HomeMy WebLinkAbout0039 TOWER HILL ROAD (11) t
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r TOWN OF BARNSTABLE BUILDING PERM14 APPLICATION
2#d
Map //70 7Z�0%arcel Co W Application#
Health Division a���1 y ts � L1 5/Q G
Conservation Division �� Permit#
Tax Collector SEPTIC SYSTEM MUST BE Date Issued �l l a 6
rer INSTALLED IN COMPLIANCE D
Treasu
WITH TITLE L Application Fee
Planning Dept. ENVIRONMENTAL.(.;ODE AND Permit Fee
,,, TOWN REGULATIONS
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address ✓ 31 � � a,
Village OS 0/Zjam
Owner Z)&Xr, Address 3 y '7'a w-7t.-
Telephone S-IX-1/6 '5' - 8 Z-9,5-
Permit Request ;SviZQ/ /07 Z i7 1'9CYQY11 -,A/-/ 74 /Z4c," 4- '7/,g .
Square feet: 1st floor:existing 900' proposed.;ZcZ 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation -:2 , ao Construction Type /a c/
Lot Size hXiz� s� �-� Grandfathered: El Yes El No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure S' s o 1 Historic House: ❑Yes U-W On Old King's Highway: ❑Yes ®-Ner -
Basement Type: ❑Full awl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new CD Half:existing new v
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: 'es ❑No Fireplaces: Existing New O Existing wood/coal stove: ❑Yes 9 fdo
P g 9
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: i
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ a =
Commercial ❑Yes ❑No If yes, site plan review# ,' T
t,
Current Use Proposed Use
BUILDER INFORMATION �o
Name 1 L4 /o a C'� Telephone Number c - Y17
Address �=�Y License# 0S-? ,Vq3
v 7,.4 le- , z'/ � Home Improvement Contractor# //0 /GO
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE - IrIOAl o L
FOR OFFICIAL USE ONLY
PERMIT-N0.
N ,
DATE ISSUED
MAP/PARCEL NO.•
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
as
FOUNDATION
P
FRAME ey:
INSULATION
FIREPLACE '
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL"
FINAL BUILDING
DATE CLOSED OUT
F ..
ASSOCIATION PLAN NO.
I
I -
F BUILDIN, y/24az .. 11
��.Icense C NST CAEGUL4,;p f
Number S RUCTION SIIP ON
I SUPERVISOR
t: Bl d 057443 I
r, r=7t 61
R
''Ife= '
((� 0�7
RONq Rest}i` tl =_ Tr.no: 2090.0
t LD E LAND:: M1
6 PIMUCO PONE)
Y ! _
FO:, ONE) - y
' . RESTDALE, MA 02
. C
Commiss(oner
t pp�IB t f
a i �7 p oL
;l ie Y�rmir�a�r / s M rem.,, atton c al►d for III use unit
X �' a !f fpund return t0
• Bua�J of 12u�lc�iu�Itceulation aPa an�� . be ore tli�.e P!ratiorrda0
"4 {ipME IAfiPROVEMENT COt�TRA�TO� :; $ouril of BuiT'iling Reg..fat�ons and Sta�ldarcls
"t a Reisti— 1U160
wn. Out Asl�tiurtp►i Place Rm]30l
'Ma.02108
giratit 2006 6ostu i, T:
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x �YP��� ��idual
iPE-
RONALD ELAN ' -
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„ •.:: 16 P1hALICO POND .�. ...___._.. . .�--.. r _. ..
�loteandcvit);►ou c!�nat�t*'c;:
FCRESDALE,MA 02B44' ;�dmuust��tor -
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���TME loy, Town of Barnstable
Regulatory Services
�� t'E'$ Thomas F.Geiler,Director
�Fo;a. Building Division.
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA b2601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, Px e--4 ,as Owner of the subject property
hereby authorize �aJ 15,t � to act on my behalf,
in all matters relative to work authorized by this buildin permit application for.
