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HomeMy WebLinkAbout0569 MAIN STREET (HYANNIS) (3) TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map S(B Parcel T"���N OF BA STABLE Application # � � go g��- l Health Division � Date Issued �' Poe Conservation Division Application Planning Dept. Permit Fee h Date Definitive Plan Approved by Planning'Board Historic - OKH _ Preservation/ Hyannis Project Street Address 5599 kU ST —T Village NN N lS Owner P M 11.E Address �A--�A Telephone Permit Request (L, 6C- 011 l-1 S MO Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 9:b• ` D Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other p- Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new t 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:Xexisting ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial J Yes ❑ No If yes, site plan review# Current Use T1 (—i s� Proposed Use 1LI �� I APPLICANT INFORMATION _ (BUILDER OR HOMEOWNER) _ Name --S &CAC-(26NIS 1 Telephone Number D Address .1 Y D X � 2-LP License# � L (� ��3 Home Improvement Contractor# i n 3- 3 Email Worker's Compensation # WC-02Z -ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE `'" Lam' _. DATE I q L F FOR OFFICIAL USE ONLY n APPLICATION# 'i DATE ISSUED MAP•/PARCEL NO. ADDRESS VILLAGE �. F OWNER ., t l i - • r } DATE OF INSPECTION: ' >; FOUNDATION r FRAME ` } i INSULATION } FIREPLACE 'r ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL l GAS: ROUGH FINAL t FINAL BUILDING Y , DATE;CLOSED OUT E A•S>S,OCIATI.ON PLAN NO. 4 T ] ] • The e'ommorwealth of Massachusetts Department of Industrial Accidents Off ce of Inveshgatrons; 600 i3-an m dn..Steeet Bastori,,MA 02111 �� www mass gov/daa Workers'-'Compensati: o Insurance Af# davl<t Builders/Contractors/Electric;<ans/,Plume a"rs Aptilicant Information . Please,PrintFLekibly; Name(Business/Organizaiion&4viduA a ill&1' 1tOirbatk CUnS`t1'6(tlon;'__ # Address` 766 Falmouth C1ty/State%Zip IVlahl>tee, N1A 02649 Phone# 508, 3�112 Are you an employer?Check the,apgropriate box Type':of project(irequired) l [ I am a employer with 7 4. I am!a general contractor and I 6 ]New construction; employees,(full and/,or part time).t` have hired the sub-contractors t 7 ❑Rernodehng 2.0 I am a sole; ro netor or artiier listed;on,the.attacled sheet:,. t p A P. ship andl.�ha've no employees These sub contractors have: 8. []Demolixion working,:for ine;m anyworkers'coin insurance; 1 Yp 9 0 Building addition [No:workers'comp.insurance If]:Weare a corporation and it$ Electrical repaus ouvadditioiis. requued] ofcers have exerersed their: t 3,.0 1 ari a horrieowiie"r>domg all work:;.: right of exemption:per 1Va 11.Ej,Pluiribing:repaus or additions myself. [No workers'coinp; e 1`52,§1(4),and we:have no. 12Roofrepairs' l msurancerequired]t comp ins trance xegtured],.: 13.0 Other•, ,. s *Atiy applicant that hdck's box"#J1 must Ml 6`411 out the section below shotiving their workers'corripensatton:,policy information:, ; tfomcowners who sibrnit thiS.affdavit indl�ting;they-,are;doing all:work and then hire outside contractors'niust submit a i��w affidavii'ndieatmgs.uch;,, .Contraetorssfhat check this box must at4nched:an additional•sh°eel Showing themime of:the sub-coitiactors.6idd their workers'comp,policy infomiatiodi 1 am ais:employer that is providing workers'c.ompenvation in.vorancefor my employees Belvw rs the pokey and job:"site. iiiformatiom. Insurance;Company Name: Star Insur-ance,, Policy#or Self iris. Liic.i/: WC 0220915 Expiration,Date. 03-27-2.01S Job Site Address: City"/Suite%Lip:` -( dOS r _ ©Z bU {Attach a copy'of the workers' compensa' ii,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 penal.:ties of a fine up to'$1,500.0U and/or one-year imprisonment,as well as:;civil penalties ins"the form of`a-STOP WORK 0,RD1 Rand a fine of up to$250.00 a.day against the violator. Be advised that a copy of this statement may be forwarded.toAhe Office of Investigations of the DIA for insurance coverage verification: I do hereby certify under:the p'ins.and penalties of erjury that the it formation provided above`is true and cgrrect: Si afore: Date: Phone#; : 508-539=1,124 Official use only D'o not write in llus apes,to be completerl,.by city.or town:official, ` City oe Town; Permit/License issuing Authority(circle one):. 1.Board of Health`2'.:Building Department I City/Towrt:Clerk, 4.ElectrkalInspector 5.Plumb;ng Inspector 6.Other. Confae"t Person:; . Phone MILLSTA-01 BDUQUET .�CG7R,i7� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/18/2014 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: Mason&Mason Insurance Agency,Inc. PHONE FAX 458 South Ave. ac No Ext:(781)447-5531 NC, /c No):(781)447-7230(A/C. Whitman,MA 02382 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance 29939 INSURED INSURER B:Star Insurance Company 000063 Miller Starbuck Construction Services,Inc. INSURER C: PO BOX 726 INSURER D: Falmouth,MA 02541 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 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 POICY LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MIOWLDDY EFF MM/DD/EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR MPF1100Y 12/01/2014 12/01/2015 _13AMA To R NTED PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N/A WCO220915 03/27/2014 03/27/2015 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Barnstable,MA 02632 - AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Ir Massachusetts Department of Public Safety ' Bo6td 6f Boildiog,;Regulations and,S#andards Con�trutian Suti�n���it' a t •. t � Syr PHILIR.'M 1ViIILE}Z ter::. 4 OUTH Expiration: Commissioner:: 03/14/20'15? �; fr. Office of Consumer Affairs and Business Regulation s 10 Park Plaza - Suite S 170 Boston, Massac setts 02116 Home Improvement tr �tor Registration Registration: 110373 Type: Private Corporation z 2 Expiration: 10/20/2016 Tr# 259061 MILLER STARBUCK CONSTRUCT? Y PHILIP MILLER,JR. P.O. BOX 726 FALMOUTH, MA 02541 olLq a`� Update Address and return card.Mark reason for change. Ej Address E] Renewal ❑ Employment n Lost Card SCA 1 ra 2OM•05111 ��ze (povrUntoal�aea�I.`a�6%liGcrd6ac�ttt6e�d ' Office of Consumer Affairs&Business Regulation License or registration valid for individui use only OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: egistration• ;° 373M. Type: Office of Consumer Affairs and Business Regulation ' E �� 2xpiration- 6 Private Corporation 10 Park Plaza-Suite 5170 h. �r� ,h Boston,MA 02116 MILLER STARBA"'__ - ON, INC. PHILIP MILLER,JRL' 40 MILL POND WAYS\ FALMOUTH,MA 02536� `k i Undersecretary Not valid without signature i i y//,,/''ri ., i� //ram Em ME 01, rro„ / / r / / r / r r e. F r , 1�d \ \ .. W� Vvtlr I I