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HomeMy WebLinkAbout0065 CAPTAIN COOK LANE r I r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel D 1`�OALI Application #06l IS �3 d d Health Division Date Issued 3I3o�I$ wz- Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address L,� C,l rAI)Y C4YOK Village r° i M A- `/AMA T� Owner P/4 C-ZZeN WA Address Telephone 612 6 Permit Request �-e, [7 mil-/I��c+ S ec� iz-cJ 1 � `Ll v lff S R-M 1) 4 C TU : W AI-e,i.- DI 7n2-4-1 e Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay' Project Valu.tiont - Construction Type .-D Lot Size Grandfathered: ❑Yes ❑ No If yes, attachsb pporting docurr entation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) ``' 3 Age of Existing Structure Historic House: ❑Yes ❑ No On Old K g ighwa):=LJ Y ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other U' yo I Basement Finished Area (sq.ft.) `,Basement Unfinished Area (sq. 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 R t C� /'ti J L A-u fz of Telephone Number �g � �� Y 576 7 7 Address M (� License # S F A- — 0 /7 8>` �4+ Q 13-7 8 Home Improvement Contractor## 7 Email L y a 1 a-1 7/0 hf S /J°ee Worker's Compensation # R C6 a ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO d S -e- GO,O 5T-/Z.Qc7-/ aN Du/2'P!sy-Pn— _3 SIGNATURE DATE FOR OFFICIAL USE ONLY s APPLICATION# DATE ISSUED MAP/PARCEL NO. t F f ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r k GAS: ROUGH FINAL s FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. E' MULTI-STATE RESTORATION, INC. FIRE* FLOOD*WIND* SMOKE*HURRICANE*VANDALISM Fed ID#050515889 CONTRACTORS REGISTRATION#140427 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT 0 M C 1&—0 1)� ,herein referred to as "Customer",authorizes MULTI-STATE RESTORATION,INC.,herein referred to as "MULTI-STATE",to perform any and all qecessary cleaning and construction services on Customers'property at: in5 ' 'n Telephone: and with respect to items that need to be cleaned at a remote location,t remo a and clean such items as necessary. l Se ;e 0 ���y� Customer authorizes Insurance Company,herein )N referred to as "Insurance Company",to directly a d solely pay MULTI-STATE. If for any reason the check should come to be or be made payable to the Customer, Customer then agrees to pay MULTI-STATE immediately upon receipt of the check from the insurance company. In order to expedite payment to MULTI-STATE, Customer hereby appoints MULTI-STATE as attorney-in-fact,authorizing MULTI- STATE,to endorse Customers'name,and to deposit Insurance Company checks or drafts for MULTI-STATE services.Customer agrees to pay Customers'deductible in the amount of$ that applies to this claim. If the loss is not covered by insurance,Custom., agrees to pa the I,otal ount to MULTI-STATE upon receipt of the invoice. - �Q_ �. I VIc °a.3 Signature of Owner It is my understanding that the services to`be performed by MULTI-STATE will be limited to those,which are authorized by my Insurance Company. Insurance Company Name . -Rg b5Tq t 4s A t Policy Number Customer agrees that MULTI=STATE is working for the Customer and not the Insurance Company or agent/adjuster. Additional rem ks: _ . ILIQS OT -124�(Y)kvvm_ �t ! l` ave read th'ocument com ely undesEaind an1 agree to same. GL lure Date Printed Name P.O. BOX 2210•MASHPEE, MA 02649.866-921-9111 •FAX 774-238-4422 Ego wMfib3gtorrr meet • fvn�u rgv�r�ut WGrke& CEk301Lpesa5�Iu=-, ce avit$uddersfC�antrachm--IMecfriciansTlambers AmEr-ant Infarmat Please Friod Legibly Name u Tw-re 5 TO 2.fin O/✓ rear (G' © T-Ts4 �S cityfsfat2fp: A3�i e e Phone 9-7 . y 7� Am yau an employer"Chtck the kpprGpriate b rt.