HomeMy WebLinkAbout0373 WINTER STREET 373
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¢ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application #
90 k 0:zq
><_{ F f ' Date Issued
Health Division ;�'s [ ; J;;>-
Conservation Division Application Fee
Planning Dept. _,. Permit Fee
J.
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Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address d Z Wf�.rO.
Village ��(�,��/�
Owner S�A��1'i ��, ���'1/ Address r,2 7 Al:irdOr
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Telephone �,/� /
Permit Request ,ldzgt�a a&-id'/
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type Zg��.,dp
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family a-/ 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
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 ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name ���4� �` ��� ,>� � ��/ Telephone Number L�W
Address yAg,`!3'J :wl;�- z License #�/ T F
Home Improvement Contractor# ✓c�� �1%
Worker's Compensation
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE L?1oZZLI
t
FOR OFFICIAL USE ONLY
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APPLICATION#
. DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
s OWNER i
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
E
PLUMBING: ROUGH FINAL
i
GAS: ROUGH FINAL
ti
FINAL BUILDING
t
t
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commortwealth of A-lassachusetts
r= Department of Indctstrial Ac'ciden.(s
l Office of.nvestigaiions
600 Washington Street -
t Boston, MA 02I11`'
`. � www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Coptractors/Elects-icians/Plun�be s
Applicant Information Please Print Legibly
Name (Business/Organization//Individual): �A 20 Irf) A f r-k-
Address: y Yf1rrl'rrll„ �^ � �
City/State/Zip: Phone # ' ro 7 7
Are you an employer'? Checic th appropriate box: Type of project (required):
I am a employer with � ❑
4. I am a general contractor and I 6. New construction
"�„�'employees(full and/of patt-tire).* have hired the sub-contractors _-___.._.._............. ."_..
2.um 1 a 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 auy capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required•.] � ,
5. ❑ We are a corporation and its 10.❑ Electrical repans or additions
3. I am a homeowner.doing all work - officers have exercised their I l.❑ Plumbing repairs or additions
myself_[No workers' comp. ` a right of exemption perMOL._ 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no'
employees. [No workers' 13.[].Ocher/, 6 a G 1�®n t QLC/ 1
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 indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
iContraetors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities havc
employees, tf.thc sub-contractors havc employees,they must provide their workers'comp.policy number,
ain an employer that is providing workers'-compensation insurance for ill" iemployees. Below is the policy and job site
inf'orination �Q-
Insurance �
Company Name:__- y 1ar-1 C 1—.- /
Policy# or Setf ins. Lic. #: (,�)�A D����� 0 1 xpiration Date: �D 3G
Job Site Address: ;) City/State/Zip:
Attach a cope of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e.'152 can lead to the imposition of criminal penalties of a
Fite up to $1.,500.00 and/or Ong-year imprisonment, as well as civil'penalties in the form of a STOP WORK ORDER and a fine
of up to $250.010 a day against the viol`atorc'Be advised that a.copy of this statement may be forwarded to' the Office of
ltavcstigations of the DIA for insurance,cdverage verification,
l do hereby certify rcr e pa' and penallies of perjury that the inforthatian provided above is trrre aril correct.
Signature:
Date:
Phone'#:
- �0 725 � l�l `�
Fe only. Do not write in this area., to be completed by city or:tot+,n official
wn: PermitlLit ense #
thority (circle one):
1. Board of Health 2. Building Department 3, Cih/Town Cleric 4, Electrical Inspector S. Plumbing Inspector
6. Otlier. ,
Phone
Contact Person:_
#:
_.�_.__-• . . . . . ,...,..., lCLi(Jlt •S. a: Gray''. ns V;lc e
Clientg: 4597 CCINSUL
ACpf?L},M CERTIFICATE OF-WkBILITY INSURANCE OArELMIWUoIY)Y,,
THIS CERTIFICATE IS ISSUED AS A MATT 7/01/2011
ER 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)i AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT:If the certifieake holder the t rrnli gnu conditio is an ADDITIONAL INSU SUBR
RED,the policy(ies)must he endars, .if OGATION IS WAIVED,sutJject lo`
ns of the policy, certain policies may require an endorsament.A statement oa this certificate does not collier rights to the
Cc11111cale holder Ill lieu of such u ndorseirient(S).
rl<CNUCI'R `
CONTACT
Boyars Gray Ina. -60. Darini;; * N-Eh MargaretYoung
...,:3.1 Rul.ilr. '13-t PHONE__.'.
jAN. ,) 5aa-rsa 4so2 --=_ F N 1--Dti�5a_z i oz
r (7 box IIial ADDREss: Youn9ma@ra9ersgray:eonl
ADDUCER _
Souttl D:nnis, NIA 02660-1601 cub-I'ONIER1oe
Ir;�Uneq NAIc_8_ '
CdpI : Cod Insulation Inc F" INSURERA.Peerless Insurance
455 Yarmouth Road '
INSURER s:Ohio Casualry Insurance Comp�lny -—.._
Hy,lnrlis, IVIA 02601 INSURER C:Atlantic Charterinsurance — _ - --
_.___....._.---:--._.
