HomeMy WebLinkAbout0096 STRAIGHTWAY - - - - — -
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel 0 lQ t O Application # l ��
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board r
Historic - OKH _ Preservation / Hyannis
Project Street Address
Village
Owner Address
Telephone�ke ,Zz, ; 0/mil
Permit Request _X ZY
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District _ ' Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 *� Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes Jlo On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new 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: ❑ existing ❑ new size _ Other: ='
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
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Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use e
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APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name ,/A Ae 4., Telephone Number s 7 7,5 Z 6
Address 4�_6 v �l�y �, �� License # A
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
U
SIGNATURE DATE AZ
F,
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FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
i
ADDRESS VILLAGE
`F OWNER
DATE OF INSPECTION:
FOUNDATION
t FRAME
F
INSULATION
t
FIREPLACE
ELECTRICAL: ROUGH FINAL
F -
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
s
FINAL BUILDING
S
DATE CLOSED OUT
ASSOCIATION PLAN NO.
1
S
t
�� ,Th.eCornrnorn�%ealt/1 ofNlassac/luse(ls '.
Department of In dustri�71 Acclden.ts
Office of Investigations
I' -
- 600 Washington Street _
Boston] MA 021I1
w ww.rn ass.go N/dia
Workers' Compensation Insurance Affidavit: Build ers/ContzactorslEJecti-iciaris/Tlumbers
rtt ..111formatiorl � Please Print Lel,ibly
Ndrnt (Business/OrgariicatiorAndividual): rA Q (,a'-�`)
City/�tale/ ih: _ Phone #: SRO c�. 7�_- �- —
r1,r e you an employer?.Checic th appropriate box: Type of project (required):
I-M l ar.rn a cmlaloyer with
4. 1 am a* eneral contractor and I
—_ 6. [� New cons4liction
ctrtptoyees (full and/or part-tire).* have hired the sub contractors .
?..(_� 1 ani a sole proprietor-or partner- listed on the attached sheet. 7. ❑ Reriol n ng
ship and have no erployees These-sub-contractors have g,' E Demolition
wol-kui for rnrI in aii ca aci F employees and have workers'
g y„ p ry 9. [] Building addition
[No workcrs'_cornp. insurance comp. insurance.
'
rt quircd]
S. [� We area corporation and its 10.❑ El ectrical rcpaus or additions.
3.[_] t am a homeowner.doing all work officers have exercised their I IJ- Plumbing repairs or additions
myself. [No workars' coinp. right of exemption per MGL 12.E Roof repairs
insurance red.u re i t C. 152, §1(4), and we have no
q 13.[] Other(, 1rilYrnr u� Q
. employees. [No workets'
comp. insurance requued]
''Any applicant that cheeks box#1 must also fill out the section below showing their vrorkcrs'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContraetors that cheek this box must attached art additional sheet showing the name of the sub-contractors and state whcthcr or not those cntit'cs have
employees, If the sub-contractors have employees,they must provide their workers'comp.policy number,
`f am an c nmployer that is providing workers' compensation insurance for my employees. Below is the policy and job site.
infvrrnatiorti • 1
Insurance Cornpany Name:
Policy II or. Self-ins. Lic. Y, (.t) �(? �"Z.5 Expiration Dater
(.
Job Site address: �r � �P =Cit)1Statep*4 6��Gf
• -��� ��^ ^^ (showing the policy number and.exhiration date).
Attach a copy of the workers compensation policy declaration page ( g p y
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal Penalties of a
floc up to $1.,500.00 and/or,or, e-year imprisonment; as we11 as civil penalties;in the fonn of a STOP WORK ORDF,R and a fine
of up to $250,00 a day against the violatoi: Be advised that a copy of this statement rnay•b6 forwarded to the Office.of
lnvcstigatiorrs of the DIA for insurance coverage verification.
TI do hereby certify itr e pa acid penalties of perjury that the information provided above is true. and cot reef.
