Icings Highway & Historical 0 G Commission approval O O (if applicable) - To be Completed Wh 1. Building 2. Electrical 3. Plumbing / Gas 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 7. Total Square Ft. (new houses b additions) Section 7a - Owner Authorization Owner's Agent or Contractor Appli s for BuildingPe PA Atoer I, ° t Qv\^ (, , as owns of the subject property, �a Wood Mt'5 on he reby au tho rize IL_ on my ehalf in all elative to work authorized by this building permit application. Sign re of Owner Date Section 7b - Owner/Authorized Agent Declaration P � as Cmgw/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. - Print n e L3 Signatur Owner/Agent Date M 9-15-99 i 2of2 D TOWN OF YARMOUT �} c BUILDING DEPARTMENT MA A C BUILDING PERMIT APPLICATION DEPARTME? TRANSMITTAL SHEET Building Site Location: 141 Proposed Improvement: Map L SIGN OFF i i _�Y__LotNo• P/• C� -77/ %A6 Address: /6/%7) I f(c%�IXjtt,1i /LsKdS (O�tr U/1(�/,�f'0 Te1No.: /� 7G6y Date Filed: 3 0 I The Building Department will be responsible for assisting the applbP y\dispatching your plans and or application to the following applicable departments. RESIDENTIAL AND/OR COMMERCIAL BUILDING WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage. CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Bonder any Type of Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e ,,I Requirements For Septage Disposal and other Public Health Activities. FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Eta I I REVIEWED BY: 1/1. WATER DEPARTMENT: DATE: N/A: V2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A. - HEALTH DEPARTMENT: br/V�� 742—D DATE: ZZ N/A 9 Z3-04 INDUSTRIAL AND/OR COMMERCIAL PERMM S. WIRING INSPECTOR: DATE: N/A: 6. PLUMBING INSPECTOR: DATE: N/A: I I 7. FIRE DEPARTMENT: DATE: N/A: COMMENTS: RECEIPT OF COPY: PLEASE NOTE SIGNATURE OF APPLICANT: DATE: wbite wpy - BuOdmg Dept - Pink eopy - Watt Dept - Yellow Copy -Haft DML - Pink Copy -End Dept - III -Fue DcpUCamavation X I The Commonwealth ojMassaehusetts . Department of Industrial Accidents ONCOollmsdpstfoss 600 Washington Street Boston. Mass. 02111 Workers' Compensation Insurance Affidavit cit. 1 am a homeowner performing all work myself. am a sole proprietor a.-.'. ha%e no one working in any capacity C:] I am an employer pro%iding workers' compensation for my employees working on this job. city' ,_phone 0. Insurance co. nolicy M II j am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below t.ho ha%ei w^ the follo%%ing twrkers' :ompensation olices: II city: phone M: l insurance co. noliey M II Failure to secure coverage as required under Section 25A of MGL 132 an lead to the imposition of criminal penalties of a fine op to SI400.00 and/or one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of S100.00 t day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage veri0ntkn. I do hereby serf fgunder the paint and penalties of perjury that the information provided above Is trite and correct Signature ate X l 2 A Ie i Print name \ ' 0.i^ k C0.n J' Phone it —7�� a atricial use only do not write in this area to be completed by city or town offleisl eiry or town: xnxrlOUT>3 _ permit/license 0 nBuilding Department pLteensiog Board cheek if immediate response is required 2fi11 OSelectmen's OMCc Health Department contact person: phone0:_ (508) 398-2231 eat. mother Information and Instructions h J Massachusetts General I_a►►s chapter 152 section 25 requires all employers to provide workers' compensation for their emplJ%ees. As quoted from the " law*% an enrplocee is defined as every person in the service of another under any contract of hire. express or implied, oral or written. An erriiph,t•er is defined as an indi► idual. partnership. association. corporation or other legal entity. or any two or more of the fore,oin_ engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the recei►ler or trustee of an individual . partnership. association oi• other legal entity, employing employees. However the o►►ner of a dwelling house havin_ not more than three apartments and who resides therein, or the occupant of the d►►ell;n_ house of another who employs persons to do maintenance . construction or repair work on such dwelling house, or un tlhe `_rounds or building_ appurtenant thereto shall not because of such employment be deemed to be an emplo%er. %lGI. Lhapter I : =section :: also states that every state or local licensing agency shall ►withhold the issuance or renc►►'al 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. Additionall►. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomtance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha►e been presented to the contracting authorm. applii.:nts Please' in the workers' compensation affidavit completely, by checking the box that applies to your situation and suppl%Iing company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial .accidents for confirmation of insurance coverage. Also be sure to sign and date the afrrdavit. The affidai it should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial .accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy. please call the Department at the number listed below. 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 permittlicense number which will be used as a reference number. The af$davits may be returned to the Department by mail 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 Department's address. telephone and fax number. 1. . The.Commonwealth Of Massachusetts Department of Industrial Accidents Mee of Imsdadon 600 Washington Street Boston. Ma. 02111 fax #: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 ' ✓�' TJO'NL//10//(bb6L(/L � /��ulfl�J • -'_� BOARD OF BUILDING REGULATIONS • License: CONSTRUCTION SUPERVISOR Number. CS 012430 B irthdate: 06/16/1940 Expires: 06/16/2004 - Tr. no: 25823 Restricted: 00 FRANK G CAPRA 40 COPPER LN CENTERVILLE. MA 02632 Administrator 00 - 35,000 d enclosed space (MGL C.112 S.60L) IA - Masonry only 1 G -1 & 2 Family Homes Failure to possess a current edition of the Massacty ens State Build4V Code is cause for revocation of INs license. DIG SAFE CALL CENTER: (888) 344-T233 U .: H��nury OF LIABILITY INSURANCE DATE 0 PRODUCER (508) 994-9688F FAX (508) 991-5461 THIS CERTIFICATE IS ISSUED AS A MATTER RI'TKOWSKI j . , OF INFORMATION & KESTENBAUM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COUNTY STREETHOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR NEW ALTER THE COVERAGE AFFORDED BY THE POLICIES NEW BEDFORD, MA 02740 BELOW. INSURERS AFFORDING COVERAGE INSURE. Fran Capra I i PO Box 664 INSURER A: Providence Mutual• _ West-Hyannisport, MA 02672 INSURERB: OneBeacon I'• �'�.• _ _ 14SMERQ Continental Cas1111'1lt31.1:0_:_.' .._ .. NSURERE: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR j MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS POLICIES. AGGREGATE LAIATS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. OF SUCH FNSR _ImTYPE OF INSURANCE POLICY NUMBER D FEC N 'FO—DEVINYBUTOR GENERAL LIABILITY P0053131 0O I LIMITS 12/13/2002 12/13/2003 EACH OCCURRENCE f 1,000,00 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OOCCUR' FIRE DAMAGE (Any one Are) S 50.000 A MED EXP (Any one person) S 5 000 PERSONAL sADVPUURY f 1 000 000 GENT AGGREGATE LMATAPPUES PER- GENEERAL AGGREGATE S 2,000 OOO POLICY LOC PRODUCTS .COMP/OP AGG S .2 000 DOC AUTOMOBILE LIABILITY XE48125 02II 02/14/2003 /14/2004 ANY AUTO COMBINED SINGLE LILT s (Ea ecdder� ALL OWNED AUTOS - t B X SCHEDULED AUTOS BODILYQJ,RATY i . S HIRED AUTOS c�=y" 250, 000 NON-0WNED AUTOS .. .: B OI S d11NJU _ denQ 500 000 - PROPERTY DAMAGE' ' ' ' _ ' .SP'N°!w .