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HomeMy WebLinkAbout0286 WINDING COVE ROAD Vat co Co 1 �I k I A s ,� y ,. o �� - 1, � �.. .�. — - ___r �.: Application number . .. ....... ....................... . .. OQtHE 1p� l I. Fee ............................`1. ... . ....................... ' Building Inspectors Initials..... NAM Iq Date Issued...... .. .I� -/. ...1..................................... PJ� Map/Parcel....... Q &............ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMA�pTION Address of Project: W �!Ac, /NUMBER / f S REET VILLAGE Owner's Name: Phone Number Email Address: G GUVI�yh CC�PIG[�� V1c�-- Cell Phone Number Project cost$ — Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property Y I hereby authorize P to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK 0 Siding (Windows (no header change)#_f( 0 Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer o ingles Construction Debris will be going to A � U-t. CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License# C5 r.&1 (attach copy) i Email of Contractor Phone number 5*. z cZ—J 7 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. .� APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am -9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and-the Town of Barnstable. Signature Date f APPLICANT'S SIGNATURE Signature Date —•U- All permit applications are subject to a building official's approval prior to issuance. I Town of Barns Able Building Departme t Services t eni MAJIM ' Brian Florence,C ,O Mass. € 63 Building CoMMISSID,ner 200 Main Street,Hyannis,MIA 012601 www.town.barnstabl!.nia.us s Office: 508-8624038 Fax: 508-790-6230 Property Owne Must Complete and Sign his Section If UsingA B der I as Owner of the ero subject 1 P P m' hereby authorize ez,, � 6")act on my behalf, in all matters relative to work authorized by this buil ' gpermit application for: 42 AP { (Address of Job **Pool fences and alarms are the responsib 'ty9of the applicant. Pools are not to be filled or utilized before fen a is installed and all final inspections are performed and accepted. I §igtature of Owner Signal1 e of Applicant Print Name Print game 1� Date Q:FORM S:O W NE R P ERM I S S I O N POOLS Rev:08/16/17 ACC CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE DATE(MMR)D/YYYY) O6/07/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Cris Webster SULLIVAN GARRITY 8r DONNELLY INSURANCE AGENCY INC PHONEo E 508)453.2529 Fa.No): E-MAIL ADDRESS: VIP@sgdins.com 10 INSTITUTE RD INSURERS AFFORDING COVERAGE NAIC 9 WORCESTER MA 01609 INSURER A: LM INS CORP 33600 INSURED INSURER B: MARKWOOD CORP INSURERC: INSURER D: 110 BREEDS HILL RD UNIT 10 INSURERE: HYANNIS MA 02601 INSURERF: COVERAGES CERTIFICATE NUMBER: 411808 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/LDDfYYY POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE TO RENTED _ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPER aa PROPERTY DAMAGE Ident $ HIRED AUTOS AUTOS UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION /� STAT TE ERH AND EMPLOYERS'LMILITY ANYPROPRIETOR/PARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED7 WA NIA NIA WC531S319674049 06I0612019 06/06/2020 (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 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the.Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/Investigations/. L CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Markwood Corporation ACCORDANCE WITH THE POLICY PROVISIONS. 110 Breeds Hill Rd Unit 10 AUTHORIZED REPRESENTATIVE Hyannis MA 02601 y Daniel M.Cro CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD .-- �.niirurrrrtivvr�/�r/�:.:•l�r:;enr'�rt3r•/%r - n Office of Consumer Affairs&Business Regulation Registration valid for Individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found retum to: TYPE:Corporatlon Office of Consumer Affairs and Business Regulation MOW It n �` One Ashburton Place-Suite 1301 100871 020 Boston,MA 02108 MARKWOOD CORP. i U� TIMOTHY M.PEARSON: Not Valid Without signature . 110 BREED'S HILL ROAD UNIT 10 Undersecretary HYANNIS,MA 02801 i t i i i ®� Division of Profess Commonwealth of Massachusetts Board of Building R iegulatioonal Li sure Regulations and ConsEr� Standards � P"isor l CS-005867 TIMOTHY PEARSON ` Eikfires: 11/12/2021 P.O.BOX 519' �y CENTERVILLEMA 028 Z3 e r h Commissioner / y 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- rJ Z� . , ► c TABLE Parcel 7'�,,�: B�,�f�5 Application # Health Division W, 10. 