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Home My WebLink About0011 BUCKSKIN PATH r ,�. Mkt: �`' � � �.x. .a � . `�'� , �"s.: f, ,t.. H � ' � _ � 3 . y �. �. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma . Parcel CJ " licatio�`#'`'` � P w Health Division R) ^. ''Dateiss ed� S K: Conservation Division Application Fee Planning Dept. yTt-= Permit'Fee�°" Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis ` Project Street Address ' v�.c.�tJs�r.� P 4-A C yr& AAA Q L 6S,_)-- Village Owner lVtVic �e,� I V%_ L^ Address I � �;�c.�, 5� ;� R-A Telephone Permit Request e,,,4k,� -L, , 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 1�ry iS Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Y Fctull ❑ 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: L4 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: O/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 ` 1�d /� ''^S kA I-A /4Telephone Number Address r C)- 60k /0S— License #_ C SSL4 /® �71 See L t, 4-, A- Gd771 Home Improvement Contractor# 16 �Ca Email 1)e C a.S;41 Q. /`t o''` Worker's Compensation # 06 -Y7 05-P6 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# ,F DATE ISSUED a MAP/PARCEL NO. ADDRESS VILLAGE ` OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED OUT ' r' ASSOCIATION PLAN NO. The.Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Print Legibly Name(Business/Organization/Individual): ��,.0 r, j— ,�v$ T� Address: City/State/Zip: St e.�,u 11 Phone �C-61"J Are you an employer?Check the appropriate box: Type of project(required): 1.[9 I am a employer with / V 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-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. ❑Demolition workingfor me in an capacity. employees and have workers' Y aP tS'- 9. ❑Building addition [No workers'comp. insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their l 1. Plumbing repairs or additions 3.❑�I am a homeowner doing all work � ❑ g P myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs . insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.90ther �t�7l�vll l�.�Lta comp.insurance required_] *Amy applicant that checks box#1 must algo fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensafion insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,''� In(U w Policy#or Self-ins.Lic.#:` J.�J —W1 U P6 1 Expiration Date: <J', Job Site Address: 1 IJ c W Sa N 1 G�` 1 City/State/Zip: CP71/V 1 I��/ Attach a copy 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 c. 152 can lead to the imposition of criminalpmalties 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 msnrance coverage verification I do hereby certi under a pains and penalties of perjury that the information provided above is true and correct Si ature: Date: O Phone#: d Of use only..Do not write in this area,to be completed by city or town nfficiaC City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instruction Massachusetts General Laws chapter 152 requires all*employers to provide workers'compensation for their employees. Pursuant to this statute,an eWloyee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in'a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual;partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments,and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such,dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance.or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to.obtain a workers' compensation policy,please call.the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line.' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill.out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year..Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions.- please do not hesitate to give us a call. f The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street. Boston,MA 02111 Td,#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749. www.ra=.gav/dia R ghtfax N1-1 8/8/2013 5 : 56: 12 AM PAGE 2/002 Fax Server , CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) jgnraghrIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT OLDER. TngmaHIS 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),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: VIVEIROS INS AGCY INC PHONE FAX 140 PLYMOUTH AVE (A/C,No,Ezt): (AIC,No): E-MAIL FALL RIVER,MA 02723 ADDRESS: 759RC INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY RETROFIT INSULATION CORP INSURER B: INSURER C: INSURER D: PO BOX 105 INSURER E: SEEKONK,MA 02771 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS 15 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'rHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR - ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OFINSURANCE L R POLICY NUMBER (MKDDIYYYY) (MMJDDIYYYY) LIMITS GENERALLIABILITY ACH OCCURRENCE $ COMMERCIAL,GENERAL LIABILITY AMAGE TO RENTED $ CLAIMS:MADE OCCUR. REMISES(Ea occurrence) VIED EXP(Arty one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE $ POLICY =PROJECT LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS .. (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE_. $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A.. WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-4705P615-13 08/022013 OB/07n014 LIMITS ANY OFFCERI?E MBERiEXCLUDED? CurNE � NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 9 yes,describe under DESCRIPTION OF OPERATIONS below E.LDISEASE-POLICY LIMIT $ 1,000.000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSUREDS MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY,THE INSUREDS MA EMPLOYEES IN STATES OTHER THAN MA. NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN STATES OTHER' THAN MA IF THE INSURED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA. CERTIFICATE HOLDER . CANCELLATION .,THIELSOH.ENGINEERING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED L95 FRANCIS AVE BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELN~EBED IN ACCORDANCE WITH THE POLICY PROV ^ r' AUTHORIZED REPRESENTATIVE CRANSTON,RI 02910 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPO rights"eserved. L.i. t � Y 1 '[ 0//, 5�,�.'; '`t,'t1i..m'�..8` C...�'�{.rC Li<l' i 1.-r.. •. r[ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 51.70 �.._..... Boston, Massachusett� 02116 Home Improvement Contractor. Registration Registration: 160461 Type: Private Corporation Expiration: 7/29/2014 Tr# 227004 ' f RETROFIT INSULATION, INC. JQSEPH REILLY _ P.O. SOX 105 -.._._.... .......__-- ......... SEEKONK, MA 02771 Update Address and return card. Mark reason for change. Address _' Renewal Employment Lost Card S C A 1 es <?i;FF,rY 11 Aff irdl&Bu ih. /deg ratio. <tl; License or registration valid for individul use only Office of Consumer Affairs & Business Reputation }` TOME IMPROVEMENT CONTRACTOR before the expiration date. 1f found return to: registration: 160461 Type: Office of Consumer Affairs and Business Regulation g J 10 Park Plaza - Suite 5170 a F .Expiration: 7/29/2014 Private Corporation Boston,MA 02116 _ RETROFIT INSULATION, INC... JOSEPH REILLY 644 RODMAN ST _ ___....._ FALLRIVER, MA 02721 'Undersecretary Not d without signature , - Mas`�c�u Boa,d s2` Of Bgi u fs _JFrt � urti,;r1 9blationStan plc- <ic�nsP SaJ�i.r`.icor S,. s and Sianga_ae'Y' C$ 1 r�6ts ds JOSEPI, 3� ��2771 F B LM0NT U lLver Af02720a a� k , . .0 610 5%2o 0 1 5 r, ti- ------- ----------- --------------------- ----------- ---------- ------ - -- -- ----. --` �� Regulatory Services t RAMSTARf.R. ! - arns� —� Thomas F.Geiler,Director i659- �� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us `Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using.A Builder w c�,n , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of job) Pool fences and alarms are the responsibility of the applicant: Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature_o wn4l Signature of Applicant ` Print Marne Print Name Date Q:FORMS:OWIQEUERMISSIONPOOLS 62012