• .- • . .... 100,000 IY ANYAUTO .;`,.:+�... ... AUTO.ONLY.EA ACCIDENT. S r=UTTy OTHER THAN _. EA ACC S AUTO ONLY . AGO CLAIMS MADE .. EACH OCCURRENCE S i AGGREGATE DEDUCTIBLE II S i RETENiX)N S II f I WORKERS COMPENSATION AND 5S59UBI61X751603 II S EMPLOMW LIABILITY 03/22/2004 C TORY LIMITS ER EL EACH ACCIDENT f SOO 00 li • "... -- EL DISEASE. EA EMPL S 500, 00 OTHER te.L:oistkmt.Pour-y w S -.500-"00 DEscIGPTION _ of oPERAnoNs/Lo CATIONSIVEIIICLESJEXCLUSIONSADDED BY ENDORSEMENTISPIMI, eernnc�n..� _ CERTIFICATE Catewood Homes Inc 1600 Falmouth Road Ste 25 Centerville, MA 02632 SHOULD ANY OF THE ABOVE DESCRIBED P EXPIRATION DATE THEREOF, THE ISSUING li - 10 DAYS WRITTEN NOTICE TO THE CE BUT FAILURE TO MAIL SUCH NOTICE SHALL I i 3 BE CANCELLED BEFDRE THE I 4NY WILL ENDEAVOR TO MAIL ATE HOLDER NAMED TO THE LEFT, SE NO OBLIGATION OR LIABILITY j m n �crc i INL A I t OF LIABILITY INSURANCE PRODUCER Dowling 8, O'Neil Insurance THIS CERTIFICATE IS ISSUED AS A MATTER Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE HOLDER. THIS CERTIFICADOESAME 222 West Main St. PO Box 1990 ALTER THE OVERAGE AFFORDED BOY THE Hyannis, MA 02601 INSURED INSURERS AFFORDING COVERAGE I Bayside Electrical Contractors, Inc. INSURERA Travelers Insurance Company 372 Yarmouth Road INSURERe: Guard Insurance Grou �,E�� lo1rno3 MFORMATION tTIFICATE EXTEND OR ICIES BELOW. NAIC # p I Hyannis, MA 02601 INSURERC: II INSURER D: I I COVERAGES NSURER E THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PE 11 D INDICATED. ''10 IISTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WFpCH 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR NSR TYPE OF INSURANCE POLICY NUMBER OLI Y EMPDE TIVE CY EX%RATIOI 1 A GENERAL LIABILITY (MM/DD/YYIN 1 11 1 U. K COMMERCIAL GENERAL LIABILITY CLAIMS MADE ERJ OCCUR - { OCP 3EN'L AGGREGATE LIMIT APPLIFS OFR• AJJAOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEDAUnxHIRED AUTOSNON-OWNEDAUTOS Drive Other Car AGE LIABILITY ANYAUTO OCCUR IJ CLAIMS MADE DEDUCTIBLE B WORKERS COMPENSATION AND EMPLOYERS, LIABILITY ANY PROPRIETORIPARTNER/EXECU THE OFFICER/MEMBER EXCLUDED? r desc e u dw S E 1AL PROVISIONS bales; OTHER 18102601 W5611ND03 10105/03 110/05/04 A AM INJURY I I 10/05/03 10/05/04 COMBINED SINGLE LIMIT (Ea a��) f1.000,000 II BODRY WURY (Per parson) S BODILY INJURY - ddeM) n PROPERTY DAMAGE (Paraeddard) f AUTO ONLY. EA ACCIDENT S 11 OTHER THAN EA ACC f AUTO ONLY. AGO f EACH OCCURRENCE f AGGREGATE f II S II S �I 08/18/03 08/18/04 WCSTATI!• OTH. f DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations performed by the named Insured subject to policy conditions and exclusions. Gatewood Homes 1600 Falmouth Road Suite 25 Centerville, MA 02632 ACORD 25 (2001/08) 1 of 2 #M31942 CANCELLATION I I SHOULD ANY OF TINE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSISTER WILL ENDiEAVOR TO MAIL 1Q_ DAYS WRITTEN TO NOTICE TO THE CERTIFICATE HOLDER NAMED THE LEFT. BUT FAILURE TD DO SO SHALL WPOSE NO OBLX7ATION OR LUIBRITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. II AUTHORIZED REPRESENTATIVE LS1 0 ACORD CORPORATION 1988 urat•i- 2 F 2 CATS OF 2 N 3 LTRAN II E • �J �"._��__w ____ww_�r� II Issue date: 7/11/03 • Proddcer: This certificate is issued as a matter of taformation only and confers mo rigghts neon the certificate holder. This'certificate does mot &Need, SOUTHEASTERN INS AGCY estend or alter the.coverage afforded by the policies below. 641 MAIN ST HYAHNIS COMPANIES AFFORDING COVERAGE _w MA 02601 Code: Sob —code: Co Ltr A: _ ARBELLA PROTECTION lasnred: _ Co Ltr B ARBELLA PROTECTION RJ BEVILACOUA 1---Co Ltr C: P 0 BOX 628 Ce Ltr D: ARBELLA PROTECTION �� ~ FORESTBALE MA 02644 ________w Ce Ltr E:____�______�__M COVERAGES This is to certifr that policies of insurance listed below have been issued to the instrtd named above for the polic peried indicated notwithstanding any regairesent term or condition of any contract or other document with respect to vhic� this certificate Nay be isseed or Nay pertains the insurance afforded by the policies described herein is'iablect to all the terms, exclusions, and conditions of Itch policies. Limits shown may have been reduced by paid claims. II Co Ltrl Type of Iastranct I-----�� I Policy lumber Policy w I effecti►e date �PolicyW l II _ espiratiet date All limits is thousands A ENERAL LIABILITY Commercial general liability 8500018147 7/15/03� 7/15/04 • General aggregate:2,000 made I I Occur Let's I Productl/comprapps Owner's I contractor's Prot slog Personal/advertislag ia): Each occorreace: 1 000 Fire damage: 160 Medical espease: 5 B (AUTOMOBILE LIABILITY An i Bate 1�86852400001�~2/21/03� _ 2/21/04 �Cembined 1_ I All awned antes Slagle limit: 9250/500 Bodily iajory Schedaled sates Per Hired antes Persia): odily iajarll Net -evened auto Garage liability (Per acciII �- I lPropertydamage: 500 X ESS LIABILITY _ _ Each __ I Other than umbrella form I 1. �! Occarreace Aggregate D I -�j WORKER'S AND I 9088680403 4/27/03r�r4/27/04 statute? j=-----------------_— ___� I EMPLOYERS' LIABILITY ! 160 500' Each accident) Disease -policy limit) (Disease-eeeh 100. m to ee .. (OTHER Description of operations/locations/vehicles/restrictions/special items: ------ CERTIFICATE HOLDER CANCELLATION 6ATEYOOD HOMES I Should nay of the above described policies be cancelled before the ratioa date thereof, the issuing companT will eadeeror to mail 10 days 1600 FALMOUTH RD STE 35 left, bat failure written Notice to the certificate holder named to the to mail such notice shall impose ao obligation CENTERVILLE MA 01632 _-liability -of ail or kind upon the company, its agents at represe&tatives. Authorised representative: _ -_--------_�-� I- JOAN M MARTIN �_ c utm rIFICATE ORLIABILITY INSURANCE ►ROOIICER SOE-398-6033 FAX SOS-760-1667 JJIAl )led -American Insurance Agency LLC THIS CERTIFICATE IS ISSUED AS A' • J9 Y ONLY AND CONFERS NO RIGHTS U 1 Atlantic Ave HOLDER. THIS CERTIFICATE DOES S8 Yarmouth Mq 02664 LTERTHECOVERAGEAF ORDER NSUAKO pe o Custom oors INSURERS AFFORDING COVERAGE 762 Falmouth Road IN8~A: Arbe a Protection In; HYannis NA 0260I ECURGRB' Hartford PISURGR C: NSURlII D I I - --------- NSURERL II iHG POLICIES OF lNgURgNCE LISTED BELOW NAVE BEEN ISSUED TO TMf: INSURED ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMEI MAY DERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS POLICIES. AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS, I D TYPE OF INSURANCE - PORKY NUMBER POLICY E GENERAL LLLBILRY 7500000373 I2/13, X COMMERCIAL GSWJW UABILIY cLAnu MADE O Occun A GENL AGGRCGATG LEATAPPLE:S PER: AUTOMOOILl LIABILITY ANYAVTO ALL Owheo AUTOS SCHEDULED AITTO$ RPMAUMS NON-OMED /UITOS RAT! DAwOOMYYyI , 07R1/2003 (FORMATION TIFICATE EXTEND OR .IES ELOW. NAIC a 1 `SPELT TO `o ' ICKIUU INDICATED. NOTVVITHSTANOiN- TALL THE HIGH IS CERTIFICATE MAYBE ISSUED OR EXCLUSIIONSMD CONDITIONS OF SUCH ATIOH II LIMITS )03 EAcNoccuRRENCE I AMAG REN O f MCD EKP(A-t om p"W) f PERSONAL S ADY EUURY f GENERALAGGRErATE f PRODUCTS • COUP/OF AOG f I I COMBINEDeNGLE LW f BOOmY NA/111Y BODILY KILMY Ir...ma.