17,0 Date Issued J;) i Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board:"-ION Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner �i%2gG ��D Address �19 Telephone J_Of S'-ZP �F 7/Q Permit Request /z '' 161/ye .9-.71P U�CGG/ f�c3�y19� �� po Square feet: 1 st floor: existing ' proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o7LG o, ayConstruction Type�,7<::il� Lot Size Grandfathered: .❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes No On Old King's Highway: ❑Yes a No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name p e—,i 2 46664 /,4 Telephone Number Address i/Z/2g/��j�g ,z-)X License # Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE G�7_S� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE-CLOSED OUT ASSOCIATION PLAN NO. Massachusetts - Department.of Public Safety :.:Board of Building Regulations and Standards Construction Supers is6l, License: CS-10098$.. HENRY E CASSIUI - 8 SHED ROW _ WEST YARMOiFTH Expiration Commissioner 11/11/2015 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. A 1 t; 2OM-05/11 Address Renewal Employment Lost Card de�oa»u��aaiuuea.�C/a1p/tKaddac/adef - \ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: -33567 Type: Office of Consumer Affairs and Business Regulation xpiration: :.:12715/20:1.6 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 4PE COD INSULAT.I'QN,'. C;' — =NRY CASSIDY 3 REARDON CIRCLE D.YARMOUTH, MA 02664 Undersecretar Y N valid wi ut sign e The Commonwealth of Massachusetts * Department of Industrial Accidents Office of Investigations IV .600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbei-s Ap plicant-Information Please Print Legibly Name (Business/Organizadon/Individual): Address: 16 �aV6jo�, CIVO City/State/Zi ��U�L��( t ��� Phone #:Are you an employer? Ch ck he appropriate box: - 1. I am a employer with 4. ❑ I am a general contractor and I Type of project(required): l employees (full and/or part-time).* have hired the sub-contractors . 6. ❑New construction 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' [No workers' comp. insurance comp. insurance.t 9. ❑ Building addition required:] 5. ❑ We are a corporation and its 10,❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their l I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12• Roof repairs 3a.❑ I am a homeowner acting as a employees. [No workers' 13. Other 0 (( ��(,1'(0� � general contractor(refer to#4) —--�_.._._._.... i comp. insurance required.]. •Any applicant that checks boa#I must also fill out the section below showing their workers,compcnsaticd policy information. --- J t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracton that check this bo;t'miist attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp•policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. I -\ Insurance Company Name: 'Ct Policy#or Self-ins. Lic.#: lSao/4�3. 1 6tUU Expiration Date: �� �() 17 Job Site Address: .� a City/State/Zip:zw ,5' �J Attach a copy of the workers' compen ation policy declaration page (showing the policy number an �, �/S P Y d expiration date). Failur6 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 viplator. 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 cerd un the pains and penalties of perjury that the information provided above is true and correct: Si a Date: Phon #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # i 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#: r From:Rogers&Gray InsuraFax: To: +15087785736 Fax: +1 5087786 7 35 Page 2 of 2 03130/2015 10:04 AM CAPECOD-27 BDELAWRENCE ACORC�" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)F — 3130/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policles 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 — g 4 NAME: Ro ers&Gray Insurance Agency,Inc. PHONE FAX (877)g16-2156 AIC No Ext: A!C Na South Dennis, NIA 02660 EMAIL —— ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURED INSURER B:SAFETY INSURANCE COMPANY 39454___ Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Ins. Co. 18 Reardon Circle INSURER D:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth, MA 02664 INSURER E: _ I INSURER