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HomeMy WebLinkAbout0089 SUOMI ROAD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r 1 A licatio MapQ�S Parcel pp Health Division Date Issued Conservation Division Application Fee 1c Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 5 / SP C> i ?)bc- 4-uahru5 M . D'Z(ea Village ►yS-J7L6t Owner a'I. ?o 1 - 6P(A) Address P7 &n117,; Xc� Telephone C �. Permit Request �5 v. �.,t�5 I c i'o�'Aa. gw "t Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new 'Zoning District Flood Plain Groundwater Overlay Project Valuation 1795_-I% 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 hway: [ Yes -4 No Ci Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ATI Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including bathe): existing new First Floor Room Counter 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 ❑ Commercial ❑Yes ❑ No If yes, site plan review # - - Current Use-- — --- - - - Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) c '� �3T6/ Name �.�� Telephone Number Address ' W3 License # Cy' ' 0 7Y(?%-5 fife mp�z C)Z"v Home Improvement Contractor# 7 � Worker's Compensation # t�GUDt��l� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO . SIGNATURE - DATE r FOR OFFICIAL USE ONLY I� APPLICATION# DATE ISSUED MAP/PARCEL NO. 9 T • ADDRESS VILLAGE t OWNER DATE OF INSPECTION: E _._-FOUNDATION,; k FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL - FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r The C©mmonwealrh of Massachusens Print Form: � Department of Industrial Accidents ' Office of Investigation 1 Congress Stree4 Suite 100 Boston,MA 02114 2017 www.mass-aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �-- Appliiant Intformation PIease Print Le 'blv Name{susinesstorDanumhon/m.vidEW): tJ4t 1 4, Address: J3 - City/State/Zip: __Tj_U 1b Ak a 2 gigb Phone#: Are/6 an employer?Ch k the appropriate box: Type of project(required): 1. I a n a employer with -e > 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the suib-contractors 6. Q New construction 2.❑ I-abi 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' . 9. Building addition [No workers'comp.insurance comp.insurance.# .= . required:] 5.F1 We area corporation and its 10-Elgectrical repairs or additions 3.El I-am a homeowner doing all work officers have exercised their. 11.0 Plumbing repairs or additions right of exemption per MGL myself.[No workers- comp. 12.E]. frepairs insurance iequued_]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 iodic ating.they are doing all work and then hive outside contractors must submit.a new affidavit indicating such. �Contractom that check thus box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. ff the sub-contractors have employees,they must provide their workers'camp_policy number: I am an employer that is providing workers'compensation insurance for my employee, Below is the policy and job site information. /J Insurance-Company Name. fTT16"n77c_ Policy#or Self-ins:Lic.# W CA DD 272(Ob Expiration Date: DV j Job Site Address: ` St c.c mli.' . � _ City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy member and expiration date). Failure to:_secute coverage as required tinder 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 da hereby certify under the pains and malties ofpedury that the in ormatron provided above is true and correct St attire: Phone#: ©ffrcial use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# Issucin�.Autltocity(ctgcle one - 1.Board of Healtif 2 Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 5.Other Tnnto�t Dowenn. bY.---a. Massachusetts-Department of Public Safety. Board of Building Regulations'and Standards Construction Supe'cisor , License:'CS-078815 JOSH EMON_D - POBOX 63.3 r_ - Truro MA 0266 Ali, Expiration Commissioner 03/25/2015 License or registradon valid for individul use only Offi ce of Consumer Affairs&Business Regulation CONTRAt:TOR _ before the expiration date: Kfound return to: 'on: ; 74235 Type:. Office of Consumer Affairs and Business Regulatio LLC 10 Park Plaza-Suite 5170 �ra(i°n: 0 Boston,MA 02116 NG,Lt G BUILDING PERFO DTI JOSH EDMOND s :sue 8 KINNIKINNICK RD 7RUR0,MA ti'L666 '~ Underset retary of valid witboet signature OWNER AUTHORIZATION FORM Lc &Joi Owne s Name) owner of the property located at 4F�q O sVoa3 1( (Property Address) 01,JGIVE, (Property Address) 1 hereby authorize (Subcontractor) an authorized subcontractor for RISE Engin bring, to act on my behalf to obtain a building permit and to perform work on my property. �Owne s ure Date 06/18/2014 22:59 8787778415 PAGE 03 CERTIFICATE OF LIABILITY INSURANCE 6/19/2014 THIS CERTIFICA170 IS 188NED At A MATTER OF INFORMATION ONLY AND COMERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOE8 NOT AFFIRMATIVELY OR NEOATIVELV` AMEND, EXTEND OR ALTER THE COVERAOE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSW UTE A CONTRACT BETWEEN THE BSUINO INSURERS). AUTHOR= REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER, IMPORTANT- N the cerWleeta holder to an ADDITIONAL INSURED.the 0agebl a)IlMtat be wARmed. I$U8ROOAT1ON 18 WAIVED,SUbjen W the terms and Conditions oN Me a*".eateln p08Nes ma nqubo an emkwaomm* A deb mat an 1hte cwWleate doss net confer ftbW Is Ms certificate holder In Saw of such PRODUCER WAGI COUNTY INSVRAUTC! ACMCY INC MMZU (976)774-2463 , (978)777-8415 123 Sylvan St ADORES Danvers, Nh 01923 1061JU .)An040100 WAMSE "AM INSURER A:Commerce Ins. Co. INURED Suilding Performance Contractin Id.0 RERe:r�aaa Undemmiters dba Nauset Insulation IISUMRC:A antic Charter P.O. Box 633 NaURER D:RB Jones Truro, Na 02666 ,Neu E: INSURER 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 19 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMIT$SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. MN TYPE OF INSURANCE POLICY NUMBER LtlY1R1 GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 7C COMMERCIAL WWRft LU/q.rrY I M TV Ea E.; s 50 000 E 0 occuR MED EXP IAmom P•m) 1 1,000 B MV0020002000041 5/1/14 5/1/15 gRSONALsADVINJunY s 1,000 000 QMRAL AGGREGATE. 1 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-CGMPIOP A00 1 1,000,000 POLICY PRO. LOC a AUTOMOBILE LIABILITY G,GURIDIP(m 1,000,000 ANYAVTO BMILY INJURY(Per person) a A A�uT09WNED ETA ED BGDDGR 2/2/14 /2/15 BODRrmuuRY(Per. 1) $ HIRED AUTOS AUTON ED S FROPERTY a x U'NBREL A Lwe OCCUR EACH occuRRENCE s 2,000,000 D EXCESS Lw cuals�tADE CUBW3904112 5/1/14 5/1/15 AGGREGATE a 2,000,000 DED immmms WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN IR ANY C 00114 sA"mUmv MIA ILL.EACNAMIOENr s 500,000 yy 109 ilMO939900 11/23/13 11/23/14 ILL DISEASE-EAEMPLOYE s 500,000 ESCRIPTION OF OPERATIONS 1w. EL DISEASE-POLICY LIMIT s 300,000 DESCRfPTION OF OPERATIONS I LOCATIONS I VEHICLES OggM ACORD 101.AGMW W Ranaft echemne.H mae ape=is n quRee) 1 CERTIFICATE HOLDER CANCELLATION Town OP Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable, Na a THE EXPIRATION DATF. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TH 1.=PROVISIONS_ AU►HORUD MMFS /ljee� m 1 OW2010 ACID NfORATION. AA dghu msma d. ACORD28(2010(05) The ACORD name are logo are registered marks of ACORD i