= T of, a'ert L 9[I am a employer With 4- ❑ I=a gt I contractor=d I 6����= araglayees(fallagdforgatt#ime�* ��hi���_ 2-El I am a sole prap�-tar orpartner- IL%tzd an the attached suet F_ ❑R niod Hng ship and have no employees Tie sub-mairactors have S_ �emoSiiio� forme in euiplu�ees andhave workers' wow � T - � 9_ �guild-mg addition [Nc•words' comp_inmrance comp-ksurarx� 1 5_ ❑ We are a corpor dionaud its ID--E]Electrical repaim m additions I❑ I am a hom er doing aII why c�cers have emmi sed their I f 0 Plumbing repaizs tx addi#ions o�varltera' _ tight of e�mpiioa per�fQ. f [N n F� r-15Z§1(4),aad we havti go I2_[]Roof repairs I. I3-❑ Other employees-LNG ' Comp_insTc ance regIDr ] 'A-Y aup &it checks bm—=01-nmstalso ffioutthe sectimbeTvwsd n�theuwodte mmpenvdiovpfficyinEunx6=- ffo-mwwnersnix,submit,Sus Ff td-y!L in del a�ding sII r�� t h�e a�tri cantractmscoactsabaliiaaecram`dsritmar sach- rsthatrI -kthisb=mastattachedcon:dd9na dsheetshvwi3gthenameofPoesn# Lsm3stateuhethecdcuottmse h v` emphUE-es_ If the snit{a adms have eq+1�c they nIIrst gmuide titer-t-1--:'comp.p olicy m—b— 'ram ffrr`ae-rrpInyer rhr�isprFrx�g trarke-rs'cotttlxt�rtsrcfia/n izrsrtrrutce far tre,��ercrg7�y�es. BeTv�s rs f�fep�&c}ezridlPb arts frt�orYctQlzr�rt. ��c,f.�.�G' I Rmmmncp Company Nam: Po arSelf itzs_Li� ` f`d- Lk) C- 5 /C �� apiratiauDate: _4� iV jDlz 5 c Tom-,,� C.�_...�;C v c�lsta�Zip: Ceti-- e z i.cc P t-c,� A±tach a copy of the-Warkers'compeusatian palm declaration page-(shoving the polky nuxaber AU d eJcg L- on date): FaRttre to secare cot etsge as rgairedniztief 5ecfiioai SA ofIUL c 152 ran Lead to the irngasifwn of ciimiaal�=ffips of a free up to SUD_OD andlor one•-years as we as ci-vil pe>zalfim in the form-of a STOP WORK ORDER-anal a fine of np to$250-DO a day against the violator_ lie advised that a copy of this statzmmt maybe be warded to the Office of ' IQregE tiom of the DIA for rn nCB Coverage vedfication- I Za harebjr cer*r ndar thi pains wid pen ahYi s u perjure fit atfhe injo rm a6aa prmidgd ab1n L-rs h7w wid correct ]date: Pie 70� ( a6 �-.3-b-77 E tr iaL resa r zjIy. Da no.t ivribr in f ds area,to be caxrpieted by ctfv trr town ref ciaL City or Town ' Perszrifi'Tacertse# L So2xd of Hexhfi 2.$uMmg Departm�mt 3.C-pTawn Qcrk 4_Elc c�aal Inspector S.Pfuurbfi2g haspector fi.Cther Cn ct Person: Phont. - 5 Massachuse.fts Sum-al Laws chapter 152 rr,-c s all employers to provide workers'comPecnssafiDn far their empIDyees, to this stainte,an anployee is di--fined.as C_-every person in the seavice of a¢othez-under any contract ofhrre, express Or izuplied, oral or An anpkyr�is defied as'-an individual,partamship,association,corporation or other Legal entity, or any two or more of the foregoing engaged in a joi ±enterprise,and iacluding the legal representatives of a deceased employer,-or the receiver or trustee of an individual,partzre4,association or other legal entity,employing employees. 1_3owever the owner of a dvvelling'lrouse having nDt more than three apartments and who resides therein, or the occupant of the dwelling horse of another who employs persons to do mzd atcnance,construction or repair work on sash dwelling house or an f e;grounds ar bmlding appurinnant thereto shaJI not because of such employment be deemed to be ar,employer." MGL chapter 152, §25C(f]also sfaias that¢every state or local licensing agency shall withhold the issuance or mnewal of a license or permit to operate a business or to con&tmct buildings in the common calth for auy applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally, MGL chapter 152, §2SC(7)states`Ntifher the commonwealth nor any of its political subdivisions shall enter into any contract for the pexfurm.ance of public work tenth acceptable evidence of compliance with the in sua-ance rt--T m.ents of fhis chapter hate been presented to the contracting authority.' Applicants Please fill out the woikers' compensation affidavit completely,by checking the boxes that apply to your sitnztion and,if necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with their cerdficatf-(s) of inmL=ce. Laoited Liability Companies(LLC) or LimitndLiability Par-tnmamips(LLP)with-no employes other than the members or partners,are not required to carry workers' compensation insurance- If an LLC or LLP does have =ployees;a policy is required. De.advised that fb.is affidavit maybe subbed to the Deparment of Industrial Accidents for cons oration ofin urmc-Coverage. Also be sure to sign and date the affidavit_ The affidavit should be manned 