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HomeMy WebLinkAbout0110 STATICE LANE IIU &U-t'c, �J*M[>o TOWN OF BARNSTABLE 35856 Permit No. ......:......... BUILDING DEPARTMENT �40.00 I } TOWN OFFICE BUILDING Cash ............... 7 ML „• �0��' HYANNIS.MASS.02601 Bond ............... CERTIFICATE OF USE AND OCCUPANCY Issued to BAYBERRY PLACE REALTY TRUST Address Lot #17 110 Statice Lane, Hyannis USE GROUP FIRE GRADING OCCUPANCY LOAD 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. December 13 93 %` ,..� 1 19................. �. .................. uildinglnspector Yti r I TOWN OF BARNSTABLE 35356 4f TYf 10 ' • BUILDING DEPARTMENT Permit No. ........ . .,a,a I Cash y o.Q0 "19." TOWN OFFICE BUILDING . HYANNIS.MASS.02601 Bond CERTIFICATE OF USE AND OCCUPANCY Issued to BAYBERRY PLACE REALTY TRUST Address Lot #11 110 Statice Lane, Hyannis USE GROUP FIRE GRADING OCCUPANCY LOAD 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. December 13 93 uilding Inspector r- PAYABLE T0: TOWN OF BARNSTABLE BULL,.. COMMISS! NERS OFFICE Jacques Morin - DA I E._._.... ACO7. 2126 �o2 o� AA,i o. vo PO# APPROVED BY DATE "-" -s -- a ly — PEI<MIi NO. ��• - uv vVv APPLICANT .*lark' Wens el -ADDRESS Centerville' , ; ' _7 #009055 (NO.) (STREET)- - (CONTR'S LICENSEE ' �y _ NUMBER OF PE 'it O - � uild Dw� 111rq STORY Single Family DWellanMT DINELL ING UNITS- ` - (TYPE OF•.IMPROVEMENT) NO. [PROPOSED USE) - - �.` a17 110 Surat C� L�iiZt', ii ��alx�li!S t:`:,o�sTa c RC-1 .AT (LOCATION) "' 0 �T :# (NO.)' - (STREET) 3 s BETWEEN AND (CROSS STREET) (CROSS STREET) - LOT SUBDIVISION k, LOT BLOCK SIZE n. z 's BUILDING-IS TO BE FT. WIDE BY FT LONG BY FT IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION r r TO TYPE r k USE GROUP BASEMENT WALLS OR FOUNDATION - - m "ITYPE) REMARKS: SC-Wer t .3770 t a, Jacques Morin `(140.00) Jacques 300 "Bearse ►vav';, Hyannis AREA OR 1304 S • ft. PERMIT 80. 50 �VOLUME ESTIMATED COST . - __-. FEE ' (CUBIC/SOUARE FEET) - OWNER Ba_;laerr Place fealty Trs. `- c. BUILDING DEPT. i�� -'' /�l 1,,�.+•, ADDRESS 300 Bearse s Wcy., va,, !I ,,, JLs BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY -ANY,STREE.T ALLEY OR SIDEWALK OR ANY PART THEREOF EITHER TEMPO ARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY_NOT SPECIFICALLY PERMITTED 'UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR 'ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS..,THE ISSUANCE OF THIS,PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS:•< .,p _ MINIMUM OF THREE CALL - •APPROVED PLANS MUST.BE RETAINED ON JOB AND THIS WHERE 'APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR .,4 - PERMITS ARE REQUIRED FOR ALL'CONSTRUCTION WORK: - CARD KEPT POSTED UNTIL"FINAL INSPECTION HAS BEEN :ELECTRICAL, PLUMBING AND i. FOUNDATIONS OR FOOTINGS.' MADE. ',WHERE'aA CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. '2. PRIORr,TO COVERING STRUCTURAL QUIREO,SUCH 8UILDING'SHALL NOT BE'OCCUPIED`UNTIL ' -. s MEMBERS(REAOY TO LATH) FINAL INSPECTION HAS BEEN MADE.` 3.'FINAL.INSPECTION BEFORE.. - 'OCCUPANCY. POST THIS CARD -SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS ` PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS i l V1 I 2 2 2 HEATING INSPECTION APPROVALS ENGI RING PA M T IWIt,19 OTHER / ? SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE .TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION. S Y y � Doti 80� .zr 1 _ 3 CERTIFIED PLOT PLAN LOCATION ,9lzvs7i 'L .S7_19_'lG 46 SCALE . . ir. 30!.... DATE .M� 67 PLAN REFERENCE �> EDWAR ` I CERTIFY THAT THE EX/.STin/G FDI�Nj>,�70N SHOWN ON THIS PLAN IS LOCATED ON THE GROUND 0. 