F: _l+ 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. LTR TYPE OF INSURANCE POLICY NUMBER IPMIDD/YYYY ISM/ODIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH77�OCCURRENCE $ 1,000,000 } CLAIMS-MADE OCCUR CBP8263063 04/01/2015 04/01/2016 PREMISES Ea OCCUrrencel $ _ 100,00 j MED EXP(Any one person) $ 5,0001 PERSONAL&AOV INJURY $ 1,000,000) GEN'L AGGREGATE LIMIT APPLIES PER: FPRODUCTS RAL AGGREGATE $ 2,000,OOOI X IRO- POLICY JECT LOC -COMP/OPAGG $ 2,000,OOOI OTHER: I 1 1 $ AUTOMOBILE LIABILITY Ee accident) SINGLE LIMIT $ 1,000,000 B ANY AUTO TBD 04/01/2015 04/01/2016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED -- — AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X AUTOS NON-OWNED PROPERTY AMAG U70S Peraccident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C. EXCESS LIAB CLAIMS-MADE EXC10006635000 04/01/2015 04/01/2016 AGGREGATE $ DED X RETENTION$ 10,000 A gre ate $ 2,000,00 WORKERS COMPENSATION PER OTH- v -I AND EMPLOYERS'LIABILITY Y/N STATUTE ER D ANY PROPRIETORIPARTNERIEXECUTIVE WCE00431900 06/30/2014 06/30/2015 E.L.EACH ACCIDENT $ 1,0001000 OFFICERIMEMBER EXCLUDED N� N/A (Mandatory In NH) It yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 — DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 1,000,0001 i DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under thh General Liability and Auto Liability when required by written contract or agreement With the Certificate Holder. t CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc. THE EXPIRATION DATE THEREOF, NOTICE VNLL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WTH THE POLICY PROVISIONS. South Yarmouth, MA 02664 _ AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD F r r r OWNER AUTHORIZATION FORM 10wer's Name) owner of the property located at zo L w \ n ©ve, (Property Address) (Property Address hereby authorize 0. Pe_ Co 1 nS ✓ Ice �' � � r - (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Z4--0511IJ Owner ignah re Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION �o��� 1 OF BARN s 01LE Map Parcel GZ� Application # 0&4 Q 5 3 Health Division ALIG 12 AN I®: 01 Date Issued Conservation Division Application Fee Planning Dept. DIVISION Permit Fee Date Definitive Plan Approved by Planning Board tL Historic - OKH — Preservation / Hyannis Project Street Address d P 111,2�X-e,�E! ' P Village hl/�fZ.1%Gib rho �s -ru_x4 Owner tZ; Address Telephone c1`J oP 94 .4 P 7 l Permit Request ,2_?U Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �,, ! Construction Type 1, V61 /�Ozl Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 211"' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes EMo On Old King's Highway: ❑Yes -O"No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION -(BUILDER OR HOMEOWNER) Name ���� d f t/��y 't Telephone Number Address /��v�i�/� �� �i/� License # Home Improvement Contractor# ,//&—Y 5 G Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / x K FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED k MAP/PARCEL NO. r ADDRESS VILLAGE OWNER k ' DATE OF INSPECTION: .FOUN DATI.ON FRAME _ 'r A INSULATION. . + . FIREPLACE = ' ELECTRICAL:. ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL - FINAL BUILDING`- `_ ' _DATE CLOSED QUT ASSOCIATION PLAN NO. s 1 OWNER AUTHORIZATION FORM (Owners Name) owner of the property located at _ o�S (0 &)IVJA/V 0f- NO (Property Address) l (Property Address) a hereby authorize Cxiv. &7X J-�►Su La�j� ' (Sub ontractor) ' i an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. I O ner's Si u o� Date 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: Build ers/Contractors/Electricians/P lumbers Applicant Information Please Print Le_ 2ibl_y Name (Business/Organizaaon/Individual): Address:�% City/State/Zip: /� T�, o phone #: ��- Are you an employer? Check the appropriate box: 1.21 I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors . 6. ❑ New construction 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' [No workers' comp, insurance comp, insurance.t 9. Building addition required:] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their . I❑ 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 3a.