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HomeMy WebLinkAbout0016 SHOREY ROAD r 4US, a 1 r Tq � - essor's'Office(1st floor Map Parcel Permit# I Conservation 0 ffice(4th )(8:30- 9:30/1:00-2:00) i ' a e Issued oard of Health(3rd floor)(8:15 -9:30/1:00-4:45) - ~- �/5' /Z '1 Fee �j Q Xngineerin�* Dept.-(3rd floor) House# 3 c� FPS _ ofINE f Pis I Us LICE oard 19 AL ry r TOWN OF BARNSTABL kV vi �� ®� � ` Building Permit Application TS ' ress Ir 7 , Village Owner Address - elephone Permit Request i First Floor square feet `� Second Floor ! square feet ZEstimated Project Cost $ o Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information ✓ame vv� a i/ Telephone Number6O8-o44549 Address License# / h S -A-za Horne Improvement Contractor# '�- orker's Compensation# _41 , NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE Z 0u / BUILDING PERMIT DENIED FOR THE FO ING REASON(S) K' FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/,PARCEL NO. ADDRESS VILLAGE OWNER s I a , c DATE OF INSPECTIO , FOUNDATION b � I , I t FRAME f INSULATION ' FIREPLACE' FINAL + _ ELEC TRICAL: ROUGH Y _ { . i PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL •=, 4 FINAL BUI DING i h DATE CLOSED OUT ASSOCIATION PLAN NO. ' t { 1 I 4 The Commonwealth (;, .4fassachusetty •�:il �`r -_-_=�;_:- Department of Industrial Accidents ` ! 011/COW, yest/gatloas' ih 600 11 asltinrtun Street . -Bus lass. 02111 Wor•ers' Compensation surance Affidavit .,----,—.. Pleas PRIN'rIdIW;7---7' I v 10139 17 1 am a homeowner perfornfing all work myself. - I am a sole proprietor and have no one working in any capacity Ltom'•.�'•"`','n►�'�.'7,..a::' - -:'� - - � -" ��-..d:.� I am an employer providing workers' compensation for my employees working on this job. cmml1am name' address: city: phone N: insuran policy# 12-1 am a sole proprietor general con cto or homeowner(circle one)and have hired the contractors listed below who have the following worke n polices: m a n -n e✓ 6 ©,�bo drne vCl-:l.-r•C;.: ..•:�'I"IR'e. .=A3+r�• 7hy"�Sae�'.Y!�IV'�4�T�•'�'^."�S comnanv name: iddress• city phone#: cur•Jn in. '#ce cam- nolicS :Attach additional sheet if tieee—a .•_.. :._.,w.: ::��:�wr r, � .:_,.;.; :.':�. :. ,� ..� y ^ . M R. >_.. u-ilurr to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one%•cars'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement mat•be forwarded to the Office of investigations of the DIIA for coverage verification I do hereby cenljr uarler a pa' are a 'cs u t the!, ornty on provided above is true and comet S/ignature Print name " 4�5 Phone . official use only do not write in this area to be completed by city or town official „ cite or town: permitAicetue# Ill Building Department (3Ucensing Board check if immediate response is required OSeleetmea's Office 011eallb Department contact person: , phone#; nUtber (mised 3M5 P1A) - - - e; r CERTIfICATE OF INSURANCE 10/24/95 HUDSON ELDRIDGE INS. AGCY , INC NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I 1I---------------- BELOW, -- -----------------------=- ----------------------- I-------265 ORLEANS ROAD I NORTH CHATHAM, MA I I 1 02650 I COMPANIES AFFORDING COVERAGE 1 PHONE508-945-0446 - ----------------------------------------------------I------------------------------------------------------------------- INSURED I COMPANY LETTER A HARTFORD INS . CO.' 1 I I COMPANY LETTER B LIBERTY MUTUAL INS. CO. I I I------------- -- ---------------------- BRENDAN J. DONOVAN --I 1 1 - ----------------------------------- I P.O.0 BOX 507 COMPANY LETTER C. - -- ----------- ------------1 I I------------ ------ - --- - --= I SOUTH CHATHAM, MA ---- --1 I 1 02659 i COMPANY LETTER D ------ ---- ------ ------------------- ----------------------------� 1 COMPANY LETTER E 1> -------- - -------=------------I COVERAGES (-==-------------=-==-------------=--==--------=-------------==-------------------==---- ---------------------------- THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY I I PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 1 + WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TERMS, EXCLUSIONS-, AND CONDITIONS OF SUCH POLICIES,-LIMITS-SHOWN.