26100 AS SHOWN HEREON AND THAT IT CONFORMS TO THE o SETBACK REQUIREMENTS OF THE TOWN OF Fs C.g1fR� WHEN CONSTRUCTED. DATE ��T7T/aAv67,e REGISTERED LAND SURVEYOR +Ij`•dFl(`��r 5 F• ,kr f sir.. .. .. !I CHECK DEPARTMENT OF PUBLIC SAFETY ` COMMONWEALTH 11010 COMMONWEALTH AVE. )'91r ENCLOSE OR.MONEY.ORD(' OF BOSTON,MASS.02215 MASSACHUSETTS I FOR REQUIRED FEE, ;,' ,... '. LICENSE CONSTR. SUPEKVISOR MADE PAYABLE TO EXPIRATION DATE ! �41SSIONER OF PUBLIC SAFf 06/30/1 99� � {.�`..,'.'��� •' EFFEC;iIVIc LIC NL` "GOM :_.l.l O b/ 3 n L''9 O S pO NOT $�Nb CASH) RESTRICTIONS t NONE s J. MARK a (rENLEL i46 SECON0 AVE PC 8UX 82$ i INCRE'A` 14 NYANNISPO'RT MA 0267ZP1{EASE NOTE f �K, r� I luN f 5w0 wRy 1 1989� x �S E� 1y119 O"1,Lo37,E FEC�IVE fEB., 1• ��,ti FEE: u 5TIN0 OPR ONLY) I ce PHOTO 100.00 a2 V t1 w�i NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY } y {, a•• rY+it r' HEIGHT: STAMPED OR SIGNATUREbF THE COMMISSIONER i tiOT. DETACH' LICENSE„ i 1� IGNATUPE I G� i SIGNATURE OF NSEE T. i!y i n N THIS DOCUMENT MUST BE .A //���TTT /C //a COMMISSIONER CARRIED ON THE PERSON OF ./y '„�"`N".!�'^. fT 3 THE HOLDER WHEN EP'TI 4 RIGHT THUMB PRINT EO IN THIS OCCU „ OTHERS c P�� 200M•2.87.81429 L , f ` r , ... 49JbJJ(Q,J(4 (.• 4F Ik w "'y* Yt?`#�' �PCJ��� l 1• j kJ YtV HOME O�`�ll`r,�;(oc/(.r.leli {q yw 3 f IMPROVEME � x - Re9istratiun 10B.80NTRACTOR Ype P 18S � y E.rpiratfun IVAr f 6ORFORArIOh 0611519, Wentel hark fra�in9. Inc a �MINISTRAT eq j e 1 . oa 45 Whida Cpnter�il(e hA 02632 I 1 t 5!', � f aI f th 5' i" Assessor's'office(1 st Floor): Assessor's map and lot number o2 3 FJS d'"Q�of 1N a Tod♦� Board of Health(3rd floor): �.7 APPROVED Sewage Permit number �041$efvWil,n BASdST&BLL i Engineering Department(3rd floor): rasa House number j �� JS• °° i6}9' Definitive Plan Approved by Planning Board 1 y_ S ��r�Y d• APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only DOE i TOWN OF BA=RNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO (f s r/C� cJ��, TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location �� � n0 9 a �t% Proposed Use Zoning District kc l Fire District Name of Owner 2�ij/J /r//, �� Adr Name of Builder G'/��i�ll C��/y � Address Name of Architect B5'C Address Number of Rooms Foundation Exterior�L � � RoofingT �/� x Floors Interior /��i � 5 Heating Plumbing Fireplace \ /i Approximate Cost Area Diagram of Lot and Building with Dimensions �-� Fee .�J a OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License O®Clt © �� BAYBERRY PLACE REALTY TRS. No 35856 Permit For 11 Story Single Family Dwelling Location Lot #17 , 110 St:atice Lane Hyannis ' Owner Bayberry Place Realty Ti s . Type of Construction Frame Plot Lot ' Permit Granted, May 10 , g 93 Date of Inspection 19 n Date Completed 19 M3_ y l Town. of Barnstable *Permit# Expires 6 m onths from issue date Regulatory Services Fee , Thomas F.Ge_iler,Director X-PRESS PERMIT Building Division DEC ® 9 ZOO$ Tom Perry,CBO, Building Commissioner 200 Main Street,Hyaanis;MA 02601 TOWN OF BARNSTABLE www.town.barnstablem-mus Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAHT APPLICATION RESIDENTUL ONLY Not Valid without Red X-Press Imprint Map/parcelNumber Property Address I 1 10 �. .' Residential Value of Work 'o V Minimum fee of S25.00 for work.under$6000.00 Owner's Name&Address y2a�"w C, t-5 Contractor's Name J! ' Telephone Number�{� t rip �J . Heme Improvement Contract icense#(if applieable) q T Construction Supervisor's License#(if applicable) C.