�Il l l I PROrem DAMAGE ScadmQ AUTO ONLY. FA ACCORNT f OTHER THAN EA ACC f AUTO ONLT: I I AGO I EACH OCCURRENCE S AGGRGCATE II S II I II I it I i X WC a ATu orH G.L EACH ACCben7 S EL. DISEASE • EA EMIT I Evidence Of Insurance for work performed within the Insured's scope of normal operat Gatewood.Homes_ 1600 Falmouth Road i2S Centerville. MIA 02632 kCORD2512001ro8) FAX: 000778-553 n C I ENDUED AM' OF THE A804c DlSCRIBED ►OUCIES BF CANCELLED BEFORE THE EXPIRATION DATE TNEREOP. TN! ISSUNG N4URERN7LL ENDEAVOR TO 1WL 10 RATS wRRTEN NOTCE TO THE EFRTD4CATS MOLDER NAMEO TO THE LUT, BUT FAILURE 70 NAIL EUCN NOTICE SHALL BAPOCE NO DEUCATN)M OR LIAEILITY S CACORD CORPORATION 1988 ORD. CERTIFICATE OF LIABILITY INSURANCE OP ID A DATE IMMDDlMM IclROWC50 07 25 03 - PRoouC THIS CERTIFICATE IS ISSUED AS A'MATTER OF INFORMATION Sullivan, Garrity 6 Donnelly ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 508-754-1767 HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 10 Imstitute Rd - PO Box 15010 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester MA 01615-0010 Phone: 508-754-1767 Fax: 508-754-1885 INSURERS AFFORDING COVERAGE II NAIC S INSURED INSURER A: Hanover Insurance Co 22292 INSURERS: Arch Insurance Company Crowell Construction, Inc. PO Box 309 So. Dennis MA 02660 INSUREac II INSURER D: I� CnVFRA[;FS INSURER E • II 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 VNTH 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAR) CLAIMS.. ,Nan RUU LTR INSRN TYPE OF INSURANCE POUCYNUMBER DATE MMlDD DATE IMMIDD/YYI LIMITS _ A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAMS MADE OCCUR - ZHN7007141 - 05/01/03 - 05/01/04 EACH OCCURRENCE $1000000 X PREMISES En ocwrx $100000 1 MED EXP'(Any"pe ) 3 5000 . PERSONAL iAMINJURY $ 1000000 . ' • GENERAL AGGREGATE S 2000000 GENT AGGREGATE LIMIT APPLES PER: POLICY ERCT El LOC • J PRODUCTS -COMPIOP AGO 32000000 �I A AUTOMOBILE LABILITY ANY AUTO ' . I . w .. ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NONOWNED AUTOS ABN7001142 ' . 05/01/03 - - 05/01/04 COMBINED SINGLE LIMIT (E'" "') S BODILY $1000000 X X it (P�,DE) Y 31000000 X (PNOPEDAMAGE S 500000 GARAGE LIABILITY ANY AUTO • AUTO ONLY • EA ACCIDENT S 1 OTHER THAN .. EAACC AUTO ONLY: AGO S S EXCESSIUMBRELLA LIABILITY OCCUR CLAMS MADE DEDUCTIBLE RETENTION 3 - - EACH OCCURRENCE S AGGREGATE S II s I S WORKERS COMPENSATION AND B EMPLOYERS;* LIABILITY IRWCIOOSOO ANY EMBERlEXCLUDEEXECVTNE O3/22/03 O3/22/04 OFFICERRJEMBER EXCLIK)ED7 f yysE6 desaW vld�r — PROVISIONS bsbw OTHER OTHER DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES! EXCLUSIONS ADD Fax #508-778-5603 ED BY ENDORSEMENT! SPECIAL PROV1910NS CERTIFICATE HOLDER TORY LIMITS ER E.LEACHACCIDENT E.L DISEASE -EA EMPLOYEE EL DISEASE, POUCY LIMIT 3500000 S500000 $500000 - Vnl\VG�LM IIVIT II GATEWOO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATTo Gat0Wl Homes DATE THEREOF. THE ISSUING INSURER WILL 1ENDEAVOR TO MAIL .10 DAYS WRITTEN 160 160Fa 0 Falmouth Road NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE' LEFT. BUT FAILURE TO DO SO SHALL Suite 25 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KING UPON THE INSURER. ITS AGENTS OR Centerville MA 02632 REPRESENTATIVES. II A EDR RESENaAir ACORO 25 12nnvnm w m�umu I.UIKYUKA I IUN I NU -J wc�VPW' CERTIFICATE OF LIABILITY INSURANCE =DATE(PM=M'mPRODUCER Qowling,& O'Neil Insurance THIS CERTIFICATE IS ISSUED AONLY CONFERS No S A MATTER OF INFORMATION RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER THIS CERTIFICATE DOES NOT AMEND,, EXTEND OR 222 West Main St. PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis, MA 02601 INSURED INSURERS AFFORDING COVERAGE I NAIC # Gutter Pro Enterprises, Inc. INSuRERA: Travelers Insurance Company P.O. Box 1197 INsuRERB: Guard Insurance Group Plymouth, MA 02362 INSURERC: II INSURER 0: COVERAGES INSURER E I I THE POUGES OF INSIIRANCP I tQ n eo ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT O TOTHER DOCUMENT WITH RESPECT TO WHED OVEFORPICOH THISEC�ERTDI CERTIFICATE MAY gE ISSUED OR DING MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .TR NSR1 TYPE OF INSURANCE P U Y FF E I POLICY NUMBER PIRA ON T MAD A GENERAL LIABILITY 1680459H3118TCT03 UM<rs ' 11/07/03 11/07/04 EACH OCCURRENCEE$3 31000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMSMAOE O Rxallt 000 rLAGGREGATE LIMIT POL PRO DMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS AGE LIABILITY ANYAUTO u CLAMS MADE DEDUCTIBLE RETENTION S B WORt(ER3 COMPENSATON AND EMPLOYERS' LIABILITY ANY PROPRIETOMPARTNEWEXFCUTIVE OFFICERIMEMBER ExCLUDEm N yes, describe under SPECIAL PROVISIONS belay OTHER I I COMBINED SINGLE LIMB (Ea aaddard) S i BODILYRrJl1RI _ (Pa penan) S • 11 BODILY INJURY - (Peramdeu) S u PROPERTY DAMAGE Pawddar ) _ i I AUTO ONLY - EA ACCIDENT >< - OTHER (THAN EAACC S AUTO ONLY: AGG S , . EACH OCCURRENCE S AGGREGATE S II s II s II 11/07/03 11/07/04 �✓C STATU OTH _ VVV 1 rand IPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I IXCIUSIONS ADDF;CED BY ENDORSEM rations performed by the named Insured subject to Policy conditions PRovIsloNs exclusions. 1 P ty conditions CERTIFICATE HOLDER CANCELLATION I I 7rAUTHORMD HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Gatewood Homes DATE THEREOF, THE ISSUING INSURER WILL END, FJIVOR TO MAIL 1600 Falmouth Road, Suite 25 �— °ATTo+I OTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE Tb DO SO SHALL Centerville, MA 02632MPOSE NO OBLIGATION OR LIABILITY OF ANY laIi UPON THE INSU RER, ITS AGENTS OR . . EPRESENTATIVES. NO ACORD 25 (2001/08) 1 of 2 #32273 - LS1 0 ACORD CORPORATION 1988 ' LLI LII YJ 19.11 rAi OU57900249 • GOLOMAN ASSOC II AC"P . CERTIFICATE OF LIABILITY INSURANCE � ins OATEpeaat„,m- I Cm t `\. • FROI T]LVA,M50 • 11 17 03 GdUbw i ASSOCIATES miSOt'aym [►$grooTcl.-Are- Is S4ttwAsAMATTERAFtNtO FIt06NC1A1. SERVICES INC. ONLY AND CONFER] NO CfRTIF7CATEI HOLDERIt�HT3 UPON 7}iF CERTiFTCATF 933 R 7H18 FAI244�IA RD. DOES NOT AMEND. EXTEND KLVMIE HA 02601 �O�mBY.THEP—oucm&sE I A'TER P:I0Da:509-775-6010 Paz:508-790-0249 liaE N 965LWi7t A: C10"12RCY IN9IU7-AA BODHEY T III !fie pRICH IV _ DBA bmcuDTICAL SYSTEM, 110 HOLDER TAMS B' BARNSTABLE MA 02669 r astsAO i COV�OES tstaemE it - T14 oo ANY REOAMaW-r0W MAY FERTAN.TteffCRA%N= rare OFl�RRMCEL6fID�DiM IIAYE 9EENCLt=070 Ti II ' CR CONarl W OFLK CONTRACT OR 071ER NClatm MMEO NONE FOR T6 P OLLY Po=smCJ.TSD.MaIVITTICTANDVIC �'•31T1NON REsFFS.TTO wtOtnss CfRfIFIGTE PMM&AQQtEOXM ARt7RL'fO BYTCfCLICEa YUY EMSUEED of WTa DOAN WAY .tVtV 4allECTTOALL TETE1ea.E>�L{EOKT AND OF31J61 INt111E RDII®OCEDlYPAOCLAI tsa i t tTFs tY rsLRi� FQLY Ril®Ct ' OEIERALUIIm7 a aTE II tJa[fi A XCOMINEPUALGENUmtVaLfry VILS172 ®o4 OC 1000000 Il/21/03 II/21/0s50000 ct•Aaa ONCE east - �!0°�L... m'wvw11111 i5000 PaitiON�LAAON a1aRY 81000000 GOICIMGFMACitPt�tTEtaifTAPPTFS PER AOOREGAW a'200000Q' PYa.LY P. tL1C-OOMIOOA00 t 2000D00 AYICY LAY II ANYAOtO aN61.EWT a VINNI Auras Party s NIiEDAVt09 . MOr'►oM'tFOAUT06 - Y imRY f dAAAOE Lal7lLlLY ' NYYAUTO. ONLY-EAACCLEM IT tip CA ACC a maw LLdkLrfy ' s oocLR FI CLAaO MACE s OEEcnat I I a AFTBITIoN s I s wta�CoaAKaAAas I s B EmpLa7H1.T 1.wjmAY Tgt•I L2ffm ot !727P�R4903 OS/03/03 05/03/04 EL ACI zr--B LENT s100000 LPROM-11Ie.tI-rAErFtorQ a 100000 WHOM_ OKEAIiE-FCLLYLYR s 500nnn MM TTc HO�LDER CATER= .sNOIADANFOFAEASOV6 FOLCEQ W6 aTst+n TETEREOF,Ta+OtREF DCFivatrosua. 