Sicrrature: -Date:
1'h01'1C Il: Q '7 ?5—, ---
- Officia[ use only. Do not-write irl this area, to be completed by city or town official
City or',Town: rr Permit/License#
issuing Authority (circle one):
1,Board of Health 2. Building Department 3, Cit3,/Town Clerk 4, Etectrical Inspector s. Plumbing Inspector
o. Other __ t
Contact Pei-son:_T_ Phone
s
10 Park Plaza Suite 5170
I"S� Boston, Massachusetts 02116
Home Improvement Copjractor Registration
J. w, Registration: 153567
-- ~- Type:. Private Corporation
Expiration: 12/15/2012 Tr# 206433
CAPE COD INSULATION, INC
HENRY CASSIDY
455 YARMOUTH RD. ------
HYAN N I S, MA 02601 Wit, r---= - -- -=----- --- --
Update Address and return card.Mark reason for change.
'U Address Renewal 0 L'mployment ❑ Lost Card
PS-CA1 0 50M-04/04-G101216
Office ' o�r�',�'mer At't'airs ��usf�nc ,Regut ition License or registration va;id for is d:%,idu! ;use on!;
HOF 6,, EN `�1" �1dpl a K1"dam before the expiration date. If found return to:
Registration.: 153567 Type: Office of Consumer Affairs and Business Regulation
Expiration: 10 Park Plaza-Suite 5170
p' 12/15/2012 Private Corporation.
Boston,MA 02116
OD INSULATION' INC.
HENRY CASSIDY '; t
455 YARMOUTH RD,• i �r—
HYANNIS,MA 02601 Undersecretary 4d ,
e
Nlassachusetts Department of"Public Sufch
Board of Building Regulations anil Stan(Iar'
,.Construction Supervisor�.L•icen-se
License: CS '100988^,
HENRY CASSIDY
8 SHED ROW N:
WEST YARMOUTH. MA 02673 n
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Expiration: 11/11/2013
('I r nm l iss iunr r' Tr#: 7620
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KouwVs. & Gray .LnS. ra(je: vv
A,3ORD,. CERTIFICATE OF LIABILITY INSUFZANCE
OAl'F(MIYIlUU/YY-Yy!
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 AFFORDED
BY A E POLICIES
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. "
ECI
IMPORTAN :If the certificate holder is an ADDITIONAL INSURED;the policy(ies)must be endol^sed.If SUBRQGATION IS WAIVED,subiact to`
Ihn tcnnu and conditions of the policy, certain policies may require an endorsemant.A statement on this certitieate does Ilat confer rights to the
Ccr'NIICdIe IIOIUCr'in IieU Ot such endorsernent(s). -
r11000CtR -
CONTACT
Pluqurs 5 Gruy Ina. ~So. Dennis NAME: Mdrgdrpt Young PHONE
508T60 460_2�~�
ADaREaa: Y un ma@ragersgray,com�
3 f Ruut�'I s 1 ac.No Ex1): r- --
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Suuu ROD➢CERt Uennls. NIA U266U-1GD'I + x 9USTOMEKID9
INSURER($)AFFORDING COVERAGL .
Ir;DUitkq ... .. NAIC 8
CuNe Cod Insulation Inc wsURERA.Peerless Insurance 18333
_ 455 Yarmouth Road
w$UREaa:Ohio Casualty Insurance Company
Hyannis, NIA 02601 INSURFRc:AtlanticCharter"nsurance-_
INSURERDt Commerce Insurance Company 34754
INSUKEK E: -
- ,INSURER F: --
CUVt!<Ac;c _ CERTIFICATE NUMBER;
fl-IA1 Ti-(E POLICIES OF INSUPANGk L15TED BELOW HAVE BEEN ISSUEp TD THE INSUREp NAtvIED DOv O OR THIC
H61 ANDING ANY REQUIREM POLICY r EftIi�D
CI ENT.TERM OR CON�ITIoN OF ANY GQNTRACT UR O'fHER OOGUn9ENT Wl"I FI RESPLC7--N IIHCAI' TO WHICH THIS
BRAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORQEQ BY'THE POLICIES DESCRIBEp HERkIIV IS SUBJECT TO AL
LAII-LOSION:,AND COivDITIONS OF SUCH POLICIES.LIMITS SHOVVN MAY L THE I'ERn l3.HAVE 6EEN REDUCED BY PAIp CLAIh9S.