— -� [ orkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certific a must Won file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to-.. �l J A V ❑Re-roof(not stripping. Going over existing layers:of roof). ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value'. (maximum.44) *Where required: Issuance of this permit does not exempf compliance with other town department regulations,i.e.Historic,Conservation,etc. ***No Pro erty Owner must sign Property Owner Letter of Permission. A y of-the Home Improvement Contractors License is required. SIGNATUREc -- Q:Forms:expmtrg Revise061306 ` ' The Commonwealth of Massachusetts Department oflndustrialAecidents Offrce oflnvestcgations - 600 Washington Street Boston,MA 02111 www.mass.gov/dia ' Workers'Compensation Tnsnrftnce.Affidavi#: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/orgmdzationiindividual):. rli, ,to 00A. WO>0-' f` L Address: Ll -City/State/Zip: &tPhone.#:__Z7V Are �ou an employer? eck the appropriate bur. -Type of project(required):. 1.�] I am a employer with 4. [] I am a general contractor and I employees(full and/or part time).* have hired the gub-contractors 6 New construction. . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet: 7. ❑Remodeling ship and.have no employees These sub-contractors have g, 0 Demolition worldng for me in any capacity. employees and have workers' 9. Buil addition [No workers'comp,insurance comp.insurance.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions '3.ElI am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself: [No workers' corm. right of exemption per MGL 12❑Roof repairs insurance required.]t c. 152, §10),and we have no employees. [No workers' ..13.0 Other comp.insurance required.] , *Any applicant drat checim box#1 mmst also M out the section belowshowing thcir workers compensation policy information. t Homeowners who submit this affidavit indicating Ibey arc doing all work sad then hire outside contractors must submit anew affidavit indicating such, tCdntractors that check this box must attached Qan additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors Uve employees,they must providt;their workers'comp.policy number. ram art employer that is providing workers'compensation insurance for my employees: Below is.the policy and job site information. Insurance Company Name: Policy#>'or Self-ins.Lic.#:_ C, p (�C Expiration Date: Job Site Address:1,10 T VA►,�,D City/State/Zip•, A r �, o Attach a copy of the workers' compensation policy declaration page(showing the policy n and expiration date �P ).. Failure-to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cnn final penalties of a fine tip to$1,500.00 and/drone-year imprisamnent;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of b for insurt;nce coverage verification. 