10 OATawRnTa GATEWOOD 1?C 8 nm wrreETane .mnEU7r KffFAurtElvaoavawiu FAX 508-779-5603 toaeuaATbwaRLuaarrY ytYrorcuvtTHE .ouRERTaAmrTsoR 1E00 rAll OYH ROAD. CENTPRVI• YX !A 02632 Lt» ACQRD CERTIFICATE OF LlABILIT' INSURANCE • ' �- • ►RooUCER 508 672 2997 THIS CERTIFICATE IS ISSUED AS A WATT JOA AM-0AAS. ONLY AND CONFERS NO RIGHTS UPOI OIAS INSURANCE NOtDER: THIS CFR`TW4CATE DOES- NOS ALTER THE VnVFOACIC ACCnoncn nv n •IsvReRA: GRANITE STATE INSUR JOEL JJAFERCONSEIRA RUCTIONDEALMGIDrls AeR e: NAUTTCUTINSURANCS pBA EJJA CONSTRUCTION 50 PICKERING ST. APT 17 EutlaERt: I I (FALL RIVER, MA 02720 �INSURR0. I 1 INStMER E I I OVERAGES II THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AeOVE FOR THE POLICY PE ANC.RE=REMENT. TERM OR CONDITION OF ANY CCNTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI MAY PERTAIµ THE INSURANCE AFFORDED sY THE POLICIES DESCRIaEOTIERELWL45UBJECT TO ALL THESERMS, DUPOLICIES. AGGREGATE LIMITS SHOWN MAY HAV E BEEN REDUCED BY PAID CLAIMS. I R'WEIRAN EFFECTIVE POLICY� MiIOR CENERALUASLJTY j i osroarz'Do3 I INFORMATION CERTIFICATE 3- EXEEHQ OR JCIES BELOW., NxTC-r i uPI OCGURRCNC[ { IUUU.UUU, x •NMERCIALoeNERALu,OR.In NC275806 W2&7= 00SQ004 100,000 CIAWSMADEOCCUR I ►EDEJCPIVYLMF�IL•) Is 599E? rERSONAL & Aw eawYI �1-0p0 CENpAAGREGATe- } GaMLCCE APPeSPER: 2,000.000. 2.000.000 OMOOLEOMe.ITY _ AWAUTO ALL OwnED AuT03 SCHEMCDAUTOS Hw=AUTOS NOn,OwnaOAUTOS .I I _ GAUGE UAERJTY ANY AUTO ECCESSIUM&FIX r . LLAILITY J OCCUR CLAWS MADE I 'DEDUCTIBLE ' i RETdTt]N S exp o Ri CONRENSATWNAIID errLorsRrLURam yyC.4g¢,ag�g AN'/ PROPRIETORNMTw2R%X'dLTNe O`rrIC.a.LIELRIaw sYCLU0ED7 - S►ICUL..OVIJbMe Ma. OTHER f GATEWOOD HOMES ISM FALMOMH RD. CENTER VILLE. MA 02632 II I CONEr.m LNCLE u"T I s fee.seaw) EOOLlkfURY - Prasa.N rROKRTY OAMAGE - IMiR+VYR) . AOTOONLT^, awAccam'T is i OrNERTw AUYOOP6Yr , L s s - t 11=103• i "M8104. :ANCELLATION I EROULD ANY OFTM ASO" 09SCI%S D PoaHOC.t SE CAwCE,=V POWTNe rxrj%*"o, DATE TNERSOF. THE ISSUING NSVROL WLL�ENOEAYOR TO MA L 10 GAYS WWrTXN ROnCfTO'TH["COrTSICAYlNDLDERNAMID TO THE LER„ IRiL••• ••�•*n n.. SAPOSE NO OEUOAT" OR UAEILITY Of AN. 1 KIND UPON THE EOURER, ITS AGENTS OR OTHONOWR ESENTATr ' ACORO CORPORATION-Inir I CERTIFICATE OF INSURANCE ffDem2iVort, THIS CERTIFICATE IS ISSUED AS J &Buckle CONFERS No RIGHTS UPON THE c Y DOES NOT AMEND, EXTEND OR.A] Inc POLICgsBELOw. • I. COMPAPIIES , 02639 INSURED Patrick K Orcutt 6a P & S Concrete 37 Ladys Slipper Lane Mashpee, MA 02649 A A.I.M. Mutual Insurance ISSUE DATE 04WDDrro =ATE HOLDER. ('HIS ONLY AND IE COVERAGE AFFORDED BY THE n RDING COVERAGE THLS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LLSTED BELOW HAVE BEEN ISSUED TO THE INSURED (NAMED ABOVE FOR THE POLICY PER1015 INDICATED, NOTYMESTANDING ANY REQUIRENuDrr,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUNfENt WITH RESPECTTO WHICH TIM 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 POLICIE S• LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ro TYPE OF DGIM"= POLICY NUMBER POIICT EYMCTnE nATs(M�TI I I T nluTs DATE(M Inn LlABILTIY ENERAL RAAGGREGATE f MERCIAL CENEL LIABBICY RODUL�SCOMP,OPAGC- S IMS MAD � ' WNERS & CONTRACTORS PROT. AL&ADV. INJURY f - CH OCCURRENCE f REDAMAGE(A' "Bm) f u'I'OAlOBIIS LusulTY ED. EXPENSE jAn, ae p> ) S AUTO MB WED S!('1. •E f LLOWNEDAUTOS EDULED AUTOS ODD-Y WJURY I f REDAUTOS N-OWNED'AVrOS ODRY WJURY ssWe[) I f - ARAGELJABILRY - OPERTY DAMACE S CESS LIAE=" i I • . BRELLA FORM CH OCCURRENCE f II f THAN UMBRELLA FORM GGREGATE WORKFR'SCOMPENSATIONAND - - EMPLOYERWCSTATU.II Oils- S LUBBlTY . A THE PROP1IETOR) 6006181012003 10212003 10212W4 EL EACH A Cm f ►ARTNERSAD(ECVTIVE Wa' OFFICERS ARE - f 1.000 OOO EL DISF.�SE-EA EMPLOYEE f 1 ()()(1 (1lVl Gatewoods Homes 1600 Falmouth Road Centerville, MA 02632 GANCELLAT-ION II SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAX. !0 DAYS WRITTEN NOTICE TO THE CERTIFICATEHOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE IIP ALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES. I II AUTHORIZEDREPREsarrATTVE ; 7 , I 1 1 S64 7272 P.01i01 PRODUCER RIDER. RISK SPECIALISTS INSURANCE AGENCY, INC. P.O.SOX 115 _ sesuRm CATAUMET MA 02534-0115 � US LIABILITY INSURANCE COMPANY CMrAW MONUMENT INSULATION, INC. AiIERICAh' $OME INSUiZANCE COMPANY 223 COUNTY ROAD II IcD BOURNE, MA 02532 :WAV'4_/�. Fw.•.rWV Mi (I Div •�kvr -•^=^.�ye!.^`�.✓i.u.<.� sNnvm�.M'r�i: �•i?''.�+.ia ""�Y��..ww�.•a.ii��..'i�i` THIS IS TO'.�--"'-•--..-•:-----`-"-."�', +�»+t.•..�.i... ..,,..,,•,,,�"�..'�'•..;:. " �� Kg:..:..-. .,;, CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F THE POL1cy PERIOO INDICATED. NOTWEH6TANDING ANY REOUIREMENC TERM OR CONWMN OF ANY CONTRACTOR OTHER DOCUMENT WEH RESPECT TO WHICH THIS EXCLL R3NS MAY 6E ISSUED OR MAY PEATSA7 THE AStJRAYC£ AFFOI= BY THE POLICIES DESCW9E HERM IS SUBJECT TO ALL THE TERMS. E'.(CI.USIONS AND CONDEIONS OF SUCH POMES. LIMES SHOWN MAY HAVE BEEN R'PnUCED BY PAID CIA J& TTPC Of DIDORAMCE I LTA PCUE`/ILVYlEA F'OUCYEfP[CT�yE POGGYflDIRATkMI ' DATs ML+oarn LwTs armoml • LDDa osRtRALLtA>auTr . X LGeAmA UA9EnY aAARS W W ® 0=UR A oRw-xsAcmm4ar PRDT CLI135745 �..r� uADiurt ANYAViD' M=EW UADD:TT ' lA�{A FC9M OAlR THAN LAIBRBJA FC M WORKER! COMPEIOAnOW AHD taLDM!RT UAABUIYMFV - $ PA WC 782 61 72 GATEWOOD ROMES,INC 1600 FALMOUTH ROAD 125 CENTERVILLE, MA 02632 508 778-5603 8/23/03 18/23/04 FINE CAMAOe e,r my 650 uEoo�iM.a.e�is5 II ComBram SNDLEUWT ! i ! I I PR318M DM&#= .. .. s r MOKY-EAACCCENT ! I 'EACHA=CMT ! , II AGG—RW.ATE s CACN OCR wem:E ' ! AOOREOATY ! I ! ' 9/5/03 19/5/04,• I i 1 - i 000 000 II a.y., •yin �.. {��yy ANOULD AKY of THE R9- T ADOYE oaaalm Pcupcs DE tAKCEIllD ltfoRE RE- CMMTMN DATE THMM ' � THE tastroLe ICONPANY WILE ENDEAVOR To Y41L i ]iQ_ an WrsTTER MOTs E TO THECZXT4Fl TE MOLDER KaoEcm rnr¢rr, BUT rARt* To rAR201=7 SMALL "NO OBUCL&TOW am UASWW af� iui: q,ra; CO r. _ �' - oR acmaEKTATnEs TOTAL P.01 I. J ]A�- CERTIFICATE OF LIABILITY INSURANCE IRODUCER P. DATEP.IMIODfM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION AcBhea —insurance Agency, Inc. 749. ONLHOLDER D CONFERSIS CATS DOES N ON THE, CERTIFICATE.. Wain street, SuiteAB ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. - DOterville, Ma. D2655 INSURERS AFFORDING COVERAGE 508re20==l INSURED Car.persca Overhead Doors NsuRERA�4y � QD tw. ,tl TIN.+ Co. ILstmaR tc Sox 517 I I INSURER c I East Falmouth, KA 02536 I+sUILEAD I COVERAGES INSURER E I TME ►OUCIES E INSURANCE RESTED BELOW HAVE BEEN tSSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIrFgTANDPIG- ANY PERTAIN. THE I TERM C C FFORION QF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHOM THIS CERTIFICATE MAY BE ISSUED OR ` MAY PERTAIN, THE INSURANCE AFFORDED HAVE THE POLICIES DESCRBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSION$ AND CONDRIDNS OF SUCH POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAN CLAMS. NSA TYPE OF INSURANCE -------- POLICY NUMBER LICV EFF 1IM IO II •� QATE GENERAL LULWLRY A NM I LeRrt j COMMEACUL GENERAL UABEIIY - EACH OCCURRENCE •F-Y-Y�/�. i CLAIMS MADE LXI OCCUR FREDAMK3F.1 N ftoj TSOO, 000 MEO EEP JL — MPP48352 W ome0") 05/28/03 05/28/049 PtRSONAL&AOVF&LIRY E : 0 - GENLAGGREDAIELIMITNlrLESPM GENERAL AGGREGATE fl•oFa�/D��-/a�/�� 1 POLICY PIG' - LOG - AUTOMOf,Kf LMBERY PRODUCTS.COLwIDpAGO f 000.000. j MIN AUNO COMBINED SINGLE LMT - ALL OWNED AUTOS Ce ww") - f j SCM MFD AUMS � I Y eR NCONwros PW nrs-�) f I NGN-DWNEDAtnos - eooLrraEwr ' (PM.rWwl I II PROPtRTr DAMAGE f f GARAGE LIABILITY (PIN Nlaa mAy .. AUTO ONLr' EA 0 CLA44 MADE YYDRKIIR7 COMIEN6ATIDN AND EMPLOYERS LIABILITY A OTIxIR GatGGMY Romer. 