HomeMy WebLinkAbout0209 CASTLEWOOD CIRCLE CAr
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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Ma � Parcel " t A licafio`#��
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Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street A dress ZDJ
Village AA &tVaJ(QAk
Owner �1��� Address
Telephone V t-2i
Permit Request �I p
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.Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
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Project Valuation Construction Type ,
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting do'cumpptation.
Dwelling Type: Single Family Two Family ❑' Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: 0 Yes-❑ 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 bath.3): 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 AppealYN
thorization ❑ Appeal # Recorded El
Commercial ❑Yes o If yes, site plan review#
Current Use Proposed Use
/{ APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
NameU Telephone Number
Address l) � Clil License#
^Home Improvement Contractor# �.J-2?
Worker's Compensation # wckbKK d
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
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SIGNATURE DATE
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FOR OFFICIAL USE ONLY
s "N. APPLICATION#
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DATE ISSUED
MAP PARCEL NO.
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ADDRESS VILLAGE
OWNER
s
DATE OF INSPECTION: _
{
_FOUNDATION_,
f.
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
f GAS: ROUGH FINAL
P
FINAL BUILDING
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DATE CLOSED OUT
f ASSOCIATION PLAN NO.
V Massachusetts -Department of Public Safety r..
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Board of Building Regulations and Standards
s Construction Supervisor
License: CS-100988
HENRY ECASSDI r'
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8 SHED ROW _ b
WEST YARMOUTH WA '
Expiration
Commissioner 11/11/2015
V01)YIfil'.0-1/,�
0I:'t CC o I:'C0fl;;UI11C.1, t1lFiirs iInd Bus'lless Re.�L.11ali`cir)
Boston) MassachT isetts 02116
l-tome lrivrovemerit CoCitractor 12e islralic�r�
R4gisU'�ltion: 153t%7
TVpr : Private ("url.)w atiull
Expiration. 12/15/2A)141 1,111 :Jsuj I
i;00 INSUI...:Al" ICON, INC
111_NIO" CASSIDY
I AI=\)DON CIRCLE
Y'ARMOUTH MA 02664
Ulrtl;licAtftlecss midrehtru eltrtl, Il'[urh reason foi ehauge.
1 rltldress LI ltc11-val I.__I "'1111)10 111out slC;Ird
uu„ „I t „u,unu r \lluirti J_ llusutttis Rel;ulutiuit Litensi of regutnuon vah(l for ijidi itlul tlst oltl)r
,�f Th yylt Mr.Ilvlh'KliVE.ML N'l" C:ON VRAC tOR Ild'Ole the c..Vpilatiun tl,ite, if fuuutl 1 tall a to:
'1 !l 9�t- / Type: Office of l"unstiin4rA7fair :uul Business Kc.btrlut$tJu
'` �/.f,,,m.uu;n I</15/2U'14I. 1:'nv lie l;orpofancil lU l.o t.l'I,rut-SWte.�17U
tiustuii,NIA 02116
llitlltlSt^('Il'liil), otviil 11,1010 f ,11A Il
The Commonwealth ofMassachraserts
Department of Industrial Accidents
Office of Investigations.
600 Washington Street
Boston,CIA 02111
www.mass.gov/dia
Workers' Compensatiou. Insurance Affidavit: Butilders/Contraautos`s/ElectriciansiPlumbers
Apoficaut information Please "Print�Legibly
Vallee (B Lis incssiorbanizabon/Cndividual):
uldtCSS _���/ i
Ciry/State/Zi L .,r. Jk,� Phone #: J Z /Z/-
--U-e You air employer? Check the appropriate box:
l. I utit a employer with. b�
1 4, D I am a general contractor and I Type of project(required):
cmployces (full andr16e part-tune).* have hired the sub-contractors 6. 0 New constauction
'.El ant a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no employees These sub-contractors have g, (l Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance) 9. [] Building addition
required:] 5. [] We are a corporation and its 10, Electrical repairs or additions
�] 1 ant a homeowner do Ling all work, officers have exercised then
1� " al 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per IvIGL 12 [] Roof repairs
Insurance required_] t c. 152, §1(4),and we have no
]a.❑ 1 am a homeowner acting as a employees. [No workers' 13.fYOther ZzJ,1
general contractor(refer to #-4) comp,insurance required]
'A-HY aPPhcant that checks box#-1 muvt also fill out the Section below showing their wockcn'cotnpensatio6�oticy iitfoiutation.
t Humeowuen who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such..