16 her y ce ' n the pains• penalties ofperjury that the information provided above,is true and correct: Sitmaiure: Date: Phone# -- FOther only. Do not write in this area,'fo be completed by city or town of`u cal n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clark 4.Electrical Inspector 5.Plumbing Inspector son: Phone#• �o61HE� y Town of Barnstable. ' y � Regulatory Services Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner 200 Main Street Hyannis,MA 02601 "w.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508=790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject • J property herebyauthorize j:C . f to act on my behalf, in all matters relative to wolaLowdb �b�fldi�ngzpper�mltplication for.. . c5 ICE �: - ,� • (Address of Job) J�tze.of�Clvmer� ate CS x �� Pent Name Q:FORMS:OWNERPERMISSION N-18-2008 15: 10 From:SANDPIPER INSURANCE 5087903560 To:15087906230 P.1/2 DATE 1 _A_0010- . CERTIFICATE OF LIABILITY INSURANCE 01M/°°""e soo8 rao°UODR '(508) 790-1919 THIS CERTIFICATE IS. ISSUED AS A MATTER OF INFORMATION Sandpiper Inmuxennao Aganay, Ina. HOLDER AND COVERT FICATEERS NO RIGHTS DOES NOT AMEND EXTEND OR 12 Enterprise Road � (lip':;'' (I"rAl:trFt+TkIE t:,SVERAGE AFFORDED BY THE POLICIkS BELOW, Hyannis MA 02601- EKS4FLQ0GNQ COVERAGE NAIC M INSURED INSURF-RA Western World Xnsuranoe Tobey W. Leary Fine Woodworking, Inc. INeuRCRn,A,I.rb. 46 Laftanae Avenue INRURrR C. IN' ,Hyannis MA 02601- INGURF .. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THC 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 OF-SORI9E1D HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ���� TTI�[NOR ADD'L TYPO OP INSURANCE POLICY NUMBER PGATI!jmm pmq PpATo MMIPplYYI LIMITS A GeNCRALLIABILITY NPP1144072 12/14/2007 12/14/2008 XAGH2�gyfflgNpe 6 1,000,000 X COMMERCIAL GeNE'RAL LIABILITYPRI'A G TO o u n°e 6 100,000 CLAIMS MAD, I;K_ OCCUR / / / / MED EXP(Arvy one are0( 6 5,000 PfflOONALA AQVIN I JURY 6 1,000,000 GLNrRAI.AGORFGA F 6 2,000,000 GCNT AGGREGATE LIMIIY APPLIES PER TS-COMP/ 6 2,000,000 POLICY P.L"7 LAC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO lee ooaldonq ALL OWNED AUTOS / / / / BODILY INJURY 80HEOULEO AUTOS (F°i Person) 6 HIRED AUTOSIiIODII.Y INJURY NON-OWNED AUTOS (Per eo°Idenl) $ PROPERTY DAMAGE (Per e04Idam) GARAGE LIABILITY l. AUTO ONLY-EA ACCIDENT 6 ANY AUTO . / / / / OTHCR'rHAN EA ACC 6 AUTO ONLY AGO 6 EXCE991UM5RCLLA LIABILITY / / / / RACH OCCURRPNCE6 OCCUR CLAIMS MADE AO REOATE 6 6 DEDUCTIBLE _RqTgNT10N 6 H WORKERS COMPENSATION AND WC 9716675 01/01/2008 01/01/2009 g )( 9MPLOVERB'LIABILITY ANY PROPRII°TORJPARTNER/EXeOUTIVe E.L.EACH ACCIDENT 6 600,000 OFFICERIMEMPER EXCLUDED? / / / / E L DIef'_A8F-eA EMPLOYEE Z 500,000 If yae,deeeribe wider gPICIAI ROVIBIONS below L.DIBEA8P_-POLICY LIMIT 6 500,000 OTHER DBSCRIP710N Oil OPERA'nON81LOCATIONONCHICLCSIPXCLUSIONS ADDED BY UNDOR86MgNTIBPDCIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( ) — (508) 790-6250 8NOU40 ANY OF THE ABOVE DESCRIBED POLICIES 00 CANCSL4E13 BEFORE THB EXPIRATION DATC THCRCOP, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE H0409R NAMED TO THE LOFT,DU'f TOWN 'OF BARNSTABLE PAI4URS TO 00 80 SHALL IMP08E1 NO OBLIGATION OR LIABILITY OF ANY KIND UPON THS t INBUR1119,1TS AGIEIN OR EPRfI6EINY rAUTHORITED RBPRtl ATIVS - HxANNrB MA 02601,- ACORD 26(2001108) ORD CORPORATION 1088 �,,,INS026 poe).DS ELECTRONIC LABLR FORMS,INC -(000)327-0b46 Pepo 1 oI 2 l �ilJJill11UJCU1- VC'1/iU Iilivell VI rumor: oiu CL� 'Board of Building Regulations and Sund,a.rds I Construction Supervisor License License: CS 84605 Restricted to: 00 TOBY W LEARY 46 LAFRANCE AVE HYANNIS, MA 02601 �--�- Expiration: 7/18/2010 Commissi-mer Tr#: 717 r i , n a eu s;nogl!m p eA aoN ao;eatslulwpd. 