iaSR
II( 7YPL OF INSUIWNck oucY EFF POLICY EXP
LIWS I O POLICY NUMBER tNVV00lY hVYUDDIYYYY Lilvil I'S'A vk NkFWL LIAFlILfr-Y
CBP8263063 0410112011 041011ZQ1 t PCII OCCUKFtL'NCL $1,000,000
X_ \Unu\Itn\ r�L vCNErv_�L I.IAt11l 111' -CTANIAGE'TIl RENTED_ --�
PRCNuS ICa nc�lfrenca) _ 5 t 000---
. h%�D C):I',(ryly Vllq I7VIDU11) 4.000
PkI.SON^l(t AUX uNJURY $1,000,000
GENERAL AGGRLGATC �21QQO,QQU
('_1 % ,.:h6r(.Al'E LM%f AI'1'Ul:a I•'ele r ---•-- - .—' - --
I 1 I�r•Ru. nl.00ucrs cbrvu>ror'AUG r2,000 0Q0_-_-- -
G nlnUrdndlLEUABu.f1Y 11MMBCKVMK 0410112011 04101)2012 COMBINED SINGLE LIMIT
.•N.AU I O (Ea a—nq
--- ^ 1-090 Q00
_ I: • - BODILY INJURY(Par p-r,,41 U'+t I�CO AUTO$ • - - )
A 7+•'14'UM.t:U AUTOS ' .. BODILY INJURY(Pa,axWgnl) $
I x PROPER1"YGAMAGE
(Par
r --_ .—_..__ _--___.__... .._-___._...•_ ._X N(_%r:-tly4f4L'II AUt U`i
I $
x
H ( unlelteLLA LIAt} TC
cl 000125g514645' 410112011 04101)201 6AcrI oc rur:FurNct- $1 UQO OOQ
1 LA SS LIAt3 —__1� �-
- .-._. .._•__.__ AIMti-NIADF. � � AGiiRhCAlt yi 000 000
n ;(ru r+Ninv 10QUQ ----____. _�— y__._...___--.:_.__:_._..._--
'NOFIKJ045 CONIPtNSAT10N _
AND CNIPLOYLRS'LIAJ3ILrl 1 -
WCA00525902 6/3012011 06130' X 4VC`'TATu- O'rfI
YIN - CI Y L�MIZ> °L'�,_.— —__._.__—
w ARI Nary txecu rive $.50U,UUU
I Off(:tfG p1F.MUCtn Frl'LUgGD? � � � I IV I. NIA E L:LA411 ACL'ICJEIVI -
iIh4nuutury Iu NH) ..._-
i I '�aax(rtw unuur `.` - E.L.DISf=ASP. EA LNIPLOY'I, $JQQ,QDD
r., r ._.---.._-__..— -----... ......_.I I%S(:r?INII(IN(;F(11�F Rr11'Il INS elnw - .
E.L.DISEASE-POL ICY LIMIT $500,000
uci�rerllUi:ur OrCIW I IUIJJ 1 LOCATION$(YEt1[CLES(At41Ct1 ACOR0101,AdtlpionaLRpmnncs Scncduk,P nwrr pacK i5 rrqu Prd) ____
Workars Corttp Information Included Officers or Proprietors
-
(Sot:Attached Uascriptiorls)
CERTIFICATE HOLDER CANCELLATION 10 Days for Norl-Pa ment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVEREDAN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR12e0 REPRESENTATIVE ,
1 (01988-2009 ACORO CORPORATION.All rights reGarved„
`;ACDRD,15(2009109). •1' Of 2 The ACORD name.and logo are registered marks of ACORD
A;668575/IV168179
MEY _. f
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OWNER AUTHORIZATION FORM t �'
(Owner's Name)
owner of the property located at
-(Property Address)
Ay
(Property Address)
hereby authorize C� p
(Subcon ctor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
07 s Signature
, 3 O
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Date