'Cuutrwors that chuck this box must attached an additional sheet showing the uama of the sub-coa¢actom and state whether or not those entitica have
curptuyccs. If the sub-contractors have employees,they must provide their worker'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees $elow is the policy and job site
lasur,u1cc Company Name: �j/d,/ G `✓��G f f�
Policy#or Self-ins. Lic. #: vG Expiration Date:
Job Site.lddress: (ICJ City/State/Zip:
Attach a copy of the rwo kern' compensation policy declaration page(showing the pollcy nn m ru and expiration date).
Failure to sccurc,coverage as required tender Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ti.nc up to S I,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WQRK ORDER and a tine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded.to the Office of
Investigations of the DlA for insurance coverage verification.
!du hereby certify ` rider the pa. rid prnalti.es of perjury that the informatl'arr provided above is true and corrac-4
'Dat • 5h 7J1,
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GAial use only. Do not write in this area, to be completed by city or town official
City or Towu: Permit/License#
Issuing Authority (circle olio'
L Board of health: 2. Building Department 3. City/Town Clerk 4.Efectrical.lmpector 5, Plumbing inspector
:6.ether
Contact Perzou: . Phone#;
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CAPECOD-27 MYOUNG_
0At'E IMMIODIYYYY)
- CERTIFICATE OF LIABILITY INSURANCE _ 71812013
TPIIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER7IFICAI'E 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 13ETVVEEi,N THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
_..._...__-._-___..----__...__..___.._..______—_ _— ___ __.:.------..._.__ .:._..._._...__._..._--._-.__-...----.---_—.
IMPORTANT: If the cOrtihCBte holder is an ADDITIONAL INSURED,the policy(ies)n1u5t be endorsed. If SUBROGATION IS WAIVED,subjecLlu
uw tunes and Conchtions of the policy,certain Policies may require an ondorsement. A statement on this certificate does not confer rights to I110
I c(;Ilil'Icatu h01(ler in lieu of such endorsements .
I',,°ricLrl LiconsL:# PC-S14062 N°MEACT Margaret YoLinc7
IRu�)urs X Gwy Insurancu Agency, Inc. PRONE - - II FAX
1434 Rtu 134 (AIC o ExI' ^ _..- — .[(Ai9,
!$Muni Dunmzi,IVIA 02660 EMAIL
- ADDRESS:'nl OLlllg CY f�El'SQr�.COn'1
• - - INSURERS)AFFORDING COVCRAGE _..__-.NAIC
INSURERA;PEERLESS INSURANCE COIVIPANY
INSURER B,COMMERCE INSURANCE COMPANY
t.apu i)ud Insulation, Inc. INSURFRC:Evanston Insuranor Company
__--
18 Reardon Circle, INSURER D.-ATLANTIC CHARTER INSURANCE GROUP _
JULIth Yarmouth, IVIA 02664 INSURERS:
. ....p,r _•._..- INSURER F:
COVERAGES r CERTIFICATE NUMBER: REVISION NUIVIBER:
III", IS IQ) CER IIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PL'RIOD
INDH:AILD NO F\01T (STANDING ANY REQUIREMENT, 'TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RC,;PEC I TO WHIC01HIS
I UVR'IIF'ICA1L MAY VE 19 UED OR MAY PERTAIN, THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN IS'SUBJECT TO ALL IHETERMS,
I:ua.U510N5 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
P�TC�F
F POLICY EkP '— —
rfR I YNe OF INSURANCE POLICY NUMBER (MMIDONYYXL M1M113 IY Y —LIMITS
UL.Nr1tAL IJAWUTY - 1000,UD0
LAGI'1 OCCUIgt�LNCk
-DAK4KGE-T0'RFNTED
A I X CONIMt.KCIAL GENERAL LIAUILITY CBP8263063 411/2013 41112:014 PREMISES IFe oc�uron aL 100,00
! I L't AIMS-MHOS I.X.1 OCCURM_f;0 EXP(Ally w?a L?orx?n) 5 5,000
PERSONAL a ADD INJURY_ -> 1,000,000
I GCNERAL AGGRIFOA re y 2,OD0,000
ieNtntthF,GAIkUMIT'APPLIESPER: I'RQOUCIS-COMPIOPAQG 5- 2,000,000
I tR ICYv.