609Z0 VW'SINNVAH , _ ...: ...... , �� 3AV 3ONVL13V1 9b f v� A8V31 A001 'ONI 'ONINNON140O.M.3NId AUV31 A901 u013eJodJ00 a>enu� ad�(1 solZO'ew°uolsog l0£I wR aaeld uo;anggsV aup 0 #al OlOZ/L1i8 'uolleJidx3 _ sp.iepups pue suoi;eln$aR sulppng jo paeog Z46£17L 'ual ej;sl6aa ; :o;ujnlaj puno3lI -alep uoiaealdxa aW aao}aq N013V211NOO 1N3W3A08dW1�3,pWOH Aluo asn lnPlAlpul ao3 plleA u01;ea;s121a.1 ao asuaalZ z �! � a o ui n �,,� e u a��ns/dMan ar s g g One Ashburton Place Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration _ = Registration: 143942 Type: Private Corporation Expiration: 8/17/2010 Tr# 0 TOBY LEARY FINE WOODWORKING; INC_..,_ TOBY LEARY 46 LAFRANCE AVE ' HYANNIS, MA 02601 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card Town of Barnstable *Permit0��03 �� Expires 6 mo ss from issue date Regulatory Services Fee 5 Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PEPMT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address b sly V ` a ❑Residential Value of Work l Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name i 'S'1 lhY� °-P 63�1 elephone Number 'l_IH- S)S(n—S 7 Home Improvement Contractor iceme#(if applicable) tA j 0�L1 Construction Supervisor's License#(if applicable) C. �n0XmPRESS PERAMT ❑Workman's Compensation Insurance J U L — $ 2008 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABL ❑ I am the Homeowner XI have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# ,n d��T� � Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) %Re-roof(stripping old.shingles) All construction debris will be taken to 1 N)`tom ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop,rty Owner must sign Property Owner Letter of Permission. A c y of the Horn Improvement Contractors License is required. SIGNATURE: QTon, :expmtrg Revise061306 The Commonwealth ofMassachusetts Department of Industrial Accidents ` Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers'Compensation Insurance.Affidavit:Builders/Contractors/Blectricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organizationandividual):• Address: q(; L %J r@.A tyG P A ' City/State/Zip: B 1!Y Phone.#: 7 7 y 2-3(o 5-5-7 Are you an employer? ck the appropriate box. Type of project(required) 1. I"am a employer with 4. ❑ I am a general contractor and I 6 El New construction . employees(full and/or part-time).'" have hired the cub-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 g, ❑Demolition working for me in any capacity. employees and have workers' c 9. ❑Building addition [No workers'comp.insurance amp•insurance. 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 rnyselE [No workers' comp. right of exemption per MGL 12❑Roof repairs inomce required.]t c. 152, §1(4),and we have no employees. [No workers' ..13.❑Other comp.insurance required] 'Any applicant that cheeks box R narst also fin out the section belowshowiag theirworkers'compensation policy informatim t homeowners who submit this affidavit indicating they are doing aU work and tben hire outside contactors must subuIIt anew affidavit indicating such. :4Contactots that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have en:Vloyees. If the sub-contractors Bove employees,they must provide flair workits'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and f ob sife information. Insurance Company Name; d 1 T v . -0 Policy#or Self--ins.Lic.