❑ I am a homeowner acting as a employees. [No workers' general contractor(refer to#4) comp,insurance required.] I Any applicant that checks box#1 must also fill out the section below showing their workers co satiod li informaiion. It Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 7z_L Policy#or Self-ins. Lic. Expiratione: Date: Job Site Address:a? �lk/�/ � _��Lo 1„/ Ci� �rl � Ciry/State/Zip:p:tea 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. Ida hereby certify un the pains and penalties of perjury that the information provided above is true and correct r Phone#: ` -! 2 i Offlcia1 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector'5. Plumbing Inspector 6. Other Contact Person: Phone#: r j CAPECOD-27 KLIGETT �--� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N6/13/2014 O 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in IIA11 of such endorsement(s). PRODUCER NTA1ers&Gray Insurance Agency, Inc. NAME: Barbara DeLawrence I0g Rte 134 PHONE _ _ iouth Dennis,MA 02660 (arc No ExIJ_ F No; 877�816 2 56 E-MAILI Ess•bdelawrence@rog,-rsgray.com _ �— INSURER SAFFORDING COVERAGE — NS RED '— INSURER A:Peerless Insurance Company — NAICq it INSURER 8:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc 18 Reardon Circle INSURER C;Evanston Insurance Comp na y South Yarmouth, MA 02664 INSURERD:ATLANTIC CHARTER INSURANCE GROUP INSURER E: - - :OVERAGES INSURERF: CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NIA O D ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS C RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E C USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OF INSURANCE POLICY EFF POLICY EXP X COMMERCIAL GENERAL LIABILITY POLICY NUMBER MM/DDIYYYY MM/D /Y LIMITS 1 CLAIMS-MADE CXJ OCCUR 7CBP8263063 EACH OCCURRENCE $ 1,000,000 04/01/2014 04/01/2015D�E _!: PREMISES(Ea occurrence)__ $ 100,000 MED EXP(Any one person) $ _ 6,000 G N'LAGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY _ $ 1,000,000 POLICY I 1 PRO" JECT LOC I—I GENERAL AGGREGATE $ 2,00,0,000 l_:I )�J r OTHER PRODUCTS-COMP/OP AGG_ $ _ 2,000,000 AUTOMOBILE LIABILITY $ T COMBINED SINGLE LIMIT ANY AUTO 14MMBCKVMK Ea accident) $ 1,000,000 ALL OWNED X SCHEDULED 0410112014 04/0112015 BODILY INJURY(Per person) $ AUTOS AUTOS ( HIRED AUTOS X NON-OWNED. BODILY INJURY(Per accidenl) $ AUTOS PROPERTY DAMAGE Per accidenl $ X UMBRELLA LIAB X OCCUR $ EXCESS LIAB EACH OCCURRENCE CLAIMS-MADE XONJ453514 $ 1,000,000 DED X RETENTION 10,000 04/01/2014 04/01/201b AGGREGATE $ WORKERSCOMPENSATION Aggregate AND EMPLOYERS'LIABILITY $ 1,000,000PER ANY ERH PROPRIETOR/PARTNERIEXECUTIVE YIN WCA00525904 OFFICER/MEMBER EXCLUDED? N/A 06/30/2014 06/30/2015 STATUTE (Mandatory In NH) E.L.EACH ACCIDENT $ 1,000,000 II yes,describe under SCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYEE $ 11000,00 DE ' E.L.DISEASE-POLICY LIMIT $ 11000,000 III ++ IRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) {er4 Compensation Includes Officers or Proprietors, to M Insured status Is provided under the General.Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. t I ITIFICATE HOLDER -- CANCFI 14TIr1W " M;assachuse"s -Depattm`o'nt of P4jblic Safety .!RAard of Building Regula;Eons •nd Standards cons Inlctiun Supcn:tso11 License: CS-100988 HENRY B CASSLl# 8 SILED.RONY WEST YA121yfOU 11 �12 ,,�-.... Expiration Commissioner 11/11/2015 r Y-- r'!`"-,'.� '—••/ i c'C.Ji �C.�//V//!/ti'/(/Lti'GIiL'G'V/!/ tl� �.i 11/ w /. CY.,llGrG!liGG:1-F,��� Office of Consumer Affairs and Business Regulation j{ �C•;:r 10 Park Plaza - Suite 5170 Boston, Massachl:lsetts 02116 I Ialne Improvement CQ'' actor Registration :.i Registration: 153507 r'ni :: _:•.:.::: :::::f Type: Private Corporation :. .. �t•:. . .. . . �.:::-••-:: Expiration; 12/15/2014 1'17F 233831 CAPE COD INSULATION INC HENRY CASSIDY 1 REARDON CIRCLE .: . . .. :°` ;: :`.. .: ................................. SO. YARMOUTH, MA 02664 ` i:l`>;;,.......: _--. __.___.._..--_..._......__.._. ;;.I;,.Y' :':. Update Address alld I'otul'n card. Marie reason I'or change. ' (] Address ] Renewal ❑ Employment Lost Card r,t.•rauir•u:e:rrl�� .vGlcddac6tcwll3 1.)Ilice ul'L'Unsnmer Afrnirs& Business Regulation License or registration valid for iudividul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to; ealstration: 153;a67 Type; Office of Consumer Affairs and Business Regulation xpiration: 1211-5/2014 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 t l 00 INSULA-i-ION,•;I.G. .. Y , uRY CASSIDY aA'OON CIRCLE YA MOUTf•i,MA 02664 Undersecretary of val' witho ' r I �F 3 � ' � `� � oo'' � °1 r /Assessor's map and lot number ........... ............................... � Bpi THE t0 P Sewage Permit number .....................2.?..../.............................. /. �jr�. � 9 8AflH9T1►DLE, i House number ......................... mum .......