-MAY-HAVE-BEEN-.REDUCED-BY-PAID CLAIMS..__ .._...- -. . COI TYPE OF INSURANCE ' POLICY NUMBER '' POLICY EFF I POLICY EXP ' ALL LIMITS IN THOUSANDS 1 ILTR I I DATE DATE I I I---I--------------------------------I----------------------------I------------=-I--------------1----------------------------------- I I I GENERAL LIABILITY I I I I GENERAL AGGREGATE 12000 I AI [X] COMMERCIAL GEN LIABILITY 1 08SBADI2051 2/11/94 1 2/11/95 I PRODS.COMP/OPS AGG. 12000 1 I I I 1---------------------I-----------1 1 1 ( ] [ ] CLAIMS MADE X] OCC. 1 , 1, I _PERS. &_ADVG__INJURY11000----I [ ) OWNERS & CONTRACTORS EACH OCCURRENCE . 1 000 PROTECTIVE ----------" - I I I I'ri_r I L -- - 1-----------I I I I I I 1 FIRE DAMAGE I I ' I I [ ] 1 I r 1 1-(ANY- ONE,F IRE)-----_11000----1 I I [ ] I I I MEDICAL EXPENSE I I I - I (ANY ONE PERSON)----110 ------- --- -------------------------------- ---------------------------- -------- ---------------- ---- I I AUTOMOBILE LIAR 1 I ------ -------------_I I CSL I I I I I I 1 I-----------------=---I-----------I I�, I I I I ANY AUTO BODILY INJURY I I ALL OWNED AUTOS 1 I. 1 I (PER PERSON) I I I I I 1 I---------------------I-----------i ` . I SCHEDULED AUTOS 1 { I I I I HIRED AUTOS BODILY INJURY I I NON-OWNED AUTOS I-(PER_ACCIDENT) I-----------I GARAGE LIABILITY I I I ly I I - I I I ---I------------------------------=-1-------------=----------------I -------------I--------------I_PROPERTY --------_-------- -----I EXCESS LIABILITY I I w I,EACH OCC I AGGREGATE I I UMBRELLA FORM -I I Ir I I i I 1 I I OTHER THAN UMBRELLA FORM I 1 I I f ' ------------- -------------- -=------------ -------------- ------------------- --- -------------------------------- ------------- I I I I 1 I STATUTORY 1 BI WORKERS' COMP IWC7312084203012 §2/28/95 p2/28/96I100 EACH ACC I I I AND 1 1500 DISEASE-POLICY LIMIT. 1 I I EMPLOYERS ' LIAB I I 1 1100 DISEASE-EACH EMPLOYEEI ---I--------------------------------I-------------------------=--1=-------------I--------------I--------------------------------- I I I I . 1 I I OTHER I I I 1 1 I _-i-- ----- --------------�--- ------� -- -- ----- -- ----------- 1---------------------------------- --.------------------- ----- k DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/S,PECIAL ITEMS 1 'CONCRETE WORK/MASONRY I �1 CERTIFICATE HOLDER (== ---- - -, ---=-----_0 CANCELLATION (-----=------===-------------------- -= --__ ---.---_ _=`, = SHOULD ANY-OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX- I PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 1 B & B HOUSELIFTING = DAYS WRITTEN NOTICE TO CERTIFICATE HOLDER NAMED TO THE LEFT, BUT P. 0 BOX 1 578 = FAILURE TO MAIL SUCH N TIE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF , 1 HARW I CH, MA ANY KIND UPON THE COMPA Y, ITS AGENTS OR REPRES NTATIVES. 