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HomeMy WebLinkAbout0241 COMPASS CIRCLE of�f 1 �r��as5 C.i�; �. .I Al Application numb e s.!%... Q► Fee .. ... ........ ..................... ..... Building Inspectors Initials.,Porto) .................. AUG 14 ,2019 Date Issued.......................... � ...�1...... AHNSABLE ' Map/Parcel...........�.Lp............ ' ca.......... TOWN OF.BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: .o�t/ e36aRi3S3 Cs�C/cam.` ��✓i�/'��if tq NUMBER STREET VILLAGE Owner's Name:, ­re. 4110 Ar/Y Phone Number, Email Address: ` Cell Phone Number Project cost$ i � oo ,, ` ". Check one ,Residential Commercial OWNER'S+AUTHORIZATION As owner of the abov ope ereby au ' e to make application or b ' e t in rd with 780 CMR Owner Signature: - Date." } TYPE OF WORK ® Siding Windows(no header change)# 0 Insulation/Weatherization Doors(no header change)# - Commercial Doors require an inspector's review ' Roof(not applying more:than,.layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration,(if applicable)# 1 J ``? 5 Y ! (attach copy) Construction Supervisor's License# _�q 0 k�`(attach copy) - Email of Contractor) 5ArZr ZIA--f 0&Ej%t2!k1_ one number ALL PROPERTIES THAT HAVE STRUCTURES OVER`75_YEARS OLD OR IF THE SUBJECT PROPERTY IS/N A HISTORIC DISTRICT. YOU MUST OBTAIN,HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. 1' 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 Fuel source being used LP tank 201bs. or> Yes No ,if yes, a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. - . 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 APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. Town of Barnstable $ Building Department Services "LR1i6Ti Brian Florence,CBO 639.� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us f _ Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section 'If Using A Builder AI s Owner of the subject property hereby authorize ��l'�! <> to act on my behalf, i in all matters,relative to work authorized by this building permit application for: (Address of b) , * of fences and al s are the responsibility of the applicant: Pools e e e o! t ilized before fence is installed and all final e ns a /o ed and accepted. a e of Signature of Applicant Nadly— Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16/17 I ✓ , E AC �. CERTIFICATE OF:LIABILITY INSURANCE_: : DATE(MMIDDIYM) �e.�.. 05/17/19 THIS CERTIFICATE IS ISSUED AS A MATTER OF IN FORMATION'.ONLY AND CONFERS NO FLIGHTS-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"CONSTITUTErA 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 have ADDITIONAL INSURED provisions or 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 NAME: JIM.HINDMAN Schlegel&Schlegel Ins Broker PHONE: arc No E 608-771-8381'i AIc No. 508-771-0663 34 Main Street al West Yarmouth,MA 02673 ADDRESS: 'schlegelinsurance(a7grriail:com - - - INSURER(S)AFFORDING(COVERAGE-: NAIC# INSURER A: NGM INSURANCE COMPANY' 147$8 INSURED INSURER 8: AIM MUTUAL Adilson Segolini INSURER C: DBA SEGOLINI CONSTRUCTION INSURER D 117 Minton Lane ---~ W Barnstable,MA 02668A 818. INSURER E: INSURER E; 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 RI=SPECT 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 D WVD POLICY NUMBER. MM DDIYYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH.00CURRENCE $ 1,000,000 DAMAGETO RENTED GLAIMS•MADE'o OCCUR PREMISES Ea occurrence $ 500;000 MEt>EXP(Any one person) S -- 10,000 A MPT8486U" 05/07/19 051.07f20 PERSONAL&AOV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PE O LOC PRODUCTS-COMPiOPAGG $ 2,000,000 OTHER: $ s AUTOMOBILE LIABILITY CC TMBiNED SINGLE LIMIT $ .. Ea amiden! - ANY AUTO «' BODILY INJURY(Per person) $ OWNER SCHEDULED BODILY INJURY(Per accident) $T^-- AUTOS ONLY AUTOS' T. HIRED` . . NOWOWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Peraickient UMBRELLA LIAR OCCUR,-: EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATION PER OR' -I- AND EMPLOYERS'LIABILITY YIN, STATUTE ER_ ANY PROPRIETORMARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,000 B 'OFFICEPUMEMBER EXCLUDED? FN] NIA AWC400-7026025-2015 05123119 05/23/20 - (Mandatory In NH) - EL DISEASE-EA EMPLOYEE $ 10,000 If yes,describe under - ` - - DESCRIPTION OF OPERATONS below E:L.DISEASE-POLICY $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ADILSON SEGOLINI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF^THE ABOVE DESCRIBED POLICIES BE:CANCELLED BEFORE - THE EXPIRATION DATE THEREOF;NOTICE WILL-BE DELIVERED IN COPY: ACCORDANCEWITH THE POLICY PROVISIONS. CUSTOMER AUTHORIZED REPRES TA'�VE O 9 8-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD J , The Commonwealth of Massachusetts Department of IndustrialAccidents 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 Legibly Name(Business/Organization/Individual): Se-co L%All �wST�'yCrf o� Address: 900/ /,4AI,�_ City/State/Zip: 499 6%one#: 7 7 t9-3 6/ 5,950-5 Are you an employer?Check the appropriate box: Type of project(required): 1.al am a employer with�_ 4. ❑ I am a general contractor and I 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 8. [:]Demolition workingfor me in an capacity. employees and have workers' - Y p tY• 9. ❑Building addition [No workers'comp. insurance comp.insurance.1 . required.] 