#: � (�7;2� (p'7 j�(� Expiration Date: Q Q Job Site Address: I ^� City/State 4: yy �� Attach a copy of the workers' compensation policy declarati page(showing the policy=4 •and erpfratian date),.. Failure, criminal secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of crinal penalties of a• fine iip to$1,500.00 and/or one-year 1mpnsoxnne4 as well as civil penaltirs in the fora 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 InvestiLrations ofl4eOIA fox insurance coveraize verification I do hereb ce the palns•and penalties ofperjuo,that the information provided above,is true and correct: Siarature Phone CD — Official use only. Do not write in this area,•tb a completed by city or town af`icial City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• h, • �ofYHE� ti Town of Barnstable. y � �. : Regulatory Services ass $ Thomas F.Geiler,Director �ATfD MA'S JAN Building Division Tom Perry, Building Commissioner 200 Main Street Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508=790-6230 Property Owner Must Complete. and Sign This Section If using A Builder as Owner of the subject property herebyauthorize on y'behalf, in all matters relative to work authorized by this biu7dingpermit application for: ((Address of Job) r I ?L Signature of Owner Date UI VA OJ Print Name QTORM&OWNERPERMISSION'' BOARD OF BUILDING REGULATIONS ZZ License: CONSTRUCTION SUPERVISOR Number: CS 084605 • ' . wme5 mEtTf1�2d08 Tr,no: 792.0 j _ Resti�cted-= TOBY W LEARY 46 LAFRANCE AVE C HYANNIS, MA 02601 --- Commissioner ,, a N-18-2008 15: 10 From:SANDPIPER INSURANCE 5087903560 To:15087906230 P. 1/2 _A_GO-R- 0�, ].8 P. CERTIFICATE OF LIABILITY-INSURANCE DATE/18/DDI2009 YYYYI • 0E vaODUCBR (508) 790-1919 THIS CERTIFICATE 19 ISSUED AS.A MATTLR OF INFORMATION Sandier Inmuranao an Ino. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P A5 ay, HOLDER.,.T-O,P_ ERTIFICATE DOES NOT AMEND EXTEND OR 12 Enterprise Road I r,I a i` {'ri41 ER HSjfy0 RAGE AFFORDED BY THE POLICIhB BELOW, H annim MA 02603.- t,QIEE(§417FOaPIIIYG COVERAGE NAIC 0 INSUROD U INSURL'RA Western World Insuranae Tobey W. Leary Fine Woodworking, Ina. INBuarR a A.I.G. 46 La France Avenue INRURER C. Ei annis MA 02601- INGURF .. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTNTHSTANDINO ANY RGQUIRGMGNT,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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. T1 INOR ADD'L TYPE OP INeuRANCQ POLICY NUMBER nATt YMMIDG/YYL PA MM,DIAWN LIMITS A GENERAL LIABILITY NPP1144072 12/14/2007 72/14/2008 VO a N 6 1,000,000 X COMMERCIAL GENERAL LIABILITY pAMA N o u enae 9 100,000 CLAIM6 MADE OCCUR / / / / PMNE.�'D rXP(Arq ane erson 15 S 1000 EFROONAL a AQV INJURY 6 3,000,000 GENERAL AGGRRGA P. 4 2,000,000 GC•NTACGREGATELIMOoI'r APPLIES PER 'r9-COMP/ 3 - 2,000,000. POLICY J.L"T LoC AUTOMOD14e 41ABILI7Y / / �. / COMBINED 6ING71.0 LIMIT ANY AUTO IEa ocaldonl) 6 ALL OMPD AUTOS / / "` /' /. - BODILY INJURY SCHEDULED AUTOS (Par'peraan) HIRED AUTOSti10DILY INJURY (Per eccldem) NON•OWNCD AUTOS j PROPERTY DAMAGE (Par accident) GARAGE LIAPILITY AUTO ONLY-CA ACCIDENT 6 ANVAUTO / / / / OTHrR'rHAN NAACO S AUTO ONLY, A00 6 FXCCSBIUMBRHLLA LIABILITY / / / / FACH OCCURMPNOFe