1600 Faiw;muti moafi; suite 25x Centax,rilleF MI► 02632 770 5603 ACORD?s-S (7f97) 02/22/03 02/22/04 --��ACC�ENi t 1 EA ACC f - I AUTO ONL 1 ADD f EACH OCCURRENCF f AOGAEGATE f II I s I II E i AarA!!EFA MPsc+ CANCELLATION >o► rnrAeorro eeeRleED*DaaE�sr�ANCEuco-eE■oRe r,rE uwRATLON DATE TII MOF. THE M3UINO INSURER WLL EfAEAVOR TO MIA_ I_ 'In DArt WRmtN NfiflEE-TO-TIEOERTN7CAYtNpLDERJUYrn... I n t0 SNALL IMPOSE NO OBLIGATION OR LMBIIJTY OF ANY RND UPON THE N.eAas N�UIRpA Rf AGENTS OR .._..-- — IL _ 1 1988 A = CERTIFICATE OF LIABILITY INSURANCE DAB'""""°°"""' 07/1$!03 PKbDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ti QoWlIng & 0' Nell Insurance ' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 222 West Main St..PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC # INSURED - - RIsURERA: Hanover Ins. Company I Busy Bee, Inc - INSURERe: Safety Insurance Company . . P.O. Box 50 . INSURERc: Associated Employers Insurance Compa East Sandwich, MA 02537 INSURER D: l .. INSURER E: COVERAGES u 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY E� VEDrM PDATE EXPIRATION (MMIDOMI -I I LIMITS I A ' GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE Q OCCUR X PD Ded:250 OHN643998501 •- 06/14/03 - 06/14104 EACHoccuRRENcE S1,000,000 DAMAGE TPREO RENTED S300OOO i HIED EXP (Myone pecan) f15 OOO ' PERSONAL aADVWURY si O00 000 GENERAL AGGREGATE s2 000 000 GENL AGGREGATE LIMIT APPLIES PER PoLIcY JEC LOC PRODUCTS •COM,IPlOP AGG s2000 000 II B AUTOMOBILE LIAMUTy AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON-OWNEO ALTOS . 3175394 - - - 01/14/03 ,.. __ 01/14/04 . .... coMenaEo SINGLE LIMITANY (Ea aeelde Q f I BODILY INJURY (Perpe m) S10O 000 , - X X ii (Per eecidmt) Bwacckl rd) .. t300 000 . ' X (p��ped�AMAGE •• $100,000 • GARAGE LIABILITY ANY AUTO - ... _... - - AUTO ONLY -EA ACCIDENT f I I EA ACC OTHER THAN - AUTO ONLY: AGG f ' S - C EXCESSA)MBRELLALWBILRY OCCUR ❑ CLAIMS MADE DEDUCTBLE ' RETENTION f WORKERS COMPENSATION AND EMPLOYERS' UABILTTY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? S yyeess d CJ be � SPECIAL PROVISONS below OTHER WCC5002932012003 - - 06/27/03 - 06/27/04 ' - EACH OCCURRENCE s ' AGGREGATE S f II WcsrATU- OTH• f • EL EACH ACCIDENT s100,000 E.L. DISEASE - EA EMPLOYEES100 000 El DISEASE- POLICY uurr s500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLD ,I ER CANCELLATION I I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ' Gatewood Homes DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10_ DAYS WRITTEN 1600 Falmouth Road Suite 25 NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT. BUT FAILURE To Do sosHAm" Centerville, MA 02632 IMPOSE No OBUGATION OR UABI11 LTY OFANY UPON THE INSURER ITS AGENTS DR REPRESENTATIVES. II AUTHORI ED REPRESENTATIVE ACORD 25 (2001108) 1 of 2 #30822 KJS O CORD CORPORATION 1988 0 TOWN OF YARMOUTH Building Department Town Hall Yarmouth MA 02664 (508) 398-2231 exL261 BUILDING PERMIT APPLICATION RECEIPT Temp Permit No.: T-04-440 Applicant Name: Frank Capra Location: 00121 CAMP ST # 1 Owner's Name: Village at Camp St., LLC Owner's Addres 1600 Falmouth Road # 25 (OFFICE USE ONLY Recorded By. IC Permit Fee: $0.00 Deposit Rec: $50.00 I I Payment Type: Check I I ChkNo.: 614 Net Owed: ($50.00) Application Date: 3/8/2004 Issue Date: 11 Expiration Date 11 Comments: 11 new construction: Centerville MA 02632 Owner's Telephone: (508) 778-9669 This is NOT a building permit. Application subject to plan review. Contact Building Department for, permit status. Official Building Permit will be issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee. 20 ' b i TOWN OF YARMOUTH WATER DEPARTMENT 99 Buck Island Road West Yarmouth, MA 02673 Telephone: (508) 771-7921 Fax: (508) 771 Date of Issue : Mar 18, Letter of Water Availability 1. Single Family Dwelling x 2. Duplex Family Dwelling 3. Condominium Dwelling 4. Commercial / Industrial 5. Other (Specify) Reference; Massachusetts General Laws Chapter 40, Section 54 To : Town of Yarmouth Building Inspector Please be advised that the Town of Yarmouth Public water sup is available to service lot/parcel(s) 21.1C1 Street 121 CAMP ST #1 as shown on Assessors sheet/map # 44 Issuance of this Letter of Availability is subject to the following provisions/restrictions. (1) The property owner agrees to comply with all Federal, State, and Local Laws, Rules and Regulations as they pertain to the use of the Public water Supply. 1 (2) The Yarmouth Water Department shall have exclusive rights as to the size, number, type and location of all water service lines, fire service lines or appurtenant items connected to the water distributioril system. (3) The Yarmouth Water Department reserves the right to requ: at the property owners expense, the installation of water mains and appurtenant items to meet water demand requisites within any structure relevant to this Letter of Availability. (4) This Letter of Availability will expire 180 days from the date of issue. I have read and understand the provisions/restrictions of this Letter Water Availability. Owner (Sign) Reference : VILLAGES AT CAMP STREET : FRANK CAPRA 1600 FALMOUTH RD # 2 5 CENTERVILLE, MA 02632 J Yarmouth Water Department I C o4•Y9R,� /�� TOWN OF YARMOUTH g� c BUILDING DEPARTMENT O �y �`�""= •3•=� BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET 11 Building Site Location: Proposed Improvement: ,vt/ L Map No: yY Lot No: i� �• -7W %6 Address: ,I 12V //%''t�, {r/ Te1.No.:%VI�GG�j Date Filed: 3 r, The Building Department will be responsible for assisting the app7l'cLiwdispatching your plans and I application to the following applicable departments. i WATER DEPARTMENT: ENGINEERING DEPARTMENT: CONSERVATION COMMISSION: HEALTH DEPARTMENT: FIRE DEPARTMENT: RESIDENTIAL AND/OR COMMERCIAL BUILDING Determines Compliance of Water Availability and or existing Determines Compliance for Parking and Drainage. Determines Compliance to Wetlands Acts; i.e, If Lot(s) Bord Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Mars: Determines Compliance to State and Town Regulations; i.e., l For Septage Disposal and other Public Health Activities. Determines Compliance to State and Town Requirements for Safety, Property Protection; i.e., Smoke Detectors, Sprinkler any Type of md, Etc Etc. ............................................................ ........................----............................------------ REVIEWED BY: . V. WATER DEPARTMENT: r DATE: 3 1% O N/A: V2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A LA. HEALTH DEPARTMENT: DATE: NIA. - INDUSTRIAL AND/OR COMMERCIAL PERMITS S. WIRING INSPECTOR: 6. PLUMBING INSPECTOR DATE: N/A 7. FIRE DEPARTMENT: DATE: N/A: PLEASE NOTE COMMENTS: RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE: u White copy - Building DepL- Pmkcopy -WatcDept. - Yellow Copy -HeahhDeit - Pink Copy -aBeeringDepL - Goldwod-FimDeptCamcvxion 04/27/2004 08:41 5083625269 MAScheck COMPLIANCE REPORT Massachusetts Energy code MAScheck software version 2.01 Release 2 CITY: Barnstable STATE: Massachusetts HOD: 6137 CONSTRUCTION TYPE: 1 or 2 HEATING SYSTEM TYPE: Other DATE: 4-26-2004 DATE OF PLANS: 04/21/04 TITLE: The Egret PROJECT INFORMATION: Mill Pond village Camp Street Yarmouth, MA. COMPANY INFORMATION: Northside Design Assoc. 