5. ❑ We are a corporation and its 10:❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 employees. [No workers' 13.❑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 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 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: L ` Policy#or Self:ins.Lic.#: '1 8� y Expiration Date: Job Site Address: Or 60 I'PA-s S i,e 6 t 11 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 certify under thepains and penalties of perjury that the information provided abov is tru and correct Signature: 1�-- G---- Date: F� /y 1 Phone#: 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#: Information and Instructions 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 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),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 cant'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 permittlicense 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. A new 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 Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia ✓Re �i,.ninona�al%�n.�.nv�a,�rac�iw.el/1 00100 of Consumer Affatm 3 Buslnass Regukftn HOME IMPROVEMENT CONTRACTOR Regtsttation v Id for Individual use only TYf E•.Individuat beiwe the expiration date. If found return to: Real straftoRw_ Explmdon IOffke of Consumer Affalm and Business Regutoftn rv05/14/2020 1000 YYashington Street-Suite 710 ADILSON SEGd `= __, 3 Boston,MA 02118 D/B/A SEGOLINI WNSMURV ION - _ ADILSON SEGOLINI a 117 MINTON •f C` WEST BARNSTABLE,MA 0M Und , Not valid without signatum emeastmy Commo iviedlth of-Massachusetts ` Division of Professiona!Licensure`- Board of Building Regulations and Standards' cow.ructi r Specialty, CSSL"-099907 s 41plres:10/14/2019 ADILSON SE�30UsNl 5 1117 MMufOIy WEST S�atNABLE MA d2868 ti r Pornmissione l/'� TOWN OF BARNSTABLE Permit No. Building Inspector VAUIrAn _ Cash OCCUPANCY PERMIT Bond X 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 Th$U Construction Address South Yarmouth lot #42A, 241 Compass Circle, Hyannis F Wiring Inspector �f � Inspection dater 1/ Plumbing Ihspecto �' Inspection date Gras Inspectork Inspection date t'Engineering Department f� ` r C ! I 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. 19_.__» _. .�GBuilding:.Inspeetor __ I Nf'nIPX CERTIFY Tit AT T"tf$ FOUNDATION 7'u iMZ. FROM SiREET VAS ANt3. I COAJ os QA Assissors map and lot numbe .......: ......�+ ��� /?- /�-7�•yFTHET� s --- o 0 Sewage Permit number �fS— SEPTIC SYSTEM- MUST BE, �Q INSTALLED IN COMPLIANCE t BAEasT4➢LE. S House number . ........................ V�lI a#-i �t :T'I .E II STATE so rnsa SANITARY CODE AND TOWN °''�ay3Y.a`0o "TIONIq TOWN OFB,A-,--R N ABLE DUILDI G .JPISPECTO APPLICATION FOR PERMIT TO .... ..... ............................................................................................ TYPE OF CONSTRUCTION ... .. ...: .......................................................................................... ..................19..1�. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .1.4112e., 1.4P ....1;`_ ................ .. .............*�. ................................................................................................... ProposedUse .. ... ........................................................................................................ ZoningDistrict .. ... ..,...........................................................Fire District .... . .,.. �c..................................................... 1 Name of Owner ...�/�............ ... +......C.E1............Address ......�...�...... g✓ Name of Builders. ................................................Address .............. Nameof Architect ......✓k'i0,4, ..e........................................Address .................................................................................... Number of Rooms .......... ...............Foundation ......'CitP�C............................................... Exterior .....S iC� �........................................................Roofing ......... 70F, ......... +...j Floors ..... 4Q-e... !. 4 .....................:.................Interior ............l�r.�S(vE ... ?i'. .................................... Heating !. !9 I�i`:�..L1 .....:......................................:................Plumbing ......... ..... i ................................................... Fireplace .....'[ .<t?... .............................................................Approximate Cost ..... ..Q.o, ............................................. 0 Definitive Plan Approved by Planning Board -----------_-------------------19________. Area .. . Diagram of Lot and Building with Dimensions Fee ..`J SUBJECT TO APPROVAL OF BOARD OF HEALTH 1 l � i -- / 6 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. NameG *.. ........ .. .. . ........ ............................ ' Theo Const. /A�310-428 l�01.2113O-. Permit for ..�a�ld.. --. �� f � � ...................................... Location- -.Qouoaaz..Cir.ojm`---------'' / . ..................^wa^� iz............................................. ~ | ` ^ Owner .....2heo..Canmt....................................... . ^ Typ� of Construction Wood'.Fpamxa------- . p ----.---------------------.. � ' Plot ............................. Lot 42L--------. -. � . . | � Permit Granted ......MarGh..26................ p7q . Date of Inspection . . .. ------.l9 ) . � � Dote Completed --��7��` �^�~---]g _ � � PERMIT REFUSED � . .............................................................. 19 . ' --.-------.--..-.-.---------- � —.-..---..----------._--..---.- ^ - -.-----_--.--.~.-.--...-.-~...... . � . . --'-'^--^-'-~--'------~-^^~'---^' � � ^ App,ove6 -��.�-------------. lQ . ! . . ---- ---------.---..-----.~.- � ----.---.--.-----.----.-...-.-.. . y � Assessor'"s map and lot number,..,.'...... ... `.�...�................ �F7HEt0 Sewtie `Pd?mit number ..... ....................................... Z BARISTADLE, i Housenumber ............ ...... ............................................. yO 1639 p i63q. 00 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO aa. TYPE OF CONSTRUCTION ...... - -. ........................................ ............................................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...:.%. ...:" .... —•G' 1, ...f..!� ��+...............................................:........:... ProposedUse rT.1��/........ .... ....►........................................................................................................................................ Zoning District ...........................Fire District .......... Name of Owner .. '+`�, i..... ...........Address ......... tic/ .............................. ` Name of Builder_.: ' •:G'..................................................Address ............... .................................................................... Name of Architect ......� !�!�•v cG Address .................................................................................... Numberof Rooms .......... ...................................................Foundation .....(,.gym ............................................... Roofing 'f Exterior ................. .............................................................. ........ .?:�........:�........................................................ /J Floors r S�� 6j " ( i Interior s1� �, � /C' ................. ...................................... ..............- .... ...................................................... Heating ................:a.. .........................,...................................Plumbing ..................�j.........................................,................... .'l .J - Fireplace ..................................................................................Approximate Cost ... ... ................................................. Definitive Plan Approved by Planning Board -------------------_-----------19________ . Area !�--�i..�._-- C, k ^ - y .. .....�.... t . .............t.. Diagram of Lot and Building with Dimensions Fee f�' .. SUBJECT TO APPROVAL OF BOARD OF HEALTH �A r t Y�+ r r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. / Name ........................................................... Thew Const. A=310-428 No ... 2,.1.13a Permit for ..Build..sIngle....... li�...........faraily...dwell;Lng.................................. ;'A.Corapass...CIX.Cle............................... Locatio .................Hyai=is............................................... Owner ......Theo-Const. . ............................... Type of Construction Wo d..FraMP,**'­**­­­ ..................................................-............................ Plot ............................��/t6).................... Permit Granted ........Mgxch..20.......1979 Date of Inspectlon ....................................19 Date Cornpletet ......................................19 PERMIT REFUSED ................................................) 19 .. ............ ............. . .............................................. ........................... ........... .. ....... . ..... .................. ....................... ...................................................... ....... .... ................ ............................................................. Approved ................................................ 19 .............. ................................................................ ...............................................................................