OCCUR CLAIMS MADE AQ REGATE 6 6 OEWOTIBLE RPTeNTION III _ - WORKERSCOMPENSATIONAND CPC 6716675 01/01/20 6 61/01/2009 s X EMPLOYERS'LIABILITY ANY PROPRIrTOWPARTNEIVEXECUTIVE L.EACHACCIDrNT 8 600,000 OFFICrRIMEMDOR EXCLUDED? / / I?L DISr'_ASE-EA EMPLOYrr S 500,066 If yes,deecrlhe user SPf6W ROVISION9eelow F.L.DISFASP_-POLICY LIMIT 6 500,000 OTHER DESCRIPTION OP OPERA'nONS/LOCATIONBNCHICLCBIPXCLUSIONe A00613 BY 9NOORSEMENriSPOCIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( ) — .,(508) 790-6230 AHOU40 ANY OP,THE ABOVE 068CRIDED POLICICB BE CANCELI.W BEFORE THB EXPIRATION .DATE THERCOP, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE H040ER NAMED TO THU LBPT,'DUY TOWN OF'AARNSTABL1L PAI4URE TO 00 SO SHALL IMPOSO NO OBLIGATION OR LIABILITY OP ANY KIND UPON THB INGURBR,IT13 ACIIINP OR 13PRt3BRNYTWOS AUTHORIZED RBPQE ATI118 HXANNIS MA '02601- ACORD 26(20010) ORD CORPORATION 1088 ,,,;INS026 ploo.OS ELECTRONIC LAGER FORMS,INC -(000)829-0548 Pepe]al 2 -� 0,11 1111, L,2� a Board of Building Regulations-and Standards One Ashburton Place Room 1301 Boston. Mass,`ahusetts 02108 Home Improvement nractor Registration ^, Registration: 143942 Type: Private Corporation Expiration: 8/17/2008 TOBY LEARY FINE WOODWOR � 03; t TOBY LEARY '�ti 46 LAFRANCE AVE HYANNIS MA 02601 <" ;'r�=` '�• ' Update Address and return card.Mark reason for change., Address Renewal -' Employment DPS•CAt t3 50M-05/08•PC8490 ' � � �.._� (.._] Lost Card Licen a or registration valid for individul use only befor the expiration date. If found return to: Boar of Building Regulations and Standards One Ashb 4 to Place Rm 1301 Bos/ton, 108 • 1 I t valid withou nat e 01/02/2002 00:31 918028624926 PAGE 01 Town of Barnstable *Permit# ,97 TLrplrer B NtONhaJrom issue date a _ Regulatory Services Fee ©D ye p Thomas F.Geller,Director Building Division Peter F.D1Matteo, Buiading Commissioner' zoo Main street, I•Iy�amtis,MA l JAN �� /�° OfPice: 508�862�03$ �. .9 ?OD Fax: 508.790-6230 �WN op Z EXPRESS PERMIT AFF TION - RESIDENTIAL ONLY eA&J/STq�C Not fValid without Red X 1°ress Imprint Map/parcel Number ° .•� / 0© ( `/ N L Property Address / o f�q l/!C e k Q li- I y It n a<./ / /W f e 0 2,4 O/y Residential Value of work 49 OO' 00 Owner's Name&Address / f v!! �C M/� 4�p 4 JL ll 64AI //0 J'fal`ce kane, Yc� �nf�f � � z�a / 771j 5ISd Contractor's Name Je �'� C ° `/ AJ Telephone Number f G0 'Yzd/-Sy Horne Improvement Contractor Licerm#(if applicable) 14 /6 7 3 7 Consttuetion Supervisor's License#(if applicable) 7 Z Z y Nt A PWorkmai*'s Compensation Imuranee Check Ono: ❑ 1 am a sole proprietor �❑ =the Homeowner L1ll I have Worker's Compensation Insurance Insurance Company Name �#C ;rXj V-e1 Pto'I zNdll,�A A/C6 f oink a worlanan's Comp,Policy# 7-P -7ff B .' 7/9 X 3 70 r ,Sr- o Permit Request(check box) [] Re-roof(stripping old shingles) Re-roof{aaeatripPiiig• Going over existing layers of roof) ' Ro-side Replacement Windows, V-Value'. �0 (maximum.44) bN J i'd-e (specify) d' e. d e. 4►'P , 36 When n9atnd; 115"M of this permit dm not exaapt compliance wii%other eaves d z eparaDe regufa8ons,t-e.Historic,Conservation,etc. y�-�ah, � f'tILI - y« i•.//te f�o,nhanE�a�lf i 1 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 014224 "Expires:04/08/2002� Tr.no: 22389 restricted To: 00 — JOHN C BOWDEN 28 LADYSLIPPER LN LNG MARSTONS MILLS, MA 02648 Administrator