INsuHERU:Commerce Insurance Conipan.•y T m 34754
. INSUKEIt E: -• -
INSURER F:'
OvckAc'c;__ CERTIFICATE NUMBER:
r:' REVISION NUMBER:
ek rii=1'l'I-f.,'f-rl-(E(ULIi:IF:S()F IN'6URANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMED ADOVE FOR THE POLICY PtL1�1CD
+i•,L?L:�TC.!i IvUTWIT H 61'ANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR QTKER DOCUMENT WI rH RESPECT TO WHICH THIS
t:tri I IrICA11-MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL"PHE•PERMS.
e.l.LUSJON6 AND CONUI'I'IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
iASR `
1 IRfYPk C)Y INSUrtANC SR p POLICY NUMBER OLICY EFF POLICY EXP
A utNLKA-t.l-lurY rmjluulYY11 NwooIY(YY - LIWInZi _
— CBR8263063 04I0112011 04/01/201 tperloL��hr«Ncr: $1000,1000
XI an 1rn ru vcNllveL L(Ak31Ll Il' a LIANlAGFTO h^ENTEII —
,... _((: h,,,h���,c k - PF.CivuS,�It•a nreturence� �IUO,000 ___
__ —I' J<accuh s �reu rnh(v y ale pulsun) _ 65.000
` . _
—' + PffRSUNAI,(4 ADY INJUI\Y $1,000,000
GENkRALAGGREGA'fka,QUataaa
i _IYI .:K6t:Al t-_l M 1 AI'1°U E.a Pglj_--. a _�_. -----'-' -- -----
1 `G yr ooucrs �oNu,r«r Ac gi2,000 000
I � �.n�'•r I CFI.. LVI: i• __ -- ---- .
p IhUl OrriGWlt:LIABU.I rY • 11MMBCKVMK - 04/0112011 041011201 COMBINED S INGLE LIMIT
,Aulr, _ (Ea nmdvnl) �
1 OUO Q0L .. -
'I "VIVO AlrfO$ .. BODILY INJURY(Par N<r:wi,( S ,.
I4ti CImOUI.CU AUTOS _�.., BODILY JURY(PO,aa_Itivnl) $ '
x u�ci>nUr<,s PROPERTY DAMAGE - -- -
1 (Par sscadanl)
X hL I`I i lV4ltil'l l gll I U j k
ii uuneL : 4101/2011 041 ., x-1,000000X ocr UU01254514645 2 r L Las J AINls- ADEa.
-
AGCRecATt u11000 000 ---
I!culn:I,n(t:
h iiv I Il 11V , 10000 --
.,. -
wul n[I<s L umlYkNsgno" WCA00525902 . 06/30/2011 06/301201 X 4Y'C YTAT11- oT
C i At U krIYIUYkRS'LIAki1Ln"Y - _ _ .. _ FI
F'h)Yt(CIUWPARI NER/L:AECU rIv[YIN
•1YYIi,tt4A4Y.hllif_h EXl'LUL)[D? a NIA a ' • E L.CACH ACCIDENT_—. $•rjOU�U UO
Ifi4,IDul ury In Nil) _. .. _..._
i1 a , - -
no>:utw unuur _ � E.L.DISEASC--to L-MNl OYl't t,SQU,UUO
II ffiPI ION(`t OPFRA'I(HN5
F.L.(?ISFASI?-PL11,1(;YUA71i $500,000
I ,
uuacmYllUN ur ortHAl lUrvS I LUGAI7UNS!VEHLCLES(Attaeft ACOR010T Addpional Rornancs Sennauk,4 more space ii rcquiraa) -
Workers Corrlp Information Included Officers or,Proprietors f
(Set:Attached Dosc: iptions)
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Pa relent 3
SHOULD ANY OF THE ABOVE DESCRIBED}POLICIES BE CANCELLED BEFORE, T
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORLEU REPR155ENTATIVK
1(:nRD
(01989.2009 ACORD CORPOI ATION.All rights Leserved L
25(20U9109) 1 :of 2„ The ACORD name and logo a
#568575/M68179 re registered marks of ACORD '
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10 Park Plaza - Suite 5170
Boston,Massachuseits 02116
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Home lmprovement,C_AtractOr Registration
u; y Registrations 153567'
Type` Private Corporation
p y F # Expiration. 12/15/2012r Tr# 206433
CAPE COD INSULATION, INC f r i r nY
HENRY CASSIDY P33i " t+
455 YARMOUTH RD. ; w
F
HYANNIS, MA 02601
m �� s
Address and return card.Mark reason for change.
Address Renewal ' "Employment 'O Lost Card'.
DPS-CAI is 5OM-04/04-G101216 - �, •
Office
o mer Affairs us ne RAe�guI ion License or registration�'afid for is u:vidu!,u a ^!;
HOMROf1( f �t7R" iu°e�a before the expiration date. If found return to
Registration: 153567 Type: :.Office of Consumer Affairs and Business Regulation
Expiration: 1.2/15/2012 Private Corporation 10 Park Plaza-Suite 5170
' Boston, VIA 02116
OD INSULATION,I_'C tl
HENRY CASSIDY;
455 YARMOUTH RD art g i <r `R
HYANNIS,MA 0260r1' Undersecretary t alid ith t�si tur'e
y
now-- 'M tssachus tts- Depurtment'of Public S'afeo
Board of Building Regulations and Standui-ds
Construction Supervisor, License
License: eSr 100988
HENRY CASSIDY,
8 SHED ROW X
WEST YARNIOUTH,.MA-02673
�3.
t ati xpir on: 11/11/2013
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k' (pnun�ssi�iuer Tr#: 7620
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OWNER AUTHORIZATION FORM `
�- f� ��
1, ���t-)--r2 `1
(Owner's Name)
•
" owner of ft'prooefty located at
(Property Address)
C.
(Property Address)
hereby authorize Y �GVA
l
(Subcontra` or) . w
an authorized subcontractor for RISE Engineering,,to act on my behalf to obtain a building
permit and to perform work on my property. ;
O nature-
a l011 t► -
F:. r
Date
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