ki IAu I Oraue ILc LIAaILi iY _ COMOINI t1 SII�GCC LIMIT-- 1000,000
AN„ull,l ^13MMBCKVMK 41112013 41.112014 BODILY INJURY(Par palmon)
� nU UVVNkU SCHEDULED -
BODILY INJURY(Pa(acddant) 5
4U105 X AUTOS - '----
I „ NCIN-C)WNL"0 f!ROPE(iTYrJ�MACi - y ..
A WNHJ AU CIS X AUTOS PL-R ACIDENI I
� � X urunccLtA LIAtf X OCCUF2 kAGli OCCURRENCE :.^ �_ --
I e�S unp XONJ453512 411=13 4/1/2014 AS-19MGA'rC R T L I OOU,00
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I CL AIM3-MADE _ _,..-.-.—,.-._—_._.,
I aril L?d-I.t1 Ni.- _ 10,000T —..— - ---- V�f BTAIU OTII —
ti,1KKEH$COMPkNSATION —� — - al.-L_-- -
END EMPLOYERS LJAPILIIY YIN
D I.jrn'PKUI'KIkIL)R/PARTNEWBXECUTIvE -_.. WCAQ0525SO4 613012013 61301:01.4 EL,EACH ACCIDENT 1,000,00U
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IJY HCa KJMEM(3NR EXCLUDED? l NIA )000,000
I.(M1lpuealufy hl NH) E.L.DISEASE EA EM_PL_0_YCt
uESCu�xwd OF O 1.L-DISL'ASI:-I'OLICY LIMIT 5 I,D00,000
I?L-jCKll'l l(�N OF OPERAI'IQIVS btilow ._ _--�-- -. ----- - --- " --"
Iiu:,�Nll'I TUN 01-C)Hzl-(AT IONS I LOCA I IONS I VEHICLES (Attach ACORD 701,Agglliup�l Rnmarhs Schzdulu,Ir mora apace Is raquhagi— -
+Wolharo Cunlpunsatlon includes Officers or Proprietors.
M(wunnl Inaurud Status is firoviLled under the General Liability when required by written contract or agreement with the Certificate 1,10lder.
I
CERIIFICAI'E I-fOLDI R CANCELLATION^---�— ----_
i
SHOULD ANY OF THE ABOVE DESCKIDEO POLICIES BF_CANCELLED DEFORE
e THE EXPIRATION DATE 11-IEREOF, NOTICE WILT. BE UELIVEREO IN
C:a G'Od In5l11at1011, (ITC
N' ACCORDANCE WITH THE POLICY PROVISIONS.
I '
AUTHORIZED REPRESENTATIVE
01988-2010 ACORD CORPORATION. All rights reservad.
ACORD 25(201 U/05) The ACORD name and logo are registered marks of ACORD
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���� vurrx�meec
mass save COMMM
PERMIT AUTHORIZATION FORM
ner of the property located at:
(Owners Name,printed)
15 Q� o
(Property Street Address) (Ciiy/Town)_
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to,perform insulation
and/or weatherization wo4myerty.
ignatur
2 `
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services:
Participating Contractor to the above referenced project:
CA,
Participating Contractor Date
Rev.12132011