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-i �nce ficense number ou the appropriate line• City or Town Officials . Please be sure tliafthe afar it is complete and prig d legibly- The Department has provided a space at the bo., m. •a has to contact. ou re tb e h canL ce a ns of the affidavit for you to fill out m the event the Offi f Invest7gatr. y garden-g aPP Please be st 'tD fill in the p=itllieense number which wM be used as a reference number. In addition-an applicant that must submit multiple pennitfHcense applications is any given year,need only submit one affidavit indicating current policy iofnrmaHon(if n(--cessary)and under"Job Site Address"the applicant should write"aE locations in (city or town)."A copy of the affidavit that has been officially staarped or marked by the city or town may be pm�ided to the applicant as proof that a valid affidavit is on file far futum pez nits or Licenses. A new affidavit must be filed out each year.Where a home owner or citizen is obtaining a license or permit not related.to any business or commercial ventzn-e (i.e. a dog license or permit to bran leaves etc.)said person is NOT required to complete tliis affida)Zt The Office of Investigations would at to thank you in advance for your cooperation and should you have any questions, please do nothesiinte to give us a call. The Department's address,telephone and fax number: ` Thy�orrfn,r�r� ajt�of MassachUslub Dt--pazt ac t Gf Iaiisfdal Aocide4ats I�astoa,MA 02111 TeL_f4 617 727-4SQO Qxt 446 ar I-&77 hL4ZS, R=4 617-727- 4-9� Revised 4-24-07 . . �gQ��dia Client#:34309 MULTISTA ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 3/17/2015 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 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: Marla Barnowskl Starkweather&Shepley PHONE FAX Alc,No E:t:401 435-3600 [A/C No): 401 431-9326 PO Box 549 E-MAIL mbarnowski@starshep.com ADDRESS: p•com Providence,RI 02901-0549 _ INSURER(S)AFFORDING COVERAGE NAIC If 401 435-3600 INSURER A:American Safety Insurance INSURED INSURER B:AmGUARD Insurance Company 42390 Multi-State Restoration Cape Cod INSURERC:Hartford Ins Group 19682 Division,Inc. P.O.Box 2210 INSURER D: Mashpee,MA 02649 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MM/DDIYYYY LIMITS A GENERAL LIABILITY EPK106790 1/01/2015 01/01/201 EACH OCCURRENCE $1 000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $50,000 CLAIMS-MADE FX_1 OCCUR - MED EXP(Any one person) $5,000 X BI/PD Ded$5,000 PERSONAL&ADV INJURY $1,000,000 - GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO- JECT LOC $ C AUTOMOBILE LIABILITY 02UENOT4762 1/01/2015 01/01/2016 EeaIIIEDSINGLELIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS .- Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION R2WC510288 - 7/16/2014 07/16/207 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $5OO OOO OFFICER/MEMBER EXCLUDED? a NIA (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more.space is required) Dennis 8r Paula McKenna Address of job site=#65 Captain Cook Ln Centerville,Ma CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE n a weL, CL. I3A11A® Jy c ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S672354/M672348 MBB L _ �le�ponznza-yuuealC� a. d"detGt " ffice of Consumer Affairs Business Regylat�on 1 -License or registration valid for individul use only _ ME IMPROVEMENT CONTRACTOR' before the expiration date. If found return to: :. Office of Consumer Affairs and Business Regulation - _j egistration 140427 TYRe. 10 Park Plaza-Suite 5170 Expiration 1p715/2015T.>: Supplement', 3rd Boston,MA 02116 MULTI-STATE.RESTORATION INC.CAPE COD RICHARD LAURIA " j00, P:' O.Box 2210 { MASPHEE,MA 02649 Undersecretary I Not valid without signature Massachusetts -Department and Standards Board of Building Regulationso c • �% _'. -7 rauluy tVllllltl lJltlllll JU41C1 VI.11/1 1 � ,,_. ', _ 784 License: CSFA ..V rs RICEARD D LAUJIA 1 LEAS DR Rockland MA 070 Expiration 04/01/2017 Commissioner Z,J [„evcL Lvwe�- BARNSTABLE �i � �4, 9 pig�"x/3 ?• vislo l (0 l 44 CS G el 0C)0 tC �Ln) C e K>t e ✓ o E 1,e J