141 Main street Yarmouth Port, MA. 02675 COMPLIANCE: PASSES Required UA - 258 Your Home - 144 NORTHSIDE DESIG Family, Detached (Non -Electric Resistance) Pe rmi t l l# Checked by/Date PAGE 03 Area or Cavity cant. Glazing/Door Perimeter R-value R-value. -------------------------------------------------------- U-Value UA CEILINGS 832 30.0 30.0 14 WALLS: wood Frame. 16" D.C. 1409 15.0 15.0 I 62 GLAZING: Windows or Doors 87 0.340 30 GLAZING: windows or Doors 40 0.340 14 DOORS 40 0.096' 3 FLOORS: Over Unconditioned Space 832 19.0 19.0 ------------------------- --------------- 21 ---------------- ----------- COMPLIANCE STATEMENT: The proposed building design described - here isj ------ consistent with the building plans, Specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy;Code.. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable standard Design conditions found in the code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and 34.4. II Builder/Designer oat i EFFICIENCY . PATING GCERYWIM ama �V �V Air Conditioning & Heating I/7TI ® MULTI -POSITION CONDENSING GAS FURNACE GAflVT SERIES a - REAT E10G1C 4-s !M eat MMR�MT :-3 SRRn7[E�xS.RaYulbn Description / Application • All models design certified by ITS to be in compliance with ANSI Z21.47 and CAN/CGA 2.3 (Canada) safety standards • Completely assembled, factory run -tested Standard Equipment • Energy saving PSC, mL blower motors • Quiet operating, sound 1 assembly direct drive blower furnace, for heating or combination heating/ . 40VA transformer for heating and air cooling application • For utility room, closet, alcove, basement or conditioning control service Combination redundant gas valve and regulator attic application • Vertical or horizontal venting with 2' PVC for . Integrated furnace control with diagnostics • Blower door safety switch 1 40k, 60k, and 3' PVC for 80k, 100k and 120k • Capable of multi -position installation — upflow, . • Energy saving Hot Surface Ignition system ' downflow or horizontal • Multiple flame roll -out switches • Outlet air limit switch • For direct vent (2 pipe) or non -direct vent (1 pipe) installations • Pressure switch for proof of, I it • Complies with California NOX Standards Construction • Completely insulated cabinei • Heavy gauge, reinforced, wrap -around insulated • Corrosion resistant 294C secondary heat exchanger that extracts energy from the gas steel cabinet with durable baked enamel finish and converts it to usable heat • Tubular heat exchanger (Primary) • Quiet, corrosion resistant plastic induced • Bottom or side air inlet blower assembly I • Aluminized steel inshot burners . Drain kit contains vent screens, drain trap, • Convenient left or right hand connection for gas, hoses & clamps electric service, combustion air and vent • Removable solid bottom block -off Optional Equipment • L P. Conversion Kit (LPT-01) • Concentric Vent Kit (CVK ) I As an Energy Star Partner, Goodman Mfg. Co., LP., has determined that this product meets the Energy star guidelines for energy efficiency Information contained herein is subject to change without notice. Made in the USA by: Goodman Manufacturing Company, LP. SS-312D 2550 North Loop West, Suite 400 - Houston, Texas 77092 www.goodmanmfk.com GMNT Series 10/01 PERFORMANCE RATINGS Model Number GMNT Natural Gas Input BTUH Natural Gas Output BTUH Propane Gas Input BTUH Propane Gas Output BTUH DOE AFUE Temp- Rise 0403 40.000 37,000 37,000 34,000 92.6 25-55 0603 60,000 55,000 55,000 51,000 92.6 35-65 0804 80,000 73,500 73,000 73.000 92.6 35-65 100-4 100,000 92,000 92,000 85,000 92.6 40-70 120-5 120,000 110,000 111,000 102,000 92.6 40-70 BEFORE PURCHASING THIS APPLIANCE, READ IMPORTANT ENERGY COST AND EFFICIENCY DATA AVAILABLE FROM YOUR RETAILER. SPECIFICATION DATA I Electrical characteristics 115/1/60 Gas service connection Y20 FPT Model Motor Blower Vent' Combustion' Filter Size In2 Electrical Ship HP Spd. Dia. Width FLA I Max Number Dia. Air Perm. / Disp. Weight Fuse 040-3 113 3 10 6 2' r 2901580 52 15 170 0803 1/3 3 10 6 2' r 2901580 52 15 180 080-4 12 3 10 8 3" 3' 3851770 7.8 15 205 100-4 12 3 10 10 3' 3' 3851770 7.8 15 225 120 5 3/4 3 11 10 3' T 4801960 92 15 265 •Note: Vent and combustion air diameters may vary depending upon vent length. Check with instructions, which accompany the furnace. 5 28" " j-198"� 4g" F—B� A" 48" 4" I 4" 8" COMB. NR MLET-' 128" � i COMB. AIR INLET GAS INLET i GAS INLET VENT i i • 1 i i 46" l 1 VENT _� b i 27" LOWVOLTAGE i 4" i 20�" ` 8 LOWVOLTAGE ELEC. I 1" i ELEC. 1 l}d i � LL iI -------- A -------------------------- i Model GMNT A B Combustible Floor Base 10403 & 060-3 14' 12 W SBM14 i 080.4 17 % 16" SBM17 100-4 21' 19Ya' SBM21 1 120-6 24 % 23" SBM24 CLEARANCES FROM COMBUSTIBLE MATERIALS Sides Rear Front* Vent I To 1' V 3' 0' 1 V Approvea for une cornact in the horizontal position. *36" clearance for serviceability recommended. SS-312D 2 A ,ti CASED (U) COIL APPLICATION OPTIONS Furnace Model Number GMNT040 3 8 GMNT060-3 GMNT080-4 GMNT1004 GMNT120-5 Furnace Width 14' 17 %' 21. 24'/i Coil Model Number Coil Width U-18 14• x II U-29. 14' x II U30 17 W x t x U-31 14' X I U32 17 W X 1 X (2) I U35 14' X I U36 17W X(1) X(2) II U-42 17G' X(1) X(2) I U-47 17 %i X I U-49 21' X(1) X(2) II U-59 21' X(1) X(2) II U30 24'W X(1) X(2) 11 U31 24 W X(1) X(2) 11 U-62 21' X (1) X (2) I I (i) using me ractory instauea oonom carnnei mier plates (2) Discard bottom cabinet filler plates Due to the rating mix/match of various coils with outdoor units it is important to match the fumace air flow for the total system capacity. Refer to furnace, heat pump and/or condensing unit specification sheets. AIRFLOW DATA CFM - NO FILTERS MODEL STATIC .1 .2 .3 .4 .5 .611 .7 .8 GMNT 040-3 HI 1370 1315 1260 1200 1140 1070 1000 925 MED 1210 1170 1130 1085 1040 9801 920 860 LOW 895 880 870 840 825 ' 780I 725 680 GMNT 06 -3 HI 1360 1300 1250 - 1190 1 1135: 1065 1000 930 MED 1200 1170 1130 1080 1035 975: 925 880 LOW 910 895 885 855 835 ' 790: 750 700 GMNT 080-4 HI 1865 1800 1735 1660 1590 1516 1415 1320 MED 1690 1645 1600 1545 1485 1410 1345 1245 LOW 1450 1400 1390 1360 1325 1270 1200 1125 GMNT 100-4 HI 2010 1945 1875 1800 1715 1626 1510 1400 MED 1725 1700 1670 1615 1550 1475 " 1375 1275 LOW 1430 1390 1350 1315 1285 1245 1160 1070 GMNT 120-5 HI 2360 2325 2300 2170 2125 2045 1945 1850 MED 1815 1750 1710 1660 1600 1545 " 1480 1415 LOW 1275 1215 1190 1145 1110 1055 985 925 vaiues inaicateo try snauea areas represent ainiuws uiat ale tuu iuw wi u=4U11q tauNc1 atulc nx. i SS-312D 3 / Y NOTE: SPECIFICATIONS AND PERFORMANCE DATA LISTED HEREIN ARE SUBJECT' TO CHANGE WITHOUT NOTICE. Quality Makes the Difference! All of our systems are designed and manufactured with the same high quality standards regardless of size or efrdency. Our designs virtually eliminate the most frequent causes of product failure. They are simple to service and forgiving to operate. We use the highest quality materials and components available because if a part fails then the unit fails. Finally, every unit is run tested before it leaves the factory. That's why we know... There's No Better Quality. Visit our web site at www.goodmanmfe.com for information on: • Goodman products • Warranties • Customer Services • Parts • Contractor Programs and Training • Financing Options SS-312D 4 MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version CITY: Barnstable STATE: Massachusetts HDD: 6137 CONSTRUCTION TYPE: 1 HEATING SYSTEM TYPE: DATE: 6-20-2002 TITLE: The Egret 2.01 Release 2 or 2 Family, Detached Other (Non -Electric Resistance) PROJECT INFORMATION: Mill Pond Village 1600 Falmouth Rd. Unit 25 Centerville, MA. 02632 COMPANY INFORMATION: Northside Design Assoc. 