(Address of Job)
Signature of Owner �,'�' Date
Print Name (v
ea n C
'l r //l7J�jl'✓fi J �Z
Q TORMS:O W NERPERMIS SION
lay� i
��- �
� �_
\ Jae t,urninuicweutin uJ lrlua;iucrnu,cu4(
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information -' Please Print Le 'bl
Name (Business/organizationadividual):
Address: ,l6
City/State/Zip: ;/&«,,,"/ice Phone#:
Are you an employer? Check the-appropriate boa: Type of project(required):
1,❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
ees(fun and/or part-time). have hired the sub-contracto# 7. ❑ Remodeling
2. msole proprietor or partner- listed on the attached sheet
ship and have no employees These sub-contractors have 8: El Demolition
working for me in any capacity. workers' comp.insurance. g, ❑ Building addition
[No workers' pomp.insurance 5• ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing an work right of exemption per MGL 1 LEj Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.[3 Roof repass
insurance required.] t employees. [No workers' 13 ❑ Other
comp.insurance required.]
*Any applicant 1hat checks box#1 must also fill out the section below showing their workers'compensation policyinforrnation'
t Homeowners who submit this affidavit indicating they are doing all work eadtheu hire outside contractors must submit anew affidavit indicating such
=Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy.and job site
Information.
Insurance Company Name:
Policy#or Self-ins.Lie. M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation p.o#cy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby eerti nder the pains and penalties ofperjury that the information provided above is true and correct
Signafore: r �G Date: S o�
Phone#: S'y 8`Y777 z,0�9
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 Departmee, 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact person: Phone#:
Information. and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for them employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as."an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the .
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealtb for any
applicant who has not produced acceptable evidence.of compliance with the Insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s);addresses)and phone numbers)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure.to sign and date the affidavit. The-affidavit 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials .
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 sire to fill in the permit/license number which will be used as a reference number. In addition;an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in , (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that.a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a dome owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax+;617-727-7749
Revised 5-26-05
www.mass.gov/air
j The Commonwealth of-Massachusetts
Department of Industrial Accidents
53 Office of Investigations
Y
600 Washington Street
Boston, AM 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plullmmbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: -�,2� Phone#: 5z -y17-6o 67
Are you an employer? Check the appropriate bop,— 'Type of project(required):
1.❑ I am a employer with 4. 21 am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sale proprietor or partner-
listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have &. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers' Comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repass or additions
3.El am a homeowner doing all work right of exempti on per MGL 11.0 Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.[:J Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.'
t Homeowners wbo submit this affidavit indicating they are 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi&under the pains andpenalties ofperjury that the information provided above is true and correct
� r
Signature: Date: o C.
Phone#: _�50 7 — y77--6 D 6 9 �'�� 77YOfficial 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 Cierk 4.Eiectricai Inspector 5.Plumbing Inspector i
6. ®Baer I
Contact Person: Phone#:
Information and Instructions
.r
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the .
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license-or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
reqdrements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The-affidavit 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials .
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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that.a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offiee of Investigations
600 Washington Street
Boston, NSA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
r ax 1L 617-727-7749
Revised 5-26-05
www.mass.�ov/cia
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DATE(MM/DD/YY)
t CERTIFICATE OF INSURANCE UE
23/2006
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
P8saro Leverone&Buckley DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
Insurance Agency Inc POLICIES BELOW.
P O Box 160 COMPANIES AFFORDING COVERAGE
Dennisport, MA 02639
INSURED' }'^
Patrick K Orclitt t COMPANY
L, LETTER A A.I.M. Mutual Insurance Co
Co dba P&S ncrete -
37 Ladys Slipper Lane _ --
Mashpee, MA 02649
COVERAGES
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 RESPECTTO 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.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIOT, LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
LAIMS MADEEDCCUR PERSONAL&ADV.INJURY $
OWNER'S&CONTRACrOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Anyone person) $
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO
I-.i �:. LIMIT $
�•
ALL OWNED AUTOS _ _ BODILY INJURY
SCHEDULED AUTOS T (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
GARAGE LIABILITY a
' PROPERTY DAMAGE $
nFN
EACH OCCURRENCE $
FORM AGGREGATE $
UMBRELLA FORM
WORKER'S COMPENSATION AND WC STATU- X OTH-
EMPLOYERS'LIABILITY TORY LIMITS
__ _6016111012005 __ 10/21/2005 10/21/2006 E $
A THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ 1,000,000.
PARTNERS/EXECUTIVE
OFFICERS ARE: X EXCL EL DISEASE-EA EMPLOYEE $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
i
R. Landry Construction EXPIRATION DATE THEREOF, THE ISSUING COMPANY WELL ENDEAVOR TO
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
16'Pimlico Pond Road LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Forestdale, MA 02644
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