�.�'..........�.......'.._..........�i/c�... 1639 �'p YAY a• TOWN OF BARNSTABLE BUILDING INSPECTOR ��/, ✓i!.''cry r L� "/,.�,� r / I1t t��+ /li APPLICATION FOR PERMIT TO ................... ''!:.....:.................................... ..... .... ... TYPE OF CONSTRUCTION ....................... ........ ..,... .....,..�.. ....................`/...L.... ... %.......................,....... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location . '�% '� 3� y l(/��U q//ivJ S �.ri/ (�. /1 /-�?��' J��/t) �� � r..:............. ..................................................................�. ...... ............................ ... ._. ProposedUse t- r t�.........................................7' �... :... ;I h ......v ��..................................................................... _ Zoning District .......h . .................. ............................................Fire District ..............................,................... Name of Owner .....: :?....*"./ Address .......:. ..��o� f. /r.-... Nameof Builder �l..............................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... _. / - �./ Number of Rooms ...............� ?..............................................Foundation ...........J.,r?Aa '-... ...61,1V �P...................... Exterior '.../--r , �.. ��4:'....�...4[/17k L =C�4�Z.'...Roofing ............ l�S x,-' ........................................ i. .. .... ............................................................ Floors ......... :.'• . /.1.... ... .............................Interior ................................ ............................. Heating ............Plumbing U ....................................... Fireplace _ '..............................................................Approximate Cost , 4 z7 G7 ................................. a s r Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area ................................. Diagram of Lot and Building with Dimensions Fee ....��.�... .............. SUBJECT TO APPROVAL OF BOARD OF HEALTHY `v 0 r r 4 J _ r 1 - / I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above } construction. Name ... ............................... 21419 Ocean Gate Land, Trutt . A=75-26 0 No ..2141,9.... Permit for one..s.tory••€rye ....................................clwel.li ......................... Location lot..#34....286••Wind.ing•400ve••Rd•: ...............Maastc s..Mi•1•is.................................. Owner .....Ocea Qate,.a..L,an4--Tru&t............. Type of Construction .......................................... ................................................. ............................. Plot ............................ t ................................ Permit Granted ............ 19 79 Ju2q 2.............. Date of Inspection .........:..........................19 Date Completed ..............................19 PERMIT REFUSED ............ 19 .............. . 1.. ! .. ................. ................ ....... ................................................. ............................................................................... Approved .:.............................................. 19 ..............................................................................: ............................................................................... i tt.Yst_ t=QM►L�( - 3 Fsr >zooM �q�J.dC7 -rA A = 3 I%d1 Lam( �LGW = 1 tO -4 = ��p G.PP.D. �� ��F'rlG tC 3oJ (SG % B 49S G.P.D. 2d� USA- tt>Op GA,L-. t) 4,>eA t--IT - USE I Ocxo G nL• +p f �Q� r� ��WALL AlZEa = l5p S.P. Burro vA AeEa= sT=. ``� '. <�qr� �(D�'tw p I-C, 1605'. yc t .o To-r.4&L 425 T0-1-6 L Fl u/ = -3 G.P'D. 1 �`I Pt-IQ'C C)L&Tt c LJ 2A7-E ; U 2 AA I u O tz LESS �vc• � Tt✓aT 'd ToP *t.N P P FN o L'Z�� G•= o o.c ,�•,�..;.�, Q,. ... J"P�e oco IWV. -.4 -Sox 4o4 Sc-uric I► V. z IL 1000 . g9 d T-ANic — GAL. 9o.d 401. Ls4-,�4 'p T Sj� w -ru i n I�I8/Q' �/z •, WAS41�D STONE �� Lc�CA.TyfG t�J ti !�/,f QS7U1J'� L4_e. uo C- Sc AL rcfJ �n.