141 Main Street Yarmouth Port, MA.02675 COMPLIANCE: PASSES Required UA = 219 Your Home = 121 I I II I Permit II Checked by/Date Area or Cavity Cont.' Glazing/Door Perimeter R-Value R-Value U-Value UA ---------------------------------------------------------------------------- CEILINGS 832 30.0 30.0 14 WALLS: Wood Frame, 16' O.C. 1432 15.0 15.0 I 63 GLAZING: Windows or Doors 128 0.320 41 DOORS 40 0.0il 66 3 COMPLIANCE STATEMENT:- The proposed building design described here ,lis consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has tieen designed to meet the requirements of the Massachusetts Energy Code.11 The heating load for this building, and the cooling load if "appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or Cool the building shall be no greater than 125% of the design load as specified in •II Sections 780CMR 1310 and J4.4. Builder/Designer, i Massachusetts Energy MASQheck Software Vei The Egret DATE: 6-20-2002 Bldg. Dept. Use CEILINGS: 1. R-30 + R-; Comments/ WALLS: [ ] 1. Wood Fram I Comments/ WINDOWS AND G 1. U-value: For windo # Panes - Comments/ DOORS: 1. U-value: Comments! AIR LEAKAGE: Joints, pene_. envelope that are sources of air leakage must be sealed. When installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfm (0.944 L/s) air movement from the the' conditioned space to the ceiling cavity. The lighting �ixture shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. VAPOR RETARDER: Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. MATERIALS IDENTIFICATION: Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-values must be l clearly marked on the building plans or specifications. DUCT INSULATION: Ducts shall be insulated per Table J4.4.7.1. - I _I DUCT CONSTRUCTION: [ ] I All accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or I joist cavities/spaces used to transport air, shall be sealedil I using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be I omitted where gaps are less than 1/8 inch. Duct tape is not I permitted. The HVAC system must provide a means for balancing I air and water systems. I TEMPERATURE CONTROLS: [ ] I Thermostats are required for each separate HVAC system. A manual I or automatic means to partially restrict or shut off the heating i and/or cooling input to each zone or floor shall be provided!1 I HVAC EQUIPMENT SIZING: [ ] I Rated output capacity of the heating/cooling system is I not greater than 125% of the design load as specified I in Sections 780CMR 1310 and J4.4. I SWIMMING POOLS: [ ] I All heated swimming pools must have an on/off heater switch and is I require a cover unless over 20% of the heating energy is from I non-depletable sources. Pool pumps require a time clock.- HVAC PIPING INSULATION: [ ] I HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels (in.): I 'PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2- RUNOUTS 0-1- 1.25-22 2.5-4' I Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 I Low temperature 120-200 0.5 1.0 1.0 1.5 Steam condensate any 1.0 1.0 1.5 2.0 I COOLING SYSTEMS: Chilled water or 40.55 0.5 0.5 0.75 1.0 I refrigerant below 40 1.0 1.0 1.5 1.5 I I CIRCULATING HOT WATER SYSTEMS: [ ] I Insulate circulating hot water pipes to the following levels (in.): I PIPE SIZES (in.) I NON -CIRCULATING I CIRCULATING MAINS & RUNOUTS I HEATED WATER TEMP (F): RUNOUTS 0-1' I 0-1.25' 1.5-2.00 2.0+' I 170-180 0.5 I 1.0 1.5 2.0 I 140-160 0.5 I 0.5 1.0 1.5 I 100-130 0.5 I 0.5 0.5 1.0 I ----NOTES TO FIELD (Building Department Use Only)-----------------� r TOWN OF YARMOU M BUILDING DEPARIMENT PLAN RUV)W & MMMI IG PERMTr PLIG4TYON REVIEEW NOTES . ADDRM. mLot:. nmaeof%ialR�view: 3 3/poi' o-. - AgDabm: NOTE - (.0 Satim 10432,p am PcwM Edwsim QAbwAim (prsmsi:-w� nanwnfam� . � �'dP� ' r�S a Spooial P�asait �i'aat'the2'gtuagBoacd ofAppeals CO&Da" {faM&:;a&) I s " 1 aj►.�i � 1 2 5535 £�30.00 NOTE: ® SEWER SLEEVE[ WITH Tr 1 OFT. O WAR LPN GRAPHIC SCALE Yarmouth I,V'11' 20 10 O 20 60 Unless and until such time as the original (red) stamp of the responsible Professional Engineer. or Professional Land Surveyor appears an this plan: (A) no person or persons, including any municipal or other IN FEET public officials, may rely upon the Information contained herein; and (8) this pion remains the property of Holmes k McGrath. Inc. 1 inch = 20 R REVISED: 3-2-04 .�► Ad PLOT PLAN holmes and mcgrath, inc.1 ,,K OF PREPARED LOT 1 D FOR civil engineers and land surveyors o?`tiP Ss9s�t 362 gifford street TIMOTHYh1. MILL POND VILLAGE p SANTOS IN falmouth, ma. 02540 N .45078 CIVIL q 9 .O •� rr YARMOUTH, MA JOB NO: 201197 DRAWN: LMC �` �,NT SCALE: 1 =20 DATE: 1-22=03 DWG. NO.: A2500 CHECKED:Pt? 20 10 559.97' 54.89 NOTE: I ® SEWER LATERAL SHALL BE SLEEVED IN ACCORDANCE WITH TITLE V IFJ WITHIN 10FT. OF WATER MAIN. '. 60 NOTICE Unless and until such tims as the original (red) stomp of the appears responsible phis plan: Engineer. or professional lumd Surveyor oppean an this plan: I (A) no person or persons, including any municipal or other IN FEET ) - - public of vials, may rely upon the Information contained herein: and (B) this plan remains the property of Holmes & McGrath, Inc. 1 inch = 20 it REVISED: 3-2-04 PLOT PLAN holmes and mcgrath, inch OF c,�`sa, OF LOT 1 civil engineers and land surveyors 'sir PREPARED FOR 362 gifford street nVorHvn+. MILL POND VILLAGE IN falmouth, ma. 02540 "cviL78 YARMOUTH, MA JOB N0: 201197 DRAWN: LMC I �` sT� ors SCALE: 1"=20' DATE: 1-22-03 DWG. NO.: A2500 CHECKED: jk5 p,= GRAPHIC SCALE 0 20 TOWN OF ,YARMOUTHi 3e BUILDING. DEPA RTb1ENT II CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: /►'L" `�� job Location: Num'b,r� vv Street I. L y Owner of Property. ` GVillage Construction Supervisor: Name License No. Phone No. J Address: / �l �/� a I I s,,-,.qt 3s C ic'r-✓. do 1414 oa G 3z It Licensed Designee: (If other than Supervisor) Name License No. 2.15 Responsibility of each license holder. 11 2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising. He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings as approved by the building official. ; 2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building and structures only pursuant to the state building code and all other applicable laws of the commonwealth, even though he, the license holder, is not the permit holder but only a subcontractor or contractor to the per Imit holder. 2.15.3 The license holder shall immediately notify the building official in writingbf the discovery of any violations which are covered by the building permit. 2.15.4 Anylicensee who shall willfullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of license by the board. 2.16 All building permit applications shall contain the name, signature and license number of the construction supervisor who is to supervise those persons engaged in construction, reconstruction, alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately cease until a successor license holder is substituted on the records of the building department. 