1 02645 -- ----------------------- - ------------- - - - ------- ----------------I = AUTHORIZED RE PRESENTAT ag,l I IACORD 25-5 3/88 = • _ The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyaaais MA 02601 Ralph Ctossen Ofrj= S08-7903227 Building C==issi F= 508-775 3344 For ofce tree only y Permit no. a Date AFFIDAVIT HOME IMPROVEMENTCONTRACTORLAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstructions,alterations;renovation,repair;modernuatton,eanversion, improvement,.mmcn-4 demolition, or eonsuuction of an addition to any pre- owner, a�ed building wmaining at least one but not more than four dandling units or to sm==which am to such residence or building be done by tepmrcd Wmractors,with certain eaptions,along with other tequire—ment—L TYPe of Work: f4��Lq-;�V-- Est.Cost Q L - ( Address Of Work: ,/O 'Mer.Name: /Date of PermitAPP . I hereby certify that: n Registration is not required for the following reason(s): Work exduded by law ob under S1,000 Building not owrler�eaLpied Ownerpoilingownpumit Notice is hereby V. ilsaL: NTRACMRS OWN PULLING TMR OWN PERMIT OR DEALING W1TFiUNItEG ro ERS 1 FOR APPLICABLE HOME IIAPROV�i' WORK DO NO? HAVE .ACCESS ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c I42A SIGNED UNDER PENALTIES OF PERJURY I hereby apply far a permit as the agent of the owner. /— 1 n Date Contractor name Regismidon No. OR / ; Home Improvement Contractor Registration •' One Ashburton Place - Room 1301 Boston, Massachusetts 02108 .. Check numbers' •u . Effective Date Application for Registration as a " Home Improvement Contractor or Subcontractor _Expiwa on Date MGL Chapter 142A, CMR 780.6 'FOR OFFICE USE ONLY _ Date I. Applicant name I O3.A.8 ol Print the name of the individual or bruin applying for the registration 2. Applicant type: ❑ Individual ❑ DBA Partnership ❑Trust ❑ Private Corporation ❑ Public Corporation 3. or Federal ID NumberV.—,:hO 72 / k Number ofEmployees � 0�'n —C 4. Address 1 Y1 n c!2tc���� 1 t I(�.: ( ) r: - �•' Print street and Number(P.O.Box not acceptable) —Ci�ry Slate ZZp TelepCh�one Number 6. Title of individual responsible for Home Improvement Contracts 1 C;�ftn•QY�"— 7. Doc the applicant or responsible individual hold any other construction related state,city,town licenses or registrations? ❑ If yes,complete the table below. Use additional paper if necessary. Yes No Type license or registration Issued By License or • Expiration Name of License Holder registration number Date oY Gl- 06 LJ 8. List all partners, trustees, officers,directors and major owners(10;'0 or greater of ownership)of an applicant partnership or corporation below.Use additional paper if necessary. (See instructions on the back) Last First, Middle initial Titre in Applicant Business To Owner Address Ellis - 0.1kt n t r-- O �D/(;Qt,�e�yl ►1 n �, t4ar wi 97 Is the applicant claiming exemption from the registration fee? {See the instructions on the back) 1 ❑ If yes,include a copy of a current Cons"ctiori`Supervisor license or motor vehicle repair shop license or registration. --10:, Registration fee enclosed: S /�� J Guaranty Fund,fee•enclosed: S c� Pursuant to Massachusetts General Laws Chapter 62C section 49A. I certify under the penalties of perjury,that I, to My best knowiedi a and belle4 have filed all state tax'returiss and paid ail state taxes required under law. 0000w Signature of applicant or applicant's ntative _' " Title held with applicant A raise answer to any question in this application'com%Wutcs grounds for suspension or revocation of the applicants' rrZistntion. 91t DEPARTMENT OF -1JSLIC SAFETY ONE ASNEURTOi ,'PACE, RM 1301 BOSTON, ice{ 02108 1618 >r� r CONSTRUCTION SUPERVISOR LIC�iti Number: cxpireS- Restricted Ta= 1G .-� �-�"� . � " -.� —.._ WILLIAM L BERGEROiJ Det ih i)Uii;c)fo, fui,.' iyii un PO BOX 1578 � �� » � b' 3, and laminate license card. hiHRWICH, hiA 02643 r lo�ep top. for i eceipt and change, fro/f address notification. of �pf r. T .• a .... C 10 c�,m: _QAoor c� f i i �C-4C-e a0 x c r�pc �U.cI V.41vuv- cooki-skso r e c)