-rC ��ro "1 l�n tit/�rr�"L Crt<TIP—1 TuAT- Tt-IC-- Ntr-,Anot t Stlorv►.1 Pt-. [>tJ IZi_t=i��r,-a6,1LE t'-IC.►:t-ni-j 'c_.vl('L�(S W ►TI d Tt 1` �jt D!L LIIr� AWL> (V� 1',1.ClC �'(:CJlE:1=Aitc_�lTy. O� T►�( : �J� 13/S,ATEtc- < {'�ttJ• V'CGts; - -LA:W,cj~ ,U2virYuC�S L. C)T< 'LA�'>E[7 Ul -i r N 0STEV-V1L_LG- c.) tiC.LS i. ( i1.1 7,J:./���t.i�• 'JZJi.;�11:�, 1 -11;L"": r.:F4=ii�Fi �1.1t✓BJLT� _� '\ _ �`- 11 I ►�I•��.� i-_ u•.t_� T:, i�r_-_ � c�.Jl- 1_n'Y" l_tF�l��•'" n;�t�t_ll:.Ati.1T I ) `Ass@sSOf s map and lot number ...... ...1..�...."5.� � 1p/% �����/ '•`�' THE Sewage Permit number ..........�.....�f 9r:....................:....... House number ��P . WSTAUM $........................ ...... ................... •'E.G i639' �0 ENVIRONMENTAL CO ° TOWN OF B AIR N S T A BCNEEGULATIONs BUILDING INSPECTOR APPLICATION FOR PERMIT TO .shy/� TYPE OF CONSTRUCTION .............................. ................ ........ev ../...5-..........9.Z.? TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .......... v� ... .1.......... ProposedUse ........ /.lV . . ..................................................................... Zoning District :....... �............................................Fire District Name of Owner ...Address ....�...... Nameof Builder /l Ile..............................................Address .................................................................................... Nameof Architect ....................................:.............................Address ................................................��...................:............... Number of Rooms ............... ./!............................................Foundation ............ ..QU./l�.G'/....�.�P!��`2�... ....................... Exterior ..... �4/. //g�J �...1�tJ�l /7� C,�GC��v2°... �� ........................................ /- / ...`./.. Roofing ............ /S`rf�... Floors .........(�l�ldl.... ..... 1`!"l/.............................Interior '!....�—. 1/S.r '�,l`..., ....................... �f Heating .... !7 Gt�......D/. ....................................Plumbing ......� c...` ... �jP ................... _ Fireplace ..............�..............................................................Approximate Cost ............ �............................ ......... ° Definitive Plan Approved by Planning Board ---------------_—-----------19 . Area �"` S ' k' ................ ................ Diagram of Lot and Building with Dimensions Fee 0 ..................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH d NOD ' d � �i I hereby agree to conform to all the Rules and .Regulations of the Town of Barnstable,regarding the above construction. Name l ..a ,��%;zz..:. .. .. ...... . ... . . .. .. ..... ............. 21419 Ocean Gate Land Trust If I No ...21419... Permit for ....Me...ator.y..fraMe dwelling....................................... ............................... Location .19t154....N.6..TArid.ing...C.Q.ve..Rd. -K.5.t.........................P� CT ...mill.$......................... Owner ......... .......... Type of Construction .......................................... ................................................................................ Plot ............................... Lot ................................ Permit Granted .......................July--Z....19 79 Date of Inspection .........19 CompletedSyr 19 Date .. .. ........... .......... (0 �///Xvo PERMIT REFUSED ................................................................. 19 M ........ • ......>............. ......... ...... ... .... . . ...... . . ........ . ........... ......... A.m..114.. ................................. vo 0 L q2 0 Appr ..... tn.'s................................. 19 it......... ...... .................................................. ................. ............................................................ 1 1 l THE TOWN OF BARNSTABLE Permit No. —. _ ______---- I Building Inspector -Naurr.n Cash --------------- -—- CO f6)9• 0V13 OCCUPANCY PERMIT Bond -------------- Igo "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 Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date 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. ..................................................................... ..... _._...._._....�_._ ._ Building Inspector