2.17 The license holder shall be responsible for requesting all required inspectionls. Failure to do so may be deemed a -violation of the permit conditions. I have read and understand my responsibilities under the rules and regulations fol licensing construction supervisors in accordance with section 109.1.1 of the state building code. I understand the construction inspection procedures and the specific inspection as called for by the building official. I I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152 Yes 2( No ❑ If you have checked yu, please indicate the type coverage by checking the appropriate box. A liability insurance policy 3100� Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 152 of the Mass. General Laws, and that my signature on this permit application wai ''s this requirement. Check one: Signature of Owner or Owners Agent Owner ❑ Agent ❑ Signature: Building Official Approval: TOWN OF YARMOUTI 1146ROUTE28 SOUTHYAPNIOUTH MASSACHUSETTS02664 Telephone (508) 398-2231, Ext. 261 — Fax (508) 398.2365 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT BUILDING ELECTRICAL GAS PLUMBING SIGNS Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1,1!Section 111.5, I hereby certify that the debris resulting from the proposed Work/dell olition to be conducted at ( a- cez-!M :J� S�- Work Address n� is to be disposed of at the following location: Said disposal site shall be a licensed solic Chapter 111, Section 150A. Signature of Applicant Permit No. 11 D to a • . 9FF1G�Sl��O� II PROPERTY ADDRESS: %a/ can 'ALCULAT! ON FOR PE COST TYPE OF ROOM ETC 1l 7/1 2S'1. 65 ADDITION ALTERATIONS i BATH BED ROOM II CERTIFICATE OF OCCUPANCY COMPUTER ROOM II DECK OPEN 11 DECK WIT7-I ROOF II (o DEMOLITION II ►�1 ��o ` DEN II DINING Rool II FAMILY ROOM II FIREPLACE I I FOUNDATION ONLY i GARAGE NO. OF BAYS II GREAT ROOM II I KITCHEN 11 II LAUNDRY ROOM II LIVING ROOM II / - _ • MUD ROOM I I _ .. _. ...., OFFICE I I PORCH CLOSED II PORCH OPEN II - REROOFING I ~I SHED I I - I STORAGE AREA I I i SUN ROOM HEATED II -- - SUN ROOM UNHEATED 11 (C [01 IN o FILE COPY Fn T C' d M sPartners, LLC Mr. James Brandolini 0S Building Inspector -Town Of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 � AUG1114 2008 11, 2008 Re: 121 Camp St Development (Mill Pond Village). F Dear Mr: Brandolini, As you already know, MassHousing and Finance Agency, as the primary lender, has taken over the Mill Pond Village Development and is the new owner. MassHousing has hired Horizon Partners to manage the condo association and to bring the development into compliance with the comprehensive permits. We have just completed the landscaping of every house with a CO and also e 4 units (106, 108, 90, and 82) that still need to pass final inspection. Loam was brought in to cover all of the side and rear yards of every unit and were hydro -seeded. The grass has come in to the point that it is being mowed on a regular basis. The work was done by Keep America Beautiful of 41 Rosary Lane, Harwich, M.A. The principal there is .--="er Crowell and his telephone nun„ �1 Thank you for your assistance in getting this development into compliance. ds, AyNgo�vey Bes Horizon Partners LLC-Project Manager 617-376-0100 ext 116 anovey@horizonp.com Phone 617.376.0100 • Fax 617.376.0101 • 549 South Street, Quincy,IMA 02169 II C.oMmonwta o� ///allactt! Official Use Only 2cc�� nn Permit No. 0` 0parhnetd o`Jire Je►vkee I I Ulu Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/07] leave blank n APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK' All work to be performed in accordance with the Massachusetts Electrical Code (MEC), i27 CMR 12 00 E (PLEASE PRT INK OR TYPE ALL INFORMATION Date: March 24, (� (� n ININ City or Town of: YARMOUTH To the Inspector drwires: W By this application the undersigned gives notice of his or her intention to perform the electrical v dJgMe `b©oKC1) a Location (Street & Number)121 CAMP ST # 1 Owner or Tenant ELAINE RICHARDSON Te one No. 617) 584-568 Owner's Address 4 CHARLES GATE EAST 4802 BOSTON MA 02215 Is this permit in conjunction with a building permit? Yes ❑ No ❑✓ (Cheep Appropriate Box) Purpose of Building RESIDENTIAL Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: INSTALL SECURITY SYSTEM PLEASE FAX PERMIT AND PERMIT# BACK TO US AT: 508 398-5666. THANK YOU ('mmnlntinn nftha Allnwinv tnhla mint ho wnivrd by thr Invmrinr of lVirec 4) No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fan No. of I Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above n- rnd. rnd. o. o mergency tg mg Battery Units No. of Receptacle Outlets No. of Oil Burners - FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners oof Delpchon sn Initiating Devices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers p eat Pump Totals: Number ons o. oSelf- -Contained Detection/Alerting Devices _ No. of Dishwashers Space/Area Heating KW al Local ❑ untetion Connecti❑ Other No. of Dryers Heating Appliances KW ecSystems:* No. of Devices or E uivalent 8 o. of Water Heaters KW o. o o• o Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP a No. of Devices or Equivecommunications alent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: $635.00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE El BOND ❑ OTHER ❑ (Specify:) I I I certify, under the pains and penalties ofperjury, that the Information on this application Is true and complete. FIRM NAME: Cape Cod Alarm Co., Inc. - - LIC. NO.: 1592C Licensee: GENE CORMIER Signature ° I I LIC. NO.: ffapplicable, enter "exempt" in the license number line.) Bus. Tel. No.-, 508 398-6316 � Address: 204 OLD TOWNHOUSE ROAD WEST YARMOUTH. MA 02673 It. Tel. No.: 800 468-8300 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: ILic. No.• SS CO 000248 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one' ❑ owner El owner's agent. Owner/Agent PERMIT FEE: $ 45.00 � Signature Telephone No. Q��C The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia . ers' WorkCompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/OrganizatioMndividual): CAPE COD ALARM CO.; INC. Address: 204 OLD TOWNHOUSE ROAD City/State/Zip: WEST YARMOUTH, MA 02673 Phone #: (508) 398-6316 Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 30 4. ❑ I am a general contractor and 16. ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors. , listed on the attached sheet. .. 7. ❑Remodeling ship and have no employees These sub -contractors have 8• ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.: 9. ❑ Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their ME] 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 13.❑ Other employees. [No workers' comp. insurance reauired.l 'Any applicant that checks box #1 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 state whether or not those entities have employees. If the subcontractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation brsurancejor my employees. Below is the policy and jab site information. insurance Company Name: Associated Employers Ins., Co. Policy # or Self -ins. Lic. #: 5006433012009 Expiration Date: September 1, 2010 Job Site Address: 121 CAMP ST 41 City/State/Zip: W. YARMOUTH MA �ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). , y 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 pedury that the information provided above is true and correct. ^nature--- �— Date: March 24, 2010 508 Phone #: () 398-6316 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 #: