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HomeMy WebLinkAbout0086 DUMONT DRIVE Application number......18.................................. Qi. Fee........ ........ . ........ r - MAM Building Inspectors Initials... 1p19 t Date Issued.... ............... ............. :71 D N?V1$ Map/Parcel. .�4... a,1�" 4&'N OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 86 Dumont Dr Hyannis NUMBER STREET VILLAGE Owner's Name: Peter Smith Phone Number 860-384-1396 Email Address: Cell Phone Number Project cost$ 5,000.00 Check one Residential X Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK 0 Siding Q Windows(no header change)# Insulation/Weatherization Doors(no header change)# Commercial Doors require an Inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to S&J Exco Dennis CONTRACTOR'S INFORMATION Contractor's name Anatoli Sivitski l9e Home Improvement Contractors Registration(if a licabie)# 168043 �/.�7 (attach copy) Construction Supervisor's License# �06040 (attach copy) Email of Contractor capecodinc@gmail.com Phone number 617-710-1001 ALL PROPERTIES THAT HAVE STRUCTURES OVER 7S YEARS OLD OR/F 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 APPLICANT'S SIG T Signature .c 44b&6• Date 4/18/2019 _ All permit applications are subject to a uilding official's approval prior to issuance. Contract total: $ , 1000 . If acceptable, initial here: Payment will be made as such: I'Deposit 1/3 $ Start day payment 1/3: $ Upon completion 1/3: $ ' Date: Signatures: Note: No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. Accepted y 4 Ja- Dater3�-J� THIS PAGE IS PART OF AND IN f CONFORMANCE WITH ROPOSAL: 86 Dumont dr Hyannis !}Yi+7 MV'Tr 'i� 'U +T'fl+ 1P ,+s fill voso Pro: � ctc�rtal,LACersq Board df uiidi g 3 ec uia lont'aoi lards CSSL.-1t�60 i WON m _ ANATOL1�SiV�TSKI 27 MILL PUNC1#tD, WEST YARMOtJTi INA026°73 w All w�rw'3.+.tf.+f+,.xi«:a'. Office of Consumer Affairs and Business Regulation ' 1000 Washington Street-Suite 710 Boston, M_Alcn' setts 02118 Home Improve rr� ,ntractorRegistration Type: Corporation CAPE COD HOME IMPROVEMENT,INC. z Registration: 168043 Expiration: 12/06/2020 27 MILL POND RD w W EST YARMOUTH,MA 02673 } w Q. 0 v0 v � s Update Address and Return Card. SCA-1 A 20M-06W Office of Consumer Affairs&Business Regulation , HOME IMPROVEMENT CONTRACTOR I Registration valid for Individual use only Corooration before the expiration date. If found return to: Exaltation Office of Consumer Affairs and Business Regulation _68D43 12/06/2020 1000 Washington Street-Suite 710 CAPE COD H^ NT,INC. Boston,MA 02118 ANATOLI SIVIT 27 MILL POND R � ) WEST YARMOUTH, A 02673 Undersecretary; Notbaiid Irith6ut Signature e • 4—. J ' r 'Aa Office of Consumer Affairs and Business Regulation One Ashburton-Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Co tractor Registration ,1 x7. TYpe: LLC Registration: 182457 BELCAPE CONSTRUCTION LLC 7 Expiration: ,.02/05/2020 42 WOODBU.RYAVE HYANNIA,MA 02601 Update Address and Return Card. SCA 1 C3 20M-W17 ?, C�oinf�zofGCUe6�'1�9 .//"(72JJ0,Cmwe/Gl Office of Consumer Affair&Business Regulation. HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. B found return to: ftealstratlgji Expiration Office of Consumer Affairs and Business Regulation f1t 451'= OPJ05/2020 10 Park Plaza-Suite 5170 ��t^4 _� r. BELCAPE CONSTR17t3,TlofF'LL Boston,MA 02116 ARLOU DZIANIS 42 W OODBURY HYANNIA,MA 02601 YVIthOtJt Signature Undersecretary , 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: Bulders/Contractors/Electricians/Plnmbers Ay>Alicant Information Please Print Legibly Name (Business/OrganimWan/Individual): Address: f. ' c�,<• City/State/Zip: e e al Phone Are you an employer Check the appropriate ox: Type of project(required): 1.❑ I am a employer with• 4.1711 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- wed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' o workers'co msurance.i 9. ❑Building addition [N comp.insurance comp. id.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner do all work officers have exercised their I I. Plumb'doing ❑ mg repazcs or additions myself[No workers'comp. right of exemption per MGL 12. Roof repairs insurance t c. 152,§1(4),and we have no ❑ ] employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I 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 him outside contractors must submit anew 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. l Insurance Company Name: �� &4,g/ Policy#or Self-ins.Lie.#: 42c, a ,2dQ__ Expiration Date: e6° D&Io-LJ..2-0 Job Site Address: f�u �- City/State/Zip: 4-64 80/ Attach a copy of the workers'compensation policy declaration page(showing the policy num er 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 11,100.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA forJusurance coverage verification. I do hereby c ' u pains enalties ofperjury that the information provided above it true and correct Si Date• Phone Off kkd use only. Do not write in this area,to be completed by clo or town ofj4cial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/rows Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Anatoli Sivitski Address: 27 Mill Pond Rd City/State/Zip: West Yarmouth, MA 02673 Phone#: 617-710-1001 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 3 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity, employees and have workers' [No workers comp. insurance p• com insurance.$ 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 .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. 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: AmGuard Policy#or Self-ins.Lic.#: R2WC940123 Expiration Date: 06/03/2019 Job Site Address: 86 Dumont Dr- City/State/Zip: Hyannis, MA 02601 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 cert6 under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: 4/18/2019 Phone#: 617-710-1001 Offlcial 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#: ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1 1 06/15/2018 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 pollcy(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 lieu of such endorsements. PRODUCER NAMffT Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY' PHONE 508 775-1620 �No: ADDRESS: Isuilivan@doins.com 9731YANNOUGH RD INSURERS AFFORDING COVERAGE NAICS HYANNIS MA 02601 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B CAPE COD HOME IMPROVEMENT INC INSURERC: INSURER D 27 MILL POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 281511 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 7 OCCUR DAMAGE TO N PREMISES Ea ocTWcurrence) $ MED EXP Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO ❑tOC POLICY❑ PRODUCTS-COMPIOP AGG $ PRO- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A AUTOS AUTOS ` BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE N/A AGGREGATE $ . DED I I RETENTION$ $ WORKERS COMPENSATION X1 STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE WA E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? WA WA WA R2WC940123 06/03/2018 O6/03/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 ff yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 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/. CERTIFICATE HOLDER 'CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION .DATE THEREOF, NOTICE WILL BE DELIVERED IN AnatOli SIVItSICI ACCORDANCE WITH THE POLICY PROVISIONS. 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 °` C� Daniel M.CrC y,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 . C�RO _ -p-� DATE(MMIDD/YYYY) R , ICATE OF LIAEIL!TY INSURANCE', 06/04/2019 THIS CERTIFICATE IS ISSUED <-.S A MATTER OF INFORMATION ONLY AND CONFERS AO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFtRA,:A,TIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE Ct; INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUC,s,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate t'7lciar is an ADDITIONAL INSURED, the policy(fes) must be endorsed. If SUBROGATION,IS WAIVED, subject to the terms and conditions of the policy,certain policies may requite an endorsement. A,statement.on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER _- -- CONTACT, .- ..- NAME: Linda SUIVan _ DOWLING & O'NEIL INSURANCE AGENCY PHONE (508)775-1620 FAX No: ADDRESS; Isullivan@doin&6om: Y 973 IYANNOUGH RD -• - - - INSURER(S)-AFFORDING COVERAGE -NAIL# HYANNIS MA 02601 INSURER A:'AMGUARD INSURANCE CO 42390 INSURED - ..µ .. ,INSURER B: *. CAPE COD HOME IMPROVEMENT INC wsURERC INSURER D: - - 27 MILT_POND ROAD_ . '..INSURERE-: - .-- WST`i ARMOUTH MA 02673' INSURER F i COVERAGES r RTIFIC.'.TE NUMBER:.410125' REVISION NUMBER: THIS IS TO CERTIFY THAT THE 01_ICIES OF M SURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED.NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING . Y RI:UIREMENT,.Tr-RM OR CONDITION OF ANY CONTRACT.OR OTHER DOCUMENT.WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MA- Y PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SIJi;d POLICIES.LIMITS.SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.` INSR ADD ;SUBIR - - 'POLICY EFF :POLICY EXP - LTR TYPE OF INSURANCE INSD i'VJ`rD, :POLICY NUMBER MMIDD/YYYY MMIDDIYYYY - LIMITS - COMMERCIAL GENERAL LIABILITY.- EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES.Ea occurrence $ MED EXP•(Any one person) $ N/A ' - PERSONAL&ADV INJURY . $- GEf.I'L AGG tEG!TE LIMIT APPLI=S PER. �. I „ GENERAL AGGREGATE $. �I PRO- ,r. POLICY u JECT ] L0 . _-- PRODUCTS-COMP/OR AGG $ f ryTHEF I $ i AUTOMOBILE LIABILITY -) - - COMBINED SINGLE LIMIT. $ • '(Ea accident i. i.NY AUTO I BODILY INJURY(Per person)` $ - Lt WMM OD ' SCHEDCA.D _—)AU OS i�AUTO II':. '{ N//` BODILY INJURY(Per accident) $ NON C" 3 PROPERTY DAMAGE HIRED AUTOS i AUic,S I - Per.accident $ $ UMBRELLALIAB I OCCUR _ i EACHOCCURRENCE $ - I EXCESS LABN/A C,L.,Info,, ,�� :AGGREGATE $. - iDED I� RETENTIONS$ - - _. $ _ - iWORKERS COMPENSATION - - _ - -X STATUTE -OERH - AND EMPLOYERS.'LIABILITY y I N� - AT R TN ERiEX EC UTIVE �f - E.L.EACH ACCIDENT $ 1,000,000 - A OFFICER/MEM DER EXCLUDED? N4A'.I N/A N/A- R2VVCO23262 06/0.3/2019 06/03/2020 - - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 ,(Mandatory yes,descrbe.Under _ DL-SCRIPTION OF OPERATIONS,below _ E.L.DISEASE-POLICY LIMIT. $ 1,000,000 N/n. DESCRIPTION OF OPERATIONS I LOCATIONL"VEfnCLEES (ACORD 101;Additio„al Remarks Schedule;may be attached if more space is required) Workers'Compensation benefits tiii N:T:,i to r'ascachl-,ettS employees only.Pursuant to.Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to ei 1ployee's i i L.:.-ler;:`Ian MassachLiSetts if the insured hires,or,has hired those employees outside of Massachusetts. This certificate of insurance show:, 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 Ymiw.nlass.gov;Iwd!yvor�,,;rs coliipensatloniinvestigations/:` CERTIFICATE HOLDER -- CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF; NOTICE, WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS: Anatoli Sivitski 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE V'JostYani,ouUl f."'a 02673 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD v& d Diane Smith 86 Dumont Dr Hyannis,MA 02601 Zoning Board Barnstable Town Hall 367 Main St Hyannis MA 02601 August 31,2016 To Whom It May Concern; We live at 86 Dumont Dr and today we went to the Town'Hall to register a complaint about the property at the rear of 11 Potter. ` We were given 2 "Citizen Request Management"sheets about prior complaints from other neighbors on Dumont Dr dated 8/9/2016 and 6/17/2014. When we arrived home we read the complaints more carefully and found that the property is zoned for office(3400),not construction.'It is rented out to`a . contractor and outside there are glass for windows,two.bathtubs;two small propane bottles, roof shingles,and old wood,some of which has been there so long that vines are growing on them. There are also many other items in the yard which are not used in an office setting. There is also a very large dumpster that has not been emptied in a very long time that is very close to the road. ` Apparently this complaint has been handled by the Health Dept and they seem to focus on the' = dumpster which is close to the road. We feel that this is a zoning issue and not a health issue.and should be investigated by your department. We also question why a large,locked dumpster is needed for a'' small office building. Please inform us of this is a zoning issue or if it a situation that should be handled by the Health Dept. We await your reply. Thank you; Diane Smith t A. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ,,b] Parcel DID Application # Health Division Date Issued (-2(.' /N Conservation Division Application F Planning Dept. Permit Fee " Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address C)L_ �>UL M()YlA_ b\n1 t Village Owner Z S, 1 I V l Address Telephone D 0 Permit Request 1Lt* ,5 ccicbfion t3 & C csb b Square feet: 1 st floors: existing proposed 2nd floor: existing proposed Total new Zoning District �1�'��Flood Plain Groundwater Overlay Project Valuation 715- 0 Construction Type Lot Size a ZZ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ ,Two Family ❑ Multi-Family (# units) Age of Existing Structure �01�c 1 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) . 0 1 P� Basement Unfinished Area (sq.ft) 1 Zd Number of Baths: Full: existing new Half: existing P, 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 C6ntral Air: ❑Yes Ud No Fireplaces: Existing New Existing wood/coal stove: q,-Yes ❑�No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existIna ❑ new size_ " Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: h. ZZ Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ y , Commercial ❑Yes ❑ No If yes, site plan review# - Current Use Proposed Use _APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) Name ��Ci (� a l �i�, }� Telephone Number`' `c l -7 - Address A!5 CO jM MfJTA CtA License # , �(A V n (��,(� Home Improvement Contractor# �� Worker's Compensation # 12-oS 1 b �t ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE- DATE FOR OFFICIAL USE ONLY APPLICATION# [FATE ISSUED MAP/PARCEL NO. :S 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. wf p The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street U1 Boston,MA 02111 www.mass.gov/dia tractors/Ee se n iumbers Workers' Compensation Insurance Affidavit:Builders/Con PlePr L bl A licant Information 4a� Name(Business/organization/Individual): Address: Phone#• — ��— City/State/Zip: ' box: Type of project(required): Are ou an employer?Check tappropriate 4. Q I am a general contractor and I 6. Q New construction 1 I am a employer with have hired the sub-contractors Remodeling employees(full and/or part-time). listed on the attached sheet.j g, Q Demolition 2.❑ I am a.sole propridtor or partner- These sub-contractors have addition ship and have no employees workers'comp.insurance. 9. El Building working for me in any capacity. 10,Q Electrical repairs or additions 5, Q We are a corporation and its [No workers' comp. insurance officers have exercised their per MGL 11:❑Plumbing repairs or additions required.] right of exemption p 3.❑ I am a homeowner doing all work c. 152,§1(4),'and we have no 12.❑Roof repairs myself. [No workers' comp. employees.[No workers' 13,0 Other insurance required.]t comp,insurance required.] enmtion policy information. •Any applicant that checks box#1 must also fill out the section below showing their workers'comp P al sheet showing the name of the sub-contractors and their workers'come.policy information. t Homeowners who submit this affidavit indicating they H are doing all work and then hire outside contractors must subrnit a new affidavit indicating dosuch. =Contractors that check this box must attached an a ees Below is the policy and Job site I am an employer that Is providing workers'compensation In for my employ information. - Insurance Company Lq Expiration Date: Policy#or Self-ins.Lic. © City/State/Zip: nr Job Site Address: b r and expiration date). Attach a copy of the workers'compensation policy declaration page(showing o e poimposition of criminal penalties of a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead t fine up to$1,500.00 and/or one-year imprisonment,as well as civil of penalties this statement may be forwa d d toin the form of a STOP the Office of d a fine of up to$250.00 a day against the violator. Be advised that a copy Investigations of the DIA for insurance coverage verification. - I do hereby certify under the pains and penaltles of perjury that the information provided above is true and correct. A Date: . nature: 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): Si epartment 3.City/Town Clerk 4.,Electrical Inspector 5.Plumbing Inspector. 1. Board of Health 2,Building D 6. Other Phone#' Contact Person: , ,ac R CERTIFICATE OF LIABILITY DATE""MIDDITIf 'ILITY INSURANCE 4/2212014 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(les)must be endorsed: If SUBROGATION IS WAIVED,subject to the terns 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 endomemen s. PRODUCER NAME-CT fly Estano Rogers&Gray Ins.-Kingston Branch PHONE FAX6- 63 Smith Lane Kingston;MA 02364 ADDREss: INSURE S AFFORDING COVERAGE NAIC 0 INSURER A INSURED CAPEENT-01 INSURER B: Capewide Enterprises LLC n1SURERc: J.P.Macomber&Sons INsuRERo: 153 Commercial Street - Mashpee MA 02649 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1865828735 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. INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY 8500050813 30/2014 30/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R PREMISES occurrence $250,000 CLAIMS MADE OCCUR MED EXP(Any one person) $5,000 PERSONAL BADVINJURY $1,000,000 GENERALAGGREGATE_ S2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: , PRODUCTS-COMP/OP AGG $2 0OO,000 POLICY X PRO-JECT LOC - $ A AUTOMOBILE LIABILITY 1020017539 0/2014 20/2015 a acINF=D SINGLE LIMIT cident 1 000()00 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident)is X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident) $ $ . A 4DED UMBRELLA LIAB OCCUR 4600050814 30/2014 30/2015 EACH OCCURRENCE $5,000,000 EXCESS LU18 CLAIMS-MADE AGGREGATE $5,000.000 X RETENTIONS 10 000 $ A WORKERS COMPENSATION 120510414 r /14/2014 14/2015 X STATLI OTH- AND EMPLOYERS LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE DFFICERIMEMBER EXCLUDED? N/A 3 E.L EACH ACCIDENT r $1,000,000 (Mandatory 1n NH) E.L.DISEASE-EA EMPLOYE $1,000,000 II yes,describe under DESCRIPTION OF OPERATIONS below - EL DISEASE-POLICY LIMIT $1,000,000 Leased Rented Equip y . LR Limit $50,000 DESCRIPTION OF OPERATIONS/LOCATIONS/tlEHiCLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION t: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE t THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED,IN + ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORQED REPRESENTATIVE 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25.(2010105) ' The ACORD name"and logo are registered marks of ACORD F, ,.. oOHEray T® vn of,Barnstable. Regulatory Services Thom as;F.Geiser,Director p rfuildin ;ivIson ono► _ ..g. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02604 www.town.barnstablema.us Office: 508-862-4038 Fax. 5..08=790=62N Property Owner Must ' Complete and Sign This Sectioa If Us uag:A I�u l&r as Owner of`the subject property hereby authorize. S�'S to.act on:mybehalf, in aIl natterS.-Telati e to work authoraed.byth s building permit application for: D ��rr, nis r (Addres,s of job)', S' afore of Owner Date l C - G,,n/,- nat y Q T ORMM OWNERPERMIS STON '• Vlze�onvr�toatcuea�.l�o,� � ------- Office of Consumer Affairs&Business Reg u ation e�la License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: eglstration: 143358 Type: Office of Consumer Affairs and Business Regulation 4 xpiratlon: 7/8-12014 Ltd Liability Corpc: 10 Park Plaza-Suite 5110 ID Boston,MA 02116 CAPEWIDfi ENTERF)+tl:�� ,L;I:C; RICHARD CAPEN 4507 R RTE 28 r_ COTUIT,MA 02635 Undersecretary Not valid withou gnature Massachusetts -Department of Public Safety Board of Building Regulations and Standards y Construction Supervisor Unrestricted.-Buildings of any use group which License: CEi-089273- ``` contain less than 35,000 cubic feet(99!m)of RICHARD M CAPtN �'% enclosed space. 122 WHITMAR Rol Cotuit MA 02635: Expiration si 11 2712015, Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For M Ucensina irrfo►niation visit: www.Mass.Gor/DPS E 'Town of Barnstable *Permit# k� OFF Expires 6.months from issue date • u:- --::Regulatory Services . Fee .. Thomas:F.Geiler,Director A fD MP't a ---. � � Building Division� Perry, Building Commissioner 200 MainStreet,• Hyannis,MA 02601-.... . �� ~a yl Office: 508-862-4038 APR..• _.. . - : •.: Fax: 508-790-6230 �AR6�! -EXPES'S:PRIGII'TMYCAT�ON _ RESIDE Not Valid without Red X Press Imprint vlap/parcel Number Property Address 4 Residential Value of Work fr Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �Q e i- a i >n p 10"-, Contractor's Name __T� Telephone Number ; Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) E ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation-Insurance . Insurance Company Name Workoman's Comp.Policy" Copy of Insurance Compliance Certificate'must be on file. • - f permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) YO.n h 2S'5 �Lr C_ -1 . [�•Re-side o- � ' Replacement Windows. U-Value,13( .44) _ Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.historic,Conservation,,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. , Home Impr vement Contractors License is required. Signature' _ f Q:Forms:expmtrg •R&Ase063004 ; The Commonwealth of Massachusetts Department of Industrial Accidents - Office of InvestIg8tl0ns _= 600 Washington Street, 7` Floor J� Boston;Mass. 02111 Workers' Compensation Insurance Affidavit: Buildin /PI mbin /Electrical Contractors ' name: 4 address: /WW�-01A 1441-4 104 1, )- ci state: work site location full ad ess :% ' p� E?i —T I am a homeowner performing all work myself, ject Type: E New Construction❑Remodel ❑ I am a sole ro rietor and have no one workin El Building Addition ❑ I am an employer providing workers' compensation for my employees working on this job I° dress. x 3 f Ds 4 yxfi "J.Gw'% M�S` �. S�V ?%{� .,x:, a '.Z«Y 4. _- mstirance ;xa 01►c,ii_ ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices 777 F. �t C�tK` p1tone# - T 3 iinsura'ncerco. :....... otic #.. ompanv Warne. . <'. . .._ . c�tY �Frone#V. s nliev . Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cer' der the pains and enahie of perjury that the information provided above is true and correct Sign ire .X/ Date Print name ��1 e r C�-` SM I Phone# �6� I^a official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department" ❑Licensing Board El check if immediate response is required ❑Selectmen's Office []Health Department contact person: phone#; []Other (revised Sept.2003) - K l.�• b Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 r ::.,. . 06 , 400 jr { f r , 1 : , : w . Air -i 02ps 0,1!9 — --- —_ 44 2 , .Q1sv � 6 :. ". ! ._ f t .._. . rAlo I � ci L.U k-fir` ' m _ . � F -41 IA j r ! i i k , _ F 1 S. v � n J� _ e. P :flex